It is widely accepted that trauma victims from an intentional mass casualty incident (IMCI) require rapid access and assessment, immediate stabilization with life-saving interventions and prompt transportation — ideally to the nearest trauma center.
However, despite this consensus, numerous self-imposed beliefs and practices within society and the first responder community often contribute to delays in these critical actions.
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This article examines the major contributory factors and explores ways to reduce these delays, ultimately enhancing survival rates.
Public preparedness and response
A significant issue impacting MCI response is the general public’s lack of knowledge regarding appropriate actions before, during and after an attack. Education efforts reach some, and are typically centered around the “Run, Hide, Fight” approach, which, while seemingly practical, is not evidence-based.
Adding “Help” to this model — making it “Run, Hide, Fight, Help” — could empower bystanders, once the threat has passed, to stop bleeding, move injured individuals to safety, place casualties in the recovery position, or provide valuable information to dispatchers. Public training initiatives like Stop-the-Bleed classes can equip bystanders with essential skills and confidence to save lives.
Additionally, there is a need for greater awareness of pre-event warning behaviors, or the “left of boom” concept, as many attackers display noticeable signs, red flags, before an incident.
There is growing evidence of a correlation between histories of stalking and/or domestic violence and an increased risk of aggressive acts, including some mass shootings [1]. Early recognition and reporting has — and will — enable law enforcement to prevent some active shooter events entirely.
Law enforcement response and prioritization
Traditionally, law enforcement officers are trained to focus exclusively on neutralizing, isolating or eliminating active attacker threats, often with large numbers of responders dedicated solely to this objective. While stopping the attacker is the top priority, most incidents conclude within a few minutes, typically with one perpetrator who either dies by suicide, surrenders, is incapacitated by bystanders or flees [2].
There is room for subsequent waves of officers to shift their focus to rendering aid, rather than simply increasing the armed presence. The “stop the killing, then stop the dying” paradigm may benefit from flexibility, allowing life-saving measures to commence sooner, especially when there are no clear ongoing threats. Delaying medical intervention while waiting for rescue task forces (RTFs) can result in preventable deaths.
Law enforcement officers can initiate life-saving interventions, including moving critically injured casualties out of the crisis site to a casualty collection point (CCP).
Another concern during a large law enforcement response is the risk of “blue on blue” incidents, repetitive searching of the same areas and wasted time. These issues can also detract from the establishment of unified command, which is essential for coordinating law enforcement, fire and EMS efforts.
Security posture and threat perceptions
A common approach among law enforcement is to maintain a heightened security posture — what can be described as “guns up” — while searching for potential secondary threats or additional shooters. This hypervigilant search for additional threats is not supported by evidence, as the vast majority of active attacker incidents involve a single shooter [2].
While remaining vigilant is important, response strategies should be guided by probability and evidence, not just possibility. In other words, maybe some of the responding officers can dedicate themselves to providing medical care to the injured.
Delays in medical access and rescue task force deployment
A notable delay occurs when law enforcement waits to thoroughly search an entire area or building — checking every possible hiding place — before admitting medical teams such as fire/EMS RTFs. On average, this practice can delay medical intervention by 20-30 minutes.
A more effective approach would be for law enforcement to immediately bring in medical assets to the crisis site once the primary threats (suspects or explosives) are ruled out, establishing a protective “safe corridor” for medical teams to operate. Ideally, lifesaving measures should begin by law enforcement even before RTF medical teams arrive.
Fire/EMS RTFs often stage at a distance, awaiting clearance to enter the scene. While responder safety is vital, a forward-leaning deployment strategy may result in timelier access to casualties. RTFs should be positioned proactively, ready to move in with law enforcement escorts as soon as an area is secured.
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Triage system variability
There is considerable inconsistency in the triage methods used by different responders, which include START, Homebush Triage Standard, Sieve, Care Flight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV, among others. None of these approaches has proven superior in terms of patient outcomes or resource allocation [3].
The exception is the “Ten Second Triage” system, recently developed in Britain, which is grounded in evidence and applicable even by non-medical personnel. This system may serve as a gold standard for immediate responders to assess and prioritize casualties [4].
Casualty management and transportation delays
Multiple phases in casualty management — such as internal and external casualty collection points (CCPs), separate treatment areas, and loading zones — can create delays, which can be detrimental to patients with penetrating trauma. Each “bus stop” between injury and definitive care decreases the chances of survival.
While CCPs may be necessary, the focus should remain on prioritizing red patients — those in critical need of intervention and rapid transport. Not all red patients are equal; responders must identify those who require more advanced care than can be provided on scene and expedite their removal and transport to appropriate facilities.
Interoperability and unified command
Responsibilities such as interoperability, unified command, family assistance, staging, patient destination and media coordination (joint information center) must be shared among all stakeholders: law enforcement, fire, EMS, hospitals, dispatch and the affected facility (whether a transit hub, hospital, school, business, mall, festival or sporting event).
The “not my job syndrome” must be overcome by fostering a truly unified command structure. Effective responses are typically enabled by pre-established playbooks and multidisciplinary trainings, exercises and workgroups that have addressed potential friction points and clarified roles in advance, building mutual respect and professionalism.
Removing the friction in MCI response
In summary, trauma victims from intentional mass casualty incidents must be rapidly accessed, stabilized and transported to trauma centers. By critically examining and addressing the various points of delay and friction — ranging from public preparedness and responder tactics to triage and command structure — it is possible to save valuable minutes, and ultimately, more lives.
References
- Dunlap JS. 2019 “The connection between mass shootings and domestic violence,” Pepperdine Policy Review: Vol. 11, Article 6.
- Rockefeller Institute of Government “Mass Shooting Fact Sheet” High Level Details about mass shootings from 1996 to today.
- Bazyar J, Farrokhi M, Khankeh H. “Triage Systems in mass casualty incidents and disasters: A review study with a worldwide approach.” Open Access Maced J Med Sci. 2019 Feb 12;7(3):482-494. doi: 10.3889/oamjms.2019.119. PMID: 30834023; PMCID: PMC6390156.
- Davidson L, Vassallo J, Cowburn P, Bull D, et al. 2025. “Evaluating 10 second triage: A novel multi-agency prehospital triage tool for major incidents.” Journal of Contingencies and Crisis Management, 33: e70025.
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