First Aid in a Mass Shooting Situation

Whatever your political leaning, mass shootings are becoming a problem, not to mention the large number of gun violence incidents that are not categorized as mass shootings.

As their prevalence continues, the wise will prepare and plan ahead so they can do their best in a difficult and dangerous situation. This guide will take you through all aspects of first aid after either you or someone else has been shot. This would be particularly useful in a post-SHTF situation, when doctors may not be available.

Disclaimer

The information in this article is provided “as is” and should not be mistaken  for or be a substitute for medical advice. Always consult your physician before trying any of the advice presented on this page. Neither the author nor www.SurvivalSullivan.com or the company behind it shall be held liable for injury or death resulting in misuse, or human error regarding the contents of this article.

Could You be in a Mass Shooting?

In 2018 there have been 340 mass shootings in America as per https://www.gunviolencearchive.org/.

As I write this article it is the 280th day of the year, so the United States has on average one mass shooting every day. A mass shooting is defined as a shooting incident where more than one person is injured or killed.

However, as one reader pointed out, you’re not going to run into a mass shooter every time you go out, so this advice applies for all gun violence incidents.

If we talk about gun violence in general, in 2018 there have been over 14,500 deaths and over 28,000 injuries including single victim incidents. In total there have been over 40,000 gun related incidents, and this number does not include the 22,000 suicides by firearm.

In 2018 there were roughly 325 million people living in the U.S.A. These numbers mean roughly 2 out of every 100 Americans has been involved in a gun related incident this year. If you think of how many people you work or study with you realize that the odds are there.

The reality of the situation is that as soon as people go down from a gunshot they need help, and that help will need to be you. Help will always be on its way, but it may be far too late for some if they are left waiting for an ambulance.

If there is an active shooter you will only add to the body count if you run from cover without thinking. By getting shot you are helping no one. The first rule of first aid in a mass shooting situation is:

Be Safe!

Only assist others if you have suitable cover or if the shooter is no longer active. If the shooter is active you must first get yourself to safety either by taking cover or leaving the area. This is important because if you have a moment of safety you can:

Call for Help

If you find yourself safe for the time being, make sure you call the emergency services first. Yes someone who is far away and has heard the gunshots may have already called them. That’s fine but it doesn’t give emergency services something vital: detailed information.

With eyes on the ground you can begin to estimate the number of injured and dead or even be able to update the police on the status and location of the shooter.

Once you have called 911 and no further information can be given to the operator, they will likely now begin to assist you in delivering first aid and prioritizing victims. By attending to those who are the most injured you are buying them precious time while you wait for ambulances and potential blood transfusions to arrive.

X-ABC

Active shooter scenes are unique in that the first step is always to stop hemorrhage or bleeding. Usual first aid protocol is simply ABC: airway, breathing and circulation. With gunshot victims, however, any ruptured arteries need to be attended to promptly.

This is the X in X-ABC. While this refers to both arterial and venous bleeding, it is the arterial bleeds which should have your attention first. This is because the arterial system is a lot more compact and high pressure than the rest of your blood supply.

If a person has had an artery severed by a bullet they will begin to bleed out very quickly. Pressure to the point of bullet entry is the number one takeaway to remember. Previous guidance recommended pressing on pressure points further up from the point of bleeding. After careful analysis government bodies now advise direct pressure to the wound only.

An arterial bleed will take a few minutes to clot in this way so make sure to keep the pressure on. If after 5 minutes there is still a large volume of blood being lost then there is one more step that you can take if a limb is affected.

Raising it above the level of the heart should reduce the blood pressure enough for a clot to begin forming. This is not advised as a first step as you could cause pain or an internal rupture to the victim without realizing.

If you cannot raise the limb and have already tried applying pressure then your last back up is the use of a tourniquet

Emergency Tourniquets

A tourniquet is anything that can be wrapped tightly around a body part to try and stem bleeding. In an active shooter situation you will have to use whatever comes to hand – usually clothing.

Take a top or belt and tie it as tightly as possible above the level of the wound. Where you place the tourniquet is extremely important. It must be placed closer to the body than the wound is. If you put it past the wound you are simply starving the limb of blood even more and making the injury worse.

Remember this method is a last resort if the previous methods have failed.

Advanced – Open Chest Wounds

There has been an update from the American Heart Association regarding applying pressure to open chest wounds. Standard practice for gunshot wounds is of course to apply pressure, and use a tourniquet if it is a limb that is bleeding. Research from the association however has shown that often people try and put ‘occlusive dressings’ on open chest wounds when they apply pressure.

What is an ‘occlusive dressing’? Essentially it is anything that is water or airtight, like plastic or waterproof dressings for example. You are urged to avoid this as it stops the proper flow of air through the chest and had been shown to actually drop the oxygen in the blood of victims.

This advice extends to using absorbable bandages, such as gauze. While these dressings draw blood away from the wound it also encourages it to clot on the surface. This turns breathable gauze into another occlusive dressing as less air flows through the more the clot grows.

Moving victims to safety

In an emergency situation there can be multiple dangers present that are not directly related to the shooter. You must be vigilant at all times and be sure of your surroundings as things will be changing rapidly. You will need to focus when you are helping yourself or others but make sure you do not end up with tunnel vision.

Refer to this active shooter guide from the department of Homeland Security, as well as to our dedicated article on surviving mass shootings. You will notice that their first point on the card is about being wary of your environment.

They also cover taking down the shooter as a last resort. This of course will be an extreme action to attempt, even if you are armed. Unless you see a clear opportunity to do so it would be best to keep yourself safe so you can help the injured as quickly as possible.

Crowds

Panic spreads like wildfire when gunshots are heard. Those who are hit are in danger of being trampled by rushing crowds as they can’t be seen easily when lying on the ground.

This usually requires moving incapacitated people and should be done with care. Never pull anyone by their leg or arm, always try to hook under their arms and lift them before moving.

Fire

Gunshot damage to cars, electricals and other flammable objects increases the risk of a fire. Make sure any victims are moved away from these sources.

Children and the Elderly

Any child separated from his parent or guardian will likely will not know what to do in such an extreme situation. Again, if it is safe for you to do so, you must help those who cannot help themselves. This also extends to the older generation, who may be too slow or simply too scared to be able to move away in time.

The Recovery Position

All victims should be lying down, preferably in the recovery position. This is the preferable position for any person in need of emergency attention, whether from a gunshot or an unidentified injury.

It allows blood flow to the brain, supports the neck and also stops a person from suffocating on their own vomit as they are lying on their side rather than their back. See this link from Harvard Medical School on how to place someone into this position.

Keeping the heart at the same level as the rest of the body rather than above it (as is the case when sitting or standing up) slows the rate of bleeding.

If you keep victims lying down you also avoid potential suffocation. Many gunshot victims will be in a complete state of shock. This combined with any blood loss is the perfect storm to make them lose consciousness and collapse. If they are in an upright sitting position the danger is that they stay that way!

On fainting, their head will simply lull forward with their chin resting on their chest. With relaxed neck muscles from being unconscious this will block off the person’s air supply. Someone who was sleeping in this way would simply wake up once their brain realized it was running out of oxygen.

If the person has fainted from blood loss however no matter how many emergency signals the brain sends to wake up and move it will not be possible. Instead the victim’s oxygen level will simply drop further until they suffocate and die.

Always Check the Airway

This also holds true if there is any sort of road traffic accident or other high impact collision, which has definitely been seen in mass shootings in the past. Your average civilian when seeing someone suffer a car crash will likely leave them slumped in the car if there is no other immediate danger.

This spawns from sensible thinking; their neck or spine might be damaged and often moving these people can worsen their spinal fracture or even disable them for life. But if you see someone slumped at the wheel, with their chin on their chest, move them!

Yes you may make any fractures, spinal or otherwise, worse. If you leave them how they are though they could suffocate to death which is certainly a much greater risk than disability.

Limb Elevation

One of the few times when a different position is preferable is when you can notice heavy bleeding. Of course at this point you need to follow the emergency first steps above, starting with keeping yourself safe and ending with assessing the situation using X-ABC.

If after applying pressure to the wound and using a tourniquet the wound is still bleeding then you will have to resort to emergency positioning. This will require staying with the victim as they will be lying directly on their back and could choke on vomit or blood.

Find something stable to move near the patient and then raise their legs onto it, above 45 degrees if possible. As the body weakens it becomes harder to pump blood to the organs that need it. Raising the legs uses gravity to push blood from the legs further up the body and back up to the brain. This should give precious extra minutes of life whilst waiting for the emergency services.

Using Tourniquets – A Repeat Warning

Tourniquets are to be used when direct pressure to the wound has failed. Do not use it without trying pressure on the wound first. This is because tying off a wound also ties off the rest of that limb from most of the arterial supply. The tourniquet also compresses the veins coming back up the leg or arm causing a backup of blood called venous congestion.

Altogether, this means that the usual toxins your muscles produce are not cleared away fast enough. If the tourniquet is left on when it is not really required this can actually do more harm than good in the long run.

The take home message is if you have controlled the bleeding using pressure and limb elevation don’t cut off the blood supply with a tourniquet!

Be Prepared

As with almost everything in life, it is best to be prepared. Don’t just read this article once. Make a note of the important points and do more research by yourself. Only if the information is ingrained in your mind will you be able to recall it automatically in a high pressure situation.

Search in your local area for first aid courses so that you can help loved ones and strangers if the worst were to happen. If you are lucky you may be able to find specially designed mass shooter first aid courses – aimed at keeping you level headed as well as effective in a dangerous and ever changing environment.

Good Luck.

first aid for gunshot wounds

About Shane Jackson (Bachelor of Medicine, Bachelor of Surgery)

Shane Jackson (Bachelor of Medicine, Bachelor of Surgery)
Shane is a medical doctor with over 8 years experience in both hospital medicine and surgery. He's completed over 2 years of surgical work focusing on trauma & orthopaedics alongside maxillofacial surgery. He has been involved in education since medical school and have written courses and taught classes. Having trained in Advanced Trauma and Life Support he is at the forefront of practical, out-of-hospital medicine which can be applied by the public to save lives.

7 comments

  1. Avatar

    I was a EMT1A for a lot of years but it’s great to read stuff like this just to refresh. Thanks

  2. Avatar

    Very good!
    I really liked the text and the links provided.
    I am Brazilian and I live in Brazil, it has been much quieter here, but it is changing fast (high speed)…
    Excuse – me for my english

  3. Avatar

    I ask that you recheck the numbers from the Gun Violence site. I believe the death toll listed is for all incidents, not just mass shootings. It does not break out the deaths from only the mass shootings. I downloaded the Mass Shooting summary for 2018 and it indicates that in the 340 instances where more than one person was killed or wounded, there were 372 deaths and 1,1347 wounded for a total of 1,719. In 171 of the 340 instances was someone killed. In 330 of the 340 instances was someone wounded.

    Still quite terrible, and the advice in the article is the best I have seen. But using the total number of gun related deaths (excepting suicides) with the number of Mass Shootings places a very unbalanced and frightening aspect to the subject. People need to be aware and prepare, but every mass shooting is not going to kill over forty people, as the article numbers indicate.

    And the actual numbers, I believe, are somewhat inflated, as they include all instance where more than one person was wounded or killed. That would include many other instances that were not where a person or group goes out to intentionally shoot people randomly or in specific groups. Things such as more than one person being wounded or killed during the commission of a crime that was simply a shooting. Accidental firearms discharges where more than one person was wounded or killed. And many others.

    The actual number of incidents where a person or a group of people went out to intentionally kill as many people as they could is significantly lower than indicated, and the numbers killed and wounded are therefore also inflated.

    Follow the advice in the article, but do not expect to run into an Active Shooter, Mass Shooter everytime you go out. Just be ready if you do.

    Just my opinion.

    • Dan F. Sullivan

      Jerry,

      I updated Shane’s article before I published, so it’s not his fault. He wrote int in late 2018, so the stats for the whole year were not in yet. I apologize for the error, I’ll fix it ASAP.

  4. Avatar

    You may want to double check the usage of pressure points. The order is supposed to be direct pressure and *elevation on the wound, if ineffective also use an arterial pressure point and then if both of those have failed or you have a severed or partially severed limb, you would move to a tourniquet. I just became a CERT instructor and FEMA is still teaching this. I also taught this treatment order as a Red Cross certified instructor.

    *Elevation should only be used if it will not cause further injury to the victim.

    The mantra for surviving an active shooter is run hide fight. Easy to remember in a high stress environment. Although I don’t pretend to be a MD, I have used the direct pressure, and pressure point technique in knife wounds and other lacerations with success in real life.

    • Avatar

      I teach Stop the Bleed from the American College of Surgeons and Basic Tactical Medic for Law Enforcement. You are all wrong on the priority and techniques for active shooters and any trauma where large loss of blood is occurring. The priority is to save as much blood (in the body) as possible, as quickly as possible. To do this, in massive bleeding, use the tourniquet first. this preserves the greatest amount of blood in the body-preventing shock, and if left on for up to 2 hours causes NO harm to the limb. This only works on arms/leg wounds. For trunk and junction wounds you can pack the wound with any cloth materials and apply direct-continuous pressure. I highly encourage anyone wanting to know the best current medical practice for trauma wounds to take a Stop the Bleed class.

    • Avatar

      Several new terms since you took your training. The CERT curriculum is from 2011 and terribly out of date on the medical ops section (I’m a CERT Master Instructor). We now teach Stop the Bleed to keep up with current medical practice. The new terminology from ALERT on active shooter is Escape, Deny, and Engage. Hide is too passive and not really what you want to do.

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