The Hartford Consensus IV: A Call for Increased National Resilience

The Hartford Consensus IV: A Call for Increased National Resilience

Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events


Lenworth M. Jacobs, Jr., MD, MPH, FACS
Chairman, Hartford Consensus
Vice-President, Academic Affairs
Hartford Hospital
Board of Regents,
American College of Surgeons (ACS)

Richard Carmona, MD, MPH, FACS
17th U.S. Surgeon General

Frank Butler, MD, FAAO, FUHM
Chairman, Committee on Tactical Combat Casualty Care
Department of Defense Joint Trauma System

Andrew L. Warshaw, MD, FACS, FRCSEd(Hon)
Immediate Past-President,
Massachusetts General Hospital, Boston

David B. Hoyt, MD, FACS
Executive Director,

Margaret Knudson, MD, FACS
Medical Director, Military Health System Strategic Partnership ACS
San Francisco General Hospital and Trauma Center

Jonathan Woodson, MD, FACS
Assistant Secretary of Defense for Health Affairs, Department of Defense

Alexander Eastman, MD, MPH, FACS
Major Cities Police Chiefs Association
chief of trauma,
Parkland Memorial Hospital
University of Texas Southwestern Medical Center

Kathryn Brinsfield, MD, MPH, FACEP
Assistant Secretary, Health Affairs
Chief Medical Officer,
Department of Homeland Security

William Fabbri, MD, FACEP
Director, Emergency Medical Services
Federal Bureau of Investigation

Karyl Burns, PhD
Research scientist, Hartford Hospital

Matthew Levy, DO, MSc, FACEP
Senior medical officer,
Johns Hopkins Center for Law Enforcement Medicine,
Johns Hopkins University

John Holcomb, MD, FACS
Chief, Division of Acute Care Surgery
University of Texas Health Science Center

Ronald Stewart, MD, FACS
Chair, Committee on Trauma
American College of Surgeons
The University of Texas Health Science Center at San Antonio

Peter Pons, MD, FACEP
Associate Medical Director,
Prehospital Trauma Life Support, International
National Association of EMTs

CDR Todd Lewis, MSC, USN
Military Assistant to the Assistant Secretary of Defense for Health Affairs

Ray Mollers
Workforce Health and Medical
Support Division
Office of Health Affairs
Department of Homeland Security

Michael Marquis
General manager,
Johnson & Johnson Consumer Products, Inc.

Stephen Fanning
President and chief executive officer,

Gary Langer
Langer Research Associates, LLC

Editor’s note: The Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events developed the following call to action at its January 7–8 meeting in Dallas, TX. This committee meeting, chaired by American College of Surgeons (ACS) Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, focused on the implementation of strategies to empower bystanders to help victims of mass casualty events. The following is the Hartford Consensus IV, edited to conform with Bulletin style.

Despite advances in the response to active shooter and intentional mass casualty events, a gap remains in our national preparedness and resilience. Drawing from experiences at myriad mass casualty events, the immediate responder (volunteer responder) represents an underutilized resource, yet one capable of dramatically increasing our all-hazards (injuries from all natural and man-made causes) national resilience. The overarching principle of the Hartford Consensus, outlined in previous reports, is that no one should die from uncontrolled bleeding. We have championed the following acronym to summarize what we have determined are appropriate steps to ensure that the maximum number of victims of these tragic events can be saved:


  • Threat suppression
  • Hemorrhage control
  • Rapid Extrication to safety
  • Assessment by medical providers
  • Transport to definitive care

Status update

Continuing in our efforts to improve survival from these events and the more common traumatic injuries that occur daily in the U.S., the Hartford Consensus met for the fourth time in January. The discussion at this meeting was focused on the role of individuals in immediate proximity to victims of injury, whatever the etiology.

Based on foundational work by the U.S. Department of Defense and the Committee on Tactical Combat Casualty Care (CoTCCC), previous Hartford Consensus reports have centered on improvements in the professional responder’s role in providing care to individuals wounded in active shooter and intentional mass casualty events. We submit that harnessing the power of immediate responders is not a new concept, as the public has been used to successfully initiate cardiopulmonary resuscitation (CPR) in the event of an out-of-hospital cardiac arrest. Furthermore, seminal work describing the lifesaving benefit of TCCC training in maximizing casualty survival among our troops wounded in combat in Iraq and Afghanistan has uniformly emphasized the importance of all personnel in dangerous environments, not just medics, being trained and equipped to control external hemorrhage when their unit members are injured (also known as Buddy Care). Because the public, by and large, has the will to help in these situations, this report seeks to outline the next steps necessary to continue to fortify our national resilience for a public response to hemorrhage control.

To date, the professional first responder community, including emergency medical services (EMS), law enforcement officers, fire and rescue personnel, and public safety officials, have widely accepted the Hartford Consensus’ principles. For example, the concept of immediate Threat suppression, which maximizes survival from life-threatening injuries, has been embraced and implemented on a national level.

External Hemorrhage control is the intervention that has proven most effective in the prehospital setting. The victim, an immediate responder, or a professional first responder should use this technique as quickly as possible once the immediate threat of further injury has been mitigated.

The concept of Rapid Extrication of casualties from areas of direct threat (hot zones) to less dangerous but not completely secure areas (warm zones) or secure areas (cold zones) expedites Assessment and Transport to definitive care. Furthermore, casualties no longer are expected to remain untreated for significant periods of time until the area is completely secure.

It is clear that the immediate responder has a role to play in rendering aid between the time of injury and the arrival of the professional first responder. The immediate responder can and should be actively involved in hemorrhage control until care is transferred to the professional first responder. Hemorrhage control kits, much like automatic external defibrillators, should be widely available in public places for immediate responder use. The professional first responder will have medical training and be equipped with bleeding control kits containing hemostatic dressings and tourniquets.

Prehospital and hospital emergency medical services have made substantial improvements in their ability to respond to mass casualty events by taking part in multi-agency drills and training scenarios, which allow hospitals to immediately assemble appropriate teams to receive and manage trauma patients. Sophisticated triage networks must be exercised to evenly distribute the injured so that individual hospitals are not overwhelmed. Hospitals located further from the incident should be seamlessly involved in the preparation and management of significant numbers of severely injured patients.

Current national opinion

The Hartford Consensus III focused on empowering the public to provide care. In intentional mass casualty events, those individuals present at the point of wounding have proven invaluable in responding to the initial hemorrhage control needs of the injured. While traditionally described as “bystanders,” these immediate responders need not be passive observers and can provide effective lifesaving first-line treatment. Examples of the effectiveness of such actions by immediate responders have been observed not only in the aftermath of the Boston Marathon bombings, multiple active shooter events, and the recent attacks in Paris, France, but also in the wake of hurricanes, tornadoes, industrial accidents, and everyday incidents, such as motor vehicle collisions. The Hartford Consensus IV meeting focused on building national resilience by outlining strategies to educate the public to become immediate responders.

When the Hartford Consensus called for the public to assume the role of immediate responder, it was uncertain how capable the average person would be at carrying out this charge. To determine the public’s ability and willingness to serve as immediate responders, a nationally representative survey was conducted to assess public opinion regarding the following:

  • Current level of training in first aid, including bleeding control
  • Willingness to render first aid for severe bleeding
  • Potential impediments to willingness to act
  • Support for changes in first responder policy to allow police and emergency medical services to render aid more quickly
  • Willingness to be trained in bleeding control
  • Support for the distribution of bleeding control kits in public places

The survey was conducted by a professional survey firm using established and validated sampling techniques. The questionnaire was administered via landline and cellular telephone interviews to a random sample of 1,051 adults in all 50 states on November 6–11, 2015. The survey findings are as follows:*

  • There is broad support for initiatives to train and equip first responders and for the public to render first aid for bleeding control in mass casualty incidents.
  • Large majorities of able-bodied Americans report that they are willing to offer such aid, especially if training and supplies are made available.
  • Training, including instruction in bleeding control, is strongly associated with the following:
    • Greater willingness to give aid
    • Fewer concerns about reasons not to give aid
    • Interest in receiving further, updated training
  • Concerns to be addressed include:
    • Getting injured during an active shooter event
    • Causing greater pain or injury
    • Bearing responsibility for bad outcomes
    • Contracting disease
  • Support for policies and procedures to make hemorrhage control training and equipment widely available is overwhelming. Specific examples include the following:
    • Near unanimous support for deployment of kits into public spaces (93 percent)
    • Strong support for training police to provide bleeding control as a part of their duties (91 percent)
    • Substantial support for faster access to active shooter and intentional mass casualty events (65 percent)

Current state of readiness and national resilience

The Hartford Consensus intends to create a vision for best-practice hemorrhage control for increasing survival after all-hazards injuries including active shooter and intentional mass casualty events. The goal is to inform and inspire decision makers around the country to effect this vision by establishing appropriate metrics, applying these metrics, and using this information to motivate decision makers.

Metrics for readiness

Metrics to assess readiness include course completion records for TCCC-based medical training. Examples of these training programs include the following:

  • Tactical Emergency Casualty Care
  • Bleeding Control for the Injured (B-Con)
    • Available through the ACS and the National Association of Emergency Medical Technicians (NAEMT)
  • Law Enforcement and First Response Tactical Casualty Care
    • Available through the ACS and NAEMT
  • Specialized Tactics for Operational Rescue and Medicine (STORM)
    • Available through Georgia Regents University, Augusta
  • Advanced Law Enforcement Rapid Response Training (ALERRT)
    • Available through Texas State University, San Marcos

Metrics for resilience

Metrics to assess resilience include the following:

  • Registry data for all wounded law enforcement officers and all casualties from active shooter and intentional mass casualty events
  • Case series reports describing injuries, treatments, and outcomes for all casualties, including reports on wounded law enforcement officers and all victims wounded in mass casualty events
  • Preventable death analyses for law enforcement officers killed in the line of duty and victims of active shooter and intentional mass casualty events

Many trauma deaths result from injuries that are intrinsically non-survivable, whereas others occur from injuries that were potentially survivable had optimal care been rendered. Obtaining a clear understanding of the proximate cause of all law enforcement officer deaths that result from trauma as well as all fatalities in active shooter or intentional mass casualty events will identify opportunities to improve care for officers wounded in the line of duty.

Enhancing citizen resilience

All potential responders to victims of a trauma event should be able to recognize the signs that indicate that bleeding is life-threatening, including the following:

  • Pulsatile or steady bleeding is coming from the wound.
  • Blood is pooling on the ground.
  • The overlying clothes are soaked in blood.
  • Bandages or makeshift bandages used to cover the wound are ineffective and steadily become soaked with blood.
  • An arm or leg is traumatically amputated.
  • The patient was bleeding and is now in shock (unconscious, confused, pale).

Immediate responders should attempt to stop or slow massive hemorrhaging initially by using their hands (gloved whenever possible) to initiate primary compression. This compression should be applied directly or just proximal to the site of hemorrhage and with the use of sustained, direct pressure. Performing this task may be difficult for someone without any first aid training, but it will significantly enhance the survival of the actively hemorrhaging injured victim.

Once the professional responder arrives at the scene, care should be transferred to this individual because he or she will be equipped with and trained in the use of more sophisticated hemorrhage control methods, such as hemostatic dressings and tourniquets.

In a manner similar to the presentation of CPR training, hemorrhage control training programs should be available to the public and offered by employers, civic and religious groups, schools, and the health care community at large.

As an increasing number of public and private locations implement plans to preplace hemorrhage control equipment or co-locate this equipment with automatic external defibrillators, clear messaging and signage should be posted so people can easily and rapidly access this equipment.

Training considerations

The primary components of enhancing citizen resilience must focus on training considerations including:

  • Determination of terminal learning objectives for bleeding control courses
  • Establishment of standard curriculum for bleeding control
    • Education of the public in bleeding control using multiple teaching methods, including:
      • Didactic education programs
      • Online modules
      • Smartphone applications
  • Tiered bleeding control education for the following:
    • Immediate responders with no equipment other than their hands
    • Immediate responders with bleeding control kits (hemostatic dressings and tourniquets)
    • Professional first responders with bleeding control kits
  • Creation of public awareness through “Bleeding Safe” communities similar to the “Heart Safe” communities that were designed to promote survival from sudden out-of-hospital cardiac arrest

Specifically, the Hartford Consensus recommends developing a curriculum for the immediate responder. The curriculum would feature a tiered approach that uses the hands of the immediate responder followed by hemostatic dressings and tourniquets when these lifesaving interventions become available. This curriculum should also outline the specific anatomic locations for effective compression of large vessels to stop massive life-threatening hemorrhage. In most cases, control of external hemorrhage can be accomplished by applying direct pressure on the bleeding vessel—even major vessels such as the carotid or femoral arteries. However, victims with life-threatening hemorrhage often bleed to death when direct pressure is the only treatment available to achieve hemostasis. For direct pressure to be effective, it must be applied with both hands using significant sustained and direct force. The patient should be stationary on a surface firm enough to provide effective counter pressure. Frequently, direct pressure cannot be effectively applied while the patient is being moved. Discontinuation of pressure to check the status of the bleeding site during transport must be avoided to ensure bleeding control.

In addition, immediate responders should be taught how to apply hemostatic dressings. For life-threatening hemorrhage from an extremity, immediate responders should be taught to apply a tourniquet. Application of direct pressure, a hemostatic dressing, or a tourniquet must be maintained without interruption until the patient reaches a location where the damaged vessel can be repaired surgically. Wounds with minimal external bleeding, suggesting no major blood vessels have been injured, may be dressed with gauze or a hemostatic dressing until the patient arrives at definitive care.

The curriculum also should include techniques to open and maintain an airway, especially in cases of massive oral hemorrhage. If the victim is conscious, this technique is usually best accomplished by having the victim sit up and lean forward to allow gravity or coughing to clear the blood from the upper airway.

The successful completion of this curriculum should result in the receipt of merit-type badges for scouts and explorer posts and certification in bleeding control.

Dissemination and implementation of a national resilience plan

A critical first step to achieving national resilience is training and equipping immediate responders and professional first responders to control external hemorrhage, along with the strategic positioning of bleeding control kits in locations where active shooter or intentional mass casualty incidents have been observed to occur.

The next step is a campaign to inspire the public to obtain bleeding control training and sustain that training. This should be actively promoted through the following:

  • Emotional appeals such as, “When you stop the bleed, you save a life”
  • Simple, consistent messaging
  • Messages that can be delivered across diverse platforms

To achieve sustainable changes in behavior aimed at immediate control of life-threatening external hemorrhage, the implementation plan should take into account the following considerations:

  • The content of the plan should include:
    • The immediate responder concept
    • An all-hazards approach
    • A standard curriculum
    • Funding for implementation and sustainability
  • The audience for bleeding control courses are:
    • Immediate first responders (public)
    • Professional first responders
    • Law enforcement officers
    • Firefighters
    • EMS personnel
  • Potential content distribution networks include:
    • The Medical Response Corps
    • The Red Cross
    • The National Disaster Medical System
    • The National Guard
    • Boy and Girl Scouts
    • Professional medical societies and organizations
    • Federal, regional, and local health departments
    • Emergency service agencies
  • Strategies to promote these concepts include:
    • Work with other groups concerned with safety
    • Gather stakeholder input and explain the value of prospective buy-in by all
    • Develop a strategic communications plan that drives demand and builds community acceptance
    • Deliver a message of health literacy and cultural competence that informs but does not inflame
    • Explain the political barriers and facilitators of implementation
    • Establish a liaison with state legal authorities to guarantee the validity of Good Samaritan protections as applied to immediate responders and first responders to encourage their participation in bleeding control

Stop the BleedSummary

National implementation of the Hartford Consensus is a meticulous and incremental process. It consists of many elements that require collaboration and strategic leadership to achieve an efficient, effective, knowledgeable, resilient, and prepared citizenry.

We strongly believe the public can and should act as immediate responders to stop bleeding from all hazards, including active shooter and intentional mass casualty events. The ACS has a long history of setting standards and educating responders through its Committee on Trauma and its programs. The ACS is therefore well-positioned to use its national and international networks to implement bleeding control education to improve survival and enhance resilience.

Author’s note:

All text and images in this article are copyright of the Hartford Consensus. For permission to reprint or for more information, contact Dr. Jacobs at

The “Stop the Bleed” poster show above was developed for public education purposes and will be available for wide distribution. To obtain copies, contact Dr. Jacobs.


*Note: A full report on the survey will be published in an upcoming issue of the Journal of the American College of Surgeons.

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