By Paige Williams
One April morning in 2014, a sixteen-year-old sophomore at Franklin Regional Senior High, in Murrysville, Pennsylvania, stole two butcher knives from his parents’ kitchen, hid them in his backpack, and took them to school. He was wearing all black and, according to witnesses, had a “blank expression.” Just before first period, in the hall of the science wing, he stabbed several classmates. Then he pulled the fire alarm. As the corridor filled with people, the boy moved down the hallway, a knife in each hand, stabbing more students. He turned and raced back up the hall—an administrator remembered him “flailing the knives like he was swimming the backstroke.” One girl later testified, “I could feel that my lip wasn’t attached to my face anymore.” A boy, stabbed in the belly, recalled, “I was gushing blood.”
The students at Franklin Regional, which is seventeen miles east of Pittsburgh, had been trained to lock themselves inside classrooms during a “code red” event. In one room, a home-economics teacher called 911 as she attended to an injured boy. A dispatcher asked where the “patient” had been hurt. “The lower abdomen,” the teacher said. “On the right side.”
“Do you have any way to control the bleeding?” the dispatcher asked.
“I’m putting pressure on it,” the teacher said. She was stanching the blood with paper towels. This was helpful, the dispatcher told her, saying, “If it starts soaking through, I don’t want you to lift it up at all. Find anything else you can to put on top of that.”
The teacher had been applying pressure for about four minutes when the dispatcher said, “We have the actor in custody,” adding, “But I don’t want you to let any of your students leave that room.” As the teacher bore down on the wound, she talked with the injured boy, her voice tense but cheerful. They joked that he could use the experience in a college-application essay. When he predicted that his mother was going to “have a panic attack,” the teacher said, “I think she will.” Then she said, “I never thought I’d have to do this.”
Gracey Evans, a seventeen-year-old junior at the time, remembers that she was walking down the hall with her friend Brett when someone rushed past them “like a black mass.” She didn’t realize that Brett was hurt until he “fell to the ground, withering in pain”—he had been stabbed in the back. In front of her, a boy in a red hoodie grabbed his stomach. A third boy collapsed. The victims took refuge in a nearby science classroom.
Brett’s wound did not look life-threatening, so Gracey dropped to her knees beside the boy in the red hoodie. She raised the hem of his sweatshirt and saw blood pouring out of a clean slit above his waistband. Although she had never witnessed real physical trauma before, she didn’t flinch. Her mother was an orthopedic nurse, and she had seen videos of athletes’ legs broken at grotesque angles.
Gracey recalls that someone handed her a “big wad” of those “terrible” brown paper towels that aren’t very absorbent. She placed them over the gash, interlaced her fingers, and pushed. A dancer, she’d been told that she was stronger than she appeared, and she worried that she might be hurting her classmate, but she kept pressing. The boy suddenly vomited, and part of his liver emerged from the wound. Gracey, nauseated, let go, and blood rushed out again. “I’m so sorry!” she cried, unable to continue. Another student, who happened to be an E.M.T., took over, buying the boy more time.
Twenty-one people had been knifed, several severely, yet everyone survived. (The attacker was later sentenced to a minimum of twenty-three and a half years in prison.) Law-enforcement and health-care professionals in the Pittsburgh area took note of the fortitude and the competence of many bystanders. Listening to a playback of the teacher’s 911 call, they marvelled at her calm and her effectiveness. Brad Orsini, an F.B.I. agent who worked the case, told me, “You’d have thought it was just another day for this woman.” At one point, the teacher had told the boy, “You know what? Sometimes when stuff happens, you go into a different state of mind. You surprise yourself at how you can handle things.”
A category of emergency known as an Intentional Mass Casualty Event is now considered a public-health crisis. In recent years, deadly attacks have occurred at schools, offices, concerts, sporting events, shopping malls, and houses of worship. They have involved guns, knives, trucks, and improvised explosive devices. In March, a gunman killed fifty people at two mosques in Christchurch, New Zealand.
Much attention has been given to the rising frequency of mass shootings in the United States, but equally alarming is their worsening severity. In the attack at Columbine High School, which occurred in 1999, thirteen people were killed and twenty-four were injured. In the 2017 massacre at a music festival in Las Vegas, fifty-eight people were killed and eight hundred and fifty-one were injured. The arsenal of the Las Vegas perpetrator included the AR-15 assault rifle, a weapon that has been used in many rampages. (In fact, he had fourteen of them with him.) Bullets shot from an AR-15 travel at an extremely high velocity; the force of the ammunition can shatter the bones in a human arm merely by grazing it. Last year, Richard Carmona, a former U.S. Surgeon General, said, “More and more, the injuries we’re seeing in the civilian world look like combat casualties.” After the 2018 shooting at Marjory Stoneman Douglas High School, in Parkland, Florida—seventeen killed, seventeen injured—a trauma surgeon opened up a victim to find at least one organ in “shreds,” with “nothing left to repair.”
For victims whose injuries are serious but survivable, rapid treatment is essential. A person can bleed to death in as little as five to eight minutes. Traditionally, during an active-shooter event, paramedics held back until law enforcement secured the area, then rushed in to treat the wounded and evacuate them to hospitals. That approach changed after Columbine. During that event, rescuers, unable to determine if the killers were dead or hiding, didn’t reach some victims for hours. In a second-floor science lab, teachers and students were stranded with a coach, Dave Sanders, who had been shot once in the neck and once in the back. Two Eagle Scouts applied pressure to his wounds, and someone else put a sign in a window—“1 bleeding to death.” Sanders died at the scene; it’s unclear whether he would have survived with quicker or different treatment.
The Las Vegas shooter positioned himself in a sniper’s nest—a hotel window overlooking the festival—and sprayed the crowd with bullets. In this case, it was impossible to stage an orderly transition from a security phase to a medical phase: victims arrived at hospitals in Ubers and pickup trucks, or in the arms of loved ones and strangers.
As public shootings became commonplace, doctors started paying more attention to them. One such doctor was Lenworth Jacobs, the head trauma surgeon at Hartford Hospital, in Connecticut. He’d grown up in Jamaica, where his father was a doctor; when Jacobs was about seven, he and his dad came across an injured bicyclist by the side of the road, and the sight of his father urgently helping a stranger left a lasting impression. Jacobs told me that trauma surgery appealed to him because each case contains a “beginning, middle, and end.” A patient presents with a problem—“a gunshot wound, a stabbing”—which is then resolved, one way or another. When Jacobs wasn’t operating, he devised protocols that would help increase survival rates in the Emergency Department. At Hartford, he founded Life Star, the first helicopter-ambulance service in Connecticut.
On December 14, 2012, a deranged young man with a semi-automatic rifle and two handguns entered Sandy Hook Elementary School, in Newtown, Connecticut, an hour away from Hartford Hospital. The hospital is a Level 1 trauma center, a designation that signifies the highest level of care. As news of the shooter reached Jacobs, he prepared to send medevac choppers to Newtown, but was soon advised to stand down. “You hear ‘Everybody’s dead’—and that makes no sense,” he told me. “Then you hear ‘It’s children’—and that makes no sense.”
Twenty first graders had been killed, along with six administrators and teachers. Jacobs wondered whether the shocking number of casualties was related to the local emergency response, or to the nature of the gunshot injuries, or both. He reviewed the autopsy reports, and, although he had successfully operated on patients with unimaginable physical trauma, he was nevertheless unprepared for what he saw. Many of the children had been shot multiple times, at close range. The reports, he said, were “overwhelming.”
The victims at Sandy Hook likely died instantly, but Jacobs, unable to “go back to business as usual,” kept thinking about what could be done to reduce casualties in the future. There was not even a second to waste in such incidents: the wounded had to be treated immediately, at the scene.
Jacobs was a regent of the American College of Surgeons, an organization with some eighty thousand members worldwide. At an A.C.S. meeting soon after Sandy Hook, he urged his colleagues to focus on mitigating losses in Intentional Mass Casualty Events. “Obviously, prevention is the way to go,” he said. “But, once something has happened, how can we increase survival?”
In trauma care, the primary cause of preventable death is hemorrhage. External bleeding can always be controlled in an extremity wound, if it is addressed quickly enough: no one should bleed to death from an arm or a leg injury, even with the loss of a limb.
This message had never been clearly conveyed to the public. Four months after Sandy Hook, Jacobs convened a small group of physicians, military leaders, and law-enforcement officials—including representatives of the F.B.I. and the Department of Defense—at Hartford Hospital. The group became known as the Hartford Consensus.
One member was Frank Butler, an ophthalmologist and a former Navy seal platoon commander. In the nineteen-nineties, Butler reviewed the state of battlefield trauma care in the U.S. military. He ultimately discovered that, during the Vietnam War, more than thirty-four hundred service members died because of hemorrhaging from extremity wounds.
For Butler, a solution came to mind: tourniquets. The devices are known to have been used as far back as 1674, during the Franco-Dutch War. Early versions consisted of a strip of cloth and a stick, which was used as a windlass. Modern tourniquets work much the same way: you snugly encircle a bleeding limb with a band of cloth, then turn the windlass, tightening the band until it stops the flow of blood.
Tourniquets lost favor after the Civil War, because of their association with gangrene and amputation. By the time of Butler’s review, medical doctrine had long held that tourniquets did more harm than good. It was true that the longer a tourniquet stayed in place the more it could damage the surrounding tissues and nerves, but in the modern era a patient could usually be evacuated quickly to a hospital. Moreover, early tourniquets hadn’t always been used properly—they were strapped below the wound instead of above it, or they weren’t tight enough. In a report, Butler argued that “the ‘no tourniquet’ rule,” a “venerated tenet of prehospital trauma care,” was wrong. As he recently put it to me, “Tourniquets save lives—period.”
Butler’s recommendations also introduced the concept of “tactical combat casualty care”: soldiers, trained with basic lifesaving skills and equipment, could act as front-line medics when necessary. Several élite combat units immediately embraced the idea. The Army’s 75th Ranger Regiment—whose members had seen comrades bleed to death from extremity wounds during the 1993 battle in Mogadishu—began training with tourniquets during simulated missions. Soldiers were taught how to apply a tourniquet to themselves or to someone else within seconds. A group of soldiers at Fort Bragg, in North Carolina, designed a tourniquet that was optimized for battlefield conditions; the device, which came to include a built-in windlass, secured by a plastic clip and a Velcro strap, is called a Combat Application Tourniquet, or C-A-T.
An outdated technique had become a modern cure. Tourniquets are now standard issue in the U.S. military, along with hemostatic dressings—sterile gauze infused with kaolin, a clay that promotes swift blood clotting. By 2012, the Journal of Vascular Surgery reported, some soldiers were embarking on missions with tourniquets “already in place” on their limbs.
In April, 2013, when Jacobs and the other experts convened at Hartford Hospital to talk about Intentional Mass Casualty Events, they discussed the tourniquet revival. The group decided that the military’s standardized approach to controlling external hemorrhage could be applied to civilian life: members of the public could be trained to identify and treat life-threatening bleeding. The Hartford Consensus devised a protocol, Stop the Bleed, in the hope that it would become as widely known as C.P.R. and Stop, Drop, and Roll.
Jacobs told me that Stop the Bleed training had to be short enough to fit “between church and cooking dinner, or between dinner and the football game,” and simple enough for a sixth grader to understand. The instruction had to focus on one goal: “Keep the blood in the body.” He and his colleagues knew that the protocol would save lives if they could persuade people to use it.
Thirteen days after the Hartford Consensus first met, explosive devices filled with nails and ball bearings detonated near the crowded finish line of the Boston Marathon. The sidewalks of Boylston Street were strewn with injured spectators. As a team of specialists later wrote in The Journal of Trauma and Acute Care Surgery, the bombing was the first major terrorist event in the modern United States “with multiple, severe, war-like, lower-extremity injuries.” More than a dozen people lost limbs in the blasts.
Boston has many hospitals, and paramedics were quick to the scene, but they were astonished by how many spectators had already applied pressure to wounds, using clothing or coffee-shop napkins. “Much of the early lifesaving was performed by amateurs,” the Washington Post reported. Although more than two hundred people were injured, only three died, and The New England Journal of Medicine credited this achievement, in large part, to “courageous civilians.”
The marathon attack confirmed the Hartford Consensus’s view: people would instantly help one another during a crisis, even when the injuries were almost unbearable to see, much less to touch. The real first responders were bystanders.
One icy morning in mid-January, Matthew Neal, a trauma surgeon and a research scientist at the University of Pittsburgh Medical Center, got in his car and drove twenty-six miles north of the city. He arrived at Mars Area High School, where more than two hundred employees of the public-school district were filing into the auditorium, for a mandatory Stop the Bleed seminar. They wore puffy coats and snow boots, and carried Starbucks cups and thermoses that were still warm.
Neal, who is thirty-eight, is tall and lean, with a resonant voice. People call him Macky. He has his own laboratory, which recently received a grant partly funded by the Department of Defense to study treatments for types of bleeding that don’t respond to compression, such as certain belly wounds. One night, when I joined his family for dinner, he told me, “My whole focus is blood.”
He stood at the front of the auditorium with Raquel Forsythe, another U.P.M.C. trauma surgeon, who wore a voluminous red scarf and had her hair in a high bun. They used a laptop to project a presentation onto a screen. One slide read, “Why do I need this training?” The answers included “mass shootings,” “motor-vehicle crashes,” “home injuries,” and “bombings.”
The stabbings at Franklin Regional Senior High had occurred in the wake of other horrific attacks in the Pittsburgh area, including shootings at an L.A. Fitness franchise and a psychiatric clinic. The city’s trauma specialists reviewed these tragedies, but, Neal told me, they often ended a case analysis “feeling a bit empty.” No matter how nimble firstresponders are, Neal is prone to say, “I can’t do anything if the patient’s dead.”
In October, 2015, the American College of Surgeons launched a national Stop the Bleed campaign. The White House backed it. President Barack Obama declared that national disaster preparedness was a “shared responsibility” between citizens and the government, and Vice-President Joe Biden described Stop the Bleed as a “call to action” for anyone “in a position to help.” Cities at high risk for gun violence, including St. Louis and Baltimore, welcomed the program. Laurie Punch, a trauma surgeon and a leader of St. Louis’s Stop the Bleed efforts, has said that trainers “want people to discover that they’re not just victims—that they can actually save a life.”
The Orlando Fire Department was modernizing its first-responder protocol when, in June, 2016, a gunman shot up the Pulse night club, killing forty-nine people and injuring fifty-three. Trauma specialists based at George Washington University Hospital, in Washington, D.C., found that four of the victims might have survived if they had received “basic E.M.S. care” within ten minutes and had been transported to a trauma hospital within an hour. (None of those who died had received tourniquets or other bleeding-control interventions.) Two days after the Pulse shooting, the American Medical Association voted to adopt a new policy aimed at training the general public in bleeding control.
In Pittsburgh, Andrew Peitzman, U.P.M.C.’s chief of surgery, urged the hospital system to embrace Stop the Bleed. Seminars were soon held throughout the region, with a special emphasis on training law-enforcement officers. U.P.M.C. announced that it would donate more than a million dollars to provide such supplies as tourniquets and hemostatic gauze to every public school, and to put “a tourniquet on the belt of every law-enforcement officer in western Pennsylvania.” By the start of this year, nearly forty thousand people in western Pennsylvania had been trained, and bleeding-control kits had been handed out to some five hundred public schools in the area—more than anywhere else in the country.
Stop the Bleed uses a “ripple” approach: volunteers train people, who, in turn, train others. At the Mars Area High School seminar, Neal and Forsythe were the volunteers, along with a group of Cranberry Township paramedics and U.P.M.C. flight nurses. The team also included a more unusual participant: Neal’s nine-year-old son, Cameron, who often helps his father teach workshops. He was standing with the other volunteers in a red-and-blue striped shirt, khaki cargo pants, and glasses. Before Christmas, Cameron’s third-grade teacher had assigned how-to presentations; recommended topics included how to bake cookies or make a paper airplane. Although Cameron has various areas of expertise—Legos, kung fu—he chose to demonstrate Stop the Bleed.
The standard presentation contains graphic images: an enormous leg gash, a nearly severed foot. Macky Neal warns audiences that the photographs may be upsetting, and trainees sometimes look away or leave. The queasiness is understandable. Blood is supposed to remain inside the body, and it can be sickening to see it released, especially in large quantities. Blood is slippery and messy, and it has a strong metallic smell. Under certain circumstances, it may transmit disease. In traumatic injuries, blood may be mixed with body tissue and teeth and bone. Neal, the son of a Pennsylvania State Police commander, believes that showing people images of severe injuries, if done sensitively, can reduce their unease in a crisis later, just as the use of dummies in C.P.R. training helps people overcome the discomfort of performing chest compressions and mouth-to-mouth resuscitation during a cardiac arrest.
Primarily, the images are intended to help attendees identify life-threatening bleeding. Many bystanders’ instinct is to cover up blood. But, as Forsythe put it, “to stop bleeding you need to see bleeding.”
Paramedics talk about getting patients “trauma naked”—moving aside any clothing and pinpointing the source of hemorrhage. The loss of a limb is automatically considered life-threatening. In other cases, there are warning signs: Is blood pooling around the victim? Is the wound spurting? Are bandages saturated? Bystanders should pay close attention to a victim who becomes suddenly irrational or loses consciousness, symptoms that suggest the onset of hemorrhagic shock. Explaining that “people can bleed to death in as little as five to eight minutes,” Forsythe told the audience, “It often takes E.M.S. that long to respond.”
The location of a wound dictates treatment. For an arm or a leg, use a tourniquet. For a “junctional” injury—neck, armpit, groin—press against the wound or pack it with gauze. (Place the victim on a hard surface, to maximize pressure.) For a chest, belly, or head wound, the most helpful interventions, such as suction or a needle thoracostomy, require E.M.S. training, but applying pressure can help a patient hold on. Skeptics sometimes ask Neal whether administering emergency care will traumatize a young person, to which he responds, “It may be more traumatic to stand there and watch someone die.” The National Center for Disaster Medicine and Public Health recently received a fema grant to design a Stop the Bleed-style program for schools.
Neal’s son climbed onstage, to demonstrate how to address a severely bleeding wound. He knelt over an object that resembled a piece of smooth firewood. It was a training limb the size of an average male adult’s thigh, with the spongy consistency of flesh. A “wound” in the limb went all the way to the “bone.”
Cameron started by explaining manual pressure. He told the audience to place one hand on top of the other, interlocking the fingers for stability. “You’re gonna push as hard as you can, shrugging your shoulders,” for at least ten minutes, he said, or until help arrives. His father added, “This is not ‘one hand while you’re calling for help on your phone.’ When it’s your job to hold pressure, that is exclusively your job.”
The next subject was tourniquets. When a victim has a potentially fatal injury to an arm or a leg, Neal and Cameron explained, tourniquets should be applied right away and should be “high and tight.” Cinch the tourniquet just below the armpit or groin, they counselled, and “you will never be wrong.”
Cameron slipped a C-A-T onto the fake limb. As he cranked the windlass, Neal asked, “How do we know when to stop?” Cameron said, “When you don’t see any more blood coming out.” Once a tourniquet is on, it must be left on: only a medical professional should remove it. (Doctors advise against using improvised tourniquets—without a proper windlass, a belt or a tie won’t be tight enough.)
They moved on to wound packing. Forsythe told the crowd, “This is the part that gives some people the willies.” The hole in the fake limb simulated a gunshot or a stabbing injury. Cameron poked an index finger into it and said, “As you can see, it’s really deep.” He steadily thumbed length after length of gauze into the hole, and said, “You’re gonna stuff it in.” The audience laughed.
The wound held several feet of gauze. When no more fit, Cameron balled up the remaining material and used it to apply pressure on top. His father explained that, beneath the skin, a wound could be surprisingly large—it was important to “get gauze down in there, to occupy that space.” Packing a wound added pressure that impeded blood flow, and the kaolin in the gauze encouraged clotting. In a mass-casualty incident, using tourniquets and packing wounds could free up first responders to move on to other patients.
The audience had questions. Which should be used first with an extremity wound, a tourniquet or wound packing? A tourniquet. What if the patient fights you? Calmly but firmly explain what you’re doing, and acknowledge that the tourniquet may be painful. Forsythe noted, “Tourniquets hurt—a lot.” (Paramedics typically give victims pain medication.) What if you don’t have any hemostatic gauze? “If I needed to, right now, I could take off my scarf or my jacket and use that,” she said.
For the second half of the training, everyone trooped to the cafeteria and broke into groups. Each table held a fake limb and a Stop the Bleed kit. The basic kit, which is sold online by the American College of Surgeons, costs sixty-nine dollars. It contains a C-A-T, a compression bandage, protective gloves, hemostatic gauze, and a Sharpie, for writing “tourniquet,” and the time it was put on, in a highly visible location, such as across the patient’s forehead.
Neal and his son claimed a table near the cafeteria’s plate-glass windows, which overlooked a parking lot white with ice. Their students included a track-and-field coach, two custodians, an eighth-grade English teacher, a fifth-grade math teacher, and various administrators. One of the administrators watched the math teacher stuff gauze into the training limb, and said to Neal, “I mean, I understand that we need to stop the bleeding, but if you use your T-shirt to pack a wound—that’s not sterile!”
“You’re not gonna introduce a life-threatening infection,” Neal told her. “We can take care of that at the hospital, with antibiotics.” He added, “I don’t mean to be blunt, but let meworry about that problem.”
As everyone took a turn with the fake limb, the track coach, who had taught at the school for thirty years, mentioned that, after Sandy Hook, each of the classrooms at Mars had been issued a five-gallon “lockdown” bucket. The typical bucket contains gloves, bandages, Smarties candy, and kitty litter, which can be used as a makeshift toilet. Shaking his head, he said, “Times have changed.”
Brad Orsini, one of the F.B.I. agents who worked the Franklin Regional case, retired in December, 2016. The Jewish Federation of Greater Pittsburgh hired him right away, as its first director of community security. Violence affecting the Jewish community had “become increasingly common around the world,” the group’s C.E.O., Jeffrey Finkelstein, said at the time.
Orsini spent twenty-eight years in the F.B.I.; during part of that time, he was a crisis manager. His new job entails conducting security assessments of the federation’s seventy or so buildings and training the fifty thousand members of the local Jewish community in how to stay safe during an Intentional Mass Casualty Event. Orsini and the federation have also begun providing free training at mosques, through the Muslim Association of Greater Pittsburgh.
At Orsini’s workshops, he stresses the importance of maintaining situational awareness: don’t walk around wearing earbuds or staring at a phone. At offices and places of worship, it’s essential to have worked out an escape plan, and to practice it regularly. To smash open a window, he advises trainees, strike the corners, not the center. He teaches Run, Hide, Fight—the protocol that has become a dreadful necessity as mass shootings have proliferated.
One morning in January, I sat in on security training at a Pittsburgh-area organization. The door was open; I had walked right in. In a conference room, employees were gathering around freshly delivered pizzas. Orsini, who is tall and bald, with a strong Pennsylvania accent, told them, “Our worst nightmare is somebody walking in here with a semi-automatic rifle and high-powered rounds.”
On a large screen, he cued up security footage from January 6, 2017, of the baggage-claim area of the Fort Lauderdale airport. As travellers wheeled their luggage past carrousels, a young man reached into his waistband, removed a handgun, and began firing at random. Orsini told the room, “Watch what the people do. They just stood there, or got down on the ground.”
The gunman killed five people. The shooting lasted about a minute. Orsini asked the group, “In seventy seconds, how far can you move?”
A woman said, “So you’re saying run.”
“I’m saying run,” he said, adding, “Do whatever you can to stay alive.”
In early September, 2018, Orsini taught the same protocol at Tree of Life, a synagogue in the Squirrel Hill neighborhood of Pittsburgh. The Jewish Healthcare Foundation had bought a bleeding-control kit for every synagogue in town. Tree of Life had installed a kit near the front door and was upgrading its security measures. The rabbi, Jeffrey Myers, did not like carrying his cell phone on Shabbat, for religious reasons, but Orsini urged him to reconsider.
On the morning of Saturday, October 27th, Myers began services at nine-forty-five. At five minutes to ten, an armed man entered and started shooting. Myers instructed congregants to run, then he, too, fled, as he had been trained to do. From a second-floor bathroom, he called 911. The gunfire grew louder, then softer, then louder again, giving him a rough sense of the shooter’s movement through the building. Myers’s phone call helped first responders understand what was happening inside.
When the gunman attempted to leave the synagogue, two police officers confronted him, and he shot at them; one was hit, and the other took shrapnel. The shooter then retreated into the building. For the next hour and a half, the city’s emergency airwaves squawked with the communications of police, medics, and swat operators working the scene.
“We are pinned down by gunfire. He’s firing out of the front of the building with an automatic weapon.”
“Trauma surgeon is with the team.”
“We got four D.O.A.s—checking on one more.”
“I got one alive!”
“Four additional victims. Eight down, one rescued.”
“Two rescued from the basement; three more victims in the basement.”
“Contact! Contact! Shots fired! Shots fired!”
“We have one operator hit high in the arm. We have tourniquetted it.”
“He’s carrying an AR-15 and a Glock.”
The emergency-medicine physician at the scene was Keith Murray, who serves as the medical director of the city’s swat force. He leads a team called the Tactical Emergency Medical Service unit, which adheres to the “tactical combat casualty care” protocol that Frank Butler recommended in the nineties, after reviewing the Vietnam War data.
Murray and the paramedics he oversees have undergone advanced swat training, including in the use of firearms. Dressed in body armor, carrying sidearms, they move with swatoperators to the “far forward” point of conflict, to provide medical care as soon as possible. Like combat medics, they risk their lives in order to save lives.
Tactical medicine, in the civilian world, is an emerging specialty. Teams like Murray’s have been trained in hundreds of municipalities, from Los Angeles to Nantucket. Jim Morrissey, a former tactical paramedic for the F.B.I.’s San Francisco swat team, recently noted that “ ‘active shooter’ incidents have shifted the way law enforcement operates.”
Pittsburgh’s first responders use an app that alerts them to urgent calls. When an incident occurs, they receive bulletins on their phones, and they can notify the group if they plan to respond. As the Tree of Life emergency unfolded, Murray and ninety others responded that they were on the way.
Murray, who is in his early forties, grew up in Nevada, in a military family. He attended medical school in Chicago, where he became interested in tactical medicine. In 2011, he moved to Pittsburgh to start the Tactical Emergency Medical Service unit, and he and Macky Neal became friends. Both have young children, and wives in the medical field: Neal’s wife, Donielle, runs a research project on liver cancer; Murray’s wife, Jennifer, is a surgeon. Until Neal met Murray, he’d never heard of a trauma doctor being attached to law enforcement.
When Rabbi Myers dialled 911, Murray was getting his son, Aspen, ready for a birthday party for Neal’s daughter, Ellie. As Murray raced toward the scene, Neal, who was heading straight to the hospital, called him and asked, “Can this be real?”
Murray and his unit entered Tree of Life wearing Kevlar helmets and body armor, alongside swat operators. Murray carried a Glock in a drop holster on his left thigh. The pockets on his tactical vest held medical gear, including hemostatic dressings, chest seals, and tourniquets.
Inside the synagogue, they found a woman who had been shot in the upper right arm, and put a tourniquet on her. They cleared room after room, making their way to the third floor, where the shooter had barricaded himself in a classroom.
As operators forced their way inside, the shooter fired. The point man went down, with a shot to the head. Another operator positioned himself on the ground in front of him, so that his body armor could block bullets “like a sponge.”
The other operators couldn’t access the room because the first two lay in the doorway. An officer shot rounds through the wall, but the attacker was moving. “He’d shoot and move, shoot and move,” Murray told me. swat operators splashed light on the darkened space, to get their bearings, and saw dust falling from the disintegrating ceiling, like snow.
An officer dragged the point man out of the doorway and down the stairs, to a treatment station that Murray had set up. The team cut away his clothes and saw that he had been hit in multiple locations, including the left arm and both legs. As the gunfire continued, Murray put two tourniquets on the point man’s arm and a tourniquet on each leg. The officer who made the rescue had been shot in the wrist, and a teammate tourniquetted him.
All eleven of the congregants who were killed died before Murray’s unit arrived. Everyone who left Tree of Life as a patient survived. The shooter, shot in the wrist and the hip, surrendered. “Suspect’s talking about ‘all these Jews need to die,’ ” someone on the emergency airwaves told a dispatcher. Murray’s team packed the attacker’s hip wound and put a tourniquet on his arm, and sent him out alive
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