When it comes to saving the life of a gunshot victim, it's all about stopping the blood loss.
Amid the horrific images from the mass shooting Sunday in Las Vegas, that may sound like a fairly obvious statement. But just in the last few years, findings from other mass shootings and from the battlefield have changed the delivery of medicine, physicians say.
Trauma researchers now recommend that emergency medical providers be brought to the scene as soon as possible — even before the threat is fully neutralized — as every additional minute of blood loss can worsen a patient's chances. Police officers are encouraged to "scoop and run," transporting trauma victims to the hospital in the back of their cruisers to minimize the loss of blood — a longtime practice in Philadelphia that is now catching on elsewhere. And tourniquets have been placed in schools, malls, and other public places, with civilians starting to get training in how to use them.
These changes stem from research showing that blood loss, while not the most common cause of death from trauma, is the most preventable, said Penn Medicine trauma surgeon Jeremy W. Cannon.
Researchers now commonly study the outcomes of past mass shootings to determine which lives might have been spared with faster action, as uncontrolled bleeding can lead to death within five to 10 minutes, he said.
"We are operating under the assumption that there must be some individuals that have potentially survivable injuries that in times past were not saved," said Cannon, who served with the Air Force in Iraq and Afghanistan. "You have to have a sense of urgency from the very beginning."
A year ago at Lincoln Financial Field, Penn trained more than 250 school nurses in the use of tourniquets, which are tightened around an injured limb to stem blood loss. In New Jersey, Cooper University Health Care has distributed the belt-like devices to police departments and schools, and it offers free classes in how to use them.
These efforts are part of a national "Stop the Bleed" campaign, at bleedingcontrol.org sponsored by the American College of Surgeons. The initiative was largely spurred by the findings of Hartford Hospital trauma surgeon Lenworth Jacobs after the 2012 Sandy Hook Elementary School shooting, in Newtown, Conn.
Improving survival from gunshots is not just about those precious minutes before reaching the hospital, said John M. Porter, chief of trauma at Cooper.
Years ago, trauma surgeons would try to repair all the damage from gunshot wounds in one grueling, marathon session. Now, they fix the most grievous injuries and save the rest for another day, he said, so as not to overtax the victim's already perilous condition.
"Fix the main things that are going to kill the person and then stabilize them," said Porter, a former Army trauma surgeon.
But what to do when the numbers of wounded are overwhelming, such as with the hundreds injured in Las Vegas? Porter said he never saw anything on that scale during his 19 years in the reserves, which included duty in the Middle East.
The greater Philadelphia area is well-supplied with trauma centers, but in many parts of the country, a mass casualty would quickly lead to shortages of ambulances, blood, and operating rooms, he said.
Even with aggressive focus on blood loss and continued improvements in surgical techniques, the toll from gunshots and other trauma remains greater than most people realize, said Penn's Cannon. According to the U.S. Centers for Disease Control and Prevention, firearm-related deaths accounted for more than 36,000 deaths in the U.S. in 2015.
Heart disease and cancer get top billing in this country as leading causes of death, but those are diseases that strike older people. Trauma, which occurs more often in younger patients, overwhelmingly accounts for the most years of life lost, Cannon said.
Every year, an estimated 5.4 million years of life are lost due to early death from trauma, compared with 3.2 million to heart disease and 4.4 million to cancer, he said.