That is to say, resources are allocated to more technological and security solutions, both of which are congruent with a robust prevention plan. The most vigorously supported, well-funded preparation and planning cannot ensure ultimate safety, unfortunately. Moreover, mass-casualty events can be the result of natural calamities, not merely narrowly focused active-shootings. Therefore, developing a post mass-casualty event plan is imperative, but doing so is often unintentionally marginalized. Why?
Victims of Time
The U.S. emergency response and rescue system is one of the best in the world. It relies on a multifaceted response system that is underpinned by highly trained professional responders. The success of the system has lulled administrators and the public into a false sense that medical care will arrive immediately once 911 is activated.
However, recent events (e.g., Boston Marathon bombing, Aurora theater shooting, Umpqua Community College shooting and Brussels Airport bombing) demonstrate that medical response to a complex mass-casualty event is often delayed, due to the inability of rescuers to access victims safely and quickly. Initiatives to expedite response such as the Rescue Task Force (RTF) model and equipping police to treat casualties are evolving, but it is not an adequate response when victims can die within 5 minutes due to exsanguination. Time to treatment is the currency of trauma care, and it is not hyperbolic to state that the price for delay can be measured in lives. So, what can administrators do?
Broaden Response Definition
No one should die of uncontrolled bleeding, and preventing death can be achieved by implementing a new model centered on public response. Empowering uninjured persons within close proximity of victims will increase the chance of survival after a mass-casualty producing event. The old model relied on professional responders arriving quickly enough to treat victims, assuming the scene was safe enough to allow access. Otherwise, responders surrounded and contained the threat. In the meantime, victims lose blood and time. Bystanders, if empowered and trained, can and will bridge the time gap by rendering aid.
The above assertion is not without precedent. A cursory examination of public buildings, schools, sports venues and airports reveals that the assumption that the public will act in a life-threating emergency is not unfounded. For instance, Automated External Defibulators (AEDs), which are used to treat sudden cardiac arrest, are commonplace throughout public venues within the USA.
Prior to the American Heart Association introducing this new link in the chain of survival, victims of sudden cardiac arrest waited for professional responders to arrive and render aid. Death from sudden cardiac arrest has been reduced markedly by adding this important link in the chain. In fact, their chain of survival is now a worldwide guideline. It is therefore not imprudent to ask that the same consideration be given to the idea of public response being the first link in the trauma chain of survival.
Many campus emergency preparedness plans suffer from the problem of focusing on technological and security solutions to prevent attacks: cameras, access-point control, door reinforcement and automatic lock-down systems, increased campus security, intelligence sharing, etc. Meanwhile, planning for response immediately after an event, specifically how to save the most lives, is often relegated to initiating local EMS. As noted above, calling 911, while appropriate for day-to-day emergencies, is inadequate in responding to mass-casualty events. How can you be better prepared?
Successful Implementation of Life-Safety Preparedness on Campus
Defining a comprehensive preparedness plan is beyond the scope of this article, but planning for how to better respond to mass-casualty events requires addressing four broad areas: 1) buy-in at the highest administrative levels; 2) educating and empowering students and faculty; 3) public-access kits; and 4) building awareness throughout the local community.
If the highest echelons of administration do not demonstrate leadership on this issue through actions and resource allocation, it will be difficult for lower management to create and implement innovative ways to address this problem. Of course, upper-echelon management has to decide between competing priorities, using finite funds. For example, a security manager at a mid-sized Southern university requested an increased response capability by placing trauma equipment throughout its football stadium and training security teams and select vendors in basic first-aid. The Athletic Director denied this request due to the policy that each event has on-site EMS at field level, which is already accounted for in the operational budget. Is this adequate preparation?
To answer this would usually necessitate extrapolating from an historical example or running a costly exercise, but technology now allows simulations to be conducted based on normal game-day attendance, the architecture of the stadium (box vs field level), the counter- and cross-f low of persons under duress and simulated reaction times of responders. In this real-world example, data illustrated that due to rescuers having to negotiate escaping fans after an event, response times exceeded 6 minutes, whereas prepositioned kits and bystander response clocked-in at less than 1 minute. Armed with accurate information, administrators can better allocate resources and lead initiatives.
Empowering bystanders to form a critical first link in the trauma chain of survival requires a coordinated approach across campus. To be effective, students and faculty need to learn how to address most preventable causes of death (e.g., hemorrhage control, basic airway management), evacuating victims, campus policies (i.e., shelter in place vs Run, Hide, Fight) and casualty collection points.
All of these can be disseminated via online learning initially, with hands-on reinforcement classes offered either for-credit or as part of orientation. For instance, a small liberal arts university in Arkadelphia, Arkansas- boasting approximately 3600 students, 169 faculty and 189 staff members-offered training on the above-mentioned tasks by issuing unique logins for on-line training as part of their faculty and student orientation.
Learning to act is not enough; one needs life-saving tools. In the case of Henderson State, their online training was in concert with public-access trauma kits in the main hallways of buildings throughout campus. By doing so, their campus is now prepared to react. Moreover, it has been reassuring to parents and students alike.
One model does not, however, work for every campus. While the principles remain the same, implementation and scale must reflect each school’s unique needs. If, for instance, your campus is sprawling and its policy is to shelter in place, how does one treat an injury within a barricaded classroom, when the aid kit is in the hallway or in a different building? As one example, a large research university located in Knoxville, Tennessee, with approximately 27,000 students, 1500 faculty and 10,000 staff members, decided to purchase smaller classroom trauma kits, which helped to satisfy the shelter-in-place treatment question. Public-access kits can also serve as a pre-positioned cache for professional responders, which leads to the final planning point.
For this extension of the trauma chain to be the most effective, it must be integrated with the local response plan and the wider community needs to be informed. Although it is not mandated that your campus lifesaving initiatives be approved by local EMS, it is best if they are informed. Depending on your local EMS system, this initiative could be received warmly or coolly. Even progressive EMS services will need time to assimilate bystanders into their response model, so initial reluctance to the idea should not be perceived as “territory protection.” To bolster the campus initiative, notifying the community is imperative, because campuses are not isolated from non-students and personnel. How do you inform nonstudent game-day attendees that you have implemented a new preparedness policy?
Some universities, for instance, might utilize a game-day PSA, showing it prior to kickoff and at half-time. Others might place a flyer in each seat, with a QR code directing attendees to an instructional video. Both suffer deficiencies. Distracted or last-minute arrival fans may not see the former. The latter is resource intensive and relies on fans having internet access with data connection, which often is not available at games.
Conclusion
There is no one-size-fits-all solution, but the above strategies are a starting point for consideration. If adroitly applied, reacting to mass-casualty producing events, whether natural or man-made, will be more effective. This alleviates some of the pressure in attempting to plan for each event precisely (i.e., earthquake vs active shooter vs trampling due to UAV bomb scares) and instead focuses on saving lives, no matter the cause, which is much more efficient. This requires administrators, students and campus personnel to reimagine the existing system, by expanding the definition and extending the reach of rescue, together making our campuses and communities safer and more resilient.
