OPTIMIZING INDIVIDUAL FIRST-AID KIT PLACEMENT IN K-12

SCHOOL ENVIRONMENTS

by
Collin N, Knolhoff

A Thesis
Submitted to the Faculty of Purdue University
In Partial Fulfillment of the Requirements for the degree of

Master of Science

Department of Computer and Information Technology

West Lafayette, Indiana
December 2023
THE PURDUE UNIVERSITY GRADUATE SCHOOL
STATEMENT OF COMMITTEE APPROVAL

Dr. J. Eric Dietz, Chair

Department of Computer and Information Technology

Dr. Sogand Hasanzadeh

Lyles School of Civil Engineering

Dr. Eric Matson

Department of Computer and Information Technology

Approved by:
Dr. Chad Laux

2
Dedicated to the victims of America’s mass casualty events.

3
 ACKNOWLEDGMENTS

While it is impossible to give proper thanks and acknowledgment to everyone who has

helped me in this pursuit, I would like to give special acknowledgment and thanks to Dr. Dietz.

His mentorship, commitment, and encouragement by various means throughout both my

undergraduate studies and my master’s degree have been invaluable.

I would also like to thank the other members of my committee, Dr. Hasanzedah and Dr.

Matson, for their support and time. Several fellow students have also contributed work to our active

shooter research or supported my time at Purdue in other ways. Specifically, I owe thanks to Jay

Lee, Krassimir Tzvetanov, and Rick Weston.

Finally, and most importantly, I would like to thank my God, family, and friends who have

supported me in ways I cannot even describe as I pursued this achievement.

4
 TABLE OF CONTENTS

LIST OF TABLES .......................................................................................................................... 7

LIST OF FIGURES ........................................................................................................................ 8
LIST OF ABBREVIATIONS ......................................................................................................... 9
ABSTRACT.................................................................................................................................. 10
INTRODUCTION .............................................................................................. 11
1.1 Introduction to the Problem .............................................................................................. 11
1.2 Statement of the Problem .................................................................................................. 13
1.3 Significance....................................................................................................................... 15
1.4 Research Questions ........................................................................................................... 16
1.5 Purpose.............................................................................................................................. 16
1.6 Scope ................................................................................................................................. 17
1.7 Definitions......................................................................................................................... 18
1.8 Assumptions...................................................................................................................... 20
1.9 Limitations ........................................................................................................................ 21
1.10 Delimitations .................................................................................................................. 21
LITERATURE REVIEW ................................................................................... 22
2.1 Search Methodology ......................................................................................................... 22
2.2 Literature Summary of the Problem ................................................................................. 23
2.3 Literature Review Related to ASI AAR’S ........................................................................ 25
2.4 Literature Related to TCCC, IFAKS, and Wounds/Blood Loss ....................................... 40
2.5 Research Related to IFAK Placement Optimization ........................................................ 48
RESEARCH METHODOLOGY ........................................................................ 49
3.1 Overview ........................................................................................................................... 49
3.2 Any Logic ® Agent-Based Modeling ............................................................................... 50
3.3 Tzvetanov Model .............................................................................................................. 51
3.4 Thesis Simulation Model .................................................................................................. 52
3.5 Experiment Outlines ......................................................................................................... 55
3.6 Agent Definitions .............................................................................................................. 58
3.7 Model Limitations............................................................................................................. 59

5
 RESULTS ........................................................................................................... 60
4.1 Data Cleaning.................................................................................................................... 60
4.2 Data Summary .................................................................................................................. 61
4.3 Data Objectives and Methods ........................................................................................... 64
4.4 Data Analysis Results ....................................................................................................... 67
4.5 Data Discussion ................................................................................................................ 71
SUMMARY AND RECOMMENDATIONS ..................................................... 74
5.1 Overview ........................................................................................................................... 74
5.2 Significance....................................................................................................................... 75
5.3 Recommendations for Future Studies ............................................................................... 77
REFERENCES ............................................................................................................................. 80

6
 LIST OF TABLES

Table 1. ANOVA of residuals proving equal variance ................................................................ 66

Table 2. One factor ANOVA of Deaths Column ......................................................................... 67
Table 3. One-factor ANOVA of Kits Left with Agents Columns. .............................................. 68
Table 4. One-factor ANOVA of Number Saved Columns .......................................................... 69
Table 5. Two-Sample T-test Between Exp 1 and 2 Average Deaths........................................... 70
Table 6Two-Sample T-test comparing Exp 1 and 2 Kits Left with Agents Means ...................... 70
Table 7. Two Sample T-Test comparing Exp 1 and 2 Number Saved Means............................. 71

7
 LIST OF FIGURES

Figure 1: ASI Victims per Year in Schools (Reidman & O’Neil, 2020) ...................................... 13
Figure 2: ASI Incidents by Year (Reidman & O’Neil, 2020) ....................................................... 14
Figure 3: Picture of Common IFAK Contents (North American Rescue, 2023).......................... 19
Figure 4. Pulse Nightclub Layout (Straub et al., 2017) ................................................................ 28
Figure 5. Experiment 1 Simulation Layout................................................................................... 56
Figure 6. Experiment 2 Simulation Design................................................................................... 57
Figure 7. Experiment 3 Simulation Design................................................................................... 58
Figure 8. Average Kits Left w/ Agents ........................................................................................ 62
Figure 9. Average Deaths ............................................................................................................ 63
Figure 10. Average Experiment Duration .................................................................................... 63

8
 LIST OF ABBREVIATIONS

ASI: Active Shooter Incident

IFAK: Individual First Aid Kit
TCCC: Tactical Combat Casualty Care

9
 ABSTRACT

With increasing frequency, American schools have been plagued with mass casualty events

perpetrated by offenders using various types of firearms. In recent years, several studies have used

AnyLogic®, an agent-based computer modeling software, to model some of these mass shooting

events. More specifically, researchers have modeled mass shooting events and how changes in

police response and victim response affect casualty rates in these scenarios.

Another model has used the same agent-based software to model mass-casualty events of

various venues. The model goes further by integrating what will be known throughout this paper

as “the bleed-out model”. The bleed-out model uses known data from these mass casualty events

to model types of injuries and their related probability of resulting in a fatality. The model also

uses known data about traumatic wound interventions from mass casualty scenarios, as well as law

enforcement and military applications, to model life-saving measures to counteract traumatic

injuries and decrease the probability of a victim becoming a fatality.

This research used AnyLogic® software to integrate agent-based school shooting models

with an agent-based bleed-out model. Once combined, individual first aid kits (IFAKs) geared

toward traumatic wound/hemorrhaging care were introduced into the environment and their

placement was arranged in several different ways. AnyLogic® software and quantitative analysis

were used to recommend best practices for implementing IFAKS in schools.

This research specifically examines whether the placement distance for IFAKS in schools

during an active shooter incident could have a statistically significant impact on the survivability

of active shooter victims. Different scenarios are assessed in the AnyLogic® model varying the

placement of a fixed number of IFAKS throughout the school during an incident.

10
 INTRODUCTION

1.1 Introduction to the Problem

Mass casualty shootings have changed the way Americans view everyday life. Specifically,

active shooter events in schools have forever changed how they function and how the staff,

students, and their families view everyday education. Mass casualty shootings are defined by the

Federal Bureau of Investigations (FBI) as the killing of 4 or more individuals, in a single incident,

excluding the shooter (Krouse & Richardson, 2015). Since 1970, there have been 191 active

shooter incidents in K-12 schools in America (Reidman & O’Neill, 2020). This data is accurate to

June 2022.

The injuries to victims of these events vary, but some of the injuries mirror those seen on

the battlefields of U.S. conflicts in Iraq and Afghanistan (Blair & Schweit, 2014). The US

Military’s experiences with these mirrored wounds in the Middle East theater led to the

development of tactical casualty combat care (TCCC) principles, and these principles were

eventually translated to American law enforcement through TCCC and Stop the Bleed courses

(Butler & French, 2015).

The history of active shooter incidents in America are examined in this research for

instances where either the active shooter delayed the first responder’s ability to immediately render

life-saving aid to victims (Pulse Nightclub) or the police response caused a delay in emergency

care (Robb Elementary). Specifically, this paper evaluates the after-action reports of the Aurora

Theater shooting, the Uvalde school shooting, the Pulse Nightclub shooting, and the Columbine

school shooting. In all these instances, for varying reasons and to varying degrees, first responders

were not able to provide immediate medical aid to gunshot wound victims. Apart from some

statements about the Uvalde police response, this research does not seek to question or “Monday

11
morning quarterback” the actions of officers responding to a tense and rapidly evolving situation.

Also, throughout the research, the names of the shooters in these four instances are not used out of

respect for the victims of the shootings.

This paper discusses in great detail the TCCC approaches that have been proven to

significantly improve mortality outcomes for victims of traumatic hemorrhaging wounds. These

types of wounds are commonly found at the scenes of school active shooter events, and while law

enforcement is mostly equipped to apply these measures to victims, law enforcement’s first goal

when arriving on an active shooter scene is not to provide life-saving care to victims but rather to

find and eliminate the threat to prevent further loss of life (Blair, 2013).

This paper uses an agent based, AnyLogic® computer model to simulate an active shooter

event that occurred at Robb Elementary School in Uvalde, Texas. Within that model, TCCC

equipment is inserted into the simulated school environment and placed in varying locations during

different simulations. This equipment (later referred to as Individual First-Aid Kits IFAKS in this

paper) and training is applied by civilians (teachers/other faculty and students) in the model so

traumatic wound victims are treated as quickly as possible.

The goal of this paper is to use agent-based computer modeling to determine if adding

IFAKS of varying quantities, at locations, in a school environment and combining varying levels

of TCCC training to those in the school environment would significantly reduce mortality rates of

active shooter victims. This paper reviews the current literature surrounding active shooters and

traumatic wound care applications, explains the methodology of the model, and provides a

quantitative analysis of the results of the AnyLogic® model.

12
 1.2 Statement of the Problem

Active shooter instances in schools have become a common discussion topic in American

culture. In 2014, the Department of Homeland Security (DHS) defined active shooters as “an

individual actively engaged in killing or attempting to kill people in a confined and populated area.”

The goal of the active shooter, according to DHS, is to inflict the maximum casualties in a

minimum amount of time (DHS, 2014).

Between 2000 and 2009, 102 active shooter events occurred. This includes but is not

limited to K-12 schools. This averages approximately 10 per year. Over the next ten-year span

(2010-2019), active shooter instances increased to 231. This averages approximately 23 instances

per year; this is more than double the average when compared to the previous decade (Blair &

Schweit, 2021). For the period 2017-2021, active shooter data shows another increase in incidents.

The number of incidents in 2021 is a 52% increase in incidents from 2020 and nearly 100%

increase from 2017 (Blair & Schweit, 2022). Since 1970, there have been 191 active shooter

incidents in K-12 schools in America. During those incidents, there were 216fatalities.

Figure 1: ASI Victims per Year in Schools (Reidman & O’Neil, 2020)

13
 Figure 2: ASI Incidents by Year (Reidman & O’Neil, 2020)

Active shooter incidents (ASI), as seen by the above definition, occur in a place where

people are confined and densely populated. FBI data shows that approximately 81% of these

confined environments are “gun-free zones” which forbid the carrying of weapons by civilians in

hopes of reducing gun violence. The zones also prevent potential victims of the active shooter from

defending themselves with a firearm (Anklam, 2014).

K-12 schools are one of these “gun-free zones.” This makes them by nature a target-rich

environment with no standard deterrent apart from an embedded school resource officer (SRO)

(Weston, 2023). In the last two decades, there have been 64 active shooter incidents in K-12

educational environments (Reidman and O’Neill, 2020). K-12 environments are the third highest

targeted environment for active shooters, and their ASIs make up approximately 15% of active

shooters casualties in the last two decades (Blair & Schweit, 2022).

14
 1.3 Significance

Data suggests that ASIs have a common denominator. Event duration and casualties have

a positive statistical correlation (Anklam et al., 2014). In other words, the longer an active shooter

incident lasts the more casualties result at the end of the attack. Furthermore, the Department of

Justice concluded that the average national police response time to active shooter incidents is five

to six minutes (Buster, 2008). In some places, the average police response time is much longer.

These two data observations are important when combined with other tactical medicine literature

later in this section.

Hemorrhaging accounts for approximately 90% of all potentially survivable law

enforcement/military deaths, which are the closest datapoints to civilian ASI casualties, and

approximately 40% of all otherwise preventable civilian deaths (Aberle et al. 2015). A significant

work of research has shown that early hemorrhagic field intervention significantly improves

patient outcomes. This body of research will be outlined in detail in Chapter 2 of this work.

As current active shooter protocols stand, the longer that an ASI lasts, and the longer it

takes for law enforcement to arrive the longer it takes for people to have access to IFAKS and

lifesaving hemorrhaging interventions. IFAKS are generally not accessible in schools and are

generally only carried by first responders. The significance of this study lies in introducing

exposingIFAKS to an active shooter environment before first responders arrive. Introducing

IFAKS into this environment for treatment before first responders arrive could have a significant

impact on the number of fatal victims. Examining the distance and deployment of these IFAKS in

schools is an important question when determining how they can best be used in schools to mitigate

casualties. Informing data and literature on this question could have a significant impact on both

policy and funding. The policy could be impacted if the literature and data demonstrate positive

results from early access to IFAKs in ASIs. Funding could be impacted if there is enough literature

15
to suggest that optimal quantity and/or distance to IFAKs in K-12 schools decreases casualty rates.

Governments may find the data compelling enough to grant money to K-12 schools in the interest

of having access to IFAKs.

1.4 Research Questions

The following questions are considered in this research project:

1. Are there real-life active shooter incidents that support the notion that earlier medical

intervention during an active shooter incident could have decreased the number of

fatalities?

2. Is there data to support that IFAK contents have a significant impact on reducing

fatalities in trauma situations?

3. Does changing the distance/deployment of IFAKS in schools during an ASI reduce

the casualty rate by a statistically significant amount?

The independent variable in this study is the distance/placement of the IFAKS in the

AnyLogic®-based ASI simulation. The dependent variable that is studied is the casualty (death)

rate of the injured in the ASI. This data will be mined as the output data from the AnyLogic®

simulation. The simulation tracks time, number of injured, and number of deceased.

1.5 Purpose

The purpose of this thesis is to determine if, through quantitative methods, the introduction

of IFAKS into an active shooter environment is advantageous to the preservation of life.

Furthermore, this work seeks to determine whether varying the distance/placement of IFAKS in

16
the school active shooter environment has statistically significant impact on victim survivability.

The project tests the following hypotheses:

1. Varying the distance/placement of IFAKS in a K-12 school during an ASI does not

impact the casualty rate by a statistically significant amount.

2. Varying the distance/placement of IFAKS in a K-12 school during an ASI does

impact the casualty rate by a statistically significant amount.

Statistical significance is measured using an ANOVA statistical test with a significance value of α

= 0.05

1.6 Scope

This research project focuses on mitigating casualties during an active shooter incident in

K-12 schools in the United States. This research specifically focuses on the use of IFAKS in the

active shooter environment. The research reviews the after-action reports of four different

infamous US active shooter incidents. Two of these incidents were specific to the K-12 school

environment. These after-action reports review in part whether IFAKS were instrumental in saving

lives during these incidents. These reviews are also used to assess the time delay of the introduction

of IFAKS and discuss whether that delay in introduction contributed to the loss of life.

Following the reviews, the project discusses the research related to the effectiveness of

IFAKs in stopping otherwise preventable trauma death. The research also discusses some of the

pathophysiology of blood loss and trauma as it relates to common gunshot wounds in active

shooter incidents. Finally, the research assesses whether varying distance and placement of IFAKS

in a school setting during an active shooter incident decrease casualties by a statistically significant

rate.

17
 1.7 Definitions

Active shooter incident (ASI) is a definitional word originally coined by the Federal

Bureau of Investigations (FBI). It originated when the agency conducted a comprehensive review

of active shooter incidents in America. As a result of that review, the FBI published a paper (Blair

and Schmidt, 2014) where the FBI defined an active shooter incident as “an individual or

individuals that are actively engaging in killing or attempting to kill people in a confined or open

populated area.”

Most believe that mass shootings are an interchangeable term with active shooter incidents,

but that is not the case. A mass shooting is defined by the FBI differently than an ASI. Mass

shootings are shootings that result in four or more gunshot victims. This is why there are many

more mass shootings recorded every year than active shooter incidents even though mass media

uses the terms interchangeably. Mass shootings can involve gang, gun, and drug violence incidents

where four or more people are shot, but those incidents do not constitute an active shooter incident

(Gun Violence Archive, 2022).

As a part of this research, individual first aid kits (IFAKS) and their contents must also

be defined. The term IFAK can be a wide-ranging term. The term can be used to describe any type

of medical kit ranging from simple first aid kits to very intricate trauma kits. For this study, IFAK

will be defined by the IFAK prescribed by the National Stop the Bleed Organization. The specific

contents of the IFAK will be outlined in chapters 2 and 3. Stop the Bleed is an organization that

sets the national standard for emergency trauma hemorrhaging mitigation techniques (Stop the

Bleed, 2023). Most of these techniques fall under the practices of Tactical Combat Casualty

Care (TCCC). TCCC is “developed by the U.S. Department of Defense, Defense Health Agency

(DHA) Joint Trauma System (JTS) to teach evidence-based, life-saving techniques and strategies

18
for providing the best trauma care on the battlefield”. TCC is the standard for pre-hospital, field

trauma medical interventions (NAEMS, 2023).

Mitigation techniques are methods to “minimize the effects or damage of an occurring

threat” (Tzvetanov et al., 2022, 5). The threat in this instance is usually hemorrhaging that results

in death. Hemorrhaging is defined as “a rapid or uncontrollable loss of blood” (Merriam-Webster,

2023). Stop the Bleed has an IFAK designed to mitigate hemorrhaging. It is a standard soft-sided

case that contains a CAT Tourniquet, Quick Clot wound dressing, Israeli bandage, and a Hy-vent

chest seal.

Figure 3: Picture of Common IFAK Contents (North American Rescue, 2023).

For this study, when IFAK is referenced, it is defined with those contents. All four of the

contents are specific brand objects that are made by specific companies so there is little variation

in effectiveness among IFAKs (Stop the Bleed, 2023).

This research uses AnyLogic® technology to create a virtual, simulated active shooter

incident environment. AnyLogic® ® is a proprietary modeling software. Version 8.4 is the version

that is used for this simulation. It is a discrete event modeling software. It models discreet events,

and agent-based, dynamic modeling environments.

19
 1.8 Assumptions

This research project makes several assumptions. They are all related to the model itself

and the resulting data from the model. The first assumption made is that the model assumes that

actors behave in a way that is rational and under a certain set of rules. This choice

simplified human behavior to rationality in otherwise chaotic circumstances. Agents act under a

certain set of rules that cause them to act reasonably under what would generally be considered a

stressful circumstance.

The second assumption that is made is about the assailant. All actors’ discharge range,

scope, and interval were fixed to reflect the reasonable actions of actual agents. The discharge

accuracy of all actors is fixed.

The third assumption the model makes is that the actors applying the contents of the IFAK

have the minimum necessary training and knowledge to successfully deploy the contents of the

IFAK. Improper applications of the tools inside the IFAK could lead to the tools being ineffective.

The model assumes that people are deploying the contents of the IFAK properly.

The fourth assumption that this research makes is that the victim is only ailed with one type

of wound and thus only requires one kind of IFAK intervention. For example, a victim could have

a leg wound that requires a tourniquet or a penetrating chest wound that requires a vented chest

seal, but the victim will not have both of those wounds while requiring both interventions.

Finally, this research assumes that the gunshot victims are all relatively uniform in health

and reasonably healthy individuals with no other significant or confounding health problems that

would render the IFAK treatment less effective than if applied to a reasonably healthy individual.

20
 1.9 Limitations

This research thesis is not capable of considering all the complexities and variations from

school to school in budgets, size, and training. Some schools might not be able to afford the

necessary IFAK equipment (e.g., 887 May only be able to buy tourniquets but not chest seals).

Some schools may not be able to provide as frequent training to interested teachers on Stop the

Bleed protocols. Some schools may be larger than others and require more IFAKs than others.

Some schools may also have more complex layouts and require a different placement than the

simpler design layout used in this model.

1.10 Delimitations

The scope of this research focuses specifically on the distance/placement of IFAKS in

schools and whether that placement affects casualty rates. Several other questions could be and

should be addressed related to IFAKs and active shooter incidents, but they will not be addressed

in this research. Among those questions is that this research does not answer the question of what

the optimal number of IFAK is in a school to maximize the reduction in casualties. This research

only uses a fixed number of IFAKs and does not venture whether varying the number of IFAKs

also impacts casualty rates.

This research also does not address any law enforcement or other first responder

interventions during the ASI. It is possible that LE and other first responders have IFAKs, and

their intervention could also decrease the casualty rate. This research does not address the possible

interventions or best practices for first responder intervention during an ASI.

21
 LITERATURE REVIEW

2.1 Search Methodology

The researcher utilized a variety of research methods to identify and evaluate sources for

this thesis. The researcher began by reviewing a wealth of ASI research from the Purdue University

Department of Homeland Security Institute. Literature from Anklam et al. (2014), Kirby (2016),

Frantz (2021), Lee (2019), Weston (2023), and Knolhoff (2022) provided a wealth of information

as it related to ASI mitigation and the significance of the ASI issue in American society. The

researcher then reviewed a wealth of other works that were referenced in the above works like

studies originating with federal agencies and other works from other respected experts in the field

of ASI mitigation.

The researcher further used a combination of search engines, including Google, Google

Scholar, and Purdue’s library database to research the issue at large and ascertain a better

understanding of the current literature related to ASIs, ASI threat mitigation, and ASI after-action

reviews (AARs). The researcher also used similar research methods, as well as a review of

Tzvetanov (2021 & 2022) to better understand IFAKs and how they relate to wounds sustained

from ASI’s and their correlating trauma treatments.

To gain a better understanding of the problem related to my research question in real life,

the researcher identified four real-world ASI incidents to study. Each of these major ASIs in United

States history has had an after-action review (AAR) conducted and documented. These ASIs

helped the researcher better understand the workings of an ASI in real life and how the actions, or

in some cases inactions, taken during the incident contributed to further loss of life. Specifically,

the AARs explain how decreasing the time between injury and treatment by IFAKs decreases the

mortality rate. The AARs discuss different strategies for how to decrease these times.

22
 The researcher also identified another necessary component to understanding the content

surrounding the research question. The researcher used Google Scholar to identify different studies

and journal articles that identified best practices for TCCC. TCCC is an important aspect of

understanding this research because the timing and application of IFAK materials are governed by

the practices of TCCC.

TCCC principles and practices also help us better understand the effectiveness of IFAK

applications as they relate to casualty rates. The researcher used several research engines to find

studies relating to the effectiveness of the major components in the above-defined IFAK in treating

gunshot-related wounds and to what degree those components have decreased casualty rates.

The researcher also used the same methodology to understand wound types and bleed-out

times, an important aspect of the research. Wound types dictate which IFAK component needs to

be used to address the issue, and different wound types vary in casualty rates and probabilities.

Bleed-out times help the model understand how long an individual victim must be treated by an

appropriate IFAK component considering the wound type before the victim becomes a casualty.

2.2 Literature Summary of the Problem

The active-shooter tragedy in America is a problem that has the potential to affect every

man, woman, and child at any time. Children can be particularly vulnerable in schools because

schools are considered “gun-free zones” (Blair & Schweit, 2014; Blair & Schweit, 2022). ASIs

have occurred across the continental United States. They have occurred in schools large and small

and schools that are in metropolitan areas and rural areas alike. So, to understand the significance

and gravity of this research, the literature first needs to establish that the problem is of great

significance. Some believe that ASIs are not a problem because they are relatively rare and would

23
never happen to them. However, all schools are susceptible to ASI’s. The last 40 years of American

history have proved that ASIs in American schools are a universal risk (Lincke & Khan, 2020).

ASIs in schools is not potential problem in the United States but an actual problem.

Furthermore, the problem is growing. Starting in the early 1970’s, the number of defined active

shooter incidents averaged around two incidents per year. However, in the last five full years, with

the exclusion of 2020 due to the COVID pandemic, the average number of ASIs in K-12 schools

in America has risen to just above seven incidents/per year (Reidman & O’Neill, 2020).

The impact is also growing, and it can be measured in several ways. The most logical and

arguably most important impact that they can have is the loss of life, generally young American

lives, that are directly caused by ASIs in schools. From 1970-1974, the average number of

casualties from ASI’s in American K-12 schools averaged at approximately six people/year.

However, since 2018, with the exclusion of 2020 due to the COVID pandemic, the average number

of people killed because of ASIs in American K-12 schools is approximately 42 people/year

(Reidman & O’Neill, 2020).

There has been a significant amount of literature that focuses on the use of IFAKS and

TCCC applications on gunshots and other penetrating wounds. Some of this literature focuses on

the effects of penetrating wounds on blood loss and the resulting physiological effects of those

wounds on the human body. The researcher reviewed several literature submissions to better

understand this aspect of the research question including Aberle, Smith, Miller, Tzvetanov, and

Eastland. These resources are expounded upon later in the wounds and bleed-out times section.

This research also required an understanding of TCCC protocols and IFAK interventions

and their resulting effectiveness on their corresponding wound types. Bennet (2014) gave the

researcher an overall understanding of hemorrhaging and other penetrating wounds and their

24
effects on victim mortality. The researcher then reviewed a total of nine journal articles that

outlined the effectiveness of the most common types of TCCC interventions for the most common

wound types outlined by Bennet.

2.3 Literature Review Related to ASI AAR’S

The unfortunate reality is that one of the best ways to learn about active shooters and

mitigation strategies is to look at real-life tragedies that have occurred in the United States. Several

of the more infamous incidents occurred in K-12 schools while others occurred in entertainment

venues. Several of these incidents have extensive and comprehensive AARs done in academic

journals that reviewed the circumstances surrounding the shooting, the police response to the

incident, and recommendations for future police response that would mitigate loss of life. These

AARs are cited individually in the coming pages.

Several of these AARs specifically review the tactical medicine response immediately

following the shooting and discuss how different approaches and quicker IFAK/TCCC application

would have led to a decrease in loss of life. This research reviews AARs from four significant

ASIs in American history: Columbine High School, Pulse Nightclub, Aurora Colorado Movie

Theater, and Uvalde, Texas Elementary. Columbine is examined because it was the first significant

active shooter incident to ever occur in a K-12 school in the United States, and it forever changed

the way American law enforcement responds to ASIs. Uvalde, Texas is included because it was a

significant law enforcement failure that resulted in significant and unnecessary loss of life. Those

failures, however, gave insight into the importance of access to TCCC and IFAK materials for

involved persons who are not arriving first responders. Pulse Nightclub is also an instance where

there was a significant delay in first responders being able to provide immediate medical care due

to tactical considerations at play when the shooter barricaded himself on the scene. Aurora is

25
included as an example because it could provide other data outside of a school setting to see if

literature could support these types of ideas in a wide variety of venues. News outlet sources are

cited in the coming sections as the AARs of each incident are individually examined.

Reviewing these after-action reviews, which are individually cited in each event section,

reveals a few trends that are discussed and applied to understanding the implications of the research

question. The first is the idea of hot, warm, and cold zones in the active shooter mitigation

environment. This includes the priority care trauma matrix and the different types of interventions

that can be applied in different zones. The second trend is the importance of timely field trauma

response and the consequences that can occur if that end is not achieved. The third trend in the

AARs is the importance of access to TCCC and IFAK materials (Straub et al. 2017), (ALERRT,

2022), (Schaenman et al, 2014), and (Columbine Report, 2012).

A. Pulse Nightclub Shooting Timeline

On June 11, 2016, a male opened fire in an Orlando nightclub and killed 49 people.

(Fitzsimmons, 2021). Up to that date, this shooting took the record for the deadliest mass shooting

in America. While the shooting did not occur in a K-12 educational environment, there are several

lessons about active shooter response and tactical medicine that can be learned by a review of the

literature around the shooting.

Around 02:00hrs on June 12, there were approximately 320 people in the Pulse Nightclub

in Orlando, Florida. About that same time, He entered the club armed with a Sig Sauer MCX semi-

automatic center-fire rifle (chambered in 5.56) and a Glock 17 semi-automatic handgun

(chambered in 9mm). He opened fire on patrons in the main area of the club. Shortly after, He was

engaged by an off-duty Orlando Police officer working extra duty. Several people were wounded

26
and killed in the initial volley of gunfire before the off-duty officer engaged him (Tampa Bay

Times, 2021)

Being confronted, the shooter moved deeper into the club. He continued shooting victims

as he maneuvered in the club. Additional on-duty Orlando Police Department units arrived on the

scene around 02:04hrs. Two more officers engaged the shooter, and he was forced even farther

into the club. He eventually entered one of the bathrooms where a hostage situation ensued. At

this point, the shooter had fired approximately 200 rounds in approximately five minutes (Tampa

Bay Times, 2021). Upon initial entry into an adjacentbathroom, he killed and wounded a few

people. The rest he held as hostages, while some were still wounded, until 05:17hrs when the

shooter was finally killed in a firefight with Orlando Police SWAT Operators (Tampa Bay Times,

2021).

B. Pulse Shooting After Action Review

The Department of Justice conducted a detailed after-action report of the shooting, and

there are several details of interest related to active shooters and tactical medicine in an educational

environment. The report notes that throughout the entire incident, 122 people had been shot; 49 of

those victims died of their wounds. (Straub et al. 2017)

The report also gives a timeline of OPD rescuing wounded patrons from the club. This

timeline again becomes important later in the literature review when hemorrhaging statistics are

addressed. It should be noted that the report states it is difficult to determine exactly how many

patrons were rescued throughout the operation, so all numbers given are the minimum number

possible. Around 02:09, seven minutes after the shooting began, the first victim was rescued by

OPD. Between 02:09hrs and 02:18hrs, officers assisted another 30 people out of the club, but these

27
individuals did not appear to be injured by gunfire. They were able to hide in different locations

throughout the club. (Straub et al. 2017)

Between 02:18hrs and 02:28hrs, OPD officers were able to extract 14 incapacitated (from

gunshot wounds) persons from the main dance floor. During this time frame (around 02:21hrs),

another wounded male was rescued from a different location in the bar. Around 02:32hrs, five

more wounded individuals were rescued from the club. At 03:06hrs, another wounded male was

rescued by OPD. During the breach by OPD SWAT operators, several more wounded persons

were rescued by OPD SWAT from the bathrooms after Mateen was killed. The last person was

extracted at around 05:27hrs, and the scene was rendered safe at 11:15hrs (Straub et al. 2017).

Figure 4. Pulse Nightclub Layout (Straub et al., 2017)

28
 The DOJ’s report also discusses an important concept to consider in casualty evacuation

and tactical medicine, zones. There are three types of safety zones in an active shooter scenario:

the hot, warm, and cold zones. Hot zones are areas where a “direct and immediate threat exists.”

A warm zone is a place where a potential threat exists, but there is no direct and immediate threat.

Best practice dictates that fire and medical assets can be employed in a warm zone where casualties

exist, but they should only be deployed with force protection. Force protection is not always

available promptly for the victims who are wounded and hemorrhaging. This is the in-between

zone where victims exist, but the deployment of medical assets may not yet be feasible. The best

outcomes for gunshot wound victims in a warm zone may come from civilian hands. Finally, a

cold zone is an area where no significant danger or threat can be reasonably anticipated. (Straub

et al. 2017)

The after-action report also devoted an entire chapter to the tactical medical interventions

used to try and save victims during the event. Tactical medicine has evolved and will continue to

evolve as the ballistic impact from various types of civilian firearms increases. Providing traumatic

wound care in the field is becoming more and more imperative to victim survival. The AAR notes

several instances where the quick deployment of TCCC applications to civilian casualties during

an ASI undoubtedly saved lives. One such example is the shooting of AZ Congresswoman

Gabrielle Giffords. Responding Sheriff’s deputies quickly deployed gear from their IFAKs and

used their TCCC training to save several lives (Straub et al. 2017) and (Kastre, 2020).

The report further outlines a consensus strategy developed by law enforcement, military,

and medical officials to address casualties in high-threat environments. The THREAT acronym

was created to communicate the order of priorities in an active shooter situation:

29
 T: THREAT SUPPRESSION

H: HEMORRHAGE CONTROL

R E: RAPID EXTRACTION TO SAFETY

A: ASSESSMENT BY MEDICAL PROVIDERS

T: TRANSPORT TO DEFINITIVE CARE

Threat suppression is usually accomplished by law enforcement personnel. A discussion

surrounding the rest of the letters in the acronym is the reason the Pulse Nightclub shooting is an

important case study for this paper (Straub et al. 2017).

Hemorrhage control is an important step for ASI victims because rapid extraction to safety

may not be possible for some time while victims are still in the warm zone. While law enforcement

is still neutralizing the threat (threat suppression), hemorrhaging can claim a victim’s life. Even

after the threat is neutralized, it can take time to provide hemorrhage control and extract victims.

In this specific example, it took time for law enforcement to adjust from an active shooter to a

hostage situation, and they were unable to immediately find victims in the warm zone and render

aid to them. Clearing the structure and finding additional victims takes time that is precious in the

blood loss equation. Learning hemorrhage care and having the equipment to implement that care

is critical for a victim to make it to the rapid extraction step and beyond (Straub et al. 2017).

C. Uvalde, Texas School Shooting Timeline

On May 24, 2022, an active shooter incident occurred at Robb Elementary School in

Uvalde, Texas. The attack resulted in the death of 19 elementary students and two teachers. 17

individuals were injured during the shooting. (NPR, 2022). Apart from the tragedy of the shooting

itself, the shooting was extensively scrutinized because of the unconventional and malfeasant

30
Uvalde Police Dept's response to the shooting (New York Times, 2022). ALERRT (Advanced

Law Enforcement Rapid Response Training) from Texas State University was asked to conduct a

full after-action review of the shooting to determine what happened and what could have been

done better on the part of the responding units.

At 11:27 a.m. on May 24, 2022, a female teacher exited an exterior back door and propped

it open with a rock so she could re-enter without having to go through the front door. At 11:28, the

shooter is involved in a single-vehicle crash near the road that leads to the parking lot of Robb

Elementary School. The suspect got out of the car and engaged two people with a rifle. They were

unharmed. At 11:31, the suspect fired his first rounds on school property into the windows of the

school. At 11:33, the suspect entered the school through the propped door on the west side armed

with a rifle (ALERRT, 2022)

At 11:33:24, the shooter reached rooms 111 and 112. He fired a series of shots from the

hallway in the direction of those two classrooms. Eight seconds later, the suspect made entry to

classroom 111 and fired several rounds in rapid succession into the occupied classroom. The

suspect then leaves the classroom and fires several rounds into room 112. The suspect then re-

enters classroom 111, and he continues firing rounds until 11:36. At this point, he is believed to

have fired approximately 100 rounds from his semi-automatic center-fire rifle. (ALERRT, 2022)

Between 11:35 and 11:36 a.m., 11 police officers made entry into the school through a

combination of the west and south entrance points. None of the officers were equipped with any

medical equipment or “go bags”. Along with spare ammunition and breaching tools, go-bags also

generally contain medical gear required to treat traumatic wounds generally associated with

gunshot wounds. At 11:36:10, the suspect exchanged gunfire with responding officers while he

was in room 111. Officers retrieved back into the hallway, and the shooter barricaded himself with

31
several victims in room 111. The suspect intermittently fired several rounds over the next hour.

(ALERRT, 2022)

Over the timeframe of that hour, officers from at least 10 different agencies arrived on the

scene and kept filling into the perimeter. Several people are documented to have suggested

breaching the door to room 111, but there was never any incident command set up and no order to

breach was ever given. At approximately 12:15, 44 minutes after the shooter entered the building,

members of the United States Border Patrol Tactical Team (BORTAC) arrived on the scene. At

12:23, Border Patrol agents had set up a medical triage area in the east hallway. At 12:50, 69

minutes after the beginning of the incident, the BORTAC team breached room 111 and killed the

suspect in an exchange of gunfire. As soon as the suspect was killed, first responders rushed

casualties from rooms 111 and 112 to the casualty collection point. It is not known whether EMS

was staged for direct transport of victims to local hospitals. In the end, 19 elementary students

were killed along with two teachers. (ALERRT, 2022)

D. Uvalde After Action Review

The law enforcement response to the Uvalde School shooting drew heavy scrutiny after the

incident was over. As evidenced above, responding officers took nearly an hour to re-engage the

shooter after their initial contact failed to neutralize him as a threat. During this time, the suspect

still fired rounds (presumably shooting what responding officers had categorized as hostages), and

victims were still actively dying from blood loss. (ALERRT, 2022) Based on the referenced above

sources, Mateen (Pulse shooter) no longer fired his weapon when he took hostages in the back

bathroom of the Pulse nightclub. This is the major distinction between the two shootings. Also, to

the best knowledge of law enforcement at the time, there was no one actively dying from a gunshot

32
wound being held by Mateen in the bathroom. Mateen was also not actively blocking access to the

injured in the main area of the club that needed medical attention.

In the Uvalde case, the AAR makes plain that the law enforcement response was

unacceptable. It acknowledges that the situation was rapidly evolving and tense and that engaging

the shooter would have likely led to law enforcement personnel being shot and possibly killed.

Engaging an active shooter is inherently dangerous to a law enforcement officer’s life but that fact

must be accepted before an incident (Blair & Duron, 2022). But the priority of life requires that

the lives of victims who are actively dying be put above the lives of responding officers.

The officers (namely the commanders) on the scene initially argued that the event ceased

to be an active killing event, but rather a hostage situation, when the shooter barricaded himself in

room 111. They saw the situation as equivalent at that point to the Pulse shooter barricading

himself in the bathroom of the Pulse Club. However, based on the differences between Pulse and

the attack noted above, this assessment was incorrect. The situation should have been considered

active because the shooter was still actively firing his weapon during the “barricade”. Even if the

shooter had not been firing his weapon during the barricade, the situation still should have been

considered an active shooter scenario because the shooter’s “presence and prior actions were

preventing officers from accessing victims in the classroom to render medical aid.” (ALERRT &

FBI, 2020, p. 2-17).

The AAR states that if officers had adhered to the priority of life, despite the risk to law

enforcement personnel, then they would have been able to stop the active threat and provide life-

saving medical aid to the wounded in the room with the shooter and victims from the surrounding

areas. The authors of the AAR believe that the failed law enforcement response directly

33
contributed to the deaths of victims who could otherwise have been saved by timely tactical

medical intervention (ALERRT, 2022).

The lessons learned in the aftermath of the Uvalde attack offer significant insights for this

study in the following ways. The Incident gives real-world verification to data that is discussed in

future sections. The data suggests that rapid medical intervention, especially for hemorrhaging

wounds, is imperative to victim survival. In a different way and for different reasons, this incident

also demonstrates a similar lesson to the Pulse shooting. Law enforcement and EMS are not always

able to provide immediate care to the wounded in an active killer event. In this case, law

enforcement’s failure to end the active threat to life meant victims did not receive care in the

timeframe they needed it. But victims might not receive care from first responders for other

legitimate reasons during an active shooter. Uvalde is an example of a scenario where civilian

access to and training on deployment of IFAK equipment could have saved the lives of victims as

they waited for emergency responders to address their wounds and provide rapid extraction and

transport to appropriate medical facilities.

E. Aurora, CO Movie Theatre Shooting Timeline

On July 20th, 2012, at 00:05 am (all local time) in Aurora, Colorado a male entered Theater

9 in the Century 16 Multiplex Theatre. The male was sitting in the front row for the premier of

The Dark Knight Rises. About twenty minutes into the movie, he left the theater through the

emergency exit by the screen. He propped open the emergency exit door with a plastic tablecloth

holder and walked out to his car in the parking lot, where he changed into protective body armor

(a gas mask, load-bearing vest, ballistic helmet, and bullet-resistant leggings) and retrieved three

firearms from his car (a Smith & Wesson M&P 15 semi-automatic center fire rifle, a Remington

34
12-gauge 870 Express Tactical Shotgun and a .40 caliber Glock 22 Gen 4 handgun) (ABC News,

2012).

The shooter re-entered the theater at approximately 00:30 a.m., and he threw a canister of

tear gas into the audience. This caused significant eye and respiratory irritation in several audience

members. The shooter started firing his Remington shotgun, first at the ceiling then at theater

patrons. Once he ran out of ammunition, he transitioned to the center-fire rifle, which was equipped

with a 100-round drum magazine. That drum magazine eventually jammed, and the shooter then

transitioned to his Glock handgun. In all, the shooter fired 76 rounds: six from the Remington, 65

from the M&P, and five rounds from the Glock handgun (Schaenman et al, 2014).

The first 911 calls came to Aurora Police Dispatch at approximately 00:39 a.m. The first

officers arrived on the scene in approximately ninety seconds. Officers entered Theater 9, and the

shooter was already gone. Officers found three magazines from a .40 caliber handgun, a shotgun,

and the malfunctioning drum magazine in the theater. There were several wounded victims, and

because of congestion and chaos outside, victims were transported in squad cars to area hospitals

until ambulances could get to the scene. This caused a significant delay in transport for those who

were not transported in available squad cars. At approximately 00:45 am, the shooter was taken

into custody without incident near his car in the parking lot (Schaenman et al, 2014).

F. Aurora Colorado Movie Theater Shooting AAR

The City of Aurora asked for an external AAR of the shooting and first responder’s actions

surrounding the shooting. The review gives insight into how the shooting response relates to

tactical medicine. The report first notes facts related to police and fire medical response after the

shooter was taken into custody. The initial police response to the shooting focused primarily on

ending the threat the shooter posed to the public; the primary focus was not responding to the

35
medical needs of the wounded per standard active shooter practice (Blair J.P, 2013). Once the

shooter was in custody, officers started triage for the victims inside the theater itself. Officers also

went outside and triaged victims at the police staging site behind the theater (Schaenman et al,

2014).

Officers were overwhelmed by the number of victims inside and outside the theater. Most

Aurora officers only had basic first aid training, and they were not properly prepared to address

any traumatic or hemorrhaging wounds. They also lacked the medical supplies necessary to

address these types of wounds (Israeli Bandage, tourniquet, chest seals, pressure gauze). There

was also an issue with ambulances being able to access the scene, so officers transported close to

twenty-seven victims in police cars (Schaenman et al, 2014).

The report also notes the need for a unified police/fire/EMS incident command to clearly

define threat levels. This report, like previous active shooter reports, underlines the need to

distinguish between a “hot zone” and a “warm zone”. The fire department and EMS never entered

the inside of the theater to tend to the wounded; the fire department considered the inside of the

theater a “hot zone”, and there was no communication between the fire and police response to

change the threat level to a “warm zone” once the shooter was in custody. Responding police units

categorized every victim in the theater as “black” (Schaenman et al, 2014); black means that the

victim sustained non-survivable injuries (Clarkson & Williams, 2022). This categorization was

likely based on the training, knowledge, and medical tools available to law enforcement personnel

at the time of the shooting. Had there been more immediate access to TCCC tools and skills from

responding police units and an interior response by Fire/EMS, it is possible some of those victims

could have survived (Schaenman et al, 2014).

36
 The report specifically notates the low presence of SWAT paramedics on the scene and

how their increased presence, or the increased training and access to TCCC resources in the hot

zone, could have potentially mitigated interior casualties. The report cites a recommendation from

the International Chiefs of Police that every officer have training in TCCC skills and applications.

Specifically, every police officer should have access to and training in the use of critical

hemorrhaging control equipment and the rapid evacuation of mass casualty victims to a pre-

determined collection point. The recommendation says that these are critical lifesaving

interventions that increase the survivability of the injured (IACP, 2018).

Within the report, specific recommendations for TCCC resources are discussed.

Specifically, the report cites the Committee on Tactical Combat Casualty Care and its

recommendations about the necessary tools in an IFAK to treat common traumatic wounds. The

gear recommended by the report to treat the victim’s wounds includes a tourniquet, a “battle

dressing” (namely an Israeli bandage), a pressure dressing with a hemostatic agent, and a

nasopharyngeal airway device. This is the type of equipment (and training to use such equipment)

that is most effective in treating wounds typically found during active shooter incidents, and the

most important factor in their success is rapid deployment (Feldman, 2015).

G. Columbine High School Shooting Timeline

On April 20, 1999, two shooters entered Columbine High School property, killed thirteen

people, and wounded over twenty more. At 11:19 a.m., the two shooters engaged their first victims

outside the school. The two assailants entered the west side of the school and engaged several more

victims with carbine rifles, TEC-9s, and pipe bombs. At 11:22 a.m., the first police officer arrived

on the scene and exchanged gunfire with one of the shooters from approximately 60 yards away.

At around 11:26 a.m., there were approximately six deputies on the scene who were all still outside

37
the school. They were attempting to rescue a wounded female when they were again fired upon by

the shooter inside the school. They returned fire but never struck the shooter. The shooters kept

walking toward the library where a significant number of students had amassed. In the locations

where the shooters had already left, several students and teachers were trying to use rags and shirts

to control the hemorrhaging of victims left behind (Columbine Report, 2012).

At approximately 11:29 a.m., the two shooters entered the school’s library. The two

shooters opened fire and either injured or killed several students and a teacher. The students were

engaged by police outside the building through a window, but the shooters moved away from the

library window and were never struck by the officer’s fire (Columbine Report, 2012).

After approximately seven minutes of systematically taunting and killing victims, they

exited the library and went to the cafeteria at approximately 11:44 a.m. They walked around the

cafeteria and different parts of the school before returning to the library around 12:02 p.m. The

shooters again exchanged gunfire with police through the shattered library window, but no one

was shot. At 12:08 p.m., both shooters killed themselves with self-inflicted gunshot wounds to the

head (Columbine Report, 2012).

Police never entered the school until the shooters had already inflicted severe carnage and

killed themselves. SWAT teams did not set a perimeter until approximately 12:00 pm, 41 minutes

after the event began, and they did not enter the school until approximately 01:09 pm, nearly an

hour after the shooters had already killed themselves. The last living victim in need of medical

care was not evacuated until 3:22 p.m. The Columbine shooting was the tragedy that forever

changed the standard law enforcement response to active shooters. Columbine changed the

response from holding the perimeter and waiting for a tactical team to ending the threat

immediately at whatever cost to responding officers. The Columbine shooting also highlights the

38
importance of near-immediate medical interventions to control hemorrhaging (Jefferson County

Sheriff’s Office, 2000).

The AARs conducted by subject matter experts in the ASI field about the Aurora, Uvalde,

and Pulse shootings have several insights, and a few trends emerged. These trends in literature are

directly related to the study’s research question. There is anecdotal evidence in these AARs to

suggest that there needs to be faster access to and application of IFAKs. However, there is very

little quantitative evidence to assert that having access to and application of IFAKS in hot and

warm zones where law enforcement is unable for some reason to immediately extract and provide

aid reduces casualties by a statistically significant amount. This is the importance of this research

using AnyLogic® technology to model an ASI and determine quantitatively to what degree these

timely interventions could reduce casualties.

Three major conclusions should be drawn from these AARs that can be applied to this

research. The first is the idea of hot, warm, and cold zones. These zones are important to this

research in that they help in understanding the current problem as it relates to IFAK deployment.

In a hot/warm zone, which is the categorization until law enforcement neutralizes the threat, other

first responders do not enter a hot zone. This requires individuals who are already in the hot/warm

zone to be responsible for their own or their fellow person’s care. This research seeks best practices

for how to deploy life-saving equipment to victims who are in the hot/warm zone.

The second concept is the importance and consequences of not rendering timely aid to ASI

victims in the field. There are several conclusions drawn by experts in the above AARs that if the

victims had received aid sooner, they would have lived. The final concept is related to the second.

The third concept is the importance of access to TCCC and IFAK materials to render aid to victims

promptly.

39
 2.4 Literature Related to TCCC, IFAKS, and Wounds/Blood Loss

A. TCCC Standards and Practices

TCCC standards have evolved significantly over the past two decades due to the United

States’ conflicts in the Middle East. This evolution has led to several standard tools used to treat

traumatic wounds in a pre-clinical setting (Campbell, 2017). The most common and effective tools

for hemorrhage control are tourniquets for extremity wounds, hemostatic gauze/dressings for

wound packing and wound pressure, vented chest seals for wounds penetrating the chest/upper

back area, and Israeli bandages for wound care in the neck area. The most effective way to control

hemorrhage and increase survivability is using tourniquets, wound packing, and chest seals to

prevent tension pneumothorax and direct pressure to affected areas. (Bennett et al. 2014) However,

in a civilian setting, it is less likely than in a military setting to have extremity wounds; this makes

a tourniquet possibly a less effective intervention when compared to a chest seal or pressure

bandage, depending on the location of the wound.

A1. Tourniquet Effectiveness

As previously mentioned, TCCC principles have evolved significantly over the last twenty

years. Since 2010, the use of tourniquets has increased approximately tenfold (Kragh 2015). Kragh

reviewed the severity of wounds in Iraq and Afghanistan from the years 2001-2010. The study

noted that the severity of wounds increased over that time, but he also noted that survivability

attributed to the use of tourniquets also increased over the same period. Several studies have

reviewed the effectiveness of tourniquets in both the military and civilian settings. Kue (2015),

Schroll (2015), Scerbo (2017), Smith (2019), and Kragh (2009), reviewed a total of approximately

2,300 patients where a tourniquet was applied to a hemorrhaging wound. All the studies found the

40
effectiveness (defined as the patient not dying due to hemorrhage) of the tourniquet to be between

87-93%. As a matter of tourniquet application, it is important to remember the below blood loss

rate data. Tourniquets are most effective when quickly applied to the wound before the wound

becomes a class IV wound.

A2. Wound Packing and Hemostatic Dressing Effectiveness

Wound packing is generally used for wounds to the abdominal cavity area. The material

used to pack wounds is generally a cloth coated with a hemostatic agent. The goal is to use

compression and hemostatic to control bleeding inside the abdominal cavity until appropriate care

in a clinical setting can be administered. The cited data below suggests that the introduction of

hemostatic gauze for wound packing has a statistically significant effect on survivability outcomes.

One such study (Koko et al, 2017) used bleeding pigs to measure the effectiveness of

packing hemorrhaging wounds with hemostatic gauze. A control group and an experimental group

were used to determine whether there was a statistically significant difference in hemorrhage

control between the two groups of bleeding pigs. The study concluded that while there was no

statistically significant difference between the different types of hemostatic gauze used to pack the

wounds, there was a statistically and clinically significant difference in hemorrhage control

between subjects whose wounds were packed with hemostatic gauze and subjects whose

hemorrhaging was only controlled by direct pressure.

A separate study of 14 Israeli Defense Force soldiers who all had hemorrhaging wounds

was conducted when they were treated with hemostatic dressings. In those instances, all but one

was caused by gunshot blasts. They were applied to both junctional and non-junctional wounds.

Approximately 80% of applications were effective in creating survivability between both

junctional and non-junctional wounds (Ran et al, 2010).

41
 A 3. Chest Seal Effectiveness

The purpose of a chest seal is to prevent tension pneumothorax from penetrating and

hemorrhaging chest wounds. Tension pneumothorax, the trapping of air in the pleural space from

a penetrating chest wound, accounts for approximately 4% of all combat casualties and

approximately 10% of all civilian chest trauma casualties. Kotora (2013) used animals to create

tension pneumothorax in a clinical setting and determined whether vented chest seals were

effective in preventing tension pneumothorax and death in the tested animals. The study concluded

that the vented chest seals used were effective in evacuating blood and air and preventing/treating

tension pneumothorax.

A 4. Israeli (Direct Pressure) Bandages

The Israeli Bandage, also known as an emergency bandage, is designed to apply direct

pressure to a hemorrhaging wound independent of pressure applied by a person. It is a device

commonly found in IFAKs. Several pieces of literature highlighted the effectiveness of the Israeli

bandage, but there is little statistical data to be found that supports those claims. One such study,

Sip (2018), a review of tactical medicine interventions for controlling hemorrhaging conducted by

the Department of Trauma Surgery in Poland, specifically highlights the effectiveness of an Israeli

Bandage for direct pressure dressings as compared to traditional physical pressure application.

B. Wounds and Bleed Out Times

Most life-threatening injuries that first responders encounter in ASIs are categorized as

penetrating wounds related to hemorrhaging. Hemorrhaging accounts for approximately 90% of

all potentially survivable law enforcement/military deaths (the closest comparable to civilian ASI

casualties) and approximately 40% of all otherwise preventable civilian deaths (Aberle et al. 2015).

42
A significant work of research has shown that early hemorrhagic field intervention significantly

improves patient outcomes.

For example, a 2016 study of civilian mass shooting injuries used both civilian and military

wound patterns. The study concluded that approximately 15% of all military deaths could have

been survivable with timely hemorrhaging control intervention. Hemorrhaging of the extremities

was the main cause of fatal blood loss, and this fatal bleeding could have been controlled with the

effective application of a field tourniquet. In the same study, a review of civilian mass shooting

casualties showed that approximately 7% of all fatal injuries could have been mitigated by timely

field medical interventions. However, most civilian preventable deaths were due to wounds

sustained to the torso. This type of wound requires chest seals and hemostatic gauze to be properly

treated (E.R. Smith et al. 2016).

Non-compressible hemorrhaging injuries are broken down into three main categories: torso

(sub-divided into abdominal and chest), junctional (a connecting point between an extremity and

the trunk of the body), and extremity hemorrhaging (Eastridge, 2012). Non-compressible

extremity hemorrhage is the type of hemorrhage that can be treated using a tourniquet. However,

extremity hemorrhage only accounts for 13.5% of hemorrhage-related fatalities. Torso hemorrhage

accounts for 67.3% of hemorrhagic fatalities while junctional hemorrhage accounts for 19.2% of

blood-loss fatalities. Approximately 85% of known hemorrhaging must be treated by medical gear

beyond an IFAK tourniquet (Eastridge, 2012).

Nicholas Miller, a nationally recognized expert in TCCC interventions, wrote in 2015

about the need to have complete IFAKs immediately at officers’ disposal to counter the bleed-out

time equation. He said:

43
 “Many law enforcement agencies elect to keep the IFAK kit in the vehicle instead
of being worn by the officer. Although this provides a marked improvement over
no IFAK at all, it may cause unacceptable delays in deployment when the IFAK is
needed, and time is critical. An officer that needs to retrieve an IFAK from a vehicle
may be delayed by the time it takes to attach the IFAK on their duty belt before
engaging the threat or the incident may cover a large area that is too far from the
vehicle to make IFAK retrieval practical. Also, the officer may be wounded and
unable to retrieve their IFAK from the vehicle. IFAKs that are always physically
on the law enforcement officer offer the best chance for successful utilization when
needed” (Miller, 2015).

Miller touched on the necessity for immediate access to IFAK tools because of the time

component related to a hemorrhaging wound. The average time to bleed out from a hemorrhaging

wound is 3-5 minutes (Aberle, 2015). Time is the greatest enemy of traumatic wound care, and

immediate access to the appropriate tools to treat those wounds is the most important factor in the

survival equation.

One necessary factor to estimate in modeling research is the initial blood volume and

estimated blood loss of a mass shooting victim. Several references were examined to determine

an accurate estimate for initial blood volume; this estimate is used as the baseline value in the

agent-based model.

All the values cited in the literature below were broken down by gender, weight, and age.

Males were found to have more blood volume on average than women. Adults were also found to

have more blood volume on average than infants or neonates. Body weight was also found to be a

significant factor in determining initial blood volume.

Morgan et al (2002) work in Clinical Anesthesiology found average blood volume per

kilogram in males was 75ml/kg while the average blood volume in females was 65ml/kg. The

infant’s blood volume was 80ml/kg, while neonates and premature neonates were found to have

an average of 85ml/kg of blood volume. A second source, Open-Anesthesia (2021), found the

same numbers in their study of blood volume.

44
 The University of Iowa Health Care created a protocol for allowable blood loss and volume

in head and neck procedures. That study found males had an initial blood volume of 65-70ml/kg,

and females had the same initial blood volume. Infants had an initial blood volume of 70-80ml/kg

while neonates and premature neonates had an initial blood volume of 80-90ml/kg (Iowa Head

and Neck Protocols, n.d.)

A study by Samuel B. Nadler (2016) called “Prediction of Blood Volume in Normal

Human Adults” found average adult blood volume in males and females to be the same as Morgan

and Open-Anesthesia. The study also found the same initial blood volume as the studies in infants

and premature neonates. The only difference in the Nadler study compared to the first two

referenced studies is that neonates have an initial blood volume of 80ml/kg compared to 85ml/kg.

A complete table of initial blood volumes can be found in the tables section.

Most of the initial blood volume values converge on the Nadler, Morgan (2002), and Open-

Anesthesia studies. Nadler’s work is also cited several times in a variety of other surveyed work,

so the Nadler values are the initial blood volume values that will be inserted into the coming model.

As initial blood volume values are a variable of the subject’s weight in kilograms, it is also

important to determine the average male and female weight in kilograms. The average adult male

weighs 90.62 kg, and the average adult female weighs 77 kg (CDC, 2021). This would mean the

average adult’s initial blood volume ranges between 5.01 L and 6.80 L of blood volume.

Another factor that must be determined for this simulation model is the rate and category

of blood loss to each type of correlated wound type before a victim is considered deceased. The

average person can lose up to 15% of their blood volume without any clinical manifestations of

blood loss; this is considered a Class I hemorrhage (Johnson & Burns, 2022).

45
 A Class II hemorrhage is classified as a 15% to 30% loss of blood volume. Victims of a

class II hemorrhage will become nauseous and tired. Extremities will start to cool and vital signs

will start to deviate from standard. Tachycardia and increased respiratory rate are the two most

common signs associated with this level of hemorrhage (Johnson & Burns, 2022).

A Class III hemorrhage is classified as a 30% to 40% loss of total blood volume. Clinical

manifestations of a class III hemorrhage include delayed capillary refill and altered mental status.

Another possible vital sign deviation at this stage is a significant drop in blood pressure. Anything

past a 40% loss of total blood volume is considered a Class IV hemorrhage. At this stage, there is

a very high risk of organ failure, coma, and death absent immediate medical interventions. Any

blood loss over 40% without almost immediate medical intervention will cause death (Johnson &

Burns, 2022).

Blood flow rate through hemorrhage is not a basic concept. There is also limited research

on actual blood loss patients because the blood flow rate is not generally a priority metric in an

emergency setting. However, there are a few studies that approximated blood flow rates in either

non-hemorrhaging people or by modeling. Johnson (1995) collected blood flow data from 21

subjects by using ultrasound technology to measure the subject’s arterial blood flow rate over time;

the study also studied the flow rate over different body stress levels. The data showed the average

blood flow rate of a person at rest was 400 ml/min. A “mild” body stress level revealed a blood

flow rate of 800 ml/min while a moderate and maximal effort level showed a blood flow rate of

1200 and 1500ml/min respectively (Johnson et al. 1995).

Tjardes and Luecking (2018) created a mathematical model to simulate blood flow/loss

rate. This model was broken down over ml loss/minute and by type of hemorrhage. A summary of

milliliter loss/ 1 min is helpful. Blood flow from the abdominal aorta (all in ml /1min) is 936. The

46
common iliac artery showed a blood rate of 468 while the internal and external iliac arteries

showed a rate of 114 and 354, respectively. Finally, the femoral artery showed a flow rate of 174

ml / 1 min.

This data is relatively mathematically consistent with the above-presented data. If the

average time to bleed out from traumatic wound hemorrhage is 3-5 minutes, and the maximum

amount of blood loss allowable before death is between two and three liters (average initial blood

volume * 40% blood loss), we would expect the aortic and iliac artery to reach the two-to-three-

liter threshold between that 3–5-minute margin while the other types of wounds may take slightly

longer.

It is also important to have a concept of wound types that occur in active shooter scenarios

as this will affect blood loss rate and survivability. Several studies have examined the placement

of victim’s wounds on the body. E.R Smith (2016) found 29% of wounds were to the head. 9% of

wound placement was to the neck. 29% of wounds were found in the chest/upper back while 14%

were found in the abdominal or lower back area. The remaining, approximately 20%, were found

in the lower or upper extremities. This study was based on a sample of 12 events spanning 139

fatalities and 371 wounded victims.

Knickerbocker (2019) examined only two events that resulted in 22 fatalities and 40

wounded victims. This study found approximately 17% of victims had wounds to the face/head

while only 3.4% of victims had neck wounds. 10.3% of victims had chest or upper back wounds

while approximately 14% of wounds were found in the lower back/abdomen area. The remaining

wounds, 55.2%, were found in the upper and lower extremities. Tzvetanov (2021) provides a

review of several more studies including these two and created a table with all wound-type

statistics that can be found in the tables section.

47
 This section of the literature review provides support for this research in two ways. The

first is that it establishes the efficacy of TCCC standards and IFAK interventions. Literature not

only establishes their efficacy, but it also establishes times by which these interventions can be

effective. This proof is important in that it establishes legitimacy to the model used in this research.

This literature review also establishes bleed-out times and initial blood volumes. This literature

confirmed that the choices made in the model as it relates to bleed-out time and blood volume are

based on reality. It is important to prove the time (3 minutes) that this research uses as the threshold

for whether the victim lives or becomes a casualty. This initial blood volume and blood loss

research gives mathematical credence to that time standard.

2.5 Research Related to IFAK Placement Optimization

The model used to develop data for this research was modified based on an AnyLogic

model created by Tzvetanov. In his latest use of this model, he published in a paper in 2023. In it,

he compared the deployment of 3 and 4 Stop the Bleed stations and sought to compare different

placement layouts along with comparing the number of kits deployed. He sought to answer if the

number of kits and the placement of kits improves performance of delivery (in time). The model

concluded what we would logically expect about the number of kits: the more kits that are available

for deployment improves delivery performance.

Tzvetanov also concluded that optimal placement of IFAKs is important to quick IFAK

delivery. Furthermore, he concluded that optimal placement of IFAKs is more important to prompt

delivery than the number of IFAKS available. This is important for this research in that it validates

the concept that researchers need to focus on how to optimally deploy IFAK in a K-12

environment. While this research does provide support for the need for this research; it does

diverge from Tzvetanov’s work in several ways. These diversions are outlined in section 3.3.

48
 RESEARCH METHODOLOGY

3.1 Overview

ASIs have become more common in American K-12 schools in the last 10 years, and

mitigation techniques have become more and more necessary to help protect one of America’s

most vulnerable populations. A significant amount of research, especially at Purdue University,

has been devoted to establishing best practices for neutralizing the offender in an ASI (Anklam et

al., 2014; Kirby, 2016). These writings focus on arming school staff and SROs to neutralize the

threat of an ASI promptly. While in a perfect world, this neutralization technique will be very

effective and swift, sometimes that is not always the case. An example would be the Parkland,

Florida school shooting where an SRO was unable to effectively neutralize the threat of that

shooting (ABC News, 2023). Even if the SRO was able to neutralize the threat promptly, which is

not always possible in more rural areas or police departments that struggle with staffing and

funding, there would most likely still be victims with potentially life-threatening wounds that

would need immediate medical attention.

Law and policymakers in America struggle to come to any type of effective agreement on

how to mitigate the offender in an ASI. While Anklam and Kirby suggest that the best mitigation

is to keep armed teachers and SROs in K-12 schools, others argue that this is an infringement on

rights and more of a danger to children than a benefit. Others argue that it is important to limit the

types and number of guns given to citizens, especially certain citizens who struggle with mental

or other psychological issues. However, there are fundamental disagreements on this issue between

lawmakers, and there will likely be little action taken either way on this issue.

Instead of focusing on best practices for neutralizing the ASI threat, which can be bogged

down by political and other pressures, this research focuses on best practices for saving lives if the

49
worst does occur. This research is focused on the aftermath of an ASI and places agency on all

individuals involved to save lives, not just the responding professionals. The idea this research

proposes, to increase access and ability to effectively treat life-threatening wounds in the field, is

an idea that could be very effective in saving lives when the worst occurs. It also is much more

likely to be commonly accepted by the public and not be bogged down by political pressures than

all other mitigation techniques.

3.2 Any Logic ® Agent-Based Modeling

The purpose of this thesis is to determine whether, in a modeling environment, varying the

deployment/placement of IFAKS would impact casualty means in an active shooter scenario by a

statistically significant measure. This model specifically used the Uvalde Elementary School

shooting incident layout as a modeling environment. However, the layout of this school can be

swapped for any other, and the model should still accomplish similar results. To accomplish this,

AnyLogic® ® agent-based modeling was utilized. AnyLogic®, version 8.4, is a discrete event

modeling software. It models discreet events, and agent-based, dynamic modeling environments.

AnyLogic® is unique in that it uses both agent-based modeling and discrete event

modeling at the same time; this allows for increased fluidity and makes it easier to model real-

world situations. Agent-based modeling is designed in part so the model designers can

individualize the behavior of the various actors in the model. AnyLogic® has been shown to create

better hypothetical situations and run more fluid situations than equation-based modeling.

Equation-based modeling requires actors to be controlled by pre-determined inputs whereas agent-

based modeling allows an emergent phenomenon to occur based on the result from the interactions

of individual entities (Bonabeua, 2002).

50
 Agent-based modeling allows modelers to create more fluid modeling environments that

capture the interactions of different agents who are acting within a set of pre-determined, realistic

rules. Discrete event modeling enables end-users to vary different parameters within the model to

see how those variables affect different outputs. Several variables were changed throughout the

model running to determine how those variables affect different outputs. Other variables were set

as constants to create a realistic modeling environment.

3.3 Tzvetanov Model

It should be noted as a matter of this research, Tzvetanov’s 2021 research, “Improving the

Fidelity of Agent-Based Active Shooter Simulations Through Modeling Blood Loss and Injury

Management” and 2023 research, “Optimizing Hemorrhage Control Kit Placement” created an

AnyLogic® model that formed a baseline for this researc. The model basis was already created as

a part of Tzvetanov’s research. In that research, he proves several necessary components that make

the model realistic such as starting blood level, injury selection, level of blood loss, blood flow

rates, and IFAK intervention applications. Tzvetanov’s research should be referenced and given

credit as the basis of this AnyLogic® model, and his proving the reality of the model has already

been established in his cited work (Tzvetanov, 2021). This research used Tzvetanov’s model as a

basis since there was no point in re-creating and re-proving a model that had already been reviewed

and proven to be reality-based.

However, this research deviated from Tzvetanov’s model in several ways to create new

data and try to answer new research questions. This research created a distinction from the original

model in that the deployment/placement of IFAKS was the focal point of the simulations using the

below experiment outlines. The model also adds several new constraints that focus not just on

IFAK delivery but IFAK application deployments. It also tracks different data outcomes than the

51
original model. These new constraints and tracked data outcomes will be outlined below in section

3.4.

3.4 Thesis Simulation Model

This thesis’s simulation model used the real assumptions from this work to create a new

simulation environment. Tzvetanov’s model creates a basis to introduce hemorrhaging wounds

and tactical medicine interventions to what would otherwise be a binary dead-not-dead choice.

Other parameters were also added to the new model: the discrete variable controls application time

was added to determine whether these variables had a significant impact on fatality rates.

The number of IFAKS in the simulated environment was also fixed. From herein, this

research will refer to individual IFAKS as IFAKS and the plural set of IFAKS as the Stop the

Bleed Kit. Stop the Bleed Kits are packages that contain a set of 8 individual IFAKS. Each

simulated environment will contain one Stop the Bleed Kit or 8 individual IFAKS.

This research uses the layout of the Robb Elementary Uvalde School shooting as a layout

design for the model. A figure of this layout can be found on page 54 in section 3.5. This research

simulates an environment where an active shooter incident has occurred and because of either an

extended response time or divided attention due to finding and neutralizing the active threat, law

enforcement is unable to render aid or establish a warm zone where other medical first responders

can render aid and evacuate victims. This creates an environment where it becomes necessary for

others, in this instance teachers, to provide life-saving medical aid through the 8 available IFAKS

located in the Stop the Bleed kit.

The model creates a logical limit where the number of people who can render aid is no

greater than the number of teachers in the environment; this research makes the number of teachers

in the environment equal to the number of classrooms in the model. There are eight IFAKs

52
available throughout the modeling environment. The model assumes that one IFAK can treat

exactly one wound and then its use is terminated. Not only are the IFAK contents of the basic Stop

the Bleed IFAK limited in scope but there are no guarantees that the type of wounds in the room

will be conducive to the IFAK being used twice. For example, if there is one IFAK in a room with

two arterially hemorrhaging wounds, there is only one tourniquet available. But if one wound is a

penetrating chest wound and one is arterial bleed from an appendage, in theory a more advanced

IFAK could treat both wounds with one kit. For simplicity of the model, it was assumed that one

IFAK can treat precisely one wound, but the IFAK could be even, but not less, effective than what

was assumed in the model.

The research uses the realistic parameters of the Robb Elementary School Uvalde shooting

to determine the number of injured individuals in the draft. Robb Elementary School had a total of

535 students plus staff at the time of the shooting. There is also an average of 25 kids/classroom

(Murphy et al, 2023). During the shooting, 21 individuals were killed and another 17 were

wounded. This totals 38 individuals who were struck by gunfire during the ASI (Associated Press,

2022). The “hit rate” totals around 7% of the school population. This average hit rate of the

population will be used in this research. There are a total of 19 classrooms in the Robb Elementary

layout used in this model, including the library and teacher’s lounge. With an average number of

25 persons/classroom multiplied by 19 classrooms, the researcher assumed 475 persons were in

the modeling environment. So, the researcher assumed 34 injured persons were in the modeling

environment by taking 7% of 475 persons.

This research also creates a time threshold for a victim to be considered a casualty for this

research. Based on the blood flow/loss research above, that research validated the assumptions

made in the model. The assumption regarding the time threshold is based on the above blood loss

53
data, and the model assumes if a victim is not treated with an IFAK intervention in 3 minutes, the

victim will be considered a casualty. Three minutes is considered on the lower end of the

hemorrhaging death time interval (3-5 minutes) (Aberle, 2015). While it is conceivable for trauma

victims to die of other complications (such as a sucking chest wound in a penetrating wound

instance), as Katzenell et al (2012) concluded, most trauma-related deaths are due to hemorrhaging.

Hemorrhaging control is the most important factor, so this model focuses on the effects of

hemorrhaging on trauma-related gunshot victims. This model also does not differentiate between

different types of wounds. The injured person is only injured or not injured. Assuming the wound

is a hemorrhaging wound is the most likely type of wound statistically.

The model also assumes a standard amount of time to address the wound. This is a key

difference between this research and Tzvetanov’s 2023 model. That model assumed 0 seconds to

apply an IFAK intervention because the model focuses on just the delivery of the IFAK from the

original location to the victim. This research incorporated a fixed time to use the IFAK intervention

when tracking iteration time so that application, not just delivery, was a focus of the research

question.

Since the model assumes the wound is related to hemorrhaging, the researcher chose to

model the amount of time it takes to apply the IFAK component after the amount of time is takes

on average to apply a tourniquet. The researcher chose 45 seconds as the fixed time to apply the

IFAK intervention once the teacher agent reaches the injured agent. Schreckengaus et al (2014)

simulated the application of a tourniquet with an n value of 89. The average time, in seconds, to

apply the tourniquet was 43 seconds. Friberg et al (2021) simulated tourniquet application with an

n value of 55 in a stress-induced environment. Assuming teachers are trained to the same

proficiency level as a standard first responder, the average application time in the Friberg study

54
was 57 seconds. Beaven et al (2018) performed a similar simulation with a population value of 24.

The average application time for that study was 37.5 seconds. These three studies, when averaged

together, provide an average intervention application time of 45 seconds.

The research also set the limitation that the teacher agent is only allowed to carry a

maximum of 3 kits from the centralized location. This will be important for Experiments 1 and 3,

which are outlined in detail in section 3.5. This prevents a potential error in the model where a

teacher agent is allowed to carry all 8 IFAKs from the Stop the Bleed kit’s central location at once,

which is not a realistic option.

This research needs to track several data points to answer this research’s questions. The

research will track three data outcomes to help answer the research question: the first is the number

of “dead” persons in the simulation. The second data point is the number of kits left in the agent’s

possession when time expires, and the third data point is the time it takes for all injured individuals

to be treated with a TCCC intervention. The researcher will extrapolate based on that data a fourth

variable called number of victims saved. It will be calculated by subtracting the number of “dead”

persons in the simulation from the initial number of injured persons in the simulation.

3.5 Experiment Outlines

This research aims to determine whether varying the distance/placement of IFAKS and

Stop the Bleed Kits in a K-12 setting during an ASI will decrease casualties. The researcher created

four different experiments, meaning four different IFAK/Stop the Bleed kit placements, to help

answer the research question. These experiments have consistent factors across each AnyLogic®

simulation. The only change variable across these four simulated environment experiments is the

placement of the IFAKs/Stop the Bleed Kits.

55
 Experiment #1: This simulation assumes that all the IFAKs will be in one Stop the Bleed

Kit, and they will be stationed in a centralized location in the school, room 116. Below is a figure

of the layout used for Experiment 1. Red crosses outline the possible locations for IFAKs, but only

IFAKS that are white and not gray are active for the experiment.

Figure 5. Experiment 1 Simulation Layout

Experiment #2: This simulation assumes that IFAKS are individually located and not in a

central location. IFAKS will be evenly split in each hallway (assuming 8 IFAKS in one Stop the

Bleed kit). Let’s assume there is 1 IFAK in rooms 102, 106, 110, 130, 132, 127, the teachers’

lounge, and the library.

56
 Figure 6. Experiment 2 Simulation Design

Experiment #3: This simulation assumes that IFAKS are evenly split (so 4 and 4 assuming

8 total IFAKS). IFAKS will be staged in groups of 4. One group will be staged in room 102, and

one group will be staged in room 126.

57
 Figure 7. Experiment 3 Simulation Design

3.6 Agent Definitions

The “teacher” agent type is a type of pedestrian type in AnyLogic®. The teacher is

programmed to find the closest IFAK to their starting position and find the closest student who has

suffered an injury. This process will continue until the teacher has no more interventions or not

more victims. This research controls for the training variable and assumes that all teacher agents

are adequately trained to respond and deploy IFAK contents. The “student” agent is spread equally

among all the classrooms in the layout. The students, for this research, are not allowed to apply

IFAK interventions. The student is only allowed to be injured.

58
 3.7 Model Limitations

The model is limited in that it greatly simplifies human behavior to where the agents make

rational decisions in what would be a tense, fluid, and rapidly evolving situation.

The model also may have a limitation in that it simplifies casualty status to whether the

victim receives treatment to prevent hemorrhage within three minutes. The model assumes that

IFAKs are interventions primarily designed to prevent massive hemorrhage. The model does not

consider that there are types of wounds that can cause death that are not treatable by IFAK

interventions such as spinal cord and brain injuries. However, hemorrhaging accounts for the cause

of most preventable deaths in studies done on gunshot victims from US wars in the Middle East

(Katzenell et al, 2012). So, the research assumes that treating hemorrhage will cover most

otherwise preventable deaths in ASI victims

59
 RESULTS

4.1 Data Cleaning

The data resulting from the AnyLogic® simulation was output into three separate Excel

spreadsheets. The researcher combined the output data into one Excel spreadsheet. The researcher

added three dummy variables to the data titled Experiment Number 1, 2, and 3, respectively. They

were assigned a binary value of 1 or 0 to denote which experiment was being evaluated. This step

was taken to aid in eventual statistical analysis.

The AnyLogic® simulation outputs showed that each experiment was run 500 times for a

total of 1,500 rows of data. 500 was found to be a converging number for the data where the data

summary analysis was consistent. The outputs that were of interest to the researcher were

experiment duration, number dead, number injured, kits left at the station, and kits left with agents.

As the data was reviewed, it was determined that there were several rows of data that were not

reflective of a real-world situation. For this reason, the researcher put the data through the process

of data cleansing.

Data cleansing is defined as “the process of fixing or removing incorrect, corrupted,

incorrectly formatted, duplicate, or incomplete data within a dataset. When combining multiple

data sources, there are many opportunities for data to be duplicated or mislabeled” (Tableau, 2023).

Data cleansing is necessary because data that is not checked, in this instance for its compatibility

with reality, can be unreliable and so can the conclusions and recommendations made based on

that data. There is no standard process to clean data. It is a subjective process based on the needs

and applications of the data (Tableau, 2023).

The data had several different types of outcomes that needed to be cleaned from the set.

There were several experiment iterations in all three experiments where the number of deaths was

60
0 and the number of injured reflected what the number of deaths should have been. This occurs in

instances where the model terminates the moment there are no more IFAKS to be used, and the

model does not wait the remainder of the three minutes for the victims to “die” in the simulation.

There were also several experiment iterations where the results showed an output of 0

throughout. This data output occurs if an agent gets “stuck” in the model, and the model

indefinitely runs. The model is set to terminate no matter what after 30 minutes within the model.

These lines were removed from the data set because those iterations were also not reflective of a

reality-based situation. There were also several iterations where the kits left with agents’ output

was 8. This indicated to the researcher that the simulation again got “stuck”, and the agents were

not able to complete their assigned tasks. These outputs were also removed from the data set since

they did not reflect a realistic iteration.

Each experiment was originally run 500 times each. Once the data was cleansed of the

above issues that were not in line with reality, the experiment had the following respective number

of iterations that were examined:

Experiment 1: n = 349

Experiment 2: n = 348

Experiment 3: n = 342

4.2 Data Summary

The cleaned data can be summarized by experiment. Experiment 1 (cleansed data) on

average terminated at 176.3 seconds, or approximately three minutes. This is denoted in the

Experiment Duration column. The average number of deaths, denoted by the column Dead, for

Experiment 1 was 27.66. The average number of injured persons who did not die, denoted by the

column Injured, was 6.32 persons. There were no IFAKs left in their original location in any of

61
the experiment iterations, and the average number of kits left in the possession of the responding

agent when three minutes expired, denoted by the column Kits Left with Agents, was 1.81. The

column names were the same across all three experiments.

Experiment 2 ended on average in 102.8 seconds or just under two minutes. The average

number of deaths for Experiment 2 was 26.90. The average number of injured persons who did

not die was 7.1 persons. There were no IFAKs left in their original location in any experiment

iterations, and the average number of kits left in the possession of the responding agents when

three minutes expired was 0.08.

Experiment 3 terminated on average in 178.6 seconds, or again roughly three minutes. The

average number of deaths for Experiment 3 was 29.22. The average number of injured persons

who did not die was 4.78 persons. There were no IFAKs left in their original location in any

experiment iterations, and the average number of kits left in the possession of the responding

agents when three minutes expired was 3.39. The below figures show in visual form a comparison

of each data category across all three experiments.

Figure 8. Average Kits Left w/ Agents

62
 Figure 9. Average Deaths

Figure 10. Average Experiment Duration

63
 4.3 Data Objectives and Methods

As previously stated in Chapter 1, the researcher sought to determine answers to the

following questions:

1. Are there real-life active shooter incidents that support the notion that earlier medical

intervention during an active shooter incident could have decreased the number of

fatalities?

2. Is there data to support that IFAK contents have a significantly significant impact on

reducing fatalities in trauma situations?

3. Does changing the distance/deployment of IFAKS in schools during an active shooter

incident reduce the casualty mean by a statistically significant amount?

Chapter 2 addressed the first two questions through a review of extensive literature related

to those topics. This chapter uses data analysis to answer the third question. As discussed in

Chapter 1, the researcher proposed the following null and alternative hypotheses:

1. Varying the distance/placement of IFAKS in a K-12 school during an ASI will not impact

the casualty mean by a statistically significant amount.

2. Varying the distance/placement of IFAKS in a K-12 school during an ASI will impact the

casualty mean by a statistically significant amount.

The researcher assigned a statistical α – value of 0.05 for these tests. The researcher decided

to use a single-factor ANOVA test to compare the means of the three different experiments and

determine whether their means are statistically significant from one another. One factor ANOVA

64
tests “compare the means of two or more independent groups to determine whether there is

statistical evidence that the associated population means are significantly different. One-way

ANOVA is a parametric test” (Kent State University, 2023). One-factor ANOVA was chosen in

this instance over a two-factor T-test because the researcher was comparing the means of more

than two groups.

When using an ANOVA test, independent and dependent variables are generally defined.

In this context, the data’s independent variable is the deployment/placement of IFAKs in an ASI

environment. The dependent variable in this data set is the number of deaths recorded because of

the ASI after IFAKs were deployed to try and save lives.

For the one-factor ANOVA test to be appropriately used, the data must meet three

conditions (Penn State University, 2023):

1. The data is assumed to be normal.

a. In general, by taking the Center Limits Theorem, data is normal if N (the

sample size of the data) is found to be greater than 30. In this data set,

experiments 1, 2, and 3 all had data sets above N =300. So, the researcher

assumes the normality of the data set and believes the data meets the first

criterion of the one-factor ANOVA test (Modkoff, 2016).

2. The data sets are assumed to have an equal variance.

a. To assume equal variance in these data sets, the researcher used Leve’s Test

for Equality of Variances. To accomplish this, the researcher found the mean

of each experiment group (listed above in section 4.2) and from this calculated

the absolute residual of each data entry by subtracting the input value from the

group mean. Then, a one-way ANOVA test was performed on the residuals,

65
 and the resulting p-value was above α = 0.05. So, the researcher assumed that

the data set has an equality of variances and passed this standard for one-

factor ANOVA testing (National Institute of Standards and Technology,

2023). Below is a table of the resulting ANOVA test on the residuals.

Table 1. ANOVA of residuals proving equal variance

3. Assumption of Independence

a. The AnyLogic® model ran 1,500 independent iterations of an ASI. There

were 500 independent iterations of each of the three experiments. No iteration

was dependent in any way on the result of any other iteration. Each iteration

runs independently of the results of the others, so the data is assumed to be

independent.

66
 The researcher also chose to check the validity of the results of the one-factor ANOVA

test. The best way to do this is to perform a post-hoc test. The researcher chose the Bonferroni

Test. The Bonferroni test adjusts p values to control the experiment-wise error rate and decrease

the change of a Type -I statistical analysis error (NIH, 2014).

4.4 Data Analysis Results

Since this data set requires comparing the means of more than two groups and meets the

criterion for a one-factor ANOVA test, this is the statistical test the researcher chose to use to test

the above null and alternative hypothesis. The results of the one-factor ANOVA test comparing

the mean number of deaths for each experiment group showed a very small resulting p-value (2E-

88). This is less than α = 0.05. Thus, in this instance, we reject the null hypothesis and conclude

that varying the distance/placement of IFAKS in a K-12 school during an ASI will impact the

casualty mean by a statistically significant amount. Below is a table showing the output of the

ANOVA test.

Table 2. One factor ANOVA of Deaths Column

67
 The post-hoc test (Bonferroni Correction) also concurred with this conclusion. The

Bonferroni Correction rejects the null hypothesis when the p-value is less than α/k, where = (a)((a-

1)/2). A is equal to three in this data set, and thus K is also equal to 3. This makes the new

significance value 0.0167, which is still larger than the one-way ANOVA’s p-value. Thus, we still

reject the null hypothesis and conclude that varying the distance/placement of IFAKS in a K-12

school during an ASI will impact the casualty mean by a statistically significant amount.

While not a part of the initial hypothesis, the author also utilized the one-factor ANOVA

test to determine whether there was a statistically significant difference in the means of the number

of kits left with agents and the number of injured victims who did not die because of intervention.

These results would be interesting information for data discussion. The one-factor ANOVA test

for each of those categories showed that there was a statistically significant difference in both of

those other categories. See the two figures below for outputs of the one-factor ANOVA tests.

Table 3. One-factor ANOVA of Kits Left with Agents Columns.

68
 Table 4. One-factor ANOVA of Number Saved Columns

When looking at the means of each of the categories, it was apparent that experiments one

and two were much closer results than experiments two and three or one and three. For this reason,

the researcher also performed a two-sample t-test of equal variances on mean number of deaths,

the mean number of kits left with agents, and the mean number of injured victims saved from

interventions. In all these tests, the mean difference between experiments one and two was found

to be statistically significant. See the two figures below for outputs of the respective T-tests.

69
 Table 5. Two-Sample T-test Between Exp 1 and 2 Average Deaths

Table 6Two-Sample T-test comparing Exp 1 and 2 Kits Left with Agents Means

70
 Table 7. Two Sample T-Test comparing Exp 1 and 2 Number Saved Means

4.5 Data Discussion

The results of the statistical tests give several insights that should be discussed. First, the

data suggests that there is a statistically significant difference in mean number of deaths based on

IFAK placement/deployment. Experiment 1 had a mean death rate of 27.7 persons (Figure 8)

Experiment 2 had a mean death rate of 26.8 persons, and Experiment 3 had a mean death rate of

29.2 persons. Experiment 2 also had the highest average number of injured persons who did not

die because of IFAK interventions. Experiment 2 had an average of 7.1 persons saved during each

iteration, while experiments one and three only had 6.3 and 4.8 persons saved per iteration,

respectively (Figure 9).

Experiment 2, deploying IFAKS systematically throughout the entire layout as opposed to

centralized locations, shows the lowest mean number of deaths of ASI victims of any deployment

strategy. The deployment location itself is integral to this outcome. However, the data also suggests

71
that the deployment strategy affects other factors that lead to the lowest death average of any of

the three deployment strategies.

The first and most obvious reason Experiment 2 may have the lowest death mean is simply

logical. The deployment of IFAKs periodically throughout a whole building allows for near-

immediate access to an IFAK for an injured individual. In contrast, Experiments 1 and 3 only keep

IFAKs close to individuals who are injured near the IFAK stock. Keeping IFAKs stocked

periodically throughout the landscape allows injured persons who may not be close to a centralized

IFAK storage point to have quick access to life-saving equipment.

Experiments 1 and 3 require that an agent traverses a much longer distance to retrieve and

use an IFAK than Experiment 2 if they are not close to a centralized IFAK storage location. As a

matter of safety during an ASI, it may also be advantageous for agents to not have to move a large

distance to retrieve and use an IFAK. Experiment 2 allows agents to travel a very short, if any

distance to retrieve life-saving supplies.

Another reason Experiment 2 may have the lowest mean death average is due to the time

in which Experiment 2 was executed compared to Experiments one and three. Experiment 2

deployed all of the IFAKS, on average, in a much shorter time than in Experiments one and three.

Experiment 2 on average took just under two minutes to deploy and use all IFAKs while

experiments one and three both took on average just under three minutes to deploy all the IFAKS.

Assuming the actual application time of the IFAK contents was approximately equal across all

experiments, the data suggests that the deployment outlined in Experiment 2 gets IFAKs to victims

faster than the other deployment/placement methods. This is logical given that an agent will only

have to walk a few doors at most to find an IFAK, retrieve it, and bring it to a victim instead of

traversing to a centralized collection point.

72
 The data also suggests a third reason that the mean number of deaths is lower in Experiment

2. Experiment 2 had on average 0.08 (approximately 0) kits left unused at the end of the iterations.

Experiments one and three had on average 1.8 and 3.4 kits, respectively, left unused at the end of

each iteration. The data suggests that since the kits in Experiment 2 are closer to the end user, there

is less time spent on retrieving the IFAKS and bringing them back to the victims and more time

spent applying the contents of the IFAKs. Since the deployment is on average about one minute

faster, all the IFAKs can be used in the first three minutes of the iteration as opposed to having 2-

to 3 IFAKs unused at the end of the iteration. This allows for more individuals to be treated with

IFAKs in that critical time frame than in Experiments one and three.

One potential logical downfall of Experiment 2 deployment strategy is that the deployment

could fall short in instances where victims are numerous and centralized (Aurora shooting as an

example). While Experiment 2 does allow for faster access and deployment of the IFAK, it does

only allow for treating one victim (or maybe multiple depending on the type of wounds presented

and the contents of the IFAK). However, regardless, the impact could be limited in an instance

where there are several victims with the same kind of wound in need of the same kind of

intervention. It is reasonable to assume the mean would not be affected significantly since there

are other IFAKs periodically stationed, but the more centrally located victims there are, the farther

agents will start needing to travel to retrieve enough IFAKs to treat multiple victims.

73
 SUMMARY AND RECOMMENDATIONS

5.1 Overview

When ASIs occur, this is a significant risk of the loss of innocent lives, and the effects of

ASIs can ripple beyond just those lives lost. ASIs have become a more prevalent issue in recent

years, and the loss of life continued to rise in number. Addressing this national plague will require

a multi-faceted approach. There is significant research (referenced above in Chapter 1) from the

Purdue Department of Homeland Security Institute that focuses on mitigation actions by the

shooter in an ASI to help prevent loss of life. However, apart from Tzvetanov’s 2021 research,

there is little research about how to mitigate loss of life during an ASI from the perspective of

mitigating victim’s injuries during an ASI.

This multi-pronged mitigation research is important, and it is also clear from above

established research that TCCC principles and corresponding IFAK applications are effective in

mitigating loss of life from penetrating gunshot wounds. This is also clear from the reviews of

several major US active shooter incidents. What is also clear from reviewing several major US

ASI’s is not just the effectiveness of these techniques but also how important it is for these methods

to be introduced to the ASI environment as quickly as possible.

Since these interventions are effective in treating the types of wounds associated with ASI

victims, there is the question of how to best deploy these interventions to the environment to

optimize this threat mitigation technique. While other research questions related to deployment,

like the optimal number of IFAKS, will be discussed in section 5.3 of this chapter, this research

sought to answer the question of what the optimal distance/placement of IFAKs in a 12-school

environment is to best minimize casualty rates during an ASI.

74
 5.2 Significance

This research established through agent-based modeling and statistical data analysis that

there is a statistically significant difference in the mean death rate of ASI victims when comparing

three different placement/deployment strategies for IFAKs in a K12 school environment. The

research concluded that Experiment 2, placing IFAKS periodically and evenly throughout the

landscape instead of in a centralized location, decreases the mean death number for victims of an

ASI by a statistically significant amount.

This research has significance for several reasons. Some of these reasons are obvious.

Some are less obvious. All of them could have a significant impact on policy and governmental

monetary investments. The first reason this research is significant is obvious: finding best practices

for active shooter response in K-12 schools is a service to the public good. Deploying IFAKs has

been proven time and again to significantly reduce casualty rates for trauma victims and is a

worthwhile and important endeavor. Even if other public policies were to somehow (however

improbable) eradicate ASIs, violence in other parts of the world shows us that evil individuals with

evil motives will find other means than guns to hurt innocent people on a mass scale.

It was for this reason this researcher focused on IFAK use and deployment for this research.

Assuming the worst will occur at some point no matter what society’s best attempts to stop it, what

are the best practices to mitigate loss of life when that day comes? This research provides a starting

point for discussion about a best practice to implement proven, life-saving measures in some of

our most vulnerable venues when the worst does inevitably occur.

This research is significant because, in a situation full of chaos and changing variables, it

is important to have as many settled variables as possible. This research suggests that there is a

best practice for IFAK deployment that has a significant impact on casualty rates. This can be a

settled variable in the ASI equation. By investing in this best practice, K-12 schools can know that

75
as far as it is up to them, they have prepared well for mitigating loss of life through the use and

deployment of IFAK materials.

The research also highlights the significance of timely medical response to favorable

medical outcomes. Chapter 2 highlighted several after-action reviews that concluded earlier

medical intervention would have reduced casualties in those particular ASIs. This research also

establishes that due to the priority of arriving law enforcement, standard operating procedures of

FIRE/EMS, and the natural standard response time, sometimes it is not possible for first responders

to provide immediate medical aid. This research suggests that timely intervention with TCCC

applications from persons other than first responders can have a positive impact on casualty rates.

It also suggests that there is a best way to deploy those applications to the end-user. Experiment 2

supports the idea that best practice is the option that gets the IFAK applications in the hands of the

end user the fastest way possible. This is the optimal response to a trauma wound in an ASI

environment.

Another significant outcome of this research is to invest in training. This research assumes

that some agents in the school, specifically teachers in this instance, had obtained at least a baseline

level of proficiency in deploying IFAK materials. However, only one state, California, requires

IFAKs in all new private and public buildings, and no state requires this training for its teachers

(School Safety Solution, 2023). In an ASI, this training is proven to be lifesaving for those who

are hemorrhaging. If the data discussed in Chapter 2 supports the idea that IFAK contents save the

lives of hemorrhaging victims and this research supports the concept that there is an optimal way

for them to be deployed in a K-12 environment, then in what ways can private entities or

governmental agencies invest in evidenced-based, life-saving interventions? Do school

corporations or state departments of education need to mandate stop-the-bleed training and invest

76
capital or grant dollars in providing IFAKs for school environments? Should Stop the Bleed

training become commonplace among students like how we now implement CPR and first aid?

While best practices for these questions may require future research, ample research suggests

timely access to IFAK materials is integral to saving lives during an ASI, and investing in people

to be well prepared to use those contents is a critical step in their use.

5.3 Recommendations for Future Studies

This research establishes the significance of ASIs in America, the tragedy of the loss

resulting from ASIs, and the importance of finding mitigation techniques to stop the loss of life

resulting from ASIs. While most research surrounding ASIs focuses on mitigating the shooter’s

actions, this research chose to focus on using TCCC procedures and IFAK products to reduce the

loss of life in an ASI. While this research has established the most optimal way to distribute IFAKS

in a K-12 school environment from a placement/distance perspective, this research leaves several

avenues open for future study and analysis.

The first avenue of future study this researcher believes would be beneficial to ASI

literature is to determine if there is an optimal number of IFAKs or Stop the Bleed kits that need

to be deployed in a K-12 school. This optimal number could be measured by several factors, and

it would be in the best interest of future research to determine by what factor the optimal number

of IFAKs should be measured. These potential factors include distance to police/EMS response,

number of students and staff enrolled/employed by the school, square footage of the school, and

staff-to-student ratio.

Police/EMS response time is important as most police and EMS will bring additional IFAK

material to the scene. The number of students/staff is a viable factor considering the quantity of

IFAK material is proportional to the number of people in the building. Square footage of the school

77
is also a viable factor that is considered in this research. If IFAKS are deployed most optimally, a

smaller school may still be farther away from an IFAK than a larger school by nature of the square

footage of the building. Finally, the student-to-staff ratio is important considering the next avenue

of future study: teacher TCCC and stop the bleed training.

Teacher training in the application of IFAKs and TCCC principles is another potential

future research avenue that could branch from this research. This research method assumed a very

average time frame for teachers to apply the appropriate IFAK content to the corresponding wound.

However, given an optimal number of IFAKs and optimal placement of those IFAKs in a K-12

school, the next logical research question is whether increasing the efficiency and stress tolerance

of teachers when applying IFAK contents would also decrease ASI casualty rates.

This research assumed that only one teacher/per classroom in the layout was available to

apply IFAK materials to wounded victims. However, the third potential future research question

is whether it is possible to decrease the ASI casualty rate by increasing the number of individuals

who are properly trained to apply IFAK contents to wounds in an ASI. Much like current first-

aid/CPR/AED courses are widely taught to high school students for a variety of reasons, future

research could consider the following question:

Would expanding the number of individuals (i.e. students) who are properly trained in

TCCC/ Stop the Bleed principles in an ASI environment decrease the mortality rate of victims

during an ASI? The concept is that increasing the number of individuals who are properly trained

to employ these life-saving tactics in an ASI environment would allow more individuals to address

wounds within the time frame necessary to mitigate the loss of life.

A final future research idea is to change the layout of the school to see if the change in

layout changes the best deployment/placement of IFAKS. In this research, the Robb Elementary

78
layout was two long corridors connecting a variety of classrooms of varying sizes. But there are

other school layouts, such as squares, T and X layouts, and circles, that could plausibly change the

best type of deployment for the IFAK.

While there are other concepts and ideas for future research that could be explored because

of this research, the above ideas for future research will help expand the knowledge and literature

on how IFAK/TCCC concepts can be employed in an ASI environment with the ultimate goal of

mitigating casualties and saving lives.

79
 REFERENCES

"A timeline of what happened at the Orlando nightclub shooting". The Tampa Bay Times. June 12,
2016. Archived from the original on June 13, 2016. Retrieved June 13, 2016.

ABC7. (2012, July 26). Aurora, Colorado Theater shooting timeline, summary, and known facts:
ABC7 Los Angeles. ABC7 Los Angeles. Retrieved December 4, 2022, from
https://abc7.com/archive/8743134/

Aberle SJ, Dennis AJ, Landry JM, et al. Hemorrhage control by law enforcement personnel: a
survey of knowledge translation from the military combat experience. Mil
Med 2015;180:615-20. 10.7205/MILMED-D-14-00470

ALERRT & FBI (2020). Active Shooter Response – Level 1. Version 7.2.

ALERRT. (2022, July 6). Robb Elementary School Attack Response Assessment and
Recommendations. Retrieved December 4, 2022, from https://alerrt.org/

Active shooter definition. ALICE Training®. (2020, April 21).

https://www.alicetraining.com/active-shooter/

Anklam, C. E., Kirby, A., Sharevski, F., & Dietz, J. E. (2014) Mitigating Active Shooter Impact
between 2000 and 2013. Texas State University and Federal Bureau of Investigation.

Associated Press. (2022, June 2). “Day by day:” Uvalde survivors recover from wounds, trauma .
Day by Day. https://apnews.com/article/uvalde-school-shooting-health-texas-education-
amerie-328d99a5803ada242bee0ded3ac3b63c

Beaven, A., Ballard, M., Sellon, E., Briard, R., & Parker, P. (2018). The Combat Application
Tourniquet Versus the Tactical Mechanical Tourniquet. Journal of Special Operations
Medicine : A Peer Reviewed Journal for SOF Medical Professionals, 18, 75–78.

Bennett, B., Littlejohn, L., Kheirabadi, B., Butler, F., & Kotwal, R. (2014, September 23).
Management of External Hemorrhage in Tactical Combat Casualty Care: Chitosan-Based
Hemostatic Gauze Dressings. Retrieved December 5, 2022, from
https://apps.dtic.mil/sti/citations/ADA614079

Blair, J. P. & Duron, A. (2022). How police officers are shot and killed during active shooter
events: Implications for response and training. The Police Journal. DOI:
10.1177/0032258X221087827

Blair, J. P. & Schweit, K. W. (2014). A Study of Active Shooter Incidents in the United States

Blair, J. P. & Schweit, K. W. (2022). Active Shooter Incidents 20-Year Review, 2000-2019.

Blair, J. P. & Schweit, K. W. (2022). Active Shooter Incidents in the United States in 2021. Texas

80
Blair, J. P. (2013). 4. In Active shooter events and response (pp. 67–67). essay, CRC Press, Taylor
& Francis.

Blair, J. P. (2013). In Active shooter events and response (pp. 193–193). essay, Taylor & Francis.

Bonabeau, E. (2002). Agent-based modeling: methods and techniques for simulating human
systems. In Proceedings for the National Academy of Sciences, 99(3). 7280-7287.

Buster C: Patrol response challenge. NCJRS Law and Order, 56(6): pp. 62-68.

Butler FK. TCCC Updates: Translating Military Advances in External Hemorrhage Control to
Law Enforcement. J Spec Oper Med. 2015 Winter;15(4):167-174. doi: 10.55460/ARZP-
RFK1. PMID: 27689379.

Centers for Disease Control and Prevention. (2021, September 10). FASTSTATS - body
measurements. Centers for Disease Control and Prevention. Retrieved December 5, 2022,
from https://www.cdc.gov/nchs/fastats/body-measurements.htm

Chase Knickerbocker, M. S., Mario F. Gomez, D. O., Jose Lozada, M. D., Jonathan Zadeh, M. D.,
Eugene Costantini, M. D., & Ivan Puente, M. D. (2019). Wound patterns in survivors of
modern firearm-related civilian Mass Casualty Incidents. American Journal of Disaster
Medicine, 14(3), 175–180. https://doi.org/10.5055/ajdm.2019.0329

Clarkson, L., & Williams, M. (2022, August 8). EMS Mass Casualty Triage. National Center for
Biotechnology Information. Retrieved December 4, 2022, from
https://pubmed.ncbi.nlm.nih.gov/29083791/

Columbine Report, "The Columbine High School Shootings: Narrative Time Line of Events 11:10
AM to 11:59 AM". May 15, 2000. Archived from the original on December 15, 2012.
Retrieved December 4, 2022

Cornelius, B., Campbell, R., & McGauly, P. (2017). Tourniquets in trauma care: A review of the
application. Journal of Trauma Nursing, 24(3), 203–207.
https://doi.org/10.1097/jtn.0000000000000290

Dealing_With_Active_Shooters-Purdue_Research_Paper-Compr.pdf

Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for
the future of combat casualty care. J Trauma Acute Care Surg 2012;73:S431-7.
10.1097/TA.0b013e3182755dcc

Feldman, R. (2015). Committee for Tactical Emergency Casualty Care. Committee for Tactical
Emergency Casualty Care. https://www.c-tecc.org/our-work/guidance

Fitzsimons, Tim. "What happened that night at Pulse". NBC News. NBC Universal. Retrieved June
12, 2021.

81
Frantz, B. M. (2021). Active Shooter Mitigation for Open-Air Venues. (Publication No. 14593671)
[Doctoral dissertation, Purdue University]. Purdue University.

French, G. (2015, April 17). The first 5 minutes of tragedy: Casualty care training all cops should
have. Police1. Retrieved December 4, 2022, from https://www.police1.com/oklahoma-
city-bombing/articles/first-5-minutes-of-tragedy-casualty-care-training-all-cops-should-
have-dD8fBu6HoyFHbNtY/

Friberg, M., Jonson, C.-O., Jaeger, V., & Prytz, E. (2021). The Effects of Stress on Tourniquet
Application and CPR Performance in Layperson and Professional Civilian Populations.
Human Factors, 00187208211021255. https://doi.org/10.1177/00187208211021255

From the Israel Defense Forces Medical Corps (A.S., A. S. (2015, October). Prehospital use of
hemostatic dressings by the Israel...: Journal of Trauma and Acute Care Surgery. LWW.
Retrieved December 4, 2022, from
https://journals.lww.com/jtrauma/Abstract/2015/10001/Prehospital_use_of_hemostatic_d
ressings_by_the.24.aspx

https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2021-052422.pdf/v

https://www.fbi.gov/file-repository/active-shooter-study-2000-2013-1.pdf/view

Guide to data cleaning: Definition, benefits, components, and how to clean your data. Tableau.
(2023). https://www.tableau.com/learn/articles/what-is-data-
cleaning#:~:text=Data%20cleaning%20is%20the%20process,to%20be%20duplicated%2
0or%20mislabeled.

Gun Violence Archive. (2022, June 18). Gun Violence Archive 2022.
https://www.gunviolencearchive.org/

IACP. (2018, April). Active Shooter Concepts and Issues Paper. Active Shooter. Retrieved
December 4, 2022, from https://www.theiacp.org/sites/default/files/2018-
08/ActiveShooterPaper2018.pdf

Interagency Board - Health Medical & Responder Safety Subgroup. "Law Enforcement Tactical
Emergency Casualty Care (TECC) Training and Individual First Aid Kits (IFAK) White
Paper." United States Government, June 2015.

Iowa Head and Neck Protocols (Maximum Allowable Blood Loss | Iowa Head and Neck Protocols,
n.d.)

Jefferson County Sheriff's Office. (n.d.). Narrative Timeline of Events. CNN. Retrieved
December 4, 2022, from
http://www.cnn.com/SPECIALS/2000/columbine.cd/Pages/NARRATIVE.Time.Line2.ht
m

82
Johnson, A., & Burns, B. (2022, August 8). Hemorrhage - statpearls - NCBI bookshelf.
Hemorrhage. Retrieved December 5, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK542273/

Johnson, D., Bonnin, P., Perrault, H., Marchand, T., Vobecky, S. J., Fournier, A., & Davignon, A.
(1995). Peripheral blood flow responses to exercise after successful correction of
coarctation of the aorta. Journal of the American College of Cardiology, 26(7), 1719–1724.
https://doi.org/10.1016/0735-1097(95)00382-7

Kastre, T. (2020, December 10). Tactical EMSs saved lives after the Giffords Shooting - gems:
EMS, emergency medical services - training, paramedic, EMT News. Tactical EMS Saved
Lives after Giffords Shooting. Retrieved December 4, 2022, from
https://www.jems.com/operations/tactical-ems-saved-lives-after-giffords/

Katzenell, U., Ash, N., Tapia, A. L., Campino, G. A., & Glassberg, E. (2012). Analysis of the
causes of death of casualties in field military setting. Military Medicine, 177(9), 1065–
1068. https://doi.org/10.7205/milmed-d-12-00161

Kent State University. (2023, October 11). Libguides: SPSS tutorials: One-way ANOVA. One-
Way ANOVA - SPSS Tutorials - LibGuides at Kent State University.
https://libguides.library.kent.edu/spss/onewayanova

Koko, K. R., McCauley, B. M., Gaughan, J. P., Nolan, R. S., Fromer, M. W., Hagaman, A. L. R.,
Choron, R. L., Brown, S. A., & Hazelton, J. P. (2017). Kaolin-based hemostatic dressing
improves hemorrhage control from a penetrating inferior vena cava injury in coagulopathic
swine. Journal of Trauma and Acute Care Surgery, 83(1), 71–76.
https://doi.org/10.1097/ta.0000000000001492

Knolhoff, C. N., Dietz, J. E., & Lee, J. Y. (2022). Magazine capacity limits and home
security. Journal of Emergency Management (Weston, Mass.), 20(2), 143-155.

Kotora, J. G., JoseHenaoCDR, F.LittlejohnCDR, L., SaraKircherBS, Lee, C., Belmont, P. J., Shen-
Gunther, J., McPherson, J. J., & Ayling, J. (2013, August 6). Vented chest seals for
prevention of tension pneumothorax in a communicating pneumothorax. The Journal of
Emergency Medicine. Retrieved December 4, 2022, from
https://www.sciencedirect.com/science/article/abs/pii/S0736467913005076

Kragh, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B.
(2009). Survival with emergency tourniquet used to stop bleeding in major limb trauma.
Annals of Surgery, 249(1), 1–7. https://doi.org/10.1097/SLA.0b013e31818842ba

Krouse WJ, Richardson DJ (2015) Mass Murder with Firearms: incidents and victims, 1999–2013.
Congressional Research Service, Washington, DC

Kue, R. C., Temin, E. S., Weiner, S. G., Gates, J., Coleman, M. H., Fisher, J., & Dyer, S. (2015).
Tourniquet Use in a Civilian Emergency Medical Services Setting: A Descriptive Analysis
of the Boston EMS Experience. Prehospital Emergency Care, 19(3), 399–404.
https://doi.org/10.3109/10903127.2014.995842

83
Lee, J. Y., Dietz, J. E., & Ostrowski, K. (2018). Agent-based modeling for Casualty Rate
Assessment of ... - IEEE Xplore. AGENT-BASED MODELING FOR CASUALTY RATE
ASSESSMENT OF LARGE EVENT ACTIVE SHOOTER INCIDENTS. Retrieved
December 5, 2022, from https://ieeexplore.ieee.org/abstract/document/8632535/

Lee, J. Y. (2019). Agent-based modeling to assess the effectiveness of run-hide fight (Doctoral
dissertation, Purdue University).

Lincke, S. J., & Khan, F. (2020). Ethical Management of Risk: Active Shooters in Higher
Education. Journal of Risk Research 23(12), 1582-1578.
https://www.tandfonline.com/doi/full/10.1080/13669877.2019.1687575?cookieSet=1

Merriam-Webster. (n.d.). Hemorrhage definition & meaning. Merriam-Webster.

https://www.merriam-webster.com/dictionary/hemorrhage

Maximum ABL calculation. (n.d.). Retrieved May 24, 2021, from

https://www.openanesthesia.org/maximum_abl_calculation/

Maximum allowable blood loss | Iowa Head and Neck Protocols. (n.d.). Retrieved Dec 4, 2022,
from https://medicine.uiowa.edu/iowaprotocols/maximum-allowable-blood-loss

Miller, N. (2015, September 28). Why do police need to train to use and carry an IFAK? Police1.
Retrieved July 18, 2022, from https://www.police1.com/police-products/tactical/tactical-
medical/articles/why-police-need-to-train-to-use-and-carry-an-ifak-3JULJldwAo67a00o/

Mordkoff, T. (2016). The assumption(s) of normality.

http://www2.psychology.uiowa.edu/faculty/mordkoff/GradStats/part%201/I.07%20norm
al.pdf

Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2002). Clinical anesthesiology (3rd ed). McGraw-
Hill

Murphy, R., Daniel, A., Cai, M., Lau, E., Schumacher, Y., & Astudillo, C. (2023, May 1). Robb
Elementary School. Texas Public Schools.
https://schools.texastribune.org/districts/uvalde-cisd/robb-elementary-school/

Nadler, S. B., Hidalgo, J. U., & Bloch, T. (1962). Prediction of blood volume in normal human
adults. Surgery, 51(2), 224–232. https://doi.org/10.5555/uri:pii:0039606062901666

National Institute of Standards and Technology. (2023). Leven’s Test for Equality of Variances.
1.3.5.10. Levene test for equality of variances.
https://www.itl.nist.gov/div898/handbook/eda/section3/eda35a.htm

NPR. (n.d.). Uvalde Elementary School shooting. NPR. Retrieved December 4, 2022, from
https://www.npr.org/series/1101183663/uvalde-elementary-school-shooting
repository/active-shooter-incidents-20-year-review-2000-2019-060121.pdf/view

84
PEREIRA, I. (2023, June 29). Former Parkland school cop Scot Peterson, who allegedly fled
shooting, found not guilty on all counts. ABC News. https://abcnews.go.com/US/parkland-
school-cop-scot-peterson-allegedly-fled-shooting/story?id=100392688

Penn State University. (2023). 10.2.1 - ANOVA assumptions: Stat 500. PennState: Statistics Online
Courses. https://online.stat.psu.edu/stat500/lesson/10/10.2/10.2.1

RA;, A. (2014). When to use the Bonferroni correction. Ophthalmic & physiological optics : The
Journal of the British College of Ophthalmic Opticians (Optometrists).
https://pubmed.ncbi.nlm.nih.gov/24697967/

Ran, Y., Hadad, E., Daher, S., Ganor, O., Kohn, J., Yegorov, Y., . . . Hirschhorn, G. (2010).
QuikClot Combat Gauze Use for Hemorrhage Control in Military Trauma: January 2009
Israel Defense Force Experience in the Gaza Strip—A Preliminary Report of 14
Cases. Prehospital and Disaster Medicine, 25(6), 584-588.
doi:10.1017/S1049023X00008797

Riedman, D., & O’Neill D. (2020). K-12 School Shooting Database. Naval Postgraduate School,
Center for Homeland Defense and Security, Homeland Security Advanced Thinking
Program (HSx). www.chds.us/ssdb/

Scerbo, M. H., Holcomb, J. B., Taub, E., Gates, K., Love, J. D., Wade, C. E., & Cotton, B. A.
(2017). The trauma center is too late: Major limb trauma without a pre-hospital tourniquet
has increased death from hemorrhagic shock. Journal of Trauma and Acute Care Surgery,
83(6), 1165–1172. https://doi.org/10.1097/TA.0000000000001666

Schaenman, P., Stambaugh, H., Cohen, H. C., Nichelini , R. W., & Souder, S. (2014, September
24). Aurora Century 16 Theatre Shooting. After Action Review for the City of Aurora.
Retrieved December 4, 2022, from
https://www.courts.state.co.us/Media/Opinion_Docs/14CV31595%20After%20Action%2
0Review%20Report%20Redacted.pdf

Schreckengaust, R., Littlejohn, L., & Zarow, G. J. (2014). Effects of Training and Simulated
Combat Stress on Leg Tourniquet Application Accuracy, Time, and Effectiveness. Military
Medicine, 179(2), 114–120. https://doi.org/10.7205/MILMED-D-13-00311

Schroll, R., Smith, A., McSwain, N. E. J., Myers, J., Rocchi, K., Inaba, K., Siboni, S., Vercruysse,
G. A., Ibrahim-Zada, I., Sperry, J. L., Martin-Gill, C., Cannon, J. W., Holland, S. R.,
Schreiber, M. A., Lape, D., Eastman, A. L., Stebbins, C. S., Ferrada, P., Han, J., …
Duchesne, J. C. (2015). A multi-institutional analysis of prehospital tourniquet use. Journal
of Trauma and Acute Care Surgery, 79(1), 10–14.
https://doi.org/10.1097/TA.0000000000000689

Sip, M., Serniak, B., Rogozinski, D., Kosec, R., Zajo, A., Vokaty, S., ... & Dabrowski, M. (2018).
Tactical medicine inspires civilian rescue medicine in the management of
hemorrhage. Disaster and Emergency Medicine Journal, 3(1), 15-21.

85
Smith, A. A., Ochoa, J. E., Wong, S., Beatty, S., Elder, J., Guidry, C., McGrew, P., McGinness,
C., Duchesne, J., & Schroll, R. (2019). Prehospital tourniquet use in penetrating extremity
trauma: Decreased blood transfusions and limb complications. The Journal of Trauma and
Acute Care Surgery, 86(1), 43–51. https://doi.org/10.1097/TA.0000000000002095

Smith, E. R., Shapiro, G., & Sarani, B. (2018). Fatal Wounding Pattern and Causes of Potentially
Preventable Death Following the Pulse Night Club Shooting Event. Prehospital Emergency
Care, 22(6), 662–668. https://doi.org/10.1080/10903127.2018.1459980

State University and Federal Bureau of Investigations.

Stein, R., & Cardia, A. (2022, October 12). State investigation fueled flawed understanding of
delays during police response in Uvalde. The New York Times. Retrieved December 4,
2022, from https://www.nytimes.com/2022/10/12/us/uvalde-shooting-police-response-
investigation.html

Stop the bleed training in schools: State Guide. School Safety Solution. (2023, May 23).
https://www.schoolsafetysolution.com/stop-the-bleed-training-in-schools/

STB Home Page. Stop the Bleed. (n.d.). https://www.stopthebleed.org/

Straub, F., Castor, J., Gorban, B., & Meade, B. (2017). United States Department of Justice.
Rescue, Response, Resilience. Retrieved December 4, 2022, from
https://cops.usdoj.gov/RIC/Publications/cops-w0857-pub.pdf

Texas State University and Federal Bureau of Investigations. https://www.fbi.gov/file-

Tactical Casualty Combat Care. Tactical Combat Casualty Care. (2023).

https://www.naemt.org/education/naemt-tccc

Tjardes, T., & Luecking, M. (2018). The Platinum 5 min in TCCC: Analysis of Junctional and
Extremity Hemorrhage Scenarios with a Mathematical Model. Military Medicine, 183(5–
6), e207–e215. https://doi.org/10.1093/milmed/usx016

Tzvetanov, K. (2021). Improving the Fidelity of Agent-Based Active Shooter Simulations Through
Modeling Blood Loss and Injury Management (dissertation).

United States Department of Homeland Security. (n.d.). Active shooter - how to respond - DHS.
Active Shooter: How to Respond. Retrieved December 4, 2022, from
https://www.dhs.gov/xlibrary/assets/active_shooter_booklet.pdf

Tzvetanov, K., Cline, T., Thomas, G., Wood, C., & Dietz, J. E. (2022). Active Shooter Mitigation
Strategies in Small Rural Churches. Emergency Management 20(2), 111-125.
https://europepmc.org/article/med/35451048

Tzvetanov, K.T. (2023) ‘Optimizing Hemorrhage Control Kit Placement [Submitted to JEM]’.

86
Weston, R. (2023). Analysis of the Relative Risks Associated with Firearms as an Active Shooter
Mitigation Technique on School Campuses (Doctoral dissertation, Purdue University

87