RUN⋅HIDE⋅FIGHT⋅TREAT SURVIVING AN ACTIVE SHOOTER AND BASIC TRAUMA CARE THE GLENDALE POLICE DEPARTMENT IN PARTNERSHIP WITH THE DENVER HEALTH PARAMEDIC DIVISION

Section 1

Overview of Workplace Violence

Overview • Planning and training for an active shooter incident

includes three phases: • Prevention • Identifying indicators of and training for Active Shooter and

Workplace Violence before an incident occurs.

• Response • What to do when an Active Shooter situation is in progress. • RUN. HIDE. FIGHT. TREAT.

• Recovery • Getting life back to a “normal state” and organizations re-open for business.

What is Work Place Violence? • Work place violence includes physically

harming another, shoving, pushing, harassing, intimidating, coercing, brandishing weapons, and threatening or talking about engaging in those activities.

Triggers of Workplace Violence • Firing or Layoffs

• Unappreciative supervisors

• Complaints from co-workers

• Being talked down to

• Bad evaluations

• Last minute orders

• Failure to get promotion

• Mandatory overtime

• Inequity of treatment

• Assignments given w/o

• Major changes in work

consideration of worker’s skills • Work-related misunderstandings • Communication misunderstanding

• • • •

assignment No clear directions at work Poor support or cooperation Extreme stress Irritable customers

Source: Society for Human Resource Management – 2012

What is the most common Cause of Death in an Active Shooter Incident?

DENIAL!!!

© Nicoletti-Flater Associates

RUN. HIDE. FIGHT. Surviving an Active Shooter Event. • The City of Houston Office of Public Safety and Homeland

Security released a video providing these key steps to follow should you encounter an active shooter.

Section 2

Active Shooters

What is an “Active Shooter” • An active shooter is defined by the U.S.

Department of Homeland Security as “an individual actively engaged in killing or attempting to kill people in a confined and populated area.” • “In most cases, active shooters use firearm[s] and there is no pattern or method to their selection of victims.” Source: United States Department of Homeland Security - 2009

ALGORITHM ANALYSIS Location of the Attacks Between 1/13/12 & 12/27/12

• 35 Incidents Between 1/13/12 & 12/27/12 • 51% of the attacks occurred in the workplace • 17% of the attacks occurred in a school • 17% of the attacks occurred in a public place • 6% of the attacks occurred in a religious establishment • 9% of the attacks occurred either in the victim’s or the offender’s residence

© Nicoletti-Flater Associates

ALGORITHM ANALYSIS (con’t) • 57% of the attackers were insiders

(Individuals who are on your radar before they attack.) • 63% of the attackers broadcast a perceived injustice • 71% of the victims initially targeted were the focus of the perceived injustice • 74% of the attackers entered through the main entrance © Nicoletti-Flater Associates

ALGORITHM ANALYSIS (con’t) Between 1/13/12 & 12/27/12

• 71% of the attackers just walked in • 49% of the attackers committed suicide • 17% of the attackers were killed • 34% of the attackers were arrested • 37% of the attacks were over in under 5 minutes • 63% of the attacks were over in under 15 minutes

National Average Police Response Time 7-15 Min. © Nicoletti-Flater Associates

Active Shooter Incidents • 1966 University of Texas – Austin, TX • Killed 15, Injured 31 • 1984 McDonalds, San Ysidro, CA • Killed 21, Injured 11 • 1986 USPS, Edmond, OK • Killed 14, Injured 6 • 1999 Columbine HS, Littleton, CO • Killed 13, Injured 21 • 2007 Virginia Tech, Blacksburg, VA • Killed 32, Injured 17 • 2009 Fort Hood, TX • Killed 13, Injured 30 • 2012 Century Theaters, Aurora, CO • Killed 12, Injured 58 • 2012 Sandy Hook Elementary • Killed 26, Injured 2 • 2013 Washington Naval Yard • Killed 12, Injured 4 • 2013 Arapahoe HS, Centennial, CO • Killed 1, Injured 1

Active Shooter Incidents • 2014 Roswell New Mexico Middle School • Injured 2 • 2014 Maryland Mall, Columbia, MD • Killed 2, Injured 5 • 2014 Fort Hood, TX • Killed 3, Injured 16 • 2014 FedEx Warehouse Hub, Kennesaw, GA • Injured 6 • 2014 Seattle Pacific University, Seattle, WA • Killed 1, Injured 2 • 2014 Reynolds High School, Troutdale, OR • Killed 1, Injured 1 • 2014 UPS Warehouse, Birmingham, AL • Killed 2 • 2014 Marysville-Pilchuck Highschool, Marysville, WA • Killed 4, Injured 1 • 2014 Florida State University, Tallahassee, FL • Injured 3

First “Killing at a School” in the U.S. • The earliest known United States mass killing at a school

occurred at Pontiac's Rebellion July 1764, where four Lenape American Indian entered the schoolhouse near present-day Greencastle, Pennsylvania. • Killed were the school’s Master and 10 children.

Active Shooter - Patrick Sherrill • USPS employee nicknamed “Crazy Pat” • Former Marine • Gun Enthusiast • Described as a “loner” • Lived with his mother • Would mow his lawn at midnight • Killed 14 co-workers and injured 6 • Took his own life • Day before shooting told one co-worker “Don’t come

to work tomorrow.” • Killed Self Source: Federal Bureau of Investigations - 2009

Active Shooter Threat 12/12/2013 • December 12, 2013 • Active Shooter Threat

day before the advised event • Students began warning other friends on Facebook Parent noticed post on child's Facebook page and alerted authorities

Active Shooter – Group Attacks

Section 3

Run Hide Fight

RUN. HIDE. FIGHT. “You

never think something like this is going to happen to you until you have to react in that situation when someone is screaming there is a gun in the building. I ran for my life.” -Florida State University Student

RUN • When an active shooter is in your vicinity: • If there is an escape path, attempt to

evacuate. • Evacuate whether others agree to or not. Fire Drill Mentality. • STOP DROP ROLL RUN HIDE FIGHT • Leave your belongings behind. • Help others escape if possible. • Prevent others from entering the area. • Call 9-1-1 when you are safe. Source: www.readyhoustontx.gov - 2012

Calling 911 • When you are safe call 911. Don’t assume others have

called already. • Provide, if possible: • Exact address, office location, building, unit number, etc. • Description of the suspect(s). • Who is he/she (stranger, ex-employee, customer). • Weapons (handgun, shotgun, rifle). • Were any explosions heard or seen (grenades, IED’s). • Location of suspect on the property. • i.e. last seen in cafeteria, administration offices, • Any entrances or exits from this particular area Source: www.readyhoustontx.gov - 2012

HIDE • If an evacuation is not possible, find a • • • • • •

•

place to hide. Act quickly and quietly. Try to secure your hiding place the best you can. If possible, lock doors. Turn out lights. Silence your ringer and vibration mode on your cell phone. If unable to find a safe room or closet, try to conceal yourself behind large objects that may protect you. Do your best to remain quiet and calm. Source: www.readyhoustontx.gov - 2012

HIDE

FIGHT • As a last resort, and only if your life

is in danger: • Work as a group if possible. • Attempt to incapacitate the shooter. • Act with physical aggression. • Improvise weapons. • Commit to your actions. Your life depends on it. Source: www.readyhoustontx.gov - 2012

FIGHT with improvised weapons • Fire extinguishers – Spray attacker and then hit him with

canister • Break room improvised weapons – • Knives and forks to stab, slice and jab attacker’s face. • Hot coffee or water from pot thrown at attacker’s face. • Cleaning fluids under the sink (ammonia, bleach) thrown on

attackers face. • Water cooler jugs thrown at attacker or used to hold him down.

Source: Surviving Workplace Violence -2005

FIGHT with improvised weapons • Stapler – Strike the attacker in the face, throat, weapon • • • • • •

hand, and groin. Pen/Pencil – Jab, stab, and scrape attacker’s face. 500 sheet paper ream – Use with both hands as if a rock and slam it on attacker’s head. Coffee Cup – Throw hot liquids in attacker’s face. Use cup to bash attacker in the head. Scissors – Stab attacker everywhere possible Phone receiver – Strike attacker in face, throat, groin, and weapon hand. Chair – Hit attacker with it and when he is on the floor slam it on top of him. Could be used to hold him down. Source: Surviving Workplace Violence -2005

Section 4

Police Arrival Immediate Action Rapid Deployment (IARD)

Background Information - Immediate Action Rapid Deployment (IARD) • 2009 • The Glendale Police Department

participated with the Denver Police Department, Aurora Police Department and other metro area police departments on an active shooter scenario at the Cherry Creek Mall. • 209 participants over four days training inside the mall from 5 am -10am on weekends.

Background Information - Immediate Action Rapid Deployment (IARD)

Lessons Learned • Although police response has increased significantly to

active shooter situations throughout the years, the gap of citizen resiliency between the time an incident initiates and the time responders arrive on scene has yet to be explored. • By introducing the concepts of the active shooter and the

basic trauma care training, potential victims can now utilized such skills and become their own care givers until first responders can arrive on scene and take control of the event.

POLICE Arrival • The first responding police officers on the scene are not there to evacuate or

tend to the injured. They are well-trained in active shooter incidents, and are there to incapacitate the shooter. • Remain calm and follow police officers instructions. • Keep your hands visible at all times.

Section 5

Basic Trauma Care Safety and Wound Identification

WARNING • Some of the images shown during

this presentation are graphic and may be disturbing to some people.

Basic Trauma Care- SAFETY • Before any care is rendered, your personal safety

must be considered first. • If you are injured, you are of no help to the injured

victim.

Basic Trauma Care for the Injured

IDENTIFY THE INJURY

Basic Trauma Care- IDENTIFY • Before your begin treatment, you must identify the

injury • Bleeding from an artery is bright red in color and

spurting or pumping. • Arterial bleeding is life threatening.

Basic Trauma Care – IDENTIFY Venous Bleeding

• Venous bleeding originates from a damaged or

severed vein. • Venous bleeds are usually dark red in color and flow

steadily from the wound. • Venous bleeding may be life-threatening if a large

vein is damaged.

Basic Trauma Care – IDENTIFY Capillary Bleeding • Capillary bleeding originates from damaged

capillaries which are the tiny blood vessels that connect arteries to veins. • Capillary bleeding is usually dark red in color and

“oozes” from the injury site.

Basic Trauma Care- IDENTIFY • Remove or cut the victim’s clothes to expose the

injured site. • By removing clothing around the injured site, you will

be able to see injuries that may have been hidden or covered.

Importance of the First Responder • “The fate of the wounded lies in the hands of the

ones who apply the first dressing” Col. Nicholas Senn, M.D. 1898

• A significant number of all trauma-related deaths

occur before the victim reaches a hospital.

Pre-Hospital Trauma Care • While EMS usually responds quickly… • Delays in access to care can occur, and sometimes… • Long delays in access to care can occur

AP Photograph

Extremity Hemorrhage

Question • How long does it take to bleed to death from a complete

femoral artery and vein disruption such as that shown in the video earlier? • Answer: • Casualties with such an injury can bleed to death in as little as 3

minutes

The Number One Medical Priority STOP THE BLEEDING, if possible • Early control of severe hemorrhage is critical. • Extremity hemorrhage is the most

frequent cause of preventable deaths. • Injury to a major blood vessel can quickly lead to shock and death.

Wound Location and Hemorrhage • Central wounds • chest, abdomen • Bleeding is internal • Bleeding cannot be

controlled in the field • Patient requires rapid transport to trauma center • Call 9-1-1 to notify EMS

Wound Location and Hemorrhage • Junctional Wounds • Where the body joins its appendages • neck, axilla, groin • Apply direct pressure to the bleeding site, or • Pack the bleeding wound with a hemostatic agent or gauze roll and apply direct pressure to the packed wound

Wound Location and Hemorrhage • Extremity Wounds • Control life threatening

bleeding with a tourniquet

Section 6

Tourniquet Application

A Preventable Death Did not have an effective tourniquet applied - bled to death from a leg wound

Ft. Hood Shootings 2009 Officer Kim Munley • 12 dead; 31 wounded on 5 Nov 09 • Officer Munley shot the assailant • She was shot in both thighs • Went into shock • Saved by Army

medic who applied tourniquet on left thigh

Basic Trauma Care – TOURNIQUET What does it do?

• If applied correctly, the tourniquet stops arterial blood

flow into the extremity and to the wound. • The restriction of blood flow limits blood loss and

may prevent the patient from going into shock.

Tourniquet Application • Apply without delay if life-threatening bleeding is noted. • Apply the tourniquet without removing clothing • Make sure it is above the bleeding site. • Tighten until bleeding is stopped. • May need a second tourniquet applied just above the

first to control bleeding. • Don’t apply directly over the knee or elbow. • Don’t apply directly over a pocket that contains bulky items. • Non-life-threatening bleeding should be ignored until life-threatening bleeding has been stopped.

Examples of Extremity Wounds That Do NOT Need a Tourniquet Through and through gun shot wound to the arm – not bleeding

Large forearm laceration – minor bleeding

Use a tourniquet ONLY for severe bleeding!

Anatomy of a Tourniquet

This photo of a C-A-TTM tourniquet shows all of the necessary components for an effective tourniquet.

C-A-T™ One-Handed Application to an Arm

Video courtesy North American Rescue

C-A-T™ Two-Handed Application to a Leg

Video courtesy North American Rescue

Basic Trauma Care - TOURNIQUETS

Do they work? •Kragh et al – Published 2008/2009 – •Tactical Combat Casualty Care •Author estimates that during the study period

approximately 2000 lives were saved during the military operations in Iraq and Afghanistan.

Impact of Using Tourniquets Studies from Iraq and Afghanistan

• Better survival when tourniquets are applied BEFORE victims go into shock • Survival if applied before shock develops – 96% • Survival if applied after shock develops – 4%

• No amputations caused by tourniquet use • Approximately 3% transient nerve palsies • All resolved in weeks to several months

Tourniquet Pain • Tourniquets HURT when applied effectively • Does not indicate a mistake in application • Does not mean you should take it off! • Once EMS arrives, they will treat the pain with

analgesics.

Tourniquets: Points to Remember • Damage to the arm or leg is rare if the tourniquet is

applied for less than two hours. • Tourniquets are often left in place for several hours during

surgery.

• In the face of massive extremity hemorrhage, it is

better to accept the small risk of damage to the limb than to have a victim bleed to death.

Tourniquets: Points to Remember • When a tourniquet has been

applied, DO NOT periodically loosen it to allow circulation to return to the limb. • Causes unacceptable additional

blood loss

Tourniquet Mistakes to Avoid! • Not using one when you should • Waiting too long to put the tourniquet on • Not making it tight enough to stop the bleeding • Not using a second tourniquet if needed • Periodically loosening the tourniquet to allow blood

flow to the injured extremity

Section 7

Packing a Wound and Applying Pressure

What do you do for bleeding from a site where you cannot place a tourniquet?

Hemorrhage Location • Junctional wounds • neck, axilla, groin • Cannot apply a tourniquet in these locations • Pack with topical hemostatic agent or plain gauze roll • Apply direct pressure • This technique can control bleeding that might otherwise prove fatal.

Junctional Wounds • Pack the wound with a hemostatic

agent or a plain gauze roll and apply pressure • Hemostatic agents are materials that will help cause blood to clot • Examples: • NuStat • QuikClot • Combat Gauze • Celox-A • Chitosan

Packing a Wound Directions (1) Expose Wound & Identify Bleeding • Open clothing around the wound. • If possible, remove excess pooled blood from the wound while preserving any clots already formed in the wound. • Locate the source of the most active bleeding.

Packing a Wound Directions (2) Pack Wound Completely • Pack hemostatic agent or gauze roll into wound and directly onto the source of bleeding.

Packing a wound Directions (2) Pack Wound Completely

Packing a Wound Directions (3) Apply Direct Pressure

• Quickly apply and hold direct continuous pressure for 3 minutes if using a hemostatic agent and 10 minutes if using plain gauze. • Reassess to ensure bleeding is controlled. • If initial packing fails to stop bleeding, pack a second gauze on top of the first and reapply pressure.

Packing a Wound Directions (4) Bandage over Hemostatic Agent • Leave packing in place. • Wrap to secure the packing in the wound. • Although the Emergency Trauma Bandage is shown in this picture, the wound may be secured with any compression bandage, Ace™ wrap, or roll of gauze.

Combat Gauze Video

Direct Pressure • Use your hand or finger. • It works most of the time for external bleeding. • Bleeding control requires very firm pressure for a

minimum of 10 minutes. • Don’t release pressure to check the wound until the

recommended time has passed. • It can stop even carotid and femoral bleeding.

Hemorrhage Location • Central - chest, abdomen • “Internal” bleeding • Cannot be controlled in

field • Rapid transport to trauma center • Identify these patients to the arriving paramedics

Section 8

Breathing and Airway Assessment

Airway and Breathing Assessment • Tools • Look • Listen • Look for obvious trauma to the air passageways • Nose, mouth, and neck (trachea) • Listen for noisy respirations • Noisy respirations = airway compromise or obstruction • Snoring, gurgling when breathing

Airway and Breathing Assessment Airway Management •

Conscious victim: 1.

Allow victim to assume any position that allows them to breathe and feel comfortable.

• Casualties with severe facial injuries can often protect their own airway by sitting up and leaning forward. • Let them do it if they can!

Airway and Breathing Assessment •

Unconscious victim 1.

The most common cause of airway obstruction is the tongue • Patients with altered mental status often

cannot keep the airway open, so the tongue falls back and blocks the airway. • Results in snoring sounds.

Airway and Breathing Assessment Airway Management • Unconscious victim: 1. 2.

Jaw thrust maneuver Place casualty in recovery position

Airway and Breathing Assessment Airway Management • Unconscious victim: • Opening the airway requires lifting the tongue from the back of

the throat • The tongue is attached directly to the mandible (jawbone) • Trauma jaw thrust - opens the airway without compromising

the spine.

Jaw Thrust

Jaw Thrust

Airway Support Place unconscious casualties in the recovery position after the airway has been opened.

Keep the Victim Warm Prevention of hypothermia (decrease in body temperature) • Minimize victim’s exposure to the elements. • Replace wet clothing with dry if possible. • Get the victim onto an insulated surface as soon as possible. • Use dry blankets, sleeping bags, clothing, or

anything that will retain heat and keep the patient warm and dry.

Basic Trauma Care - Keep Warm • Our body’s reaction to bleeding is for blood to clot in

order to stop the bleeding. • Blood loss = heat loss • A low body temperature inhibits the ability of our

blood to clot.

Hypothermia Prevention • Key Point: Even a small decrease in body

temperature can interfere with blood clotting and increase the risk of bleeding to death. • Victims in shock are unable to generate

body heat effectively. • Hypothermia is much easier to prevent

than to treat!

Section 9

EMS Arrival

EMS Arrival • The first responding EMTs or paramedics have a number

of important actions to complete before treatment of victims will begin: • Assess the magnitude of the incident • Approximately how many casualties are there

• Determine needed resources • Personnel, ambulances, etc

• Request the needed resources

Triage of Patients • After the initial actions have been completed, EMTs and

paramedics will begin the triage process • Triage means to sort patients according to the

seriousness of their injuries and assign priorities for treatment and transport

Triage of Patients (cont’d) • What this means is that every injured person will be

assessed and a determination made about how quickly he or she requires emergency medical treatment and transport to the hospital. • Patients with life-threatening injuries will be treated and

transported first. • Patients with less serious injuries will be treated and

transported after those with life-threatening wounds.

Triage of Patients (cont’d) • Even though you may be injured, if there are additional

seriously or critically injured victims, the EMT or paramedic may move on to the next patient. • As more help arrives to the scene, all victims will be

treated and transported.

Summary of Key Points • Stop life-threatening external hemorrhage. • Use a tourniquet for hemorrhage from those locations where a tourniquet can be placed. • Pack the wound and apply pressure for those locations where a tourniquet cannot be placed. • Open the airway in victims with decreased levels of

consciousness who are making noisy respirations or not breathing at all. • Keep victims warm.

Section 10

Organizational Recovery

RECOVERY from an ACTIVE SHOOTER SITUATION • After the active shooter has been incapacitated and is no

longer a threat, human resources and/or management should engage in post-event assessments and activities: • Account for all individuals at a designated assembly

point to determine who, if anyone, is missing and potentially injured • Determining a method for notifying families of

individuals affected by the active shooter, including notification of any casualties

RECOVERY from an ACTIVE SHOOTER SITUATION • Assessing the psychological state of individuals

at the scene, and referring them to health care specialists accordingly • Identify and filling any critical personnel or

operational gaps left in the organization as a result of the active shooter • Returning operations to a state of “normal.”

RECOVERY from an ACTIVE SHOOTER SITUATION • After an Active Shooter Situation, the following mental

health issues may arise. • Anxiety • Depression • PTS which can evolve into PTSD • Survivors Guilt

-A strong recommendation is to complete a “Debrief” as a group. -All personnel should receive, at the minimum, 1 counseling session (alone) with trained mental health professionals. *Prior to an event, train key personnel and supervisors on how to deal with employees after a critical incident.

QUESTIONS?

Individual Trauma Aid Kit (ITAK) Elastic Bandage

CAT Tourniquet

Shears

Gloves Gauze Roll