There’s been little political will to end mass shootings. But in the five years since Sandy Hook, these surgeons have evangelized a method to save victims’ lives.
Bruce Ure lay on the ground and watched bits of AstroTurf bounce around him. It reminded him of the way a rainstorm rolls in, with big splats ricocheting off the ground — except these were bullets.
A few minutes earlier, the deputy police chief of Seguin, Texas, had been relaxing in the hospitality tent of the Route 91 Harvest Festival in Las Vegas. His friend J.R. Schumann worked for the concert’s sponsor, Sirius XM, and treated Ure to the opportunity of a lifetime: three days of hanging out in the exclusive, artists-only section beside the festival’s main stage, not far from the glittery-gold Mandalay Bay Hotel.
As Jason Aldean took the stage around 9:30 p.m., the friends chatted about what they would do for the rest of the evening. Then Ure heard the first pops. “What a jerk,” he said. “Someone is setting off fireworks.” Schumann said he didn’t think they were fireworks, but Ure, confident that his 40 years in law enforcement meant he could identify gunshots, thought the sound was too high-pitched.
Then came a burst that left no doubt about what they were hearing. “Gun! Get down!” Ure screamed, throwing himself to the ground. He heard a shot land close to his head and felt a sharp pain in his right hand. When he saw the inch-long gash, he figured he’d been hit by shrapnel. He wondered why shots kept coming closer and realized the shooter was somewhere above them. At that point, his training kicked in; he yelled to the people around him to use the tour buses as a shield, to tuck down behind the tires.
He noticed there were two kinds of gunshots: a series of crisp staccato, then a switch to something more muffled. He decided the group should make a run for the exit during the next round of muffled shots. He later learned that was when the gunman switched windows, firing away from the artists’ tent and directly into the crowd. The moment he heard the switch, he bolted.
As Ure neared the exit, he saw a young man lying on the ground, bleeding heavily. Ure thought he was dead, until he saw the man’s face. He picked him up and, with the help of an ex-Marine, carried the man out of the venue. Ure got a clear look at the man’s thigh, which was gushing blood, once they put him down. It looked like he’d been hit in the femoral artery, the thick vessel that carries blood to the lower part of the body. Unless they stopped the bleeding, the young man would die within minutes from blood loss.
It was a rare day that Ure wasn’t wearing a belt. But the injured man, a 27-year-old Canadian named Zach Belitsky, had one on — not a big Western-style belt like many of the concertgoers, but a sleek leather belt about one-inch wide. A perfect tourniquet for the thigh, Ure thought.
Ure put the tourniquet on as high as he could, just like he’d been trained to do, and pulled it as tight as he could. “I said to him, ‘It’s just you and me until we get to the hospital.’”
This may sound like an example of chance: a young man with the misfortune of getting shot at a country music festival, and the good luck that a bystander who knew what to do was there to help him.
But it is also a story about design. Ure knew exactly what to do because he’d recently been trained in the techniques to triage major blood loss. A person quickly losing blood will die in minutes. But if first responders and civilians can intervene, the injured stand a chance of survival. Ure is one of at least 300,000 people who have been trained in a technique a group of trauma surgeons began evangelizing after a gunman slaughtered 20 children and six adults at Sandy Hook Elementary School five years ago this week.
More than 1,800 people were killed and over 6,200 were wounded in mass shootings between 2011 and 2016, the last year for which figures are available. The pace of shootings has far exceeded the political will to do anything that might prevent them from happening in the first place ― which means more Americans now rely on bystanders like Ure to save their lives.
The word ‘tourniquet’ comes from the French “tourner,” to turn. Nearly 350 years before Ure fashioned a tourniquet out of a belt on the grounds of a country music festival, a French army surgeon, Etienne Morel, described using a tourniquet at the siege of Besançon during the Franco-Dutch War. It was the first recorded instance of such a device being used to stop blood loss on a battlefield.
In his history of the tourniquet, surgeon and retired U.S. Air Force Col. David R. Welling writes that both the North and South used tourniquets during the American Civil War. But they weren’t always used properly; applying one in the wrong place or at the wrong time, or too loose or too long, could lead to unnecessary limb damage or loss.
World War I did nothing to boost the reputation of tourniquets. By then, the complications of improper use were evident, prompting physicians writing in the United Kingdom’s Royal Army Medical Corps Journal to report, “We are inclined to think that tourniquets are an invention of the Evil One.” More harsh critiques followed tourniquet failures in the Spanish Civil War and World War II. Even as late as 1992, tourniquet use was strongly discouraged in both military and civilian courses on pre-hospital trauma care, out of fears they caused damage to limbs.
But in the mid-1990s, the American military began to change its approach to care of soldiers injured on the battlefield. There was a new focus on trauma care in the field, zeroing in on things like tourniquets, bandages and dressings. These devices could stop or slow life-threatening bleeding from a limb, the leading cause of preventable deaths among U.S. combat casualties during the Vietnam War. More military doctors and medics began to argue that tourniquets, when used properly, could spare lives and limbs. By 2005, with the wars in Iraq and Afghanistan in full swing, the U.S. Army advocated the use of the tourniquet as a “stopgap” measure in combat, and began issuing tourniquets to soldiers.
John Kragh, an orthopedic surgeon and researcher for the Army, was deployed to Ibn Sina Hospital in Baghdad, Iraq, in 2006. On his first day, he noticed a soldier brought in with a tourniquet tied around a limb and saw an opportunity to continue his research on tourniquet use with firsthand examples.
Over the next seven months, he and two nurses studied what happened as soldiers and combat medics got better at applying tourniquets in the field. In what is now a frequently cited study of modern tourniquet use, they reported that none of the 232 patients who received tourniquets lost limbs because of them.
“Big bleeding is bad. And if you can stop it, that’s good,” said Kragh. “And if you can stop it quickly, that’s better.”
ragh, who sometimes signs his emails “TEGOTUS” ― Tourniquet Expert Geek of the United States ― is a blunt-talking scientist who may know more about tourniquets than anyone else. In 1993, he was the battalion surgeon for the U.S. Army Rangers, the elite rapid-deployment unit, serving in Mogadishu, Somalia, when a young Ranger, Jamie Smith, bled to death — a story eventually made famous in the film, “Black Hawk Down.” Since then, he’s been laser-focused on learning how to stop bleeding and save lives with tourniquets.
He speaks quickly, rattling off information in complex sentences. But he’s trained enough non-scientists in tourniquet use that he knows to slow down and simplify when his audience gives a thousand-mile stare. “The body doesn’t give a crap where the bullet is coming at you from; it’s how it goes through the artery or the bone or the limb, that’s what makes a difference between living and dying risk.”
Tourniquets are well-suited for the needs of the battlefield, explains Kragh. They serve three purposes: chaos control, because they buy time for medics in situations where they are dealing with multiple injuries; shock control, because some evidence suggests that if you can delay the onset of shock, you may be able to stop the mechanism of death; and bleeding control.
Kragh says the techniques pioneered on the battlefield should be put to use to save civilians as well.
“When you’ve got big penetrating trauma, lots of bullets, stuff like that, it’s close to combat, it’s pseudo-combat,” said Kragh.
And when bystanders are taught how to treat injuries, just like in combat, they can save lives. “If you know what you’re doing,” Kragh said, “your performance is better than if you don’t know what you’re doing.”
As Ure clutched the belt he’d fixed around Belitsky’s leg, someone else called out to him, assuming he was a medic. A group carried two injured women over to Ure who were both bleeding from gunshots. Ure said what they needed most was a car to get the injured to a hospital. Someone managed to flag down a service worker in a white Toyota compact, and told him they needed to get to the nearest hospital. “That guy, the driver, he is the real hero,” Ure insisted.
They managed to fit the wounded into the car, one in the front seat and two in the back. Ure squeezed in the back as well, holding Belitsky’s leg across his lap and maintaining his grip on the belt. Ure told the driver that they needed a trauma center, not an ordinary hospital. They Googled to find the closest one.
The driver stopped at the first traffic light, and Ure screamed at him to go through. “You’re not going to get a ticket, I promise,” he told the driver. They saw ambulances speeding past in the opposite direction, toward the concert grounds. There was no point in flagging one down, Ure figured. Dozens of other injured people needed help and their small group had a running start.
If the shooting at the Route 91 Harvest Festival in Las Vegas had happened five years earlier, the response would have been much different. Roles in mass casualty events then were distinctly defined: law enforcement responded to the immediate threat and secured the scene; emergency medical services were held back until it was deemed safe; and, it was assumed, bystanders stood by.
But that philosophy has started to change, largely due to the work of a group of trauma surgeons who became concerned that they couldn’t save shooting victims if they didn’t survive long enough to make it to their operating tables.
On Dec. 14, 2012, Lenworth Jacobs, the director of trauma and emergency medicine at Hartford Hospital, heard an active shooter situation was unfolding at Sandy Hook Elementary School in Newtown, Connecticut, nearly 30 miles away. As the nearest Level 1 trauma center to Newtown, Hartford Hospital and its staff were immediately put on alert. Jacobs and colleagues stood by, ready to receive scores of injured people.
No one arrived.
“That made absolutely no sense to me,” Jacobs said in October 2013, the first time I heard him describe events of that day.
“Then, pretty quickly, we heard there were 26 dead people, two injured people. That also didn’t make sense,” he said. “That is not how it works. It’s usually the reverse ― there are a lot more injured people than dead people.”
In order to understand what happened in the elementary school, the medical examiner asked Jacobs to review the autopsies with him. Jacobs described it as “the single most powerful thing that I have done.”
Jacobs took his concerns to the American College of Surgeons, which established a committee to create a national policy on enhancing “survivablily” for mass shootings and other high-casualty events. At the committee’s first meeting in April 2013, members agreed that stopping blood loss as fast as possible and quickly transporting the wounded to a hospital was critical to saving lives in mass-casualty shootings. No one, they believed, should die from uncontrolled bleeding.
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