NREL is a national laboratory of the U.S. Department of Energy, Office of Energy Efficiency and Renewable Energy, operated by the Alliance for Sustainable Energy, LLC.

After Aurora:

Tactical Combat Casualty Care in the Aftermath of an Active Shooter

Joseph Thill

Director, Office of Security & Emergency Preparedness

Presented to Energy Facilities Contractors Group, March 12, 2014

2

Don’t Doubt That This is Combat!

• The Threat/Adversary: Violence with

an intended outcome

• Weapons of war: High powered

firearms, Improvised Explosive

Devices (IED) that cause the same

chaos and horrific wounds (physical

and mental) that exist on the battlefield

• To defeat, requires unity of effort, maneuver, speed,

and directed violence to neutralize the threat

• The recovery and response that is used on the

battlefield (Stabilize, Transport, Triage, Treat)

3

Don’t Doubt That This is Combat!

• Perpetrated by individuals

• Perpetrated by groups

• Potential to evolve to a coordinated

effort to disrupt, terrorize and engage

the US on our own soil

• It has and will happen in:

• Our Schools

• Our Malls

• Our Government Facilities

• Our seats of National Power (Economic,

Military, Infrastructure)

4

Agenda

• Overview of the Aurora Theater Shooting

• Excerpt from “After Aurora” by 9News Denver

• Introduction to Tactical Combat Casualty Care

(TCCC) and the Role it Can Play in Preparing For and

Responding To the Active Shooter/Coordinated

Assault

Pretending it won’t happen does a disservice to those

who have suffered in the past and those who may in

the future.

5

July 20th, 2012 Aurora, Colorado

• 12:40am at the Century Theater 16 inside Theater 9

• James Holmes the alleged shooter opens fire after throwing gas canisters; AR-15, shotgun and Glocks: FBI finds 238 bullet holes and impact marks

• 12 Killed (including a 6 year old girl)

• 58 wounded

• 8 minutes after 911 call, suspect in custody

• 11 minutes after 911, first wounded person is transported

6

July 20th, 2012 Aurora, Colorado

• Unprecedented evacuation of wounded

• Changes to how we will respond to these events in the

future

• Changes to Tactics, Techniques and Procedures

• Changes to Police Training

7

AFTER AURORA

8

Tactical Combat Casualty Care (TCCC)

“The fate of the wounded rests with the

one who applies the first dressing.” -Nicholas Senn, M.D., 1898

9

Tactical Combat Casualty Care (TCCC)

• Rooted in a 1996 Study of Military Emergency

Medicine

• Focus on treatment at the point of wounding to

treat “survivable” wounds

• Three distinct environments:

o Care Under Fire

o Tactical Field Care

o Tactical Evaluation Care

• Three Goals:

o Identify the causes of preventable death on the

battlefield

o Address them aggressively

o Combine good medicine with good tactics

10

(Data based on the Wound Data Munitions Effectiveness Team (WDMET) during the Vietnam War between 1967 and 1969)

11

Tactical Combat Casualty Care (TCCC)

World War II Vietnam OIF/OEF

CFR 19.1% 15.8% 9.4%

Note: CFR is the Case Fatality Rate – the percent of those wounded who die from wounds

• Good Tactics are good medicine

• Right treatment at the right place at the right time

• Training all service members in the treatment of preventative techniques

o Combat Application Tourniquet (CAT)

o Israeli Pressure Dressing

o Combat Gauze/”Quick Clot”

o Nasal Pharyngeal Airway

o Saline Lock and IV Infusion

• All Service Members trained in TCCC (aka Combat Lifesaver Course) prior to entering theater

12

Tactical Combat Casualty Care (TCCC)

• Tourniquet as an immediate treatment for extremity wounds

• Up to the mid-1990s, medics were training not to use tourniquets

• Highly effective for: o Hemorrhage from extremity wounds

o Junctional hemorrhage (where an arm or leg joins the torso, such as in the groin area

after a high traumatic amputation)

• Study of tourniquet use showed

no detrimental effects tied to use

(2001-present)

Over 2500 deaths occurred in Vietnam

secondary to hemorrhage from

extremity wounds. These casualties had

no other injuries.

“We believe that the strap-and-buckle

tourniquet in common use is

ineffective in most instances under

field conditions…it rarely controls

bleeding no matter how tightly

applied.” –AMMED Journal 1945

13

Tactical Combat Casualty Care (TCCC)

• Combat Application

Tourniquet (CAT)

• Pressure Dressing

(Israeli Bandage)

14

It Works!

TCCC has helped U.S. combat forces to achieve the highest casualty survival rate in history

“I am writing to offer my congratulations for the recent dramatic advances in pre-hospital trauma care delivered by the U.S. military. Multiple recent publications have shown that Tactical Combat Casualty Care is saving lives on the battlefield.”

Dr. Jeff Salomone American College of Surgeons Committee on Trauma

Chairman of Prehospital Trauma Subcommittee Letter to ASD Health Affairs

10 June 2008

“The new concept of Tactical

Combat Casualty Care

has revolutionized the

management of combat

casualties in the pre-

hospital tactical setting.”

-Critical Care Medicine July 2008

A recent U.S. Army Training and Doctrine Command survey of Soldiers in combat units found that TCCC is the second most valued element of their training, exceeded only by training in the use of their individual weapon.

COL Karen O’Brien, TRADOC Surgeon

CoTCCC Meeting April 2010

15

Tactical Combat Casualty Care (TCCC)

• TCCC is being adopted by EMS and Law Enforcement across the country

o Key component of Advanced Law Enforcement Rapid Response Training (ALERRT)

for Active Shooter

o Aurora Police Department, Colorado trained all officers in one and two day

iterations at Denver Health

• Why?

o Highly effective and easy to train

o Applicable during Active Shooter and Mass Casualty (Boston Marathon)

• During an Active Shooter or Mass Casualty Event:

o EMS will be overwhelmed

o Security situation may prevent fast evacuation to treatment facilities

o Hospitals/Trauma Centers, especially those closest to the event, will be overwhelmed

The goal is to intervene at the right time to prevent death due to bleeding

while awaiting transport to extended care!

16

Questions?