Instruction for Review 2

R E V I E W

Mass Casualty Shootings and Emergency

Preparedness: A Multidisciplinary Approach for an

Unpredictable Event This article was published in the following Dove Press journal:

Journal of Multidisciplinary Healthcare

Patrick Melmer 1

Margo Carlin 2

Christine A Castater 2

Deepika Koganti 2

Stuart D Hurst 2

Brett M Tracy 2

April A Grant 2

Keneeshia Williams 2

Randi N Smith 2

Christopher J Dente 2

Jason D Sciarretta 2

1Grand Strand Medical Center, University

of South Carolina, Myrtle Beach, SC

29572, USA; 2Grady Memorial Hospital,

Emory University School of Medicine,

Atlanta, GA 30303, USA

Abstract: Mass casualty events (MCE) are an infrequent occurrence to most daily health-

care systems however these incidents are the causation for new hospital preparedness and the

development of coordinated emergency services. The broad support and operational plans

outside the hospital include emergency medical services, local law enforcement, government

agencies, and city officials. Modern-day hospital disaster preparedness goals include sched-

uled training for healthcare personnel to ensure effective and accurate triage for a high-

volume of injured patients. This MDT collaboration strengthens the emergency response to

optimize the delivery of life-saving care during MCEs. This review identifies the clinical

importance of the interdisciplinary team interactions and the lessons learned from past MCE

experiences, strengthening healthcare system readiness for such critical incidents.

Keywords: mass casualty, multidisciplinary, mass shooting

Introduction A mass casualty event (MCE) is characterized by multiple fatalities and

a sudden temporal surge of injured patients necessitating emergency services.1

Emergency resources are saturated within hours as critically injured patients

arrive to the nearby hospitals. Current MCEs are an epidemic culminating from

mass shootings, bombings, or other atrocities against human life. In the United

States (US), mass shootings are the most common and most closely tracked type

of MCE.2 Also referred to as “mass killings”, this type of MCE is rather defined

as three or more killings in a single event, while others reference it as greater

than four.

Modern-day hospital disaster preparedness goals include scheduled training

for healthcare personnel to ensure effective and accurate triage for a high-

volume of injured patients. Accurate triage is essential in these circumstances

of multiple critically ill patients with limited resources. Those hospital facilities

closest to the incident may receive a disproportionate share of injured patients,

and although MCEs remain infrequent to daily healthcare systems, emergency

departments (ED) and trauma centers worldwide are establishing protocols to

prepare for such events. Our objective is to review and discuss emergency

response, hospital preparedness, and the multidisciplinary approach necessary

to provide immediate emergency care to the injured during a critical incident

following a mass shooting.

Correspondence: Jason D Sciarretta Tel +1 404 251-8914 Fax +1 404 523-3931 Email [email protected]

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Mass Casualty Team Collaboration Local hospital operations require a team leader to effec-

tually coordinate and communicate with various healthcare

disciplines and hospital departments. The broad support

and operational plans outside the hospital include emer-

gency medical service (EMS), local law enforcement,

government agencies, and city officials. Integrated clini-

cal-alert system through community healthcare systems

enhance the response of all neighboring hospitals.

Following any type of MCE, internal and external com-

munication with community leaders and partners (EMS,

healthcare personnel, public health officers, law enforce-

ment and government agencies) is essential. Interfacility

communication in conjunction with management systems

help coordinate all participating team members to help

optimize acute care needs. This multidisciplinary team

(MDT) collaboration strengthens the emergency response

to optimize the delivery of life-saving care.

All patients presenting via EMS will be rapidly triaged.

Commonly, surgical intervention is required for the criti-

cally injured. Operating room personnel should not only

anticipate an acute surge of patients directly from the ED

but also prepare for multiple and simultaneous procedures.

Collaboration with the anesthesia team, OR staff, and

surgical specialist (ie, trauma team, vascular and orthope-

dics) is crucial for improved outcomes. An MDT approach

to a polytrauma patient can provide a reduction in anesthe-

sia time, maximize OR availability, and shorten overall

hospitalization. Coordinated surgical care with surgeons

operating in parallel provides operating room efficiency

and surgical stabilization of the injured.3

Emergency Response and Triage Historically, triage methods during wartime conflicts

improved patient outcomes and survivability. The field

triage process effectively utilizes acuity levels for the

injured at a designated area. Optimal field triage by first

responders requires pre-incident training. The goal is to

identify and prioritize the injured before emergency trans-

port. Traditional mass casualty triage systems involve Sort,

Assess, Lifesaving Intervention, Treatment/Transport

(SALT) and Simple Triage and Rapid Treatment

(START) triage methodologies. Triage systems commonly

assign each victim to green (minimal), yellow (delayed),

red (immediate), or black (dead) categories. These colored

designations can be changed at any time due to clinical

status; however, focus should remain on a rapid

assessment. Primary triage systems are not built for deter-

mining resource allocation.4 First responders should trans-

fer stable patients to an ancillary or non-hospital facility

for immediate resource allocation to critical patients.

Smaller hospitals experiencing a nearby MCE may not

be able to care for all patients, especially outside the

urban metropolitan area.

Below is a brief summary of notable mass casualty

shootings, and Table 1 demonstrates the world’s deadliest

mass casualty shootings in the last 35 years.

1. Boston Marathon Bombing: April 15, 2013, Boston,

Massachusetts

The Boston Marathon Bombing resulted in 5 deaths

and 264 injuries. Two explosions, separated by one block

apart, occurred in downtown Boston during the annual

Boston Marathon. Each explosion killed at least one indi-

vidual, while wounding over 200 hundred others and caus-

ing pandemonium. A well-publicized manhunt was

undertaken for the suspects, Dzhokhar and Tamerlan

Tsarnaev. Multiple agencies, including police, rescue

workers, medical personnel, and other organizations,

were part of a city-wide response to the crisis.5

2. Pulse Nightclub Shooting: June 12, 2016, Orlando,

Florida

The Pulse Nightclub Shooting resulted in 49 deaths and

53 injured. A security guard, Omar Mateen, opened fire

inside of a busy nightclub. At the time, this event marked

the deadliest mass shooting by a single shooter in US

history (later surpassed by the Las Vegas Shooting). It

remains the deadliest attack against the LGBTQ+ commu-

nity in the US.6 Due to the nature of the close quarters in

the nightclub, and the complexity of the incident with

hostage-taking by the shooter, the initial tactical response

of the police were questioned and investigated.7,8 The US

Department of Justice released a report highlighting that

while the local agencies acted well given the circum-

stances, further training would be needed in order to pre-

pare for such future possible terrorist attacks.8

3. Charleston Church Massacre: June 17, 2015,

Charleston, South Carolina

The Charleston Church Massacre resulted in 9 deaths

and 3 injured. At one of the most historic churches in the

United States, a white supremacist attacked African

American churchgoers during a service. Before being sur-

passed in 2017 and 2018 by the Sutherland Springs Church

Shooting and Pittsburgh Synagogue Shooting, respectively,

the Charleston Massacre was the deadliest MCE at a place of

worship in America.9 Despite swift local response, the

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Table 1 Deadliest Mass Casualty Shootings

Mass Shootings City, Country Year Death Toll

Garissa University College Attack Garissa, Kenya 2015 148

Peshawar School Massacre Peshawar, Pakistan 2014 149

Paris Attacks (November) Paris, France 2015 130

Norway Attacks Oslo, Norway 2011 77

Westgate Shopping Mall Attack Nairobi, Kenya 2013 67

Las Vegas Shooting Las Vegas, Nevada, 2017 58

South Korea Shooting of 1982 Uiryeong County, S. Korea 1982 56

New Zealand Mosque Shootings Christchurch, New Zealand 2019 51

Orlando Nightclub Shooting Orlando, Florida, USA 2016 49

Sousse Beach Mass Shooting Sousse, Tunisia 2015 38

Port Arthur Massacre Port Arthur, Tasmania, Australia 1996 35

Virginia Tech Shootings Blacksburg, Virginia, USA 2007 32

Tian Mingjian Incident Beijing, China 1994 28

Sandy Hook Massacre Newtown, Connecticut, USA 2012 27

Sutherland Springs Church Shooting Sutherland Springs, Texas, USA 2017 26

Kampala Wedding Massacre Kampala, Uganda 1994 26

Luby’s Shooting Killen, Texas, USA 1991 23

Walmart Shooting El Paso, Texas, USA 2019 22

San Ysidro McDonald’s Massacre San Ysidro, California, USA 1984 21

2015 Bamako Hotel Attack Bamako, Mali 2015 20

2010 Chihuahua Shootings Chihuahua, Mexico 2010 19

University of Texas Tower Shooting Austin, Texas, USA 1966 18

Dunblane Massacre Dunblane, Scotland, UK 1996 17

Erfurt School Massacre Erfurt, Germany 2002 17

Stoneman Douglas High School Shooting Parkland, Florida, USA 2018 17

Hungerford Massacre Hungerford, Berkshire, UK 1987 16

Winneden School Shooting Winnenden, Germany 2009 16

Columbine High School Massacre Columbine, Colorado, USA 1999 15

Edmond Post Office Shooting Edmond, Oklahoma, USA 1986 15

Toulon France Shooting Toulon, France 1995 15

Zug Massacre Zug, Switzerland 2001 14

Luxiol Massacre Luxiol, France 1989 14

2015 San Bernandino Attack San Bernardino, California, USA 2015 14

École Polytechnique massacre Montreal, Quebec, Canada 1989 14

Pashupatinath Temple Shooting Mandsaur, India 1983 14

Aramoana Massacre Aramoana, New Zealand 1990 13

Fort Hood Shooting Fort Hood, Texas, USA 2009 13

Binghamton Shootings Binghamton, New York, USA 2009 13

Baku Shooting Baku, Azerbaijan 2009 13

Velika Ivanča Shooting Velika Ivanča, Serbia 2013 13

Kamwenge Trading Centre Shooting Kamwenge, Uganda 1994 13

Aurora Shooting Aurora, Colorado, USA 2012 12

1999 Atlanta Shooting Atlanta, Georgia, USA 1999 12

Rio de Janeiro School Shooting Rio de Janeiro, Brazil 2011 12

Campinas Massacre Campinas, Brazil 2016 12

Cumbria Shootings Cumbria, England, UK 2010 12

Charlie Hebdo Shooting Paris, France 2015 12

2011 Rio de Janeiro School Shooting Rio de Janeiro, Brazil 2011 12

Washington Navy Yard Shooting Washington, D.C., USA 2013 11

Geneva County Massacre Geneva County, Alabama, USA 2009 10

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majority of victims died on scene. Coordinated action by the

police and other authorities resulted in the arrest of the

perpetrator in North Carolina. The Federal Bureau of

Investigation denounced the Charleston Massacre as a hate

crime which sparked an intense nationwide discussion

regarding domestic terrorism.10

4. Las Vegas Massacre: October 1, 2017, Las Vegas,

Nevada

The Las Vegas Massacre resulted in 58 killed and 422

injured. This event is the deadliest mass shooting in the

history of the United States. The massacre occurred during

the 2017 Route 91 Harvest Music Festival on the Las

Vegas Strip. Stephen Paddock killed 58 and injured over

800 others, both as a direct result of gunfire and the

pandemonium that ensued.11 Hundreds of victims were

transported to multiple surrounding hospitals, quickly

overwhelming and disrupting care across the city.12 This

event was notable for the volume of injured patients and

potentially worse outcomes had law-enforcement been

unable to reach the shooter. As seen following other

mass shootings, national debate on gun laws proliferated.

Bump stocks, the accessory the shooter used to increase

his rate of rifle fire, were heavily criticized and ultimately

banned by states and the United States Justice

Department.13 Multiple aspects of the multi-healthcare

system response continue to be studied, such as the utili-

zation of blood products.14

5. Marjory Stoneman Douglas High School Shooting:

February 14, 2018, Parkland, Florida

The Marjory Stoneman Douglas High School shooting

resulted in 17 killed and 17 injured. Expelled student,

Nikolas Cruz, opened fire in Parkland, Florida. The event

surpassed the Columbine High School Massacre as the

deadliest high school shooting in the history of the

United States. Occurring only a few months after the Las

Vegas Shooting, public outcry was particularly fierce. The

police department responding to the shooting was heavily

criticized for its ineffectiveness and lack of response.15

The young age of the high school victims galvanized

efforts at political reform regarding gun control and school

safety.16

6. Christchurch Mosque Shootings: March 15, 2019,

Christchurch, New Zealand

The Christchurch Mosque Shooting resulted in 51

killed and 49 injured. Though mass shootings have been

widely noted to be increasing in frequency in the United

States, the 2019 Christchurch shootings in New Zealand

marked a rise in MCEs on a global scale.17 A total of 100

victims were killed or injured in two consecutive shootings

at mosques in the country’s first mass shooting in over 20

years at the time.18 Emergency response was swift and

coordinated, with the local hospital systems activating

their mass-casualty plan.19 Following the attacks, gun

control issues were raised across New Zealand, which

has some laws akin to those in the United States, such as

non-tracking of purchased firearms.20 International com-

parisons were made to New Zealand’s neighbor, Australia,

which after the 1996 Port Arthur Shooting in Tasmania,

sparked the largest gun violence reducing efforts in the

world, complete with severe purchase restrictions.20

7. Sandy Hook Elementary School Shooting:

December 4, 2012, Newtown Connecticut

The Sandy Hook Elementary School shooting resulted

in 27 killed and 2 injured. The deadliest mass shooting at

a grade school in United States history, the Sandy Hook

Massacre was notable for the very young age of its vic-

tims, the majority between six and seven years of age.

Adam Lanza killed his mother and 26 other victims before

committing suicide in Newtown, Connecticut.

Investigations following the incident focused on mental

health and learning disorders after noting a diagnosis of

Asperger’s in the shooter.21 Further reporting by the state

of Connecticut’s Office of the Child Advocate described

the shooter as having a history of antisocial tendencies and

a myriad of developmental and behavioral health

problems.22

8. El Paso and Dayton Shootings: August 3, 2019

The El Paso shooting resulted in 22 killed and 24

injured. The Dayton, Ohio shootings resulted in 9 killed

and 27 injured. These events both occurred after a gunmen

opened fire on dozens of civilians in popular shopping

areas. Occurring on the 216th day of the year, these events

marked more mass shootings in 2019 than days of the year

at that point in time.23 Both cities saw coordinated efforts

at care for the critically injured at local trauma centers. As

details continue to emerge about these events, the recent

spur of increasing MCEs continues to fuel intense debate

on gun legislation.24

The Aftermath: Social Services and Family

Support A community’s ability to handle any MCE depends on the

critical demand and capabilities of the treating healthcare

facility. Lessons learned from previous MCEs include the

aftermath support necessary to guide and inform the

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victims, their families and all professional personnel

involved during the incident. Following the 2013

Washington, D.C., Navy Yard shooting, the after action

report highlighted the necessary notification and commu-

nication process for victim families and advocated for the

collaboration and structured processes during a critical

incident.25 Establishing a family assistance center (FAC)

in the aftermath of an MCE is crucial to hospital strategic

planning in the aftermath of an MCE. This platform pro-

vides social workers, counselors, and volunteer commu-

nity support groups to those in need of assistance.

Similarly, the after action report of the 2013 Boston

Marathon bombing recommended that a plan FAC be

established prior to any MCE so that jurisdictions can

quickly establish necessary services for victims and their

families.26 The San Bernardino terrorist shooting incident

report advocated for a FAC location where amenities such

as food, water, and charging stations were provided for

victims while they waited to receive updated

information.27

Mass shootings are associated with negative psycholo-

gical outcomes in survivors and community members.

FACs may also offer assistance with mental health, pas-

toral care, and a variety of short-term and longer-term

needs for affected family members. This interdisciplinary

team provides the skills and services by both medical

(MSW) and occupational (OSW) social workers. MSWs

will care for patients and families who have encountered

a life-altering trauma, while OSWs use similar skills to act

in response to mental health needs of their healthcare

colleagues that may arise following the disaster

response.28 The mental health consequences, including

post-traumatic stress, require a coordinated effort to

arrange readily accessible mental health services for

those affected. Immediate interventions may include psy-

chological debriefing, community outreach and coping

strategies in an effort to diminish any psychological reper-

cussions extended to the community.

Discussion While many hospital facilities will never experience such

an event, this has been an unfortunate reality for some US

healthcare systems. In 2017, 11 mass shootings were

reported in the United States, more than in any

other year in recorded history.2 Of all recorded shootings

occurring in 2017, there were 117 fatalities and 587

casualties.2 Almost 50% of all fatalities and more than

90% of the casualties occurred on October 1, 2017, at

a music festival in Las Vegas where a gunman opened

fire on the crowd.2

Even as recently as producing this manuscript, MCEs

continue to dominate the global news market. Within 24

hrs, two separate mass shootings occurred in Dayton, Ohio

and El Paso, Texas, with at least 29 dead and 27 more

injured on August 3, 2019. Following these two events,

251 recorded mass shootings occurred in the United States

in 216 days, a sobering milestone in US history. To date,

more than 520 people have died in mass shootings and at

least 2000 have been injured (Table 1).23 Recently at the

Gilroy Garlic Festival in Northern California, 3 people

were killed and 15 wounded. On May 31, 2019, 12 people

were killed and 4 others wounded by a city worker at

a Virginia Beach government municipal center.29,30

Blood Bank Preparedness MCEs challenge the utilization of resources at all levels,

with blood being no exception. Damage control resuscita-

tion (DCR) has become a key concept that has been

adopted from military to civilian practice.31,32 These prin-

ciples include hemorrhage control (ie, the use of tourni-

quets,tranexamic acid) within the first 3 hrs and

transfusion of 1:1 or 3:2 ratios of red blood cells to fresh

frozen plasma.33–35 While crystalloid was initially the

product used in resuscitation, blood products are now

considered the gold standard in DCR even in pre-hospital

settings.36

While patient outcomes have improved with the use of

blood, the logistics of obtaining, storing, and supplying

blood are much more complicated than intravenous fluids.

While crystalloids can be given to any patient, blood must

obviously be group O until the patient’s blood type is

known. Moreover, crystalloids can be stored for years,

while blood products have a limited shelf life. Finally,

the administration of blood, unlike crystalloid, is limited

by its availability, which is tested during MCEs as many

patients require the use of massive transfusion protocol.

Based on prior MCEs, the highest demand for blood is

during the initial 4 hrs when the most gravely injured

patients are brought to the hospital, using two-thirds of

the total blood transfused.36–38

There is no standardized protocol for the preparation of

blood products in MCE; however, several countries have

published their individual experiences and subsequent

recommendations. Israel has experienced over 1600 terror-

ist attacks between 2000 and 2005, finding that 6.7 units of

blood and 4.5 units of components were needed per one

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moderately or severely injured patient. The National Blood

Services in Israel is a national, non-profit organization that

manages the supply and distribution of blood and has been

successfully able to provide products as needed with the

development of a national preparedness blood program.39

A study using a computerized simulation model of a UK

major trauma center found that even small volume MCEs

could overwhelm trauma centers’ blood supplies and

restocking would be necessary. The authors also suggest

a central supplier for blood as a solution for the massive

demand for blood during MCE.37,38

Review of the Las Vegas mass shooting showed that

over 500 units of blood were used. Local stock in the

treating hospitals along with United Blood Services and

American Red Cross contributions allowed for an ade-

quate amount of transfusion products without the need

for public donation.14 As MCEs increase in number and

lethality, the ability to provide blood products in the pre-

hospital and hospital setting is of paramount importance to

reduce mortality. Creation of national, or even interna-

tional, protocols may help create a more organized system

for storage, delivery, and utilization of blood during MCE.

For now, relying on the blood banks of local hospitals as

well as national organizations appears to be universal

practice.

Lessons Learned The intensifying epidemic of violence resulting in mass

casualty incidents has promoted the development of effec-

tive and coordinated response protocols. Affected centers

have published their institution’s debriefing and analysis of

quality improvement recommendations. These personal

accounts provide not only a platform for the development

of institutional mass casualty response protocols but also

offers a component of experience to those that have not

been faced with such an event. Acknowledging the pros

and cons of tactics employed in the face of an MCE also

helps other facilities prevent similar mistakes. Lessons

learned from previous incidents include, but are not lim-

ited to, securing the emergency department, using remote

damage control approach to guide resources, evaluation of

the complex trauma patient, and management of the

aftermath.40–43 It is essential to fundamentally appreciate

the magnitude of these high-pressure, high-volume events

in order to develop an institutional response protocol.

Establishment of a partial lockdown early in the

response is essential to maintaining the efficiency and

safety of the response system.41 Complete lockdown

prevents entry of medical personnel; however, it is impor-

tant to consider ambulances as a potential threat. As these

vehicles are capable of carrying up to 4000 pounds in

explosives, designated ambulance checkpoints a safe dis-

tance from the hospital are recommended.41 A facility’s

ability to receive or provide information may be inhibited

by overloaded or shut down telephone systems in law

enforcement’s attempts to prevent remote detonation of

an explosive.41,42 Real-time communication may be pro-

vided to hospital personnel through social media at pre-

determined time intervals.41 Prearranged teams of medical

personnel should be stationed within the emergency

department with back-up teams at a distance, in the event

the primary team is compromised. Consideration of pri-

mary and secondary blast effects should be based on the

building’s architecture when planning evacuation.41

Furthermore, the chain of command should be well estab-

lished and easily referenced, as one facility identified dis-

ruption of patient flow as multiple “leaders” tried to

implement simultaneous and potentially contradictory

plans.41

Coordination of care of the critically injured patient in

immediate need of intervention is supply and personnel

intensive. The appropriate triage of high volumes of

injured patients is essential for resource allocation after

a mass casualty incident. Evaluation of complex injury

patterns includes concomitant blast and crush injury, pene-

trating and blunt visceral injury and neurologic and ortho-

pedic injury. Rapid triage, anticipated clinical course and

complications of this injury complex are best determined

by mature judgment.41–43 Reviewing and continued reas-

sessment of the patient, management plans, and imaging

helps optimize patient care and prevent complications

associated with missed injuries.40 Mass transportation of

those patients not requiring immediate life-sustaining

interventions to nearby facilities clears the responding

trauma centers for critically ill patients.43 This mainte-

nance of clinical capacity is essential to the MCE

response. A designated individual (ie, trauma medical

director) should coordinate all operating room personnel,

cancel all elective cases, prepare for simultaneous opera-

tions and need for delayed second-look operations.40

It is essential to maintain close supervision and documen-

tation of time limits in provider care. Hospital staff may

experience physical and emotional exhaustion in caring for

injured patients in a crisis.40 Residents who served at Orlando

Regional Medical Center during the Pulse Night Club

Shooting experienced burnout, major depression, or post-

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traumatic stress disorder (PTSD) lasting 6 months after the

crisis had ended.40 On November 13, 2015, Paris suffered

four suicide bomber attacks within 40 mins resulting in 495

wounded and 130 dead.40 Providers followed 840 firefighters

with a psychological check-up within 4 weeks of the inci-

dent, 1/3 followed up 3 months later, all underwent repeated

PTSD screening.40 Furthermore, facilities should anticipate

media attention and plan accordingly. Recommendations

include establishing regular conferences, creating an official

website, setting up a call center with a hotline and designat-

ing a family gathering area.40 This organized response to

anticipated media attention and its consequences prevents

distractions from the care of patients and ensures a unified

hospital message.40

Simulation Exercises There have been many suggestions about ways to improve

the performance of providers and hospitals during an

MCE. One thing that can be helpful is simulation exercises

and drills. Advantages of these practices include identifi-

cation of deficiencies, developing and implementing solu-

tions, and increasing confidence in practiced and learned

strategies.44,45 After the Sandy Hook shooting, the

Hartford Consensus conducted a number of surveys and

released reports focused on enhancing survivability from

both active shooter and MCEs. One key point was that

simulation and training events can help to avoid delays in

reaction time. In addition, all simulation exercises should

include both practice and conversations about evacuation

policies and procedures.46

Recent reviews of the events after the Boston Marathon

bombing identified planning and simulation exercises as

a key part of the successful triage and treatment of

victims.44,47 SimWars is one example of a simulation exer-

cise that focuses on teams participating in an identical and

observed mass casualty exercise followed by a group dis-

cussion and debrief. Participants are assigned roles and are

tasked with triaging patients while observers complete

a checklist on each patient. Results show that both parti-

cipants and observers develop new understanding about

how to triage patients in MCE.48 Another technique is to

utilize one hour computer-based simulations to assess

management and self-efficacy. By the end of multiple

sessions, participants exhibit improved abilities to triage

and treat trauma and in-hospital patients.49 Another recent

simulation involving an active shooter in a hospital

showed a 70% improvement in knowledge and preparation

for an MCE.50

Overall, simulation exercises provide many advantages

to first responders. They improve knowledge of emergency

activities and improve competence and confidence in

a potential MCE.51 One major advantage to simulation

exercises that has been seen across multiple studies is the

ability to identify gaps or limitations in plans, protocols or

procedures so that solutions can be implemented.

Simulation exercises have been shown to produce stress

in participants, with the most stress being seen with those

responsible for triage. Despite this stress, participants have

performed effectively and efficiently despite any reported

higher stress level.52 Long-term retention of skills learned

during simulation exercises is an area that is both lacking

and conflicting in current research. This is most likely only

due to difficulties in longitudinal follow-up; however, it

remains an area of concern. Overall, there are different

options for simulation exercises that exist and there is little

doubt that these are helpful in the setting of a real MCE.

Stop the Bleed The Stop the Bleed Campaign is a national effort by the

American College of Surgeons to reduce morbidity and

mortality in hemorrhage. The initiative is based on the reali-

zation that civilian bystanders are the true first responders.

Empowering the public to provide life-sustaining support

with simple clinical skills has enormous potential to decrease

morbidity and mortality following an MCE. Objectives of the

training programs are to motivate learners to act when faced

with a hemorrhagic emergency, teach learners how to distin-

guish life-threatening from non-life-threatening bleeding and

to apply pressure.53 A follow-up study questioned the reten-

tion and application of clinical skills of those citizens trained

in Stop the Bleed. Pasley et al found that 60% were success-

ful at tourniquet placement after training.54 This means that 6

of 10 people in that particular group were theoretically able

to respond to and control hemorrhage. It is essential that there

is a firm understanding of the psychological impact of these

events on all those involved and interval requalification is

necessary for preservation of skills. Courses are provided by

the American College of Surgeons Committee on Trauma

and are offered throughout the country. Locations of training

include churches, gun clubs, libraries, and high schools.

Gun Violence and Mortality Gun violence is a national epidemic. At this point in the history

of the United States, both intentional and unintentional gunshot

injuries are both socioeconomically and psychologically

devastating. In 2010, of deaths resulting from gun violence in

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high-income countries, 90% of the women, 91% of the chil-

dren aged 0–14 years, and 92% of the young adults aged 15–24

years occurred in the United States.55 In 2015, the overall

firearm death rate was 11.4 times higher in the US than in

other high-income countries with the rate increasing between

2003 and 2015.12 Although healthcare providers have been

attempting to debrief and optimize therapy following an MCE,

there has been an exponential increase in deaths resulting from

firearms. Refining our trauma systems and enabling the public

as first responders may preserve the critical golden hour after

trauma, but it is not a solution to this public health crisis. With

the continued attempts to optimize preservation of life follow-

ing a MCE, our conversations must also focus on prevention.

Compromise is not only essential for regulation of access to

firearms but also necessary to maintain the balance of protect-

ing our citizens from our constitution, where a right to bear

arms does not undermine the right to life.

Conclusion Although all hospitals should support a mass casualty stra-

tegic plan, no hospital can administer all emergency care

during a large-scale incident independently. Hospital prepa-

redness and emergency response are increasingly coordi-

nated with the collaboration of different healthcare systems,

EMS, emergency management, and public health agencies.

This multidisciplinary approach to any mass casualty inci-

dents provides practical and effective triage methods while

providing critical emergency care for the injured.

Author contributions All authors contributed to data analysis, drafting or revis-

ing the article, gave final approval of the version to be

published, and agree to be accountable for all aspects of

the work.

Disclosure The authors report no conflicts of interest in this work.

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