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Injuries in Mass Shootings

Injuries in Mass Shootings​

A recent study on wound patterns sustained by casualties in Civilian Public Mass Shooting (CPMS) shows a significant variation from those wounds seen in combat engagements. When compared to combat-related gunshot wounds sustained by friendly forces in military and law enforcement engagements, a CPMS event results in a markedly higher incidence of thoracic and head injuries, many occurring with the shooter at closer range.

The causes of these differences are somewhat ill-defined, but may be related to several factors:



Military and Law Enforcement Officers are better equipped and use body armor, making lethal hits on center mass less likely.



Military and Law Enforcement are trained for the fight. They have greater situational awareness, can identify pre-violence indicators, and are familiar with critical concepts such as immediate action, utilization of cover, movement under fire, weapons and tactics, etc.  This skill set makes them harder to engage in general, and much less likely to sustain a center mass / critical “hit” during an engagement.


Military and Law Enforcement are known to be combative targets.  When fired upon, we shoot back.  This dynamic commonly results in increased comparative distance of attacking fire, especially noted in Military combat.  Civilian Public Mass Shootings tend to be more unilateral in nature, resulting in significantly closer initial and ongoing engagement distances.  An attacker in CPMS can close the distance to targets easily, but it is psychologically and tactically more difficult for an attacking shooter to approach someone who is prepared to fight back with a firearm.  Coupled with other factors, the increased distance makes for wider shot groupings.

Target and Attacker Response

Victims in CPMS events typically respond to gunfire by fleeing, hiding, freezing, or dropping.  The attacker commonly has relatively unchallenged movement and ability to kill at onset of the event.  Lt. Dave Grossman pointed out in his fine work, “On Killing” that a high casualty rate occurs when an enemy is fleeing in full retreat.  In CPMS, an opening salvo of heavy, semi-indiscriminate fire on any fleeing victims is common.  If the scene progresses, the rate of fire tends to slow and become more deliberate and accurate.  The attacker seeks out hiding or frozen individuals, and thoracic and head shots occur at closer range.  In hostage scenarios such as the 2015 attack at the Bataclan Concert Hall, in which victims are controlled or compliant, distance from attacker to target can be minimal, and thoracic and head shots become increasingly common.

In contrast, Military and Law Enforcement are trained to respond aggressively to an attack.  Their Immediate Action involves returning fire, seeking cover, rapidly establishing fire superiority, etc., and all of these things have a profound effect on the attacking shooter.  Attackers are either wounded or killed in a gunfight, or they respond by seeking cover, fleeing, committing suicide, or surrendering.  When contrasted to a CPMS event, the result is less accurate incoming fire with an associated decreased incidence of thoracic and head injury, a shorter average incident time, and a lower overall casualty rate.

While not specifically related to the incidence of thoracic or head injury, the frequency of attacker suicide in CPMS is a noteworthy factor, especially as it relates to target response.  A recent analysis of FBI and Media Reports showed that 44% of Mass Shootings occurring between 2009 – 2015 ended with the attacking shooter committing suicide, and that this was especially common following the arrival on scene of armed opposition such as Law Enforcement.  It seems clear that the faster a weapon is brought to bear against an attacker, the quicker the scene ends, all things considered.


Injuries and Treatment

First Responders dispatched to CPMS events should be prepared to encounter a high percentage of severe thoracic injuries such as Traumatic Hemothorax, Open and Tension Pneumothorax, etc., in addition to abdominal, extremity or multi-system injury.  A significant amount of rapid mortality in CPMS results from injuries which cause potentially reversible airway and respiratory compromise.  Therapies such as simple “finger” thoracostomy, needle decompression, chest tube placement, endotracheal intubation, and others should be anticipated, with needed equipment kept in ample supply.

It bears mentioning that a recent NTOA study of 371 patients with gunshot wounds sustained in CPMS events identified no fatalities due to exsanguinating extremity hemorrhage. This is not to imply that extremity wounds and bleeding control should be de-emphasized, but rather is presented here so that First Responders might have an accurate picture of which injuries to expect in a “typical” CPMS casualty scene.

Working Together

As First Responders, we must continually refine interdepartmental training of Police and Fire Departments to best respond to a CPMS event. Law Enforcement response to mass shooting is evolving to an immediate response model, in which the first responding officers on scene are trained to hunt down and engage an attacking shooter as rapidly as possible, without waiting for mobilization of a SWAT Team. It is imperative that we examine and adjust our Emergency Medical Response to fall in line with this more rapid pace.  Doing so means recognizing the fact that Medics cannot wait to treat the wounded until a scene has been completely cleared and declared secure.  To increase patient survivability, they need to move toward the fight.

Departments such as Lake Geneva Fire Department and Mercyhealth EMS in Wisconsin are leading the way in this move toward a more coordinated response with Law Enforcement. Their EMTs are being issued ballistic gear, and are trained to operate in 3-man “Rescue Task Force“ (RTF) Teams. RTF units will provide patrol officers with the same sort of medical support that SWAT medics provide SWAT teams. They will operate in LEO – determined “warm” zones, moving into the scene behind the first responding patrol officers, helping to direct fleeing victims and treating patients as they find them. This rapid response is especially important given the severity and short treatment window of the anticipated injuries seen in CPMS.

Training the Public

It is apparent that the primary causes of the variation between CPMS and Combat engagement related injury patterns are the training and response of the individuals attacked.  The better equipped civilians are to observe pre-attack / pre-violence cues and appropriately respond to a CPMS event, the less likely they are to sustain significant injury during such an event. This fact underscores the need for increased training of civilians in both emergency response and active defense.


Ben Kincaid is the founder of Complete Threat Preparedness.


  • Smith, Edward Reed, Geoff Shapiro, and Babak Sarani. “The Profile of Wounding in Civilian Public Mass Shooting Fatalities.” Journal of Trauma and Acute Care Surgery 81, no. 1 (2016): 86-92.
  • Kevin Gerold and Mark Gibbons “Review of Mass Shooting Events Supports Current Trauma Guidelines”. NTOA / TEMS Journal (Fall 2016)
  • Grossman, “On Killing” (1996)
  • Chris Schultz. “City EMTs Rescue Train With Ballistic Gear”. Lake Geneva Regional News (November 2016)
  • Everytown Organization. “Analysis of Mass Shootings” (August 2016)

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