Prepared For the Worst

April 22, 2015

If an active shooter situation occurred in your school, would you know how to respond? One Ohio clinic held a daylong seminar to ensure its athletic trainers would be able to answer, “Yes.”

The following article appears in the April 2015 issue of Training & Conditioning.

By Chris Giordullo

Chris Giordullo, MEd, ATC, is Education Director of the Robert S. Heidt Sr. Wellington Foundation, which offers professional education for the athletic trainers of Wellington Orthopaedic and Sports Medicine in Cincinnati. He can be reached at:

It’s mid-morning, and you’ve just arrived at your high school’s athletic training room. Sitting at your desk catching up on paperwork, you hear a loud pop echo through the hallways. Moments later, you hear another burst, and it sounds like it is getting closer. A frantic voice over the loudspeaker says there is a shooter in the building. As the gunshots continue, you can make out the panicked voices of students and staff. You have a split second to think. In that moment, you ask yourself: What should I do?

Athletic trainers spend a great deal of time preparing for a worst-case scenario injury. Our schools have emergency action plans in place for every type of athletic injury and rehearse these plans regularly. However, recent school shootings and the Boston Marathon bombings indicate that athletic trainers should also be prepared for emergencies of a different nature.

Schools are not immune to violence, and with that violence comes an immediate need for medical care. In a school shooting, there is a chance that an athletic trainer will be the only health care professional on the premises, so they need to be ready to step in.

This was the rationale behind the active shooter training seminar that Wellington Orthopaedic and Sports Medicine held in June 2013. Our Cincinnati clinic contracts out more than 40 athletic trainers to area high schools and junior high schools. We wanted to ensure our staff would be ready for anything that might occur.

Of course, we hope our athletic trainers never have to put this training to use. But in the event of an active shooter situation, a properly trained athletic trainer could make the difference between life and death.


Preparation and education have always been a priority at Wellington Orthopaedic and Sports Medicine. The Robert S. Heidt Sr. Foundation provides annual in-house continuing education courses to ensure our athletic trainers are informed about the most recent sports medicine practices.

The idea for an active shooter seminar came up during a brainstorming session on new educational opportunities for our athletic trainers. The Foundation then collaborated with Wellington staff and school administrators to discuss the best way to educate our athletic trainers about their role in an active shooter scenario.

One of our first steps was finding a group that could provide proper education and training. After learning of an active shooter course offered by the Tactical Medical Division of the Dayton, Ohio, SWAT team, we reached out to them. Fortunately, the team was very gracious and able to come to Cincinnati to put on a course for our staff.

We held the course at Saint Xavier High School, which is centrally located, making it easy for our staff athletic trainers to attend. In addition, we extended an invitation to our school administrators and local media to raise awareness about the class.

The course lasted a full day and was split into two parts. First, we held a lecture session to educate our athletic trainers on the logistics of an active shooter event. This was followed by a lab session where they could practice the triage skills necessary for handling a mass casualty scenario.


The lecture focused on how to deal with an active shooter during a school day. To provide context to their lessons, the instructors were engaging and referred to real-life situations, such as the shooting at Columbine High School in Littleton, Colo.

Through these examples, our athletic trainers were better able to understand the unique factors that separate an active shooter situation from other mass casualty events. Schools are considered “soft” targets because they have little to no security. Frequently, there is no pattern or method to how a shooter selects their victims, and their behavior is often unpredictable. The Wellington athletic trainers learned that it’s nearly impossible to talk the shooter down once they commit to the act. At that point, they are solely focused on inflicting as much harm as possible.

With these considerations in mind, the SWAT team explained the three options athletic trainers have if they are ever in a school building during an active shooter situation: run, hide, or confront.

Run: Getting away from the shooter is always the first option. Our athletic trainers were told to leave their belongings behind and head to their school’s designated safe space outside. They can help other students and staff escape but were instructed to leave them behind if they are reluctant to go. Once athletic trainers reach a safe place, they can call 911 and provide the dispatcher with any information they have, including how many shooters are on the premises, their location and physical description, the type of weapons used, and the number of victims.

Hide: In some situations, our athletic trainers wouldn’t be able to run, in which case they should hide. For example, if the shooter is in the classroom right next to them, hiding in their room is their best option. The SWAT team encouraged them to have a pre-planned hiding space. Ideally, they are to hide out of view from the shooter and either lock all doors or block them with chairs, desks, or bookshelves. When hiding, our athletic trainers were instructed to silence their cell phones, avoid conversations, and pay close attention to their surroundings.

Confront: Running and hiding are the best options for our athletic trainers’ safety. However, there could be an instance where confronting the shooter is the only available option. This is the last thing they should try, and it should only be attempted if their life is in imminent danger. Once they decide to confront the suspect, they have to fully commit. Our athletic trainers were told to incapacitate the shooter in any way they can, whether that is by throwing things at the gunman or trying to strike them. The best-case scenario is the shooter goes down and can no longer fire on anyone.

At first, our athletic trainers had trouble accepting the run, hide, or confront lesson. It was a totally different mindset to adopt. In an emergency situation, their initial response is to act—to help people who are hurt. None of our athletic trainers would hesitate to put themselves in harm’s way to save somebody else.

However, when an active shooter is involved, the SWAT team was adamant that they were to think of their own safety. Bottom line: if they are struck by a bullet running into the fire, who will be around to help the students after the shooter is contained?

It took a lot of discussion to overcome this mental hurdle. With the SWAT team members’ input, our athletic trainers helped each other talk through their issues with this advice. Although it was tough to swallow, everyone eventually realized that in order to help the most people in an active shooter situation, they had to keep themselves safe first.


Emergency medical personnel are not allowed to enter the site of an active shooter situation until the police have declared it secure. Often, athletic trainers will be the only health care providers in the building and will have to care for wounded individuals outside or hiding in their area until further help arrives. In the lab session, our athletic trainers practiced how to respond.

Victims of an active shooter need to be cared for similarly to the triaging that takes place in a combat zone. Tactical Combat Casualty Care (TCCC) is the standard for the management of combat casualties within the Department of Defense, and athletic trainers should use this protocol when in an active shooter situation.

The first step of TCCC is a quick assessment of the victim. This includes tourniquet application and airway management.

With gunshot wounds, the biggest concern is bleeding. An athletic trainer’s first step is applying direct pressure with whatever they can find to cover the wound. If that doesn’t stop the bleeding, a tourniquet should be put on.

Wellington’s athletic trainers frequently read about tourniquet application in industry literature. However, it’s a pretty rare occurrence in the field, so they don’t get much practice in doing it correctly.

Fortunately, the SWAT team demonstrated the proper protocol. Then, each athletic trainer practiced putting a tourniquet on a colleague and had one put on them. The SWAT team provided materials similar to what athletic trainers would have available in an active shooter situation, such as sticks, belts, and rulers.

Experiencing the amount of pressure applied by the tourniquet was eye-opening for many in attendance. As it clamped down on their arteries, our athletic trainers remarked that they could feel their blood flow slowing down. It was a valuable lesson in just how tight the tourniquet needed to be to do its job and potentially keep someone alive.

Next, our athletic trainers learned how to secure a victim’s airway. If a victim falls unconscious after sustaining a gunshot wound, his or her jaw can relax, causing the tongue to slide back and block the airway. The instructors did a live demonstration on how to use a nasopharyngeal hose to open an airway on one of the SWAT team members.

The final piece of the triage instruction came as a surprise to many in attendance. Once they stopped the bleeding and secured the airways, our athletic trainers were instructed to move on to the next victim. In addition, if they were to encounter someone who wasn’t breathing and didn’t have a pulse, they were told to move on to the next body.

As with accepting the run, hide, or confront options in the lecture session, this was difficult for some athletic trainers to accept. Everyone understood that this method was employed to ensure they reached as many victims as possible, but it went against many of their practices. However, after they ran through some practice simulations and saw the triage skills in action, many saw its necessity.


Throughout the lecture and lab sessions, the SWAT team gave our athletic trainers an inside look at the protocols for an active shooter situation. Knowing law enforcement’s priorities helped the Wellington staff better understand their role.

The SWAT team instructed our athletic trainers on what to do once the police arrive if they are outside of the school building. Because the police are on high alert and won’t know who is a victim and who is a suspect, it’s important not to run toward them, yell, or point them in any direction. Instead, the athletic trainers were told to drop anything they were holding, put their hands up, and spread their fingers.

The instructors emphasized how important it is that our athletic trainers stay calm and follow any officers’ instructions. They should only provide information if it is requested. If the police decide to evacuate them from the area, they should follow the instructions immediately.

Finally, the SWAT team also ran through how to communicate with medical personnel once they arrive on the scene. It is important that our athletic trainers identify themselves, then alert the EMTs to any triaged victims and communicate treatment protocols. The emergency team will provide next-level care to any victims, including advanced airway treatment, IV therapy, splinting, immobilization, and transport to a hospital.


Overall, Wellington’s staff and school administrators were able to soak up a lot of valuable information from the active shooter training session. One of the biggest lessons was the importance of not trying to help until the site is deemed safe. Our athletic trainers understood that triaging during an active shooter situation is not the same as running onto a soccer field to treat an ankle sprain. Unless the site is secure, they are limited in how much they should maneuver and help anyone.

Looking ahead, we plan to hold a refresher course on how to handle an active shooter scenario. Our athletic trainers would like to get more practice with some of the hands-on aspects, like tourniquet application, and it would be good to review the run, hide, and confront options.

If any clinics or athletic training staffs are considering holding their own active shooter training sessions, I’d highly recommend it. Communicate with local police, EMS, and the nearest hospital emergency room to set up an action plan for dealing with mass casualties in an active shooter situation.

It is important to have an action plan in place and practice it so it becomes routine, much like a fire drill. For some, it may seem like an inconvenience, but being prepared can save lives. That alone makes having a plan worthwhile.



By Robyn Gust

Robyn Gust, MS, ATC, is the Manager of the Sports Medicine Department at Trinity Hospital in Minot, N.D. She is also an athletic trainer and adjunct instructor for Minot State University. Gust can be reached at:

The tragic bombings at the 2013 Boston Marathon served as a wake-up call to the sports medicine community that athletic events aren’t immune to mass casualty situations. As we started to think through this at Trinity Sports Medicine in Minot, N.D., we discovered a lack of communication and understanding among our athletic trainers, local emergency personnel, and the entities we cover throughout northwest North Dakota. The problems included:

• Trinity athletic trainers weren’t knowledgeable about mass triage care and were not informed of their local EMS’s response plan for a mass casualty event.

• Local EMS personnel were unaware of athletic trainers’ skill sets and responsibilities and did not know that Trinity Sports Medicine provided coverage to most contact sporting events in northwest North Dakota.

• There was no regular, formal communication between Trinity’s athletic trainers and local EMS, which led to a disconnect regarding their emergency action plans.

• None of our contracted schools or teams understood how to handle a mass casualty event at an athletic contest.

These findings hit us like a ton of bricks, and we immediately set out to rectify the situation. Our first course of action was providing an introduction to mass casualty triage to our athletic trainers. The local ambulance department taught our athletic training staff the method they use for mass casualty events, called START, which stands for “Simple Triage and Rapid Treatment.” The basis of START is to quickly make a determination on a patient based on their respiration, perfusion, and mental status. Depending on the results, the athletic trainer attaches a triage tag to designate if the patient’s care is deemed immediate, delayed, or if the individual is deceased, before moving on to the next victim.

To learn the basics of incident command, Trinity athletic trainers also completed online courses in National Incident Management Training through the Federal Emergency Management Agency. Incident command is vital in bridging the gap between the protocols of athletic trainers and emergency personnel. The classes focused on how to set up a unified command system for managing large-scale casualties.

In addition, our athletic trainers now all carry mass triage care kits, which include 30 triage tags, a yellow incident commander identifying vest, a red medical commander identifying vest, and a mass casualty plan sheet. The vests allow EMS to immediately identify incident command personnel at an athletic event without having to search and question those on scene. This is vital to expediting an efficient transfer of command and care. The plan sheet is a pre-event outline that identifies everyone’s roles and the locations that will be utilized should a mass casualty situation occur.

To educate EMS personnel, Trinity Sports Medicine set up in-services with city and rural ambulance and fire departments throughout northwest North Dakota. Our goal was to help them understand the skills and responsibilities of athletic trainers and what sites we cover. In order to ensure ongoing communication, I now attend monthly EMS planning meetings for several counties.

The final step was getting our contracted entities on board by educating them on mass casualty events at athletic contests, the role of on-site temporary incident command, and how to complete the mass casualty plan sheet. Each Trinity athletic trainer met with their school administration to discuss these matters.

In the world of athletic training and emergency management, the motto is, “Prepare for the worst and hope for the best.” By getting all parties in northwest North Dakota on the same page with our mass casualty plan, we feel we have greatly improved our preparation.

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