Instruction for Review 2

DOI: 10.1111/1745-9133.12479

S P E C I A L I S S U E A R T I C L E

C O U N T E R I N G M A S S V I O L E N C E I N T H E U N I T E D S TAT E S

Rapid response to mass shootings

A review and recommendations

Paul M. Reeping1 Sara Jacoby2 Sonali Rajan1

Charles C. Branas1

1Columbia University

2University of Pennsylvania

Correspondence Paul M. Reeping, Department of Epidemiology,

Mailman School of Public Health, Columbia

University, 722 West 168th Street, New York,

NY 10032.

Email: [email protected]

Research Summary: We conducted a scoping review of literature indexed in the National Library of Medicine’s

journal citation database, MEDLINE, and Scopus to iden-

tify articles in which the rapid response of hospital staff,

emergency medical services personnel, the police, and the

public to mass shootings is covered. Sixty-five articles were

included, and critical themes related to reducing the harm

from a mass shooting were summarized.

Policy Implications: According to our findings, when mass shootings occur in the United States, several evidence-

informed steps can be taken from the moment the first bul-

let is fired until the last injured individual is transported

to the hospital to promote a rapid response that can reduce

death and disability. Ten recommendations are made rang-

ing from recognition of the need for rapid response and

bystander training to triage and transport training of police

and avoidance of over-response.

K E Y W O R D S firearms, mass casualty incidents, mass shootings, rapid response, review

On October 17, 2017, just after 10 PM, the highest causality mass shooting event in U.S. history

occurred at a music concert in Las Vegas, Nevada. From a 32nd floor window of the building across

from the concert venue, a single individual shot more than 1,000 bullets into the crowd on the ground

below. After performing retrospective evaluation, the devastating human toll of this shooting was con-

firmed; more than 800 people were injured, more than 500 required medical care, and 58 people died

(Lake, 2018). Arguably, the response to this mass shooting was also one of the most profound tests of

Criminology & Public Policy. 2020;19:295–315. wileyonlinelibrary.com/journal/capp © 2019 American Society of Criminology 295

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the capacity of the local hospital system, emergency medical services (EMS) system, and law enforce-

ment in and around Las Vegas in rapidly responding to a civilian act of mass violence.

In a case study published by the Nevada Hospital Association, the author reviewed the many lessons

learned in the aftermath of the shooting. The socially and medically complex nature of these kinds of

human-made disasters was highlighted. For example, people at the scene of the Las Vegas shooting

behaved differently than they might have in the aftermath of other high causality events, such as a

multiple-vehicle road traffic crash (Lake, 2018). In Las Vegas, many victims fled the scene of the

shooting and sought medical care on their own, bypassing EMS and established protocols for choosing

appropriate medical facilities and notifying hospitals of impending arrivals (Lake, 2018). Many vic-

tims and noninjured bystanders also used smartphones and mapping applications to find health-care

facilities. Given the sheer volume of victims, both trauma centers and smaller community hospitals

received patients with major injuries and little notice (Lake, 2018). As a result, these hospitals experi-

enced unplanned strains on their resources and staff capacities (Lake, 2018).

The Las Vegas mass casualty shooting may have been unusual in its magnitude, but its need for a

rapid multisector, mass casualty, and mutual aid response is not unique. Both medical and law enforce-

ment responses are necessary and interdependent when contending with mass casualty incidents and

reducing the risks of death. The findings from research spanning two decades on the use of law enforce-

ment personnel as a coordinated part of the medical response to shootings have demonstrated benefits

in terms of rapid access to medical care and mortality reductions (Band et al., 2014; Branas, Sing,

& Davidson, 1995; Wandling, Nathens, Shapiro, & Haut, 2016). In addition, based on the results of

national research funded by the Centers for Disease Control and Prevention more than a decade ago,

rapid access to accredited trauma center hospitals in the United States has been shown to reduce the risk

of death significantly for people who are severely injured (MacKenzie et al., 2006). The findings from

further national research on the mass casualty response capabilities of 25 major U.S. cities showed

that longer wait and transport times needed to distribute high numbers of severely injured patients to

trauma centers after fast-onset mass casualty incidents resulted in predictable increases in mortality.

This research was funded by the National Institutes of Health and conducted in conjunction with Office

of the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human

Services, and its findings highlight the need for a coordinated systems-based approach to mass casualty

incidents that includes multiple public sectors—hospital, EMS, and law enforcement—and appropri-

ate execution of multijurisdictional mutual aid agreements (Carr, Walsh, Williams, Pryor, & Branas,

2016).

Mass shootings are a category of mass causality incidents for which there is no single definition or set

of criteria. The Congressional Research Service designates mass shootings as incidents in which four or

more people are killed with a firearm, in one event, and at close proximity. By comparison, the Federal

Bureau of Investigation’s (FBI’s) operationalizing of a mass shooting differs in that its definition

requires an “active shooter” (an individual attempting to kill people in a populated area). Nongovern-

mental and media organizations also track mass shooting events over time. In these databases, mass

shootings are identified as any incident that occurs in a public place, with a firearm, where three or

more people are killed, and where the motive seems to be indiscriminate (Follman, Aronsen, & Pan,

2019).

By many of these definitions, mass shootings have been increasing in frequency and lethality in

the United States (Center for Victims of Crime in partnership with the Office for Victims of Crime,

2018). Mass shootings garner extensive public attention and often become the center of policy debates

around firearm ownership and prevention efforts (Shultz, Thoresen, & Galea, 2017). It is important to

note, however, that many U.S. cities contend with multievent and multivictim firearm injury scenarios

on a near everyday basis, most of which do not make the news. In an article published in 2019, the

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authors found that firearm-injured patient clusters, where four victims of firearm violence arrived to

Philadelphia hospitals at the same time from an event that occurred in temporal and spatial proximity,

are common (Beard et al., 2019).

Whether they warrant their own set of dedicated policy and practice interventions, or simply are a

more extreme example of the burden of “everyday” firearm injury and mortality in contemporary U.S.

society, the occurrence of mass shootings highlights critical gaps and challenges in current emergency

and trauma systems and subsequently offers opportunities to improve efforts and streamline existing

systems. Some of these gaps include the lack of consolidated data on nonfatal firearm injuries and

interventions that occur in the pre-hospital arena, understanding of the capacity of and outcomes from

publicly oriented mass trauma response campaigns, and identification of common principles and best

practices applicable to all who might participate in a rapid response from victims and bystanders to the

clinicians at specialized accredited trauma care hospitals (Callaway, 2018).

With these gaps in mind, the purpose of this review is to describe the scope of publication and

major findings of literature and make recommendations pertaining to the processes and impact of rapid

response by health systems, EMS, and law enforcement in the aftermath of mass shooting events. To

our knowledge, we are the first to evaluate research and reports dedicated to the current evidence

on rapid response optimization and mortality prevention and to include multisectoral prehospital and

in-hospital efforts. The conclusions drawn from this review may help guide future research, improve

practice, and support new policies.

1 M E T H O D

We conducted a scoping review (Colquhoun et al., 2014) of literature indexed by the National Library

of Medicine’s journal citation database, MEDLINE, in which all biomedical and life science journal

articles published since 1946 have been captured, through the PubMed interface, which in addition to

Medline includes other biomedical, criminological, and social science content from 1996 onward. We

also searched Scopus, in which all PubMed content is catalogued but additionally includes literature

from social science and criminology journals. We conducted both searches from the beginning of

each database through September 2019. With so few articles published on mass shootings, the search

terms were set to be sufficiently sensitive to capture all literature on response to mass shootings. These

included “mass shooting” OR “mass killing” OR “mass homicide” OR “mass murder” OR “active

shooter” OR “school shooting” OR “mass casualty incident” and “shooting” OR “mass casualty

incident” and “firearms” OR “mass casualty incident” and “homicide”. “Response” was included as

an additional required search term for Scopus as a result of the large number of articles produced

via the previous search terms. Articles were uploaded to Rayyan (Ouzzani, Hammady, Fedorowicz,

& Elmagarmid, 2016), a platform for sorting and identifying appropriate and relevant articles for a

scoping review.

Once the articles we identified were added to the database, the titles and abstracts of each were

reviewed for fit with our inclusion criteria. To meet inclusion eligibility, an article must have been pub-

lished in English and must have direct relevance to medical, EMS, police, school, or civilian responses

to mass shooting events in the United States. We excluded articles in which the relationship to rapid

response was missing or indirect, for example, case studies in which mass shootings were described

but not how the medical system, police, or citizenry reacted to reduce harm after the event; descriptive

statistical analyses on the incidence of mass shootings in relation to legal, demographic, and historical

trends; protocols specific to dealing with an active shooter in the hospital; and psychological studies

of mass shooting perpetrators and victim responses. After the title and abstract review, any article in

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F I G U R E 1 Literature search and selection process [Color figure can be viewed at wileyonlinelibrary.com]

which a match with inclusion and exclusion criteria remained unclear was evaluated on the basis of

review of the article’s full text. All articles selected for final review were read in full and then collated

into distinct overarching themes, agreed to by the three authors.

2 R E S U LT S

In total, 1,129 articles were identified from which 34 were determined eligible for inclusion based

on title and abstract review alone, and an additional 78 articles required full text review to determine

inclusion eligibility. Of those 78, 31 were eligible, yielding a total of 65 articles that were ultimately

sorted, evaluated, and summarized in this present review. A flowchart outlining the search and selection

process is illustrated in Figure 1.

Of the 65 articles included in this review, most (n = 36) were a mixture of commentary, case reports, summaries of lessons learned, and suggestions for management of future mass shooting events. Eight

articles were descriptive epidemiologic studies, nine included the results of a survey, and seven involved

a simulation, either computer (agent-based models) or through reenactments. Four articles were eval-

uations of educational programs, and one article was a presentation of the outcome of a randomized

control trial. The articles included in this scoping review can be identified by a (*) in the Reference

section.

The earliest article included in our review was published in 1999. The number of articles published

per year on mass shootings, as well as the number published specifically on “rapid” response to mass

shootings, is graphed in Figure 2.

Clear themes emerged among the articles, which are also illustrated in Figure 1. Most (n = 19) were focused on hospital training and response, followed by articles focused primarily on EMS training

and protocols (n = 14) and police response (n = 11). Thirteen articles were focused on rapid school response and notification, whereas the rest were on citizen response (n = 9).

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F I G U R E 2 Number of articles published per year on mass shootings and rapid response to mass shootings available on pubmed and scopus

2.1 Hospital response 2.1.1 Clinician perceptions of preparedness A rapid response to mass shooting events may hinge on the preparation and capacity of physicians and

other clinicians at nearby hospitals where victims are first treated. In an article published in 2008, the

authors examined the predictors of perceptions toward mass casualty emergency response preparedness

among pediatric surgeons (Chokshi, Behar, Nager, Dorey, & Upperman, 2008). They found that three

quarters of the surgeons surveyed felt that they would were “definitely” responsible to participate in

a mass casualty emergency; however, only a quarter believed they were “definitely” prepared to do

so. Preparedness was predicted by whether the surgeon attended national conferences and/or if he or

she had previous disaster response experience. The same proportion (74%) of surgeons in this study

who believed that they were unprepared for a mass casualty emergency also endorsed the need for more

training. The findings highlight the potential disconnect between what medical professionals, including

nurses and other clinicians in hospitals, might perceive as their required role in rapid response to mass

shooting events and what they have been trained and practiced to do in order to feel confident in their

ability to respond well and save lives.

2.1.2 Planning and drills In the disaster planning literature, scholars have more broadly suggested that one way to help medical

professionals feel more confident responding to a crisis may be through the implementation of frequent

and realistic planning and training drills (Gowing, Walker, Elmer, & Cummings, 2017). Although some

type of disaster planning was mentioned in many articles, in six articles, the authors detailed the impact

of planning for a mass shooting event through training drills that include administrative, clinical, and

security personnel (Albert & Bullard, 2016; Cheatham, 2016; “Dealing with school shootings, vio-

lence: how Jonesboro and Denver hospitals met this new challenge to emergency preparedness.,” 1999;

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Glasofer & Laskowski-Jones, 2018; “Mass shooting in Colorado: practice drills, disaster preparations

key to successful emergency response.,” 2012; Sofer, 2018). For example, in two articles, the authors

describe the relationship between comprehensive training drills and the capacity of nearby hospitals

to respond to the Pulse nightclub mass shooting in Orlando, Florida, in June 2016. The nearest hospi-

tal to the scene of the shooting was only a few blocks away and received dozens of patients in rapid

succession. The administrators from this hospital credit the success of the hospital’s rapid response to

recently conducted training exercises (Albert & Bullard, 2016). The Orlando Regional Medical Center,

the hospital to receive the majority of the victims, had undergone an active shooter drill only 3 months

before the shooting. During the drill, substantial efforts were made to provide as much as realism as

possible in which included the participation of 15 hospitals, 50 agencies, and 500 volunteers (Glasofer

& Laskowski-Jones, 2018). Although it is not possible to know the number of lives saved as a result

of this training exercise, the hospital credits the drill with helping to identify and rectify processes in

need of improvement. They also stated that the drills likely increased the confidence of medical staff

to act quickly when responding to an actual mass shooting event (Glasofer & Laskowski-Jones, 2018).

The importance of drills was not limited to retrospective evaluation of the Pulse nightclub shootings.

Sofer (2018), as part of the Emergency Nurse’s Association, outlined the importance of mass shooting

drills that included training for the mobilization of significantly increased surgical services and addi-

tional security and safety measures to contend with the potential for secondary violence. Sofer credited

the rigorous disaster planning of the University Medical Center of Southern Nevada (UMC-SN) for its

ability to handle the large influx of patients after the mass shooting in Las Vegas in 2017.

2.1.3 Communication Scholars have suggested that two distinct aspects of communication are crucial for responding quickly

to mass shooting events. The first is signaling to hospitals near to an event that they will be receiving an

influx of patients. The type of injuries most common in the aftermath of a shooting event are likely to

cause rapid and life-threatening hemorrhage, and the faster victims receive resuscitative measures and

definitive care in the hospital, the more likely they are to survive (Alarhayem et al., 2016). Therefore,

the sooner the hospital can receive notice of a mass casualty event, the sooner hospital staff can mobilize

surgeons and other staff to respond to the medical needs of multiple patient admissions at the same

time or in rapid succession. Often communication of a mass shooting event occurs when the first

patient arrives to the hospital or via a phone call from first responders en route. For example, after the mass shooting in Aurora, Colorado, in July 2012, the primary receiving hospital heard that there was

a shooting at a movie theater via emergency dispatch radio. Hospital staff did not know the extent of

the shooting’s impact, initially disregarded it as “street” violence, and therefore did not activate the

hospital’s disaster plan until the first patient arrived (Johnson, 2012).

An emergent strategy may decrease the time from a shooting event to when a hospital receives

notice to prepare by including signaling from social media platforms like Twitter. In a study released

in 2017, the authors examined five multiple casualty events, including the 2012 Sandy Hook and 2014

Marysville school shootings. They found that a threshold can be identified based on the number of

tweets about a given event that can signal that a mass casualty incidence has occurred. They also found

that this signal, for all of the events studied, preceded the first patient arriving to the hospital (Callcut,

Moore, Wakam, Hubbard, & Cohen, 2017).

The second major form of communication is the need for a receiving hospital to process and dissem-

inate information about victims quickly to their family members, law enforcement, and the media. Soon

after a mass shooting event, hospitals typically need to manage and respond to a staggering number

of phone calls and requests for information from family members and friends that are worried about

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the status of loved ones who might have been in close proximity to the event. For example, after the

Aurora shooting, the hospital was forced to implement a hotline to handle the hundreds of phone calls

received from the public. This hotline was set up ad hoc the night of the shooting, but in a retrospec- tive evaluation, the authors noted that the absence of and need to plan and develop such a hotline was

known prior to the event (Koehler, Scott, & Davis, 2014). In addition, on the basis of lessons learned

in the initial hospital’s response, a “telephone tree” was established in the pharmacy department and

managed by second-year pharmacy residents to streamline communication about the mass shooting to

medical professionals (Shakowski, Page, Fish, & Stolpman, 2014).

The relationship between a hospital’s capacity to manage external communication and media report-

ing surrounding an event can also impact early medical response. For example, after the 2009 Fort Hood

shooting, the news networks covering the incident broadcasted the main receiving trauma center’s tele-

phone number (Wild et al., 2012). This led to an influx of more than 1,300 phone calls, which compli-

cated communication within the hospital. As a result, two individuals were inappropriately transferred

from the trauma center to a regional hospital without a trauma center designation (Wild et al., 2012).

The pressure of the number of incoming telephone calls was attributed to errors in triage designations.

2.1.4 The “second wave” effect In studies of trends of patient arrivals after a mass shooting, scholars have identified what is referred

to as a “second wave” effect. For example, immediately after the mass shooting in Aurora, one of the

first patients to arrive to the University of Colorado Hospital was a young woman with her infant,

transported in a private vehicle by her boyfriend. She only had a few wounds and none that were

life-threatening. It was much later when those who were most hurt arrived (Johnson, 2012). This phe-

nomenon, in which the less injured arrive significantly before the patients in need of critical care, has

not been unique to the Aurora shooting. There was a similar second wave effect after the Pulse night-

club mass shooting: the first wave arrived at the hospital at 2 AM, whereas the second wave did not

arrive until 3 hours later when the police were able to infiltrate the club and kill the gunman as the

most severely injured were not able to escape until this point (Albert & Bullard, 2016). A second-wave

effect also occurred after the Virginia Tech shooting in 2007 in Blacksburg, Virginia (Armstrong &

Frykberg, 2007). Appreciating the potential for this trend may be a vital component of how hospitals

prepare and predict patient needs after a mass shooting event by specifically resisting judgment about

the severity and causality rate of an incident on the basis of the first patients to arrive.

2.2 EMS response 2.2.1 Triage One of the most important duties of first responders to an event with mass casualties is properly triaging

patients for treatment and/or transport. In ten articles identified in this review, researchers evaluated the

importance of prehospital processes to improve EMS triage after mass shooting events. For mass casu-

alty incidents, like a mass shooting, triage must be done quickly and accurately with a proper command

structure to diminish confusion among responders (Kelley, 2008). One option is to use what is known

as “intuitive triage,” in which an experienced first responder relies on his or her general impression

of the severity of an injury and sense of required urgency for response. In a recent analysis using a

simulated disaster, Hart, Nammour, Mangolds, and Broach (2018) found that intuitive triage was not

only faster but also was statistically no different than more traditional triaging methods, such as Simple

Triage and rapid treatment (START), which is an algorithmic approach to assign hierarchical severity

and urgency labels to victims using multiple points of observed and measured physiologic criteria.

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Relatedly, in an article published in 2009, Talving, DuBose, Barmparas, Inaba, and Demetriades

described various forms of penetrating trauma injuries that might be caused by a shooting event and

classified them by likelihood of survival if a patient reaches definitive medical care; a process that

could potentially improve the effectiveness of mass-shooting specific triage. For example, penetrating

head injuries associated with specific physiologic responses, such as respiratory arrest, fixed and

dilated pupils, and extreme hypertension might be designated as “unsalvageable,” whereas other

penetrating head injuries might be more amenable to medical intervention. For each major injury type,

the authors provided an algorithm to help guide EMS first responders during these mass causality

emergencies. Generally, algorithms for sorting victims are helpful in reducing errors during triage and

therefore in reducing mortality, as was observed during the 2009 Fort Hood mass shooting (Strommen,

Waterman, Mitchell, & Grogan, 2015).

Even with clear algorithms, it can be difficult to triage victims in the chaotic and often hazardous

environment that surrounds mass shooting events. For example, during the Fort Hood shooting, many

patients were undertriaged (those whose injuries were classified less life threatening than they truly

were). This was likely a result of the lack of a security for EMS first responders (Wild et al., 2012).

Errors during triage were also prevalent after the Virginia Tech shooting. Although only one individual

was undertriaged, 69% of victims were overtriaged (determined to need more attention and resources

than injuries warranted) at the scene (Armstrong & Frykberg, 2007). Both of these forms of misclassi-

fication can threaten an effective rapid response. Although overtriage might seem to be a problem that

medical professions are willing to bear, it can be harmful in its depletion of limited resources and time

in mass causality events. Researchers have suggested that although triage errors are bound to occur

in chaotic scenes, like a mass shooting, implementation of several levels of triage can help minimize

errors and optimize rapid response (Talving, DuBose, Barmparas, Inaba, & Demetriades, 2009).

Implementation of in-person simulations, integrating simulation content generated via the Delphi

Method by subject matter experts (Cicero et al., 2014), may improve the EMS providers’ knowledge and

skill level for appropriately triaging patients at the scene of a mass shooting (Cicero et al., 2012). In an

effort to understand integrated responses by law enforcement officers and the EMS better, simulations

of active shooter incidents were performed. Through these “real-life” trainings, errors in triage were

spotted and first responders received immediate feedback and hands-on practice on what to do if the

simulated event occurred in the future (Bachman et al., 2019).

Another way of improving EMS triage practices includes the use of virtual simulations. A video-

game intervention, titled “60 Seconds to Survival,” was shown to have some success in improv-

ing triaging knowledge of EMS providers (Cicero et al., 2017). In this game, players have to triage

12 victims in three scenarios, one which includes a school shooting. They are then provided in-game

feedback of their performance. In this randomized control trial, the intervention group, those who

played the game, had a significant improvement from their baseline score, whereas the control group

did not. Thus, the video-game intervention could have value in improving triage among EMS providers

(Cicero et al., 2017).

2.2.2 Rapid transport Rapid transport of victims to hospitals is important for reducing the likelihood of mortality (Blackwell

& Kaufman, 2002; Crandall et al., 2013). Ideally, victims, particularly those with penetrating injuries,

should be taken directly to a Level 1 trauma center (those that have the resources and training to pro-

vide the highest level of surgical care for trauma patients) by EMS. In some mass causality situations,

however, this may not be possible as a first course of action. When, as a result of transport or distance

constraints, it is not possible to transport victims to a Level I trauma center, rapid transport may involve

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moving victims to the closest trauma and nontrauma hospital emergency departments for stabilization,

after which they can be transferred if advanced medical interventions are required. Initial transport of

patients to lower acuity and nontrauma center hospitals was noted in the evaluation of the response to

the Virginia Tech shootings (Kaplowitz, Reece, Hershey, Gilbert, & Subbarao, 2007).

2.2.3 The “Warm Zone” During mass shootings, first responders are entering dangerous situations. For that reason, EMS

providers typically wait until the area of a mass shooting is cleared of any threat by law enforcement

before they enter to take care of victims. Recently, however, there has been a call for EMS to proceed

into the “warm zone,” an area that is secured by police officers but not totally cleared, so that they

can administer life-saving procedures sooner than they would have if they had waited until an area was

designated as “all-clear” (Mechem, Bossert, & Baldini, 2015; Smith & Delaney, 2013). Practically, a

warm zone is created through joint policies, communication, and collaboration between the police and

EMS, as well as physical measures, such as police car formations that create barriers between where

EMS providers are working and a potential or known threat (Molloy, Newlin, & Racht, 2017).

In a recent study, a scenario-based survey was administered to EMS professionals to gauge their

willingness to enter the warm zone. In these scenarios, the EMS would be part of a “Rescue Task

Force,” in which they would enter with the second wave of police officers. Although most responded

that they would enter the scene if they were supplied with ballistic gear, two thirds would not enter

if they did not have any ballistic gear or a firearm. Individuals with military or other tactical training

were more likely to enter without gear than were those without similar training. The responses to this

survey reveal that although the EMS will in some cases enter the warm zone, it requires the support of

police officers and appropriate defensive gear (Chovaz, Patel, March, Taylor, & Brewer, 2018).

In Philadelphia, Pennsylvania, the fire and police departments collaborated to form a similar struc-

ture to the “Rescue Task Force” described earlier. In their “Rapid Assessment Medical Support” pro-

gram, all municipal paramedics trained with the police to learn how to move into a mass shooting scene

properly and to use available protective gear (Mechem et al., 2015). Similar cross department collabo-

ration was emphasized by a 2011 article in which the author stated, “Both EMS and law enforcement

need to come together, train together and work together to better respond to these unfortunate accidents”

(Morrissey, 2011, p. 48). Nevertheless, care must be given to ensure the EMS not put themselves in

areas where they are not secured or without protection from the police.

The literature also describes the emergence of and advocacy for tactical emergency medical sup-

port teams, or TEMS, embedded in civilian EMS services and ready for response to mass shooting

events. TEMS team members are non-military EMS, medical or nursing personnel trained using mili-

tary methods for responding during police actions and emergencies involving potential shooters where

there is need to be “prepared to deal with limited resources, delayed transport and a higher occurrence

of penetrating injuries” (Carhart, 2012).

2.3 Police response 2.3.1 Integrated response The ability for the EMS to enter the “warm zone” is predicated by police tactics that then give EMS

security. To be able to accomplish this, as well as successfully stop the perpetrator, an integrated

response between all responding police jurisdictions and EMS and fire departments may yield the

greatest overall benefit (Griffith, Ablanedo, & Nenneman, 2015; Keating, 2016; Marino, Delaney,

Atwater, & Smith, 2015). In one article, Ojasalo, Turunen, and Sihvonen (2009) detailed the setup of

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a command center that includes the leadership of all responding police jurisdictions and EMS teams.

Here, decisions can be made that are consistent across all responders, and it enables “real-time” updates

as well as systematic approaches to identify or search for victims and perpetrators (Monteiro et al.,

2014). In another article, Frazzano and Snyder (2014) discussed the need for these kinds of integrated

approaches especially in light of future threats of “hybrid targeted violence” (HTV), which includes

not only a firearm but also chemical and fire related.

2.3.2 Training The primary goal across most police interventions for mass shooting preparation is to train officers

to respond to these incidents to save the greatest number of lives possible; however, the approach and

content of these trainings vary. The Advanced Law Enforcement Rapid Response Training (ALERRT)

Center at Texas State University, which was founded by tactical officers from the San Marcos Police

Department and the Hay’s County Sheriff’s Office, trains officers in tactical techniques, movement for-

mations, and communication strategies (Martaindale & Blair, 2019). They also teach the first arriving

officers to form an active shooter response team quickly and encourage officers to begin to provide aid

for victims once the shooter(s) are no longer an active threat. This program has trained 130,000 from

nearly half of all agencies in the United States. Members of ALERRT also wrote a book titled “Active

Shooter Events and Response,” in which the authors called for more advanced and “aggressive” tactics

to be used by the police during mass shootings (Blair, Nichols, Burns, & Curnutt, 2013).

Police officer training with dedicated focus on hemorrhage control has also been described in the

literature. The Tactical Casualty Care for Law Enforcement and First Responders is a training program

to help police officers better care for victims for mass shootings before they are cared for by EMS

or other medical professional (Pons et al., 2015). Specifically, through this hands-on training, police

officers are taught how to create and apply a tourniquet and stop bleeding. If given this training, Pons

et al. argued that police officers would feel more comfortable acting as medical first responders in mass

shooting events that have limited EMS and transport resources and a large number of casualties.

2.3.3 Hospital transport by police Although it is usually standard that a patient is transported from the scene of a shooting to the hos-

pital via an ambulance, this might not be possible or effective when there are many casualties and

resources are sparse. Dr. Zane, the head of the University of Colorado Hospital Department of Emer-

gency Medicine, credited rapid transport to the hospital by police as being the factor that saved the most

number of lives after the Aurora mass shooting (Johnson, 2012). In fact, most patients in Aurora were

transported by police car or private vehicle to definitive hospital care (Shakowski et al., 2014). Most

recently, the NYPD rapidly transported victims of the 2019 Brownsville mass shooting in Brooklyn,

New York, via police car after 12 people were injured by gunshot. The officers were credited by the

receiving hospital as doing “an amazing job in terms of saving lives in that moment” (Barton, 2019,

para. 2).

Rapid transport by police may be an ideal component of mass shooting response when ambulances

are unavailable. This approach has a strong basis in published literature. Known informally as “scoop

and run,” it is a standard prehospital transport strategy for victims of penetrating injuries, primarily

from shootings, in Philadelphia. In the several articles focused on evaluation of police hospital transport

in Philadelphia and a few additional municipalities, the authors suggested that it is at least as effective

as transport via EMS ambulances. It may, in fact, be life-saving because of the greater presence of

police vehicles on patrol and the often faster response times of law enforcement to shooting incidents

(Band et al., 2011; Band et al., 2014; Branas et al., 1995; Wandling et al., 2016).

REEPING ET AL. 305

2.3.4 Advanced techniques In two articles, emerging technologies were introduced that police may use in the future to help to

eliminate or reduce threats during a mass shooting event. Based in crowd and network dynamic theory,

computer simulations may be able to predict the best way for police officers to evacuate victims during

a mass shooting (Gunn, Luh, Lu, & Hotaling, 2017). For example, computer simulations demonstrated

that a “divide-and-conquer” approach in which victims are split into groups, as well as guiding victims

from one secured room to the next, offer the most effective way to evacuate victims in the shortest

amount of time (Gunn et al., 2017).

An unmanned aircraft system (UAS), or drone, may also have utility in stopping active shooters

(Wallace & Loffi, 2017). During the Las Vegas mass shooting, the shooter had barricaded his room,

was in an elevated position, and had numerous firearms. The environment was also chaotic during the

shooting, and the rush of victims trying to escape made the area difficult for police to navigate and

take measures to stop the threat. Authors have since argued that the use of a drone during this situation

would have been helpful in more quickly stopping the shooter and that it should be considered as an

alternative to reduce harm in future shootings events (Wallace & Loffi, 2017).

2.4 Educator and school response 2.4.1 Educator preparedness Response to mass shootings is increasingly of interest to the general public but in particular to

educators and school administrators as more than 200 school shooting incidents, although not all mass

shootings, have occurred in primary and secondary schools in the United States (Cox, Rich, Chiu,

Muyskens, & Ulmanu, 2018). As such, researchers have studied if and how educators are prepared to

respond to a shooting in their school. A survey conducted in 2006 was mailed to 3,670 school super-

intendents across the United States and chosen at random (Graham, Shirm, Liggin, Aitken, & Dick,

2006). Although most (86%) reported that that their district had a response plan, a third reported that

they had never before held a drill for students and staff. Forty three percent had never collaborated with

local EMS to discuss what to do in a school shooting scenario, and 22% did not have a plan for children

with physical or learning disabilities (Graham et al., 2006). Similarly, the findings from more recent

research on principals’ perceptions of firearm risks in high schools (n = 349) highlighted that less than half of the schools represented in this sample had been trained with regard to how to respond to a

school shooting (Price, Khubchandani, Payton, & Thompson, 2016; Thompson, Price, Mrdjenovich,

& Khubchandani, 2009). Furthermore, the results of this work confirmed that many principals are

unsure about what specific training and programs to implement as there is little evidence guiding

existing school gun violence prevention practices (Price et al., 2016). Similarly, on the university

level, a survey was conducted using a convenience sample of 28 schools with radiologic programs

and found that only 5 schools had detailed plans in place for an active shooter incident (Curtis, 2009).

2.4.2 Planning and drills Schools should be perceived as safe places for students (Cornell, 2015). And some scholars have

recently focused on the evaluation of action plans and drills that school personnel and students may use

to respond to an active shooter. For example, the authors of a 2017 paper suggested that schools develop

a Safety Committee that can disseminate protocols and initiate drills mimicking what actions students,

teachers, and staff should take if there was ever an active shooter in the school. These authors also sug-

gested that these protocols should cover several aspects of rapid response, including how school staff

should communicate with one another and to their students if there is an emergency in the school, and

306 REEPING ET AL.

how to plan for students who have disability conditions (Selekman & Melvin, 2017). [Although not a

formal school environment, nursing homes and rehabilitation centers have a similar need as a result of

the fragility of older persons and the difficulty that will be faced in facilitating evacuation (Martin &

Powell, 2017).] There has also been computer simulated research on what type of “lockdowns” should

be implemented in schools. Traditional lockdowns, which typically involve the locking of doors and

moving students away from windows, have not been determined to be effective as a more dynamic,

multioption response where students evacuate the area, create barricades, and as a last resort actively

resist the shooter (Jonson, Moon, & Hendry, 2018).

As schools and families contend with the possibility of mass violence, elected officials have also

put forth plans to guide school protocols. Unfortunately, some of these suggested practices are not nec-

essarily grounded in empirical evidence, yet are being used to inform some school safety practices.

For example, after the May 2018 mass shooting in a high school in Santa Fe, Texas, Governor Greg

Abbott proposed a “School and Firearm Safety Action Plan.” The report contained several sugges-

tions for schools, some of which the existing research base findings confirm has some efficacy, such as

implementing behavioral threat assessment processes (Astor et al., 2013; Borum, Cornell, & Jimerson,

2010) and increasing the number of mental health professionals in schools, which school administra-

tions universally agree is a reasonable investment. Abbott also called for the increased presence of

law enforcement on school campuses, although it is unclear whether law enforcement is a deterrent

to violent crime on school campuses (Kubena & Watts, 2019). In this same report, Abbot also called

for a push to “harden campus facilities,” including the installation of metal detectors, building phys-

ical structures around a school’s campus in a barricade-like fashion, and using video surveillance to

monitor a school’s campus (Abbott, 2018). Unfortunately, these practices have not been shown to be

effective (Hankin, Hertz, & Simon, 2011).

In response to the Hartford Consensus, an initiative aimed at empowering citizens to participate

in hemorrhage control (Jacobs et al., 2013), 26 elementary school educators and administrators were

given “short, intensive” instruction on how to apply hemorrhage control properly and their general

role as a first responder. Before the training, all teachers reported low confidence in their ability to

apply tourniquets and act properly as a first responder. After the training, all teachers reported feeling

confident in these acts. The authors reported that this is evidence that the Hartford Consensus can be

applied to real-life scenarios and to help train the public on their role as first responders (Ramly et al.,

2016), including in a school setting.

2.4.3 Alert systems and social media During a mass shooting, it is imperative that students and staff are notified of the event as soon as

possible so that they can evacuate or protect themselves. In five articles, all based in university envi-

ronments, the authors examined the best way to alert students, faculty, and staff to an incident and the

role that social media has on both rapidly spreading information. In one article, the researchers argued

that social media, as a result of its real-time use and proliferation among college students, could be used

as the best way to notify students during a mass shooting, although they cautioned that there needs to

be more research in understanding the best way to do so (Haupt, Kapucu, & Morgan, 2017). In contrast,

in another article, the authors recommended against the use of social media because of the negative

emotions associated with users during these incidents. For example, their survey responses revealed

that individuals who used social media as their primary source of information were more likely to be

under greater distress as a result of rumor transmission (Jones, Thompson, Schetter, & Silver, 2017). In

another article, the authors went further, stating that there should be rules and social media monitoring

developed for these scenarios to limit misinformation and rumors (Mazer et al., 2015). Regardless, the

REEPING ET AL. 307

responses to a survey of which communication methods work best during an emergency demonstrated

that mobile devices, e-mail notifications, and face-to-face communication were taken the most seri-

ously by students and that mass media, including television and social media, were the least effective

(Stephens, Ford, Barrett, & Mahometa, 2014). With this in mind, push notifications on phones (and on

computers) could be implemented as a way to inform students, faculty, and staff quickly of a possible

active shooter or mass shooting (Egnoto, Svetieva, Vishwanath, & Ortega, 2013).

2.5 Civilian response 2.5.1 Hemorrhage control Five articles included an evaluation of the role of nonmedical and nonpolice actors in hemorrhage con-

trol after a shooting event (Jacobs, 2015). Tourniquet use, specifically, has been identified as an under-

used life-saving technique in the aftermath of a mass shooting that can be implemented by bystanders

and other first responders from the general public (Klassen, Marshall, Dai, Mann, & Sztajnkrycer,

2019). One study group reviewed the autopsy records of victims of the Pulse nightclub shooting and

found that none of the deceased, including 16 individuals that had potentially survivable wounds, had

documented tourniquet application (Smith, Shapiro, & Sarani, 2018).

As noted, in these three articles, the authors described what has become known as the “Hartford

Consensus,” in which efforts for empowering civilians to participate in hemorrhage control were the

primary focus. In 2013, the Joint Committee to Create a National Policy to Enhance Survivability from

Mass Casualty Shooting events was formed by the American College of Surgeons. Along with physi-

cians, the committee included individuals from public safety organizations, and it was later expanded

to include the Federal Emergency Management Agency and the National Security Staff of the Office

of the President. These meetings produced the initial Hartford Consensus, with its main outcome

being the implementation of better hemorrhagic control (Jacobs, 2014). In the committee’s second

paper, the Hartford Consensus II, they called for better education of the public (individuals at the scene

who are uninjured or minimally injured) on what to do to save lives (Jacobs & Burns, 2014). In the

Hartford Consensus III, the group expanded these recommendations to include that prior to the arrival

of any medical or police first responders, bystanders should perform actions like tourniquet placement

to control bleeding and contribute to the reduction of preventable prehospital deaths (Jacobs, 2015).

Throughout these recommendations for the public to take an active role during a mass casualty event,

the committee advocated that the public not put themselves in danger to perform hemorrhage control,

and that any actions they do undertake should be legally protected via Good Samaritan laws.

The recommendation of the national Stop the Bleed Campaign that emerged from the Hartford Con- sensus is that all areas where a large number of individuals will coalesce should have supplies on hand

to treat the bleeding of at least 20 victims if a mass shooting were to occur (Goolsby et al., 2019). The

American College of Surgeons also started a Bleeding Control training and assessed the successful-

ness of educating the public on hemorrhagic control. More than 500 employees at Gillette Stadium in

Massachusetts participated in the study; after the training, the reported likelihood to help during an

emergency increased, as well as the comfort to control hemorrhage. Therefore, it is possible to train a

large number of individuals hemorrhage control even if they have little training in first aid (Chaudhary

et al., 2019).

2.5.2 Run, hide, and fight Three particular actions, “run, hide,” and “fight,” are suggested by the Department of Homeland Secu-

rity (DHS) for victims experiencing a mass shooting. The first act to “run” involves evacuating the area

308 REEPING ET AL.

of a shooting quickly and safely. If this is not possible, the second act to “hide” includes locking or

barricading doors, silencing cell phones, and moving away from windows or places where one could be

hit by a bullet. Finally, if unable to run or hide, the third act is to “fight” the shooter for self-protection.

According to DHS, this should only be done as a last resort to incapacitate the active shooter (U.S.

Department of Homeland Security, 2008). Although the effectiveness of this action plan in response to

simulated or real-time mass shooting events has not been evaluated, one author group looked specif-

ically at the effectiveness of the “fight” portion. Using an agent-based model, they found that if even

a small proportion of victims were to attempt to tackle or swarm the active shooter, the total number

of individuals shot would be reduced (Briggs & Kennedy, 2017). They noted, however, that this puts

those fighting back at greater risk and should only be done as a last resort.

Related to the last resort option, fight, some research has been done on what it would take to stop

a mass shooting by a citizen. For example, how many individuals would be killed in a gun-free zone

under different conditions was examined in one computer simulation (Kirby, Anklam, & Dietz, 2016).

The researchers found that locking the doors was about as effective as having 10% of the individuals

be concealed carry holders in reducing the number of deaths. The addition of an armed security guard,

however, drastically reduced the number of deaths. Similarly, in another study, the authors looked

at how many off-duty police officers would be needed to stop an active shooter in a stadium (Glass,

Iyer, Lister-Gruesbeck, Schulz, & Dietz, 2018). They found, through a computer simulation, that in a

stadium of 4,000 people, 38 off-duty police officers would be needed; in a stadium of 18,000, greater

than 120 officers would be needed to reduce the casualties to three or less. Thus, a large number

of trained citizens would be needed to stop a mass shooting in large-scale events, exemplifying the

importance of the run-and-hide suggestions given by the Department of Homeland Security.

3 D I S C U S S I O N

Based on the findings from our review, when a mass shooting occurs, there are several critical steps

that need to be taken, between the moment the first bullet is fired until the last victim is admitted

to the hospital, by which a rapid response can potentially reduce death and disability. Therefore, the

following ten recommendations are taken from the best available evidence and thinking in facilitating

rapid response to mass shootings:

1. Understand that firearm injury is a “surgical disease” and that the faster someone who has been

seriously shot gets to a designated trauma center hospital operating room, the better (Carr, Caplan,

Pryor, & Branas, 2006).

2. Conduct large-scale trainings of police, educators, and the public in hemorrhage control, taking

care not to expose young children to trainings designed for adults. Hemorrhage kits can be kept in

areas where crowd sizes are large.

3. When arriving at the scene of a mass shooting, police, EMS and other first responders should form

an integrated command center. To the extent possible, transport of seriously injured people to a

trauma center hospital should be a first priority by whichever public safety professionals are first

to arrive on scene and can safely transport.

4. After being appropriately trained, police should be permitted to triage and transport people who

have been seriously injured in a mass shooting to a designated trauma center hospital, without wait- ing for EMS personnel. Jurisdictions should establish direct police-to-hospital transport polices and dedicate equipment and training in support of these policies.

REEPING ET AL. 309

5. Police and EMS professionals should be thoroughly trained in systematic procedures for accurately

triaging people in mass shootings. Simulations and virtual trainings can help prepare these public

safety professionals for mass shooting events and triage.

6. With proper training, equipment, and support from police, EMS professionals can safely be

brought into the “warm zone” near a mass shooting and begin to transport and administer medical

support sooner than they otherwise would be able to.

7. Before the first seriously injured people arrive at their emergency departments from a mass shoot-

ing, all hospitals should follow the team-based model used at trauma centers and be well prepared

in advance to receive these patients. This can be expedited using closed-channel, public safety

communication systems that have been tested and prepared in advance, although disaster response

coordinators and hospital managers are also encouraged to monitor social media for unplanned

patient surges.

8. Hospitals should not only be aware that they are likely to experience additional waves of severely

injury patients from a mass shooting, but also be prepared in that these waves of additional people

may be more severely injured than the first wave to enter the hospital (Carr et al., 2016).

9. Hotlines can be established to better address concerns from family, friends, and the community

and prevent overburdening of local communications systems.

10. Medical and public safety systems should only direct appropriate responders onto the scene of mass

shooting and discourage “good Samaritan” response from random members of the public, as well

as from non-essential medical and public safety professionals who may be off-duty or coming from

far away. Despite often being well-intended, mass casualty over-response is inefficient, creates

congestion, and can dangerously impede evacuation and treatment (Carr et al., 2016).

Even though responding to a mass shooting will inevitably be difficult, these steps, if implemented,

can help to save lives and decrease burdens on first responders, other medical professionals, educators,

and affected families and communities.

In 2016, a systematic review was published specifically on the best prehospital ways to respond to a

mass shooting, with focus mostly on the actions of the EMS. The main themes the authors found were

consistent with ours, highlighting the value of hemorrhage control, improvements in triage, simula-

tions, and tactical emergency medical support or TEMS (Turner, Lockey, & Rehn, 2016). We, however,

have expanded the scope of their review and have looked at all forms of improving rapid respond to

mass shootings, including the role of health systems, the education sector, and the general public.

Some limitations to our scoping review must be taken into consideration. First, although we used

Pubmed/MEDLINE and Scopus, which include medical, sociology, and criminology journals, there

was little gray (non–peer-reviewed) literature in our review that could be informative in considering

best practices for rapid response. We did keep search terms as open as possible, however, to ensure

that we did not miss any important articles. Nevertheless, this review should be used as a guide for

further exploring the literature on rapid response to mass shootings as it may not include specific

procedures that are localized to specific law enforcement jurisdictions, hospital networks, or school

districts. Another limitation was that most of the articles included in our search were commentaries or

reflections, and few were empirical studies. The reason is because of the lack of support for research

in the area of gun violence prevention as the result of substantive federal funding limitations (Alcorn,

2017). With that said, many of the included articles contain first-hand responses and real-life expe-

rience from individuals who had a role in rapidly responding to a mass shooting, which are valuable

in understanding how the medical professionals, the EMS, and the public can better respond to these

events.

310 REEPING ET AL.

With this in mind, some notable areas need greater research. For example, the role of social media in

identifying people involved in mass shootings and mobilizing first responders is unexplored. Although

advocated as the correct procedure for public response to mass shooting, the “run, hide, fight” strategy

has yet to be systemically evaluated. Because of the nature of this topic, there is also little empirical

evidence beyond simulations, surveys, and case reports from which to build best practices and research-

based interventions. As such, we suggest that more research be conducted, including stronger designs

like case-control studies, to understand better the best tactics for rapid response to mass shootings in a

variety of settings including public spaces, large venues, and schools.

4 C O N C L U S I O N

Ultimately, to reduce casualties and deaths from mass shootings, the United States must invest in efforts

to prevent these tragedies from occurring in the first place. This means investing in initiatives stemming

from multiple sectors: For example, implementing stricter firearm laws known to be associated with

reductions in mass shootings (Reeping et al., 2019), advancing programming efforts in schools and

neighborhoods to address factors that are known to predict violence, increasing access to health care

and mental health care across communities, and rethinking law enforcement practices (Leser, Looper-

Coats, & Roszak, 2019). As mass shootings continue to persist, however, planned and efficient rapid

response, which also includes multiple, coordinated medical and law enforcement sectors, is also a

key approach to minimizing the death and disability that an active shooter inflicts. This rapid response

should consider all parts of a mass shooting: from when the first bullet is fired until the last patient

is transported to the hospital. By using new and coordinated trainings, drills, and technologies, the

public, educators, law enforcement, EMS, and medical professionals can feel more confident and better

respond to these tragic events.

O RC I D

Paul M. Reeping https://orcid.org/0000-0003-1703-6379

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AU T H O R B I O G R A P H I E S

Paul M. Reeping is a PhD student in Epidemiology at the Columbia University Mailman School of Public Health.

Sara F. Jacoby is an Assistant Professor in the Department of Family and Community Health at the University of Pennsylvania School of Nursing and a Senior Fellow of the Leonard Davis Institute

of Health Economics.

Sonali Rajan is an Associate Professor of Health Education in the Department of Health and Behavior Studies at Teachers College, Columbia University. She also holds a secondary faculty

appointment in the Department of Epidemiology at the Mailman School of Public Health.

Charles C. Branas is the Gelman Endowed Professor and chair of the Department of Epidemiology at the Columbia Mailman School of Public Health.

How to cite this article: Reeping PM, Jacoby S, Rajan S, Branas CC. Rapid response to mass shootings: A review and recommendations. Criminol Public Policy. 2020;19:295–315. https://doi.org/10.1111/1745-9133.12479