Virginia Tech: at least 33 dead, worst US school shooting to date

[drewkitty]

The Shooter:

"a young man wearing a short-sleeved tan shirt and black ammunition vest" . . . "carrying an automatic weapon" . . . "reloaded while looking at me" . . . "about 19 years old" . . .
"dressed "almost like a Boy Scout" . . . "tried three more times to force his way in and then began firing through the door" . . . "He was very silent" . . . "a .22-caliber handgun and a 9 mm handgun were recovered at the scene" . . . "police found the front doors of Norris Hall chained shut" . . . "two pistols and several clips of ammunition"

The Response:

"And then all the cops were trying to get into Norris Hall and they used like a bomb or something to open one of the doors." . . . "The police came up. They all had bulletproof vests on, machine guns. They were telling us to put our hands above our head and if we didn't cooperate and put our hands above our heads they would shoot. I guess they were afraid, like us, like the shooter was going to be among one of us. So we were told to keep our hands above our head and run out of the building. At one point, somebody didn't have their hands above their head and one of the cops stated, you know, put your hands above your head, like we're going to have to shoot." . . . "There must have been at least over 20 or 30 cop cars and ambulances. Like, every street was lined with them. I did not see like openings at all, like, it was really scary. All the cops had, like, vests on, and some had guns in their hands and everything. I felt like I was in a war zone" . . . Roil's professor ushered about 20 students into a nearby office, where they listened to gunshots outside. About 20 minutes later there was a knock on the door. "It was the SWAT team," Roil said. "They had weapons pointed straight in our face telling us, 'Get your hands up! Everyone get your hands up!'"

Advice:

• If you hear gunfire, unless you are a trained responder, go the other way! Quick!
  
• If under handgun fire, run away and dodge left and right in a broken-field style. If you are shot, keep going!
  
• The only time you should attempt to go hand-to-hand with a shooter is if the only alternative is your certain death. Pick up any object that can be used as a weapon. Scream. Attack ruthlessly and without compunction. Have the idea that you will stop only when you see smeared bits of brain where the shooter's skull used to be. Ignore injuries, your only hope of survival is to murder before you are murdered.
  
• If under rifle fire, use concealment (that which blocks line of sight) and cover (which stops bullets) to break contact and run away. Broken-field dodging against a trained rifleman is suicide, but if he's shooting at you anyway . . .
  
• Keep your hands in sight at all times when nervous cops are present.
  
• If cops are operating tactically, obey police commands instantly and without argument. The alternative could be sudden death. Literally.
  
• In an 'active shooter' scenario, lock yourself in someplace and stay away from doors and windows. Use the telephone ONLY to report the location of intruders.
  
• First aid for gunshot wounds: apply firm direct pressure to limb wounds. If still bleeding, press harder. Only if trained, use a tourniquet to control life-threatening limb bleeding that does not respond to direct pressure (<30% of gunshot wounds, <10% of all wounds). Abdominal wounds: cover the exposed gut with sterile (preferred) or clean cloth. Do not push spilled organs back into the body. Point out the person to paramedics for immediate triage and transport. Chest wounds: beware pneumothorax (air in the chest cavity) and its more lethal cousin, hemothorax (blood in the chest cavity). Cover both entry and exit wound with something that blocks air, such as plastic. Hold firm pressure. Monitor very closely. If plastic makes breathing more difficult, remove it briefly and replace. If a person is for-sure-dead no pulse no breathing, cover their face with a piece of cloth.
  
• Fire / EMS: Reminder to first responders and EMTs: both CPR and C-spine are NOT TO BE DONE in this type of incident. This is a grossly unsafe scene and attempting either will get you killed! Apply O2 if available, remember your local triage protocol and realize that professional responders will not enter the scene until police have sounded the all clear. If your local SWAT team has tactical EMS, consider yourself lucky. If you're responding to the call, you will be expected to stage in a nominally safe area. Note how I put that. Lock the doors to your rig and keep your engine running.
  
• Security: the most life-saving thing you can do is to keep civilians away from the shooter. The next most life-saving thing you can do is provide intelligence to responders. Use your radio to report the present location and path of intruders. Dispatchers: track the progress of the intruder through the building / campus / complex with times written on a facility or campus map. By narrowing the number of buildings that need to be cleared (slowly and painfully) you may save many, many lives.
  
• Civilian armed / off duty police: you are in grave danger of sudden death, not only from the shooter but from responding law enforcement! If you have a uniform or ID, display it prominently. If not, keep your weapon concealed and engage only if you get a good shot at the shooter. In a confused situation, shout your name and agency / status every few seconds. "John Doe! Smith PD . . . State Corrections . . . Concealed Weapons Permit!" Be ready to comply with police commands instantly. An order from uniformed police to disarm is absolute.
  
• Police: follow your agency protocols. Typically the patrol units set up a perimeter and then your shooters go into it. Wear your armor and your raid jackets! Never, ever bring a pistol to a gunfight. Establish IC and a CP ASAP.
  
• Media: if you operate under a tactical info-sharing model with your local agency, you know what to do. If you don't, take up a good vantage and stay clear of the gunfire!
  

Sigh. So easy to Monday morning quarterback. So difficult when it happens in your back yard.

Comments

[drewkitty.livejournal.com]

I wrote it. Parts are based on National Standard Curriculum: First Responder; Newport Beach START (Simple Triage & Rapid Transport) and the US Army first aid manual. Others are based on California POST Basic Dispatcher's Course; the Incident Command System; the state of California WoMD / counterterror course for security officers. In the course of my employment, I've been exposed to various Fortune 500 company emergency response plans including "active shooter" plans.

I have been training civilian first responders for four years now. I think I know something about the subject.

Who are you?

[ef2p.livejournal.com]

Ooops, that was me.

I stay very skeptical of what I read on the internet (especially in blogs) unless it is attributed.

The flag that really put questions in my head had to do with tourniquets. When I did my EMT in 2000, tourniquets were out of style. They could be back but I doubt it. I was taught that if you apply a tourniquet, the patient is going to have to have the limb amputated. So by applying a tourniquet, you are consciously making the decision to attempt to save a life my losing the limb. Yes you say 'Only if trained'. And yes the whole life over limb thing. However if you're trained, you know this already, so even mentioning tourniquets here seems like a recipe for mistakes.

I'm also curious to see where you got the percentages for bleeding that does not respond to direct pressure (<30% of gunshot wounds, <10% of all wounds)? Those seem high to me.

I've also trained for a fair bit of wilderness search and rescue (cave rescue, high angle rescue, wilderness and rural SAR, ski patrol...). A lot of the wilderness medicine is figuring out how to do things with very limited supplies. When I was doing ski patrol, I gradually trimmed and trimmed my medical gear until I was down to: pen, paper, 4x4 gauze pads, a SAM splint and several triangle bandages because that is all I was using anyways. I mention this because I have heard of (but never used) the following trick: Tampons and maxi-pads make great dressings for gun shot wounds (and other nasty puncture wounds). For a GSW to a limb, just pop the tampon in the hole. I know it seems gross and strange, they are designed to handle blood. Plus in a room full of adults, your much more likely to have 'feminine hygiene products' that sterile bandages, occlusive dressings...

I'm not saying you are wrong. Most of it seems like good advice to me. But outside the medical arena, I do not have the expertise to give it a thumbs up or down.

[drewkitty.livejournal.com]

I don't blame you for your skepticism.

Battlefield experience in Iraq has caused a resurgence of interest in tourniquets in EMS, especially for GSW and blast. A lot of lives have been saved by improvised tourniquets, if I recall correctly at least one during Virginia Tech. While we're on the subject of bleeding control, pressure points were dropped in the last major first aid revision. Rationale: they did studies, and pressure points don't work.

The problem is a GSW limb injury that nicks or severs an artery. Conventional direct pressure may not work on such a strong arterial bleed, although it should be attempted first and continued, more firmly, during any other attempt at bleeding control. Those few wounds that require a tourniquet, often require one _quickly_ due to spurting blood loss and rapid onset of shock. Yes, lose a limb to save a life, but we're talking about over 1000ml of blood loss here. Not a trickle.

I was told in refresher training for a leading first aid training provider that 90% plus of all bleeding wounds can be stopped by direct pressure. That implies the under 10% figure I gave.

The other classic reason for tourniquet is a mangled limb, as would result from an industrial accident or stepping on a land mine. Imagine a sideways cut along the length of an artery, or if it helps visualize better, a drinking straw. Where do you put direct pressure?

Thus the US Army and US Marine Corps basic first aid kits had tourniquets added back in. Any backwoods person can improvise a tourniquet quickly with any cutting tool (EMS shears?) and any flexible material. Wide band and lanyard would be best.

Also, paramedics in my area have been using a partly inflated BP cuff as a hasty method of bleeding control for some years now.

I can't go with the tampon trick, because I can see doing great harm by manipulation inside a wound. (This wouldn't stop Navy SEALs or John Ringo.) I do agree with maxipads as good trauma bandages.

I'll add that the French first aid course never dropped tourniquets and that an interesting take on the subject can be viewed in the Wikipedia article on tourniquets.

Fortunately, I haven't had to stop a truly outrageous bleed. I'll let LJ know when and if it happens.

[drewkitty.livejournal.com]

Here's the link to the VT student -- an Eagle Scout no less! -- who applied an electrical cord to his own femoral bleed and saved his own life.

http://www.mercurynews.com/news/ci_5692940

Look for Exits

[ef2p.livejournal.com]

I was listening to NPR's (http://www.npr/org) Day to Day (http://www.npr.org/templates/rundowns/rundown.php?prgId=17) last night. They were interviewing someone who was at the University of Texas shootings in 1966 (http://en.wikipedia.org/wiki/Charles_Whitman). The interview was shocked to find out the guest always looks for the exits when he enters a building, even 40 years later.

The interviewer's attitude really disturbed me. Looking for the exits is one of the most basic things you can do to increase your chance of survival anywhere (school, plane, dance club, home, theater, mall...). It take close to zero time, and knowing where to go gas save valuable seconds in an emergency. This applies not just to shootings but also to fires, earthquakes, tornadoes, power outages, riots, terrorist attacks, etc. You have a much greater chance of needing to know where the exits are than needing to know how to deal with a shooting rampage.

Re: Look for Exits

[drewkitty.livejournal.com]

That is very practical advice which I completely overlooked, because it is so second nature to me in what I do for a living.