Shooting Victim Management

What do you think is the most common injury leading to preventable death in civilian public mass shooting events? Many individuals might guess severe extremity bleeding, but the data tells a different story. 

On this episode of From Science to the Scene, Dr. Ash Panchal breaks down a critical study that every EMS Clinician needs to understand. The research looks closely at autopsy reports to find out what causes potentially preventable death in these terrible situations. The data reveals that civilian injuries are very different from military injuries, meaning our traditional response plans must adapt. 

Instead of the extremity wounds often seen on the battlefield, the vast majority of these civilian casualties suffer from hidden, non-hemorrhaging chest wounds, where a tension pneumothorax can quietly become fatal. Compounding this challenge, fewer than one in four of these individuals ever survive long enough to reach a hospital bed. This devastating reality proves that the windows of time for lifesaving medical intervention and rapid scene transport are overlapping and incredibly short. 

We must continue to learn how to improve our triage, care, and movement of patients in chaotic environments. Tune in to explore how the SALT mass casualty triage protocol helps us make a difference when every second counts.

 
Read the full study here: https://pubmed.ncbi.nlm.nih.gov/31029762/

Transcript

SPEAKER_00 0:15

Hey everybody, it's Osh Panchel again. Today we're gonna bring back an older manuscript that was identified by ABEM's EMS lifelong learning and self-assessment. And it was considered one of the key articles that we need to know as EMS clinicians and physicians. Now, the reason I'm bringing this back is it addresses a really tough question for all of us. The management of civilian mass shooting victims. Now, when we think about this population, we know that it's it's gonna be really difficult for us to manage this population, but we need to understand the data around it. So the paper we're bringing back is called The Incidence and Cause of Potentially Preventable Death After Civilian Public Mass Shooting in the United States. Notice they're talking about preventable death, and that's what the focus is on. And this paper's, like I said, it was a little older, it's from 2019, but it gives us really good framework of where we're at. So we know that the rising frequency of civilian public mass shooting events is a significant public health interest across our country. It's not getting less, it's getting worse, which means, and I think our agency says the same thing, it's a matter of time when it'll affect us. And there's a strong need for us to revise these traditional police, fire, emergency response paradigms to be ready for this. Now, a lot of this gained a lot of momentum after Combine in '99, and this was reinvigorated after Century 16 movie shooting and even Sandy Hook. So one of the big things that we're thinking about is what's the focus right now? So let's frame this. The focus right now is rapid care at or near the point of wounding. We want to push for immediate medical care, and it starts with our non-medical personnel, and then we go for to rapid extraction to definitive trauma care. All of this in the framework of immediate medical care training through our Stop the Bleed programs. Now, the problem is, are there really preventable deaths in these horrible situations? Now, what we do know is there are there are some data looking at potentially preventable deaths. The rate is anywhere from 7 to 30%, really precise, right? And it's based really on two small studies: 139 patients from 12 events and 49 fatalities with a fatality rate about 48%. And that was at the Pulse Nightclub shooting. Now, these studies all demonstrated that military and civilian injuries are not the same. They're not analogous. As of evidenced by the higher probability of death associated with civilian uh shootings, 45%, versus our military shootings, which are like 10%. So very, very different scenarios. So the really the objective of this big study was to determine the fatal wounding characteristics after these civilian public mass shooting events, and they wanted to use a larger data set to better evaluate the question. So, with that in mind, what's the methods? They accessed the New York Police Department's 2016 active shooter summary report. This has data since 1966, and they cross-referenced this against the FBI active shooter events from 2000 to 2017. So now we've built this large data set spanning a large amount of time period. They looked at the medical examiner or coroner reports for all these civilian public mass shooting events from 1999 to 2017, and they contacted them and they requested the autopsy records so they could really get into the nuts and bolts of exactly what happened. And then they got a panel of trauma surgeons, a coroner, a forensic pathologist, an emergency physician, and a critical care advanced practice paramedic. And they all independently reviewed and decided if the injuries that were sustained were survivable or non-survivable. So what is survivable? Pre-hospital care available within 10 minutes of the injury with definitive medical care within an hour. And that's set by the pre-hospital trauma life support guidelines. That is our goal, and that's what's survivable. Now, wounds that were considered fatal, that was if they involved both cerebral hemispheres, midbrain or the brain stem, spinal cord, uh above the C5, the heart, non-extremity major vascular structures, or multiple solid organs. Let's be honest, these are pretty straightforward. These are bad things that people are not going to survive from. So, with that in mind, let's dive into the study. And when we look at the first figure, they really define the population they're looking at. It was 230 victims with a fatality ratio of about 40% in this population. The first thing they dove into was they started saying, okay, how many GSWs actually occurred per person? The mean gunshot wound per person was four. And of the 877 gunshot wounds that occurred, 235 had fatalities. As you'd expect, the more GSWs, the more fatal. If you had one, your fatality rate was 1.5. If you had two, 9.8. If you had three, 22.5. So we recognize that that as we're in these events, the more gunshot wounds, the more problems you're gonna have. Now let's talk a little bit more about the potentially preventable death. Of all these fatalities, 12% arrived to the hospital and had some sort of intervention. Of all these patients, 15% were considered potentially preventable deaths. 15%. So who are these individuals and what was the primary organ? So in their figure, figure three, they actually talk about the the organ distribution and what organs were most injured in people with primary, primarily preventable deaths. And surprise, surprise, it was the lung. Not something I would have thought, but lung injuries were the number one concept there. So most important in this this the most important injury in this cohort was a gunshot wound to the chest uh without hemothorax or major vascular injury when they looked at the autopsies themselves. So presumably, these lung injuries I'm telling you about, they died of tension pneumothorax. Now, 9% of these gunshot wounds were in the abdomen, 9% in the neck, 2% in the extremity. And so you can see that the use of tourniquets for this population wasn't the thing that could prevent the injury or the death. Last but not least, one of the things we always talk about are junctional vascular injuries and using junctional tourniquets and all that stuff. There were no preventable death events related to any type of junctional vascular injury in this whole cohort. So the scary concept six percent incidence of vascular injury was amenable to using external hemorrhage control. What does that mean? Only 6%. 59% had nonvascular lung injuries that highlight the need for stabilizing measures by trained pre-hospital personnel. And only 26% of the potentially preventable uh deaths actually arrived at the hospital. So we need to work again on rapid extraction and transport. And I think we all knew this. The more rapid extraction and transport we can do, the better, and the more people we can save. But this is not easy in these chaotic environments. Now, when we put all this and put it all together, what brings us brings us all together for us is the salt mash casualty triage protocol. This was again released in 2008, and it's really the most unified concept that we've had to actually intervene and improve lives. And in that salt triage protocol, we know that one of the biggest things that we need to do is do interventions early and do those life-saving interventions. So one of the biggest things that brings all this home is how we base so much of our interventions on. And it's the salt mash casualty triage system. This was released back in 2008, and it was a really strong movement by everybody: the American College of Emergency Physicians, American College of Surgeons, American Trauma Society, NEMSP, National Disaster Life Support Education Consortium. Everyone got together and really thought this through about what we should do. And when we think about the salt mash triage categories, one of the biggest things that we think about is not only sorting early on, but performing life-saving interventions so that we can prevent some of these injuries. What we're seeing in this from this study is that there is some significant injury and death that we can prevent, but at the same token, what we see in the civilian state may not be the same that we see in the military state, and the interventions may also not be the same. There's still so much for us to learn. Secondly, one of the biggest things we need to keep in mind is the more we work on either identifying, extracting individuals, the more lives we have, the potential chance to save. Again, so much more we work. So with that in mind, thanks for joining us. Whether you're hidden the books or hidden the streets, stay safe, stay curious, and keep bringing science to the scene. Thanks so much.