Chapter 1
The Chain of Survival
This post is the introduction to the book. If you are interested in the book, please go to this link to buy it.
On May 24th, 2022, after shooting his grandma at their house, an 18-year-old man crashed his truck into a drainage culvert next to Robb Elementary School in Uvalde, TX. People rushed to see if the man was OK, and he exited the vehicle firing at them with a semi-automatic rifle. The people (including teachers from the school) fled and called 911. A lockdown was declared at the school. The attacker proceeded toward the school and entered through an unsecured door. He quickly went to rooms 111 and 112 accessing them through an unsecured door. He then fired more than 100 rounds at the students and teachers in these rooms. Law enforcement officers were on scene quickly and entered the building around the end of the barrage of bullets. They moved toward the classrooms that were under attack. However, when the attacker fired through the door and wall at the officers, the officers fell back. Dozens, and then hundreds, of officers arrived on scene, but they did not make entry into the classrooms for more than an hour and seventeen minutes after the shooter entered the school. Ultimately, 19 students and 2 teachers were murdered.
As information around the attack began to come out, it became apparent that almost everything that could go wrong that day did go wrong. Outrage followed. This book is not directly about the Uvalde events. We are certain that numerous reports and other books will cover the Uvalde tragedy in great depth. This book is about developing a coherent framework for responding to these events in the hope of avoiding tragedies like Uvalde.
The Chain of Survival
We will use the concept of the chain of survival to organize this book. The chain is a conceptual framework that we developed from years of research into how to best respond to these attacks. The complete chain is presented in Figure 1. On the left side of the chain is a potential victim. We define a victim as a person who has been caught in an active attack and may be killed. On the right-hand side is a survivor. We define a survivor as a person who was a potential victim but was not killed.
Between the victim and survivor are five links. These represent critical phases for moving a potential victim to survivor status. These links are civilian response, law enforcement response, stabilization, transport, and definitive care. Civilian responses are the actions that potential victims take to protect themselves while they are waiting for law enforcement to arrive. Law enforcement responses are the actions that arriving law enforcement officers take to deal with the attacker(s) when they arrive. Stabilization is medical care provided at the scene of the attack to prevent the injured from dying in the next few minutes. Transport involves moving the victim from the attack site to a facility that can provide the level of care needed to stop the victim from dying. Finally, definitive care refers to that higher level of care. Usually, definitive care will involve surgery at a trauma center.
Most potential victims will not need to move through all the links to become a survivor. Those that avoid being seriously injured through effective civilian response, rapid law enforcement intervention, or just plain luck will exit the chain before the stabilization link. These exits are indicated along the bottom as a series of arrows. Only the seriously injured will need to move through the complete chain to become survivors. Additionally, first responders can enter the chain if they are injured during their responses.
We chose to represent the phases with links because maximizing survival requires each phase to connect to the next. If a link is broken for an individual, that person will not become a survivor. For example, if a victim’s response during the civilian response phase is ineffective, they may be killed before law enforcement responds to the scene. If the victim avoids being killed immediately, but is seriously injured, they may die if arriving law enforcement neutralizes the shooter (successfully completes the law enforcement response phase) but fails to provide stabilization such as placing a tourniquet on the victim when the victim has a serious arterial bleed.
We refer to the first two links (civilian response and law enforcement response) as the Stop the Killing Phase. During this phase, the primary focus is on stopping the attacker(s) from injuring more victims. During the Stop the Killing phase, it is likely that only civilians and the first few responding law enforcement officers are present. The primary goal during this phase is to prevent as many people as possible from being injured or killed.
After the attacker has been stopped, the emphasis shifts from Stopping the Killing to helping those that have been injured. We refer to this phase as Stop the Dying. The Stop the Dying phase is composed of the last three links (Stabilize, Transport, and Definitive Care) in the Chain of Survival. During this phase, civilians, law enforcement, fire, and EMS may all be in the scene. When we discuss the Stop the Dying phase of response, our focus will be on Potentially Preventable Deaths (PPD). Research into these attacks suggests that about 1 out of every 6 deaths in these events is a PPD. That is, if the victim was provided a higher level of care more rapidly, they may have survived. Unfortunately, some people who are injured in these events will have wounds that are not survivable, and there is nothing that responders can do. The primary goal during this phase is to have 0 potentially preventable deaths.
The Importance of Time
Time is a critical factor during all parts of the response. The more quickly each link is started and then connected to the next, the more victims will become survivors. The more quickly victims at the attack location take effective actions to protect themselves, the fewer people will be injured. The more quickly law enforcement responds, the less time the attacker can injure victims. The more rapidly stabilization is applied to injured victims, the fewer victims will die at the scene. Quick transport to definitive care allows those who can be saved to be saved.
The importance of speed will influence much of the discussion that follows in this book. There is a speed verses safety tradeoff that must always be considered. Often policies are written to maximize first responder safety without regard for the impact that the policy will have on the speed with which first responders can act to save lives. These policies might keep first responders safe but could cost the lives of many citizens. Our experience has been that many of these policies are poorly calibrated to the actual risk of the situation. They are often derived from series of “what if” type deliberations instead of looking at the data from the actual events to better understand where assuming a little more risk might dramatically enhance that speed of operations and save many lives. In this book, we will use data to drive our suggestions.
Theoretical Framework
Daily contact with practitioners helps to keep us out of the academic ivory tower and grounded in the everyday reality of these events. We will not bore you with an overly academic approach as our focus is on improving practice; however, as academics, we do believe there is a theoretical framework that can help guide this discussion.
This framework is Resilience Engineering (RE). RE is defined as “the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions” (Hollnagel, 2011, p. xxxvi). RE was originally developed for use in preventing and mitigating the damage caused by accidents in industrial settings. According to RE, the key to responding successfully is that people must understand the situation and adjust their behaviors accordingly.
For people to be resilient in a situation, they must exhibit four key abilities: responding, monitoring, anticipating, and learning. Responding means that the person must know what to do. Monitoring means that the person must know what is important in a situation and pay attention to how the situation may be changing. Anticipating means looking farther into the future to see what might be coming so that you can prepare beforehand. Learning simply means that the person must examine both successes and failures to improve their ability to respond, monitor, and anticipate in the future.
We apply these abilities throughout the book in hopes of aiding response. The entire book is our attempt to examine these events and help the reader learn so that civilians and responders will be able to better anticipate, monitor, and respond. In each of the chapters, we will draw out specific things that should be anticipated and monitored. We will also present general responses that have proven to be effective in these events.
Book Structure
We begin the book with a deep dive into the active attack data derived from more than 20 years’ worth of events. In section two of this book, we draw on these data and other research to discuss the Stop the Killing phase of the event. This section consists of a chapter on civilian response and one on law enforcement response. In section three, we discuss the Stop the Dying phase of the response. This section consists of two main chapters. These are stabilizing the wounded and transporting the wounded to definitive care. The third chapter in this section briefly discusses the definitive care aspect of response. Given that definitive care is the realm of surgeons and hospitals, we simply provide a brief overview of some of the key issues in this chapter.