1. Gould, Kathleen Ahern PhD, MSN, RN

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As I write this, families prepare for a new school year. Shopping for school supplies, children will be kept a bit closer, as parents are more vigilant-and more frightened. This year, children will be welcomed back to school with enhanced active shooter drills. Many communities will align with first responders and local health care facilities to provide education and resources toward what is an unavoidable threat. Parents may purchase bulletproof backpacks and review communication plans with children. A recent Associated Press article confirms-"Safety is high on the minds of many parents, especially after two back-to-back mass shootings in El Paso and Dayton, Ohio, that left 31 people dead."1,2 Stop the Bleed kits will be added to public spaces, next to automatic cardiac defibrillators and Narcan kits, most recently added to provide opioid reversal medication for lay bystander use. Today, civilians prepare to serve as first responders on a scale that is unprecedented. A new reality exists; violence may result in mass casualty anywhere, anytime.


Health care providers continue to provide support and education. In the August 2019 issue of the New England Journal of Medicine Journal Watch, Dr James McMullan3 shares the new Mass Casualty Trauma Triage Document released in July 2019. The document, a white paper from the US Department of Health and Human Services Assistant Secretary for Preparedness and Response, highlights differences in violent and other mass casualty incidents.4 This valuable resource offers planning considerations supported by evidence from literature reviews, expert consultations, and interviews with first responders and health care providers. However, McMullan reminds us that traditional training and education for mass casualty incident may not include situations created by civilian active shooters, currently a very real threat for civilians, first responders, and all health care providers.


The white paper identifies civilians as immediate responders, a newly defined role that precedes first responders. This redefined population encourages novel training such as "Stop the Bleed" and discusses the distribution of hemorrhage supplies. Stop the Bleed is a national awareness campaign and call to action intended to cultivate grassroots efforts that encourage bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives. The Department of Homeland Security website provides information for anyone interested in taking a course or hosting a training session.5 Additional sections of the white paper provide guidance for triage, stabilization, and resource allocation. A final comment addresses the recent mass shootings-a heartbreaking reminder that we all must prepare to handle a mass violence event.


There some frightening realities outlined in the report as McMullans reminds us that triage is not the same as patient assessment. Triage in mass casualties is an assignment of resources based on the initial patient assessment and consideration of available resources. It also redefines "mass casualty" to reflect a situation in which medical resources are overwhelmed, at least temporarily, and will concentrate specifically on events with extremely large numbers of patients.4 The appendix within the white paper includes extensive resources and acknowledges the expert providers who formed the mass casualty triage roundtable participants, who convened to inform this document on January 24, 2019. Although the white paper does not offer formal guidelines or recommendations, it is a must-read for all providers.




1. D'Innocenzio A. Mass shootings give rise to bullet-resistant backpacks. Associated Press. August 10, 2019. Accessed August 12, 2019. [Context Link]


2. NBC News. Sales of bulletproof backpacks soaring after weekend of mass shooting. August 6, 2019. Accessed August 12, 2019. [Context Link]


3. McMullan JT. Planning for the next mass violence event. N Engl J Med Journal Watch. 2019;5. [Context Link]


4. ASPR TRACIE. Mass casualty trauma triage: Paradigms and pitfalls. 2019. Accessed August 12, 2019. [Context Link]


5. Department of Homeland Security. Stop the Bleed. and Accessed August 12, 2019. [Context Link]