Training Curriculum on Active Shooter Attacks, Civilian Response, Casualty Care – Case Study

In a world where active shooter situations are on the rise and everybody from bank employees to elementary school students are starting to receive at least some kind of training or drills related to active shooter events and mass shooting situations, the need for comprehensive civilian response and casualty care training has never been more acute. Alongside private employers, many states and local municipalities are now making these trainings mandatory.

What an individual does in a crisis is extremely important − not only for their own survival but for the lives of others as well. We recently participated in the development of a training program on how civilians should act in active shooter situations, how they can respond to an unfolding crisis, what steps they can take to mitigate losses and assist others in the absence of medical personnel. Trainings like this one can teach the general public to make informed decisions under extreme stress. As each person improves their own preparedness, the community becomes stronger together.

This article will provide some examples of the content and exercises that can be included in a curriculum focused on active shooter situations, civilian preparedness and response, as well as critical care in the aftermath of a life-threatening event. Unless stated otherwise and excluding the information that exists in the public domain, the materials described here are property of the Virginia Department of Criminal Justice Services.

What Locations are Vulnerable to an Attack?

From 2000 to 2019, there were 347 active attacker events in the US. An active attack is included in these statistics if the attacker intended to commit mass murder, regardless of the number of deaths or injuries that resulted. Numerous active attacks have taken place in the U.S. in the recent few years. Several of them are described below.

King Soopers Supermarket, Boulder, CO (2021)

On March 22, 2021, a mass shooting occurred at a King Soopers supermarket in Boulder, Colorado, United States. Ten people were killed, including a local on-duty police officer. The alleged shooter, 21-year-old male, was arrested after being shot in the right leg. He was temporarily hospitalized before being moved to the county jail. After the gunman was taken into custody, police searched through the store and evacuated people who had remained inside. A shelter-in-place order was issued in the area at 4:18 p.m. and lifted at 6:40 p.m. Up to fifteen agencies responded to the shooting, including the Jefferson County SWAT, the FBI, the ATF and local police departments. A fire department ladder truck was used to get a SWAT team onto the roof. At least three medical helicopters were summoned to a staging area at nearby Fairview High School.

More information about the 2021 Boulder shooting.

Atlanta, GA (2021)

On March 16, 2021, a series of mass shootings occurred at three spas or massage parlors in the metropolitan area of Atlanta, Georgia, United States. Eight people were killed, six of whom were Asian women, and one other person was wounded. A suspect, 21-year-old male, was taken into custody later that day. According to police, the suspect said he was motivated by a sexual addiction that was at odds with his religious beliefs. He had previously spent time in an evangelical treatment clinic for sex addiction. He was charged with four counts of murder in Atlanta, and four counts of murder and one count of aggravated assault in Cherokee County.

More information about the 2021 Atlanta spa shootings.

Dayton, OH (2019)

A 24-year-old band singer entered the Ned Peppers bar in August 2019 in Dayton with a sibling and friend. He left at midnight and returned an hour later with a semi-automatic pistol. He fired 41 rounds into the crowd in less than 30 seconds. Local police arrived within 20 seconds, killing the shooter. The entire attack lasted 32 seconds. Nine people lost their lives that night and 17 others were injured.

More information about the 2019 Dayton shooting.

Virginia Beach, VA (2019)

A 40-year-old disgruntled city employee opened fire at a municipal building in May 2019 in Virginia Beach. Over the course of 28 minutes, the attacker shot city employees outside the building and on all three interior floors. The building was under renovation at the time, and several employees thought the sound they heard was from a nail gun or other construction tool. Police response was slowed due to electronic security doors that required a badge to open. The shooter was killed by responding officers once they gained access to the building. Twelve people were killed and four others were wounded.

More information about the 2019 Virginia Beach shooting.

Las Vegas (2017)

A 64-year-old former businessman opened fire into an estimated 22,000 fans at the Route 91 Harvest music festival in October of 2017. In just over ten minutes, he fired more than 1,000 rounds of ammunition from a 32nd floor window in the Mandalay Bay hotel. Many in the crowd initially mistook the gunfire for fireworks. When they realized what they were hearing, they began to flee but were hindered by a security fence. An hour later the shooter was found dead in his room from a self-inflicted gunshot wound. Sixty people lost their lives, 411 more were wounded in the shooting, and another 456 were injured during the panic. To date, this is the deadliest mass shooting committed by a single individual in the U.S.

More information about the 2017 Las Vegas shooting.

Alexandria, VA (2017)

A 66-year-old unemployed business owner fired on 24 congressmen who had gathered at a park in Alexandria in June 2017 to practice for the Congressional Charity Baseball game. The shooter exchanged fire with three Capitol Police who were there to protect the House Majority Whip. Two Alexandria police officers responded to the 911 call and arrived three minutes later, joining the gunfight. The attacker was shot and later died of his injuries. Five people were injured. Several witnesses said their lives were saved by the presence of the Capitol police officers, who pinned down the shooter and limited his ability to continue firing.

More information about the Congressional baseball shooting.

Charlottesville, VA (2017)

A 20-year-old part-time security guard deliberately drove his car into a crowd of people who were peacefully protesting a white supremacist rally in August 2017 in downtown Charlottesville. It was estimated that the car was traveling between 23 and 28 miles per hour when it struck the crowd. A few seconds after the impact, some in the crowd began hitting the car with various objects, resulting in the driver backing up and speeding off. A deputy arrested the driver about a mile from the attack. He is currently serving two life sentences without parole. One person died and 19 others were injured.

More information about the Charlottesville car attack.

U.C. Santa Barbara (2014)

A 22-year-old college dropout went on a killing spree near the UCSB campus in May of 2014, using firearms, knives, and his vehicle as weapons. The spree began with the stabbing of three men in the attacker’s apartment. Three hours later he shot three women outside a sorority and a student inside a nearby deli. He continued to drove through town, shooting pedestrians from his window or striking them with his car. He exchanged gunfire with police twice. The spree ended when the attacker’s car crashed into a parked vehicle. He was found dead inside with a self-inflicted gunshot wound. Six people were killed and fourteen others were injured.

More information about the 2014 Isla Vista killings.

Looking at the events described above, it becomes clear that attacks can take place anywhere, at any time. The deaths and injuries from just the events we listed is staggering. As much as it hurts to discuss these events, it’s important to learn from past attacks in order to prepare for future ones.

Here’s another illustration of the distribution of attacks across the US.

Source: FBI, Active Shooter Incidents, 2000-2018. https://www.fbi.gov/file-repository/active-shooter-incidents-2000-2018-100119.pdf/view

Characteristics of Mass Murder Events

Numerous studies have been done to identify common characteristics of mass murder events. Here are some common characteristics:

• Most attacks are carried out using firearms.
• Most attackers act alone.
• Attacks happen in a variety of public places.
• A substantial number of attacks happen indoors.
• Attackers don’t always have a connection to their targeted locations.
• There are often warning signs.
• Most shooters reach an identifiable crisis, or tipping point, in the weeks or months before the shooting.
• Attackers study other attackers to find validation and motive.
• Mass attacks usually involve a lot of planning and preparation.
• Most firearms used in mass attacks are obtained legally.
• Attackers frequently have a history of antisocial, sometimes violent, conduct.
• There is usually no pattern or method to an attacker’s selection of victims.

Civilian Response and Casualty Care Training for the Community

The greatest hurdle a community faces is the lack of knowledge and training when an active attack occurs. Emergencies happen wherever people work, play, live, or visit. Being prepared means maintaining a state of readiness – specifically, developing emergency plans and completing preparedness training. Here are a few examples of how some state and local agencies deliver training to their communities.

Virginia Active Attack Program

The website for the Virginia Department of Criminal Justice Services describes the state’s “Whole Community Approach” to its active attack training program. The program’s goal is to enable citizens and first responders to work together to “stop the killing and stop the dying.” Available training courses are offered upon request to community organizations, schools and institutions of higher education, law enforcement agencies and Fire/EMS.

Learn more about Virginia Active Attack Program.

Franklin County, Ohio Civilian Response Program

The website for the Franklin County Sheriff’s Office in Ohio has a link to their CRASE (Civilian Response to Active Shooter Events) training program. Their site has a description of the standard and advanced CRASE courses and the time needed to complete them. The page names a deputy to contact for more information and includes a form that an individual or group can fill out to request a class.

Learn more about Franklin County, Ohio Civilian Response Program.

Maryland State Police Civilian Training Program

The Maryland State Police developed a program to deliver the Civilian Response and Casualty Care program using two State Police Troopers per county. This approach established an outstanding connection between the assigned Troopers and citizens. The Maryland State Police core training team members acted in a support role for other state and local personnel in high-profile areas of the state. This type of forward-thinking has resulted in the training of more than 10,000 citizens in Maryland.

Learn more about Maryland State Police Civilian Training Program.

Building a Public Civilian Response Program

It’s important to remember the following when building your program:

• Make it community-specific. Conduct research on violent incidents in the community so the content is relevant.
• Make it audience-specific. Every audience has a unique dynamic. Consider specific needs for audiences in commercial, religious, and business locations.
• Keep the material updated. Active attacks are on the rise, which brings about a constant change in information. Revisit your materials to update statistics and strategies.

You’ll develop trust by understanding the culture, context, and history of the communities you serve before an emergency occurs.

The Human Reaction Under Stress

Under stress, the human mind will react according to how it has been prepared for the situation. Once engaged in a life-or-death struggle, the mind searches for a response based on similar situations it has encountered. If a person fails to train, the mind will search an empty database.

The Station Nightclub fire is an example of why it’s important to know your surroundings. It also shows the effects that extreme stress can have on your decision-making skills.

https://www.youtube.com/watch?v=bknYdprA9ug

The band Great White was playing a show at a nightclub called The Station in West Warwick, Rhode Island in February 2003. An estimated 450 people were in attendance that night. The majority of them were crowded into an area surrounding the band. A small pyrotechnics display that was part of the show ignited flammable acoustic foam in the walls and ceilings surrounding the stage. Black smoke engulfed the club in 5 ½ minutes.

When patrons figured out that the building was on fire, they moved toward the front entrance where they had entered the club. This exit quickly became clogged, and panic ensued. More than half of the people died near the main entrance although there were three other exits in the nightclub. Lack of familiarity with their surroundings and the effects of extreme stress severely limited the ability of patrons to make good decisions that might have saved their lives.

In the context of a violent encounter, our brain has a series of alarm systems that prepare us to deal with the threat.

Disaster Response Psychology

In Amanda Ripley’s 2008 book on survivors, she identified three phases of disaster response: denial, deliberation, and decisive moment.

Denial

At the beginning of an attack event, it’s more common to deny that a disaster is happening than to panic and stampede. This is due to two psychological concepts:

Normalcy Bias: a condition in which our brains tend to interpret information as if it’s part of our everyday experience. And,

Social Proof: the tendency to look to other people for cues about how to behave in new or uncertain situations.

When confronted with a live or die situation, your mind must work quickly to identify and react to the event that is taking place. All too often, those who are first to identify a threat fail to act. Denial costs precious seconds, slowing law enforcement response and impacting the survivability of victims.

Deliberation

The deliberation phase begins once denial is overcome and a person realizes the situation is threatening. At this point in the attack, you must decide what to do. As stress rises, the pre-programmed actions in the primitive brain take over. For many people, these actions are limited to fight, flight, or freeze. Knowing that your stress response can overwhelm your rational brain is critical during an active attack. It’s possible to think through potential scenarios when you’re not under stress and create action scripts, a process known as mental scripting. Professionals like Olympic skiers may mentally run the course to get their mind, body, and game plan ready before an event. The same is true for us – we can mentally ‘run the course’ before an active attack and be ready if it happens.

Be deliberate. Have your plan ready. Depending on where you are when an event occurs, your time and distance to safety may be short. Hesitation is not to your advantage.

Decisive Moment

Once the deliberation phase is over, you need to act quickly and decisively. Three to five minutes is the average time it takes for law enforcement to arrive after a 911 call. An officer’s first priority is to move in and confront the attacker. Once the threat has been isolated, distracted, or neutralized, officers will begin providing medical aid to the wounded. Your role is to respond correctly to police, following all commands until the situation is controlled.

Community, business owners, security staff, and citizens can work together to keep venues safe. If an attacker is identified and intercepted before he can cause harm, the citizens in that venue may not need to react. A workable and effective security plan can be enacted during the three to five minutes it takes for first responders to arrive on the scene.

Active Shooter Methodology

Shooters frequently pre-plan their attack, including how to penetrate a building. In many incidents, poor perimeter or site security made pre-planning easier for the attacker. According to FBI research, shooters most frequently enter a facility using one of these three methods:

“Push” type assault – attacker enters through a door carrying a weapon and begins firing.

Hidden weapons – attacker smuggles in a weapon during a visit to the attack location beforehand, and then uses the weapon later in the assault.

Unlocked or non-public access – attacker enters a location using an unlocked exit, loading dock, freight elevator, or parking garage.

Proper organization, technology, and training can prevent some attacks. Here are some critical strategies to ensure safe venues:

• Use and monitor security cameras.
• Secure non-public access doors with locks and electronic devices.
• Electronically disable security badges immediately after an employee resignation.
• Monitor and report warning signs and unusual or suspicious behavior.
• Partner with law enforcement and community agencies to develop and practice an active shooter prevention plan.

RACE – React, Activate, Care, and Evacuate

The acronym RACE stands for React, Activate, Care, and Evacuate. Acronyms are useful in remembering critical steps to take during an emergency situation.

R – React. A response to an active attack event begins with your reaction. Depending on the situation and your proximity to the threat, you will make a decision to run, hide, or fight – or all three.

A – Activate. After you react to save your life, your next step is to call 911 and calmly explain what’s happening.

C – CARE. Once in a position of relative safety, you can begin the CARE process. CARE is an acronym for Control the bleed, open the Airway, check Respirations, and counteract Exposure. These are actions you can take to assist the injured, including yourself.

E – Evacuate. Assess your situation and determine the best way to evacuate.

R – React

Here are examples of actions you might take in the “React” phase of the RACE model:

• Avoid, or separate, from your attacker.
• Deny entry to your attacker in whatever location you have taken refuge.
• Defend yourself by fighting for your life.

These are choices you will make as you cycle through denial, deliberation, and the decisive moment when you take action. Remember, your stress levels will be increasing at the same time, threatening to overwhelm your reasoning.

Once an attack begins, things happen quickly and it may be too late at that point to develop a strategy. “Avoid” begins with mental scripting – thinking through potential scenarios when you’re not under attack and creating action scripts you can follow if an attack occurs. Frequently, your best chance for survival is to avoid an attacker altogether by fleeing the scene to a place of safety.

Avoid/Run

Avoid/run tips:

• Know your exits. If you’re inside a building, don’t limit your thinking to doors only. Consider secondary exits, like windows, fire escapes, even breaking through drywall.
• Know your surroundings. If you’re outside, shield yourself from bullets or explosive materials using hard cover, such as concrete or other solid structures. Avoid running toward dead-ends and barriers that slow your path to safety. In the Las Vegas music festival shooting, a security fence hindered concertgoers from fleeing, increasing the number of deaths and injuries.
• Leave ASAP. Put time, distance, and barriers between you and the attacker as quickly as possible.
• Take advantage of distractions. If you’re in the attacker’s sights and can’t run immediately, watch for moments when the attacker is distracted. In the Sandy Hook school shooting, some students survived because they ran out of the classroom while the shooter was reloading.
• Ensure your safety first, then call 9-1-1.
• Anticipate and manage your stress reaction. If you don’t have a plan, your natural tendency will be to freeze. Use strategies you learned in the Preparedness module to manage your stress, such as tapping into your willpower, using combat breathing, and shifting the emotion from fear to anger.

Deny Entry

If you find that you cannot get away from an attack by exiting the building, your next option may be to barricade yourself in a room.

Here are a few very important steps you should take:

• Know your surroundings. Look around your location, particularly in places you are unfamiliar with. Rooms that do not have a lock are more difficult to secure.
• Buy yourself some time. A locked door is a temporary obstacle to an attacker who is looking to kill as many people as he can before police arrive. Make yourself a “hard” target during an active attack.
• Turn off the lights and silence your cell phone. Doing this makes it less likely you’ll be discovered. A dark room is also a disadvantage to an attacker whose eyes may be accustomed to a lit environment.
• Barricade the room. Inward opening doors are much easier to barricade than outward opening ones. Use furniture or other objects to help secure your location. Desks, filing cabinets, and chairs make good barricades. A belt, power cord, or strap from a shoulder bag can be used to hold a door closed.
• Look for other exits from the locked room. Check out windows and secondary doors, but keep in mind that you may need to barricade these also if you cannot use them to escape.
• Ensure your safety first, then call 9-1-1.

Playing dead and “hide and hope” are not effective survival strategies. Although victims who play dead sometimes survive, there are documented cases where attackers returned to people who were already down and shot them again. In the same manner, if you decide to hide and hope, you’re trapped without a plan if the attacker finds you. In both these cases, a locked, barricaded room is a better option for survival.

Lie very low on the floor or move behind heavy structures to shield yourself from gunfire through the door. If an attacker gains access despite a lock, your barricade will be an obstacle he has to overcome, allowing precious time for you to get ready to fight. Move 90 degrees to the side of the door, staying close enough to defend but still out of sight.

Be aware of the danger of windows in or near a locked door. The attacker at Sandy Hook shot out the window next to the locked front school doors and walked through the window. The shooter at a high school in Minnesota shot out a window, reached in, and unlocked a classroom door where students were hidden. Remember to barricade windows at the same time you barricade doors.

Defend

It’s important to remember that you have the legal right to defend yourself! The question, though, is do you have the ability to defend yourself? If Avoid/Run and Deny Entry have failed, you may have to defend yourself if you want to survive.

• Position yourself for advantage. Hiding will only delay the inevitable. Instead, position yourself where you have the advantage of surprise – such as near a door and out of sight.
• Swarm the attacker. In most situations, the attacker is outnumbered. If you can, get others to help you fight when the attacker is at a disadvantage
• Fight dirty. Use improvised weapons, gouge eyes, bite, kick, pull hair – whatever it takes to injure your attacker before they can injure you.
• Fight on. Mentally prepare yourself to be shot or injured. If you’re not incapacitated, keep fighting.

Knowing that your stress response can overwhelm your rational brain is critical during an active attack. Here are a few tips to manage the stress response.

Turn fear into anger.

Get mad and go on offense. Your heart rate will increase, sending blood to the large muscles. These physical changes will make you faster, stronger, and ready to fight.

Use self-talk.

Tell yourself you’re going to win at all costs. Refuse to give up no matter how overwhelming the odds might be.

Breathe.

Breathe in through the nose for four counts, hold your breath for four counts, breathe out through the mouth for four counts, and then hold your breath for four more counts. Repeat this cycle four times. This is called combat breathing, which can help you focus and gain control. Use this technique if you feel like you’re about to be incapacitated by fear.

Source: Maimonides Emergency Medicine. https://www.maimonidesem.org/blog/box-breathing-technique-nbspnbsp

Situational Awareness in Active Shooter Events

The importance of being situationally aware cannot be overstated. Immediate responders frequently tell police that “the attacker came out of nowhere.” We know that’s not true – the attacker made his approach when no one was paying attention. If you’re caught off guard, you won’t be in the right mindset to respond. The Virginia Tech shooting is an example of Avoid Deny and Defend strategies used by different people and the results of those actions. Twenty-seven students and five faculty died that day. What we can learn from this tragedy may save lives in the future. See the diagram below showing the Norris Hall floor plan illustrating the path of the shooter and the reactions of the students and staff.

Room 206: The attack began in room 206. The attacker walked in and started firing. No one had time to take action before the attack. He left and returned to this classroom later where he continued to shoot victims multiple times. In this room, 92% of the people were shot and 77% were killed. Playing dead was the survival strategy used by victims in this room.

Room 207: This was the second room attacked. The shooter entered the room, killing the teacher and several students as he walked down the aisles. He left and returned to this classroom later, but the students used their bodies to barricade the door. The shooter was able to open it about an inch and fired several shots into the doorknob, but did not hit anyone. In this room, 85% of the people were shot and 38% were killed. Although this room initially did not react, their later successful attempt to deny entry saved lives.

Room 211: The professor in this room heard the shots and told students to huddle in the back of the room and call 9-1-1. Students attempted to block the door with a desk but weren’t quick enough and the shooter gained entry. He shot the teacher and walked down the aisles, shooting students. The attacker returned later and continued to shoot students. In this room, 100% of the people were shot and 67% were killed. As in room 206, playing dead was the primary survival strategy used by students in this room.

Room 204: Professor Liviu Librescu (a holocaust survivor) held the classroom door shut when the attacker tried to enter, instructing his students to escape through the windows. The attacker shot Librescu through the door and pushed his way in, killing the professor. Most of the students made it out through the windows and survived. In this room, 36% of the people were shot and 14% were killed. The attempt to deny entry ultimately failed but was successful long enough to allow two-thirds of the class to escape.

Room 205: Students in room 205 had time to react. They pushed a large teacher’s desk against the door and laid low to hold it in place. The attacker fired through the door and pushed against it but never entered the classroom. This was a successful attempt to deny entry. No one was shot in room 205.

A – Activate First Responders

React is the first step in the RACE acronym, before Activate. Focus first on the threat, using ADD: avoid, deny entry, or defend. Once you’re in a safe place, call 9-1-1 and report as much information as you can to police dispatchers.

Law enforcement’s priority is to locate and stop the threat. All other actions are secondary. Evacuating uninjured people will be one of the last things they do.

Your focus as an immediate responder now shifts to listening and responding to law enforcement commands. Remember, they don’t know you and will treat you as an “unknown” until they’re sure you aren’t a threat. The attack scene is just as chaotic for officers as it is for you.

Citizen Intervention

Citizens often do not get involved in matters that don’t concern them. The pie chart below shows the reasons why citizens don’t get involved. The reverse, however, is also true: if you take the initiative and provide medical attention, others are likely to follow your lead.

Good Samaritan laws were created so that bystanders will assist when people are injured, ill, or in peril. They mitigate the fear of being sued or prosecuted if injury or wrongful death occurs because of someone’s assistance.  

Caring for the injured is part of the RACE strategy. BATH is an acronym that defines the treatment protocol for an injured person. Acronyms like BATH can help you remember critical steps to take during an emergency situation.

B – Bleeding: Controlling blood loss is a critical first step in saving a person’s life. This can be done by manually applying pressure to a ruptured vessel or using a tourniquet. Depending on where a person is injured and how severe or deep the injury is, death can occur within two minutes. Average law enforcement response time is three minutes. Average EMS response time is six to nine minutes. This means you may be the only one on scene who can administer life-saving medical care.

A – Airway: An injured person cannot breathe if their airway is obstructed. The tongue is the most common obstruction. Placing a person in the recovery position can often keep the airway open. Stopping blood loss may be the first step in the process but opening the airway is often the second.

T – Tension Pneumothorax: If a person suffers a chest wound anywhere between the neck and the abdomen there’s a strong possibility that air will enter the hole and cause internal complications. “Pneumothorax” is air in the chest cavity. As air increases, the pressure in the space increases and, the lung begins to collapse. Covering the hole in the chest cavity is critical in preventing respiratory failure.

H – Hypothermia: Loss of body heat is a serious concern while you’re tending to blood loss or respiration issues. Hypothermia can trigger negative cascading effects that interfere with stabilizing an injured person. You will need to know and understand warming techniques in order to counteract exposure.

Twenty percent of trauma deaths are considered preventable. The main cause in these cases is uncontrolled bleeding. Active attackers use weapons that result in severe hemorrhaging, requiring quick action on the part of immediate responders to save the lives of injured persons.

How Shock Affects the Body

Shock is the collapse of circulatory function in the body, caused by severe injury or blood loss. It’s a natural reaction when the body’s demand for blood is greater than its current supply. As the body loses blood, it loses temperature, which means the blood that is left is no longer able to form blood clots. A person in shock will appear pale and sweaty and his pulse will be weak. If unchecked, death can result.

A clot is a plug that fills a hole. An initial weak plug can form in as little as five minutes. To form a strong plug requires at least thirty minutes of wound pressure. After forty-five minutes, the plug will be at maximum strength. Rough handling may disrupt the clot, so immobilize an injured limb with a splint before moving the body.

Tourniquets

Tourniquets are fast and highly effective devices that control major bleeding from arms and legs. They work by applying pressure around an injured limb to stem the flow of blood. The girl in the video used a commercial tourniquet, but makeshift items can be used in an emergency. Tourniquets require a strap, a windlass, and a lock. Remember that you may be applying a tourniquet to an injury of your own rather than another person’s. Both adults and children can learn to apply a tourniquet.

Here are the four steps of tourniquet application:

1. Place the tourniquet around the injured limb, above the wound and as high as possible.
2. Pull the strap really tight. The tighter you pull the strap now, the less the windlass will need to be turned later.
3. Twist the windlass until the bleeding stops. A properly applied tourniquet really hurts, but if you loosen it because the person is in pain the bleeding can restart.
4. Lock the windlass in place. If the windlass is not locked, it can come loose when the person moves or is transported.

This technique requires practice, including drills on applying a tourniquet with one hand or with two. Choose anything you have at hand when you need a tourniquet strap in an emergency: a strip of cloth, a bike tube, a bandana or scarf, a backpack strap, an extension cord, or even a bra. If the item you choose is at least 1 ½ inches wide, it’s less likely to cause nerve damage. For a windless, use a carabiner, a stick, a handle from a lift jack, a pocket knife, or a pair of scissors.

Wound Packing

Wound packing is a way to control severe bleeding in areas of the body where a tourniquet cannot be applied – such as the chest and torso or around joints. Never pack a chest or abdominal wound as it can mash uninjured vital organs.

These are wound packing steps:

1. Find the source of the bleeding.

1. Aggressively apply pressure either directly onto the wound or just above it.
2. Fill the space with packing dressing, down to the bone if possible. Regular gauze will require about five minutes of direct pressure to begin clotting. Hemostatic gauze is faster and better, if available. In emergencies, a torn t-shirt or rag can substitute for gauze. Antibiotics can be administered later to manage complications from non-sterile materials.
3. Apply direct pressure to the wound so clots have time to form, and then bandage the wound.

Airway

Knowing the basics of lung function when an active attack occurs can buy you much-needed time until EMS arrives. The tongue is the most common airway obstruction. Use the head tilt, chin lift method, then place the person in the recovery position to keep the airway open.

Check for Open Chest Wounds

Here’s the proper way to check for open chest wounds:

• Remove any clothing from the chest area.
• Rake your hand over the chest skin, keeping your fingers together to avoid missing any injuries.
• Check damaged clothing and bloody areas which might indicate chest wounds.
• Roll the person and check for exit wounds. Remember, if there’s a hole going in, there’s most likely a hole coming out. Both will need to be located and sealed.

You’ll need to look for and seal entrance and exit wounds from the person’s neck to lower abdomen. Remember not to wound pack this area of the body, as doing so may injure internal organs. Check the armpits carefully since wounds in this area are often missed. Be alert for signs of a collapsed lung, also called a tension pneumothorax, which means air is building up between the chest wall and lung. Symptoms include severe shortness of breath, bulging veins on the neck, and bubbling blood from the chest wound.

Commercially available chest seals can be used to close an open wound. If these are not available, use anything that keeps air from passing through – such as a plastic bag, piece of cloth, or your hand. Make sure the material you use extends at least two inches beyond the edge of the wound. Tape the patch on three sides, leaving one side open to let the air out but keep air from coming in. Monitor the person until help arrives.

Hypothermia

Exposure and hypothermia can worsen the effects of a person’s injuries. Trauma patients cannot maintain their own body heat when they lose blood, and hypothermia alters their ability to clot. In active attacks where hemorrhaging is common, this becomes a deadly cycle. You’ll need to know the symptoms of hypothermia and take action until EMS arrives. Adults and children share some common symptoms of hypothermia. Older adults with medical risk factors and young children are at greater risk of hypothermia.

Symptoms of hypothermia in adults:

• Shivering
• Exhaustion
• Confusion
• Fumbling hands
• Memory loss
• Slurred speech
• Drowsiness

Symptoms of hypothermia in children:

• Cold, bright red skin
• Low energy
• Drowsiness

Active warming techniques help generate heat in injured persons. Passive warming techniques help trap or retain existing body heat. If a person has lost a lot of blood, active warming techniques need to be used in conjunction with passive ones. Follow these guidelines:

• Remove wet clothing and replace it with dry. Wet clothing and wet skin act as a radiator, pulling heat away from the body and accelerating hypothermia.
• Move the person off the ground and into the sun. The sun acts as an active warming agent. The ground draws heat away from the body, which is the opposite of what you want.
• Cover the person with a blanket or coat to trap body heat. Covering the body is a passive warming technique, however, and should be combined with active warming options.

The troubling statistic is that twenty percent of trauma deaths are considered preventable. The main cause in these cases is uncontrolled bleeding. A person can bleed to death in just five minutes, or even less if their injuries are severe. Compare this to the average response time for EMS in this country, which is six to nine minutes. If you don’t act before help arrives, you can potentially lose a life.

Evacuate

Evacuation is the final component of the RACE strategy. This is different from what you’ve learned in fire or natural disaster drills. Here, evacuation means moving to a place that is safer than where you are now. This might mean leaving an open hallway to find a room with a lock where you can barricade. You may need to evacuate more than once, each time moving to a safer location. Help others as you go, especially those who can’t help themselves.

Here are some examples of evacuation locations:

Open stairway to the first-floor lobby: Attackers often use a “push” type assault where they enter through public doors at ground level and begin shooting immediately. Stairways that empty into large open spaces like lobbies or central hallways are risky for two reasons: the attacker may still be on that floor, and open areas offer limited options for protection.

Emergency stairwell: In armed attacks against multi-floor buildings, the ground level is often where the attack originates and may be a dangerous location while an event is active. Emergency stairwells offer lower risk if they discharge outside, through exits at ground level, rather than into lobbies or corridors. You’ll also need to consider the possibility that stairwells are being used by attackers. In the 2019 Virginia Beach Municipal Center shooting that you read about in module one, the attacker used stairwells to access multiple floors. In the 2015 Charlie Hebdo attack in Paris, however, employees used stairwells to evacuate upward, ultimately finding safety on the rooftop.

Window: Any window less than three stories high or any opening large enough to crawl through is a potential escape route during or after an attack. In the 2007 Virginia Tech shooting that you read about in module two, students in Room 204 escaped by jumping out the second-story window of their classroom. Be aware that attackers have used strategies such as activating fire alarms to herd victims outdoors for an ambush. Check the area outside a window or door before using it to escape.

Vent: Air conditioning or air vents are unconventional exit options but have been successfully used in active attacks. In the 2016 Pulse nightclub shooting that you read about in module one, eight people escaped through an air conditioning vent. In the 2013 Westgate Shopping Mall attack, people in a restaurant evacuated to safety through an air vent.

If you’re not aware of the exact location of the attacker, the combined effects of fear and lack of situational awareness may make you hesitant to evacuate. Staying put may be the best plan until responders arrive. The decision to evacuate is further complicated if you are injured or tending to someone else who is injured.

Moving the Critically Wounded

Rapidly moving the critically wounded to professional care is one of the many important actions you can take. Moving them incorrectly, however, creates more problems than it solves. Use anything in your environment to help you, such as a chair with wheels or a projection screen as a stretcher.

A single-person drag can be a quick way to move someone to safety but it’s not as easy as it looks. Use it to move someone a short distance. If the injured person is unconscious, they’ll be completely limp, meaning you have to support their entire weight.

Two people may be necessary to move a larger person or to evacuate where there are stairs or other barriers to dragging. This technique requires communication and coordination between the two people.

Three people carrying an injured person makes evacuation much easier. This technique requires communication and coordination between the responders.

Active attacks are unpredictable and evolve quickly. Because these attacks usually end before police arrive, immediate responders must be prepared to decide between evacuation and shelter-in-place. If you choose to evacuate, remember these tips:

• Know the escape routes in the location you’re in and have a plan in mind.
• If you believe you’re making the right decision, evacuate regardless of whether others agree to follow.
• Leave your belongings behind.
• Help others escape, too.

Active Attack Aftermath

Active attacks are traumatic events. Even if you escape physical injury, you will likely experience mental and emotional trauma. Many survivors of active attacks report having nightmares, post-traumatic stress disorder (or PTSD), and survivor’s guilt. Getting professional help is a “first aid” response that shouldn’t be missed.

Finally, remember, only you can save yourself. As an immediate responder, what you do matters!

Active Attack Training Terminology

Active Attacker	An individual(s) actively engaged in killing or attempting to kill people in a confined and/or populated area; in most cases, an active attacker could use firearms, vehicles, or other weapons to produce mass casualties, and there is no pattern or method to their selection of victims (DHS/FBI/ALERRT).
ADD	An acronym that stands for Avoid, Deny, Defend. This is a strategy that empowers immediate responders to make choices early in the decision cycle when the tactical circumstances demand it.
ALERRT	Advanced Law Enforcement Rapid Response Training at Texas State University.
Civilian Response	Civilian response to active attack events.
Combat Breathing	This is a technique to control extreme stress. Breathe through the nose for three counts, hold your breath for two counts, breathe out for three counts, and then pause for two counts before beginning the next breath.
EMS	Emergency medical services.
EMT	Emergency medical technician.
Immediate Responder	Those civilians who are present when an active attack begins.
Mental Scripting	Thinking through if/then scenarios and mentally rehearsing them before a stressful event occurs.
Modern Brain	The part of the human brain that manages rational thought.
Normalcy Bias	When our brains tend to interpret information as if it is part of our everyday experience.
Post-law Enforcement Response	Resolution of an active attack event after law enforcement arrives on the scene.
Pre-law Enforcement Response	Resolution of an active attack event before law enforcement arrives on the scene.
Preparedness	A state of readiness before an attack.
Primitive Brain	The part of the human brain that manages emotion and stress.
R.A.C.E.	An acronym that can be used to remember critical steps in an emergency situation. It stands for React, Activate, CARE, and Evacuate.
Situational Awareness	Being aware of your surroundings; specifically, knowing what is around you, who is around you, and what they are doing.
Social Proof	The tendency to look to other people for cues about how to behave/act in a novel or ambiguous situation.