Global & Disaster Medicine

Archive for the ‘Mass shooting’ Category

Analysis of the Active Shooter Incident in San Bernardino, CA

van Stralen, Daved, Sean McKay, George T. Williams, Thomas A. Mercer. 2017. Tactical Improvisation: After-Action/
Comprehensive Analysis of the Active Shooter Incident Response by the San Bernardino City Fire Department
December 2, 2015. San Bernardino, CA: San Bernardino County Fire Protection District.

Anatomic Site                                                         Fatal                                                       Nonfatal
Victims                                                                         14                                                               15
Head, Neck                                                                   3                                                                 0
Face                                                                                2                                                                 0
Chest, upper back                                                     25                                                                8
Abdomen, pelvis, lower back                                    6                                                                4
Upper extremity                                                           5                                                                7
Lower extremity                                                           9                                                                9
Total                                                                             50                                                              28
Wounds per victim                                                3.57                                                           1.87


Anatomic Site Cause
Head and neck                                                                                 3
Chest                                                                                                10
Abdomen                                                                                          6
Femoral vessels (junctional)                                                         1
Total                                                                                                20



Georgia: Police were searching for a gunman who entered the Dart Container Corporation plant and shot an employee.


“……At least one person has been shot at a food-service container plant near Atlanta, and the shooter is believed still inside the plant, a federal source with knowledge of the situation said Friday.

Gunfire was reported Friday morning at Dart Container Corp. in Conyers, about 25 miles east of downtown Atlanta, and authorities are looking for a shooter, Rockdale County Sheriff’s Deputy Lee Thomas said.,,,,”

Six people were killed in a shooting in a hospital in the eastern Czech Republic today

Pensacola: Active shooter today

Within the United States, firearm mortality rates and YPLL remained constant between 1999 and 2014 and has been increasing subsequently.

Citation: Bailey HM, Zuo Y, Li F, Min J, Vaddiparti K, Prosperi M, et al. (2019) Changes in patterns of mortality rates and years of life lost due to firearms in the United States, 1999 to 2016: A joinpoint analysis. PLoS ONE 14(11): e0225223.

Data Availability: The data can be downloaded from


Between 1999 and 2016, the national rates of firearm mortality and YPLL indicating a shift in the burden of mortality towards younger individuals. While an increase in mortality was noted starting in 2014, the change towards an increase was set much earlier in different subgroups and states. Additional studies to examine county-specific patterns and the factors that explain the differences in trajectories is needed. Future interventions, programs, and policies should be created to address this shifting burden locally and should bear in mind the populations that are being most affected by shifts in firearm death……”


Secret Service

“……Some of the key findings from this study, and their implications for informing school violence prevention efforts, include:
• There is no profile of a student attacker, nor is there a profile for the type of school that has been targeted:   Attackers varied in age, gender, race, grade level, academic performance, and social characteristics. Similarly,   there was no identified profile of the type of school impacted by targeted violence, as schools varied in size,   location, and student-teacher ratios. Rather than focusing on a set of traits or characteristics, a threat assessment     process should focus on gathering relevant information about a student’s behaviors, situational factors, and   circumstances to assess the risk of violence or other harmful outcomes.
•  Attackers usually had multiple motives, the most common involving a grievance with classmates: In addition to   grievances with classmates, attackers were also motivated by grievances involving school staff, romantic       relationships, or other personal issues. Other motives included a desire to kill, suicide, and seeking fame or   notoriety. Discovering a student’s motive for engaging in concerning behavior is critical to assessing the   student’s risk of engaging in violence and identifying appropriate interventions to change behavior and   manage risk.
•  Most attackers used firearms, and firearms were most often acquired from the home: Many of the attackers      were able to access firearms from the home of their parents or another close relative. While many of the firearms      were unsecured, in several cases the attackers were able to gain access to firearms that were secured in a locked   gun safe or case. It should be further noted, however, that some attackers used knives instead of firearms to      perpetrate their attacks. Therefore, a threat assessment should explore if a student has access to any weapons,      with a particular focus on weapons access at home. Schools, parents, and law enforcement must work together      rapidly to restrict access to weapons in those cases when students pose a risk of harm to themselves or others.
•  Most attackers had experienced psychological, behavioral, or developmental symptoms: The observable mental      health symptoms displayed by attackers prior to their attacks were divided into three main categories:   psychological (e.g., depressive symptoms or suicidal ideation), behavioral (e.g., defiance/misconduct or symptoms      of ADHD/ADD), and neurological/developmental (e.g., developmental delays or cognitive deficits). The fact that half
of the attackers had received one or more mental health services prior to their attack indicates that mental health   evaluations and treatments should be considered a component of a multidisciplinary threat assessment, but not   a replacement. Mental health professionals should be included in a collaborative threat assessment process that      also involves teachers, administrators, and law enforcement.
•  Half of the attackers had interests in violent topics: Violent interests, without an appropriate explanation, are   concerning, which means schools should not hesitate to initiate further information gathering, assessment, and      management of the student’s behavior. For example, a student who is preoccupied or fixated on topics like the      Columbine shooting or Hitler, as was noted in the backgrounds of several of the attackers in this study, may be the      focus of a school threat assessment to determine how such an interest originated and if the interest is negatively      impacting the student’s thinking and behavior.

•   All attackers experienced social stressors involving their relationships with peers and/or romantic partners:      Attackers experienced stressors in various areas of their lives, with nearly all experiencing at least one in the six   months prior to their attack, and half within two days of the attack. In addition to social stressors, other stressors      experienced by many of the attackers were related to families and conflicts in the home, academic or disciplinary      actions, or other personal issues. All school personnel should be trained to recognize signs of a student in crisis.   Additional training should focus on crisis intervention, teaching students skills to manage emotions and resolve      conflicts, and suicide prevention.
•  Nearly every attacker experienced negative home life factors: The negative home life factors experienced by      the attackers included parental divorce or separation, drug use or criminal charges among family members, or      domestic abuse. While none of the factors included here should be viewed as predictors that a student will be   violent, past research has identified an association between many of these types of factors and a range of negative     outcomes for children.
•  Most attackers were victims of bullying, which was often observed by others: Most of the attackers were   bullied by their classmates, and for over half of the attackers the bullying appeared to be of a persistent pattern   which lasted for weeks, months, or years. It is critical that schools implement comprehensive programs designed to     promote safe and positive school climates, where students feel empowered to report bullying when they witness it      or are victims of it, and where school officials and other authorities act to intervene.
• Most attackers had a history of school disciplinary actions, and many had prior contact with law enforcement:     Most attackers had a history of receiving school disciplinary actions resulting from a broad range of   inappropriate behavior. The most serious of those actions included the attacker being suspended, expelled, or      having law enforcement interactions as a result of their behavior at school. An important point for school staff      to consider is that punitive measures are not preventative. If a student elicits concern or poses a risk of harm      to self or others, removing the student from the school may not always be the safest option. To help in making      the determination regarding appropriate discipline, schools should employ disciplinary practices that ensure      fairness, transparency with the student and family, and appropriate follow-up.
• All attackers exhibited concerning behaviors. Most elicited concern from others, and most communicated their      intent to attack: The behaviors that elicited concern ranged from a constellation of lower-level concerns to   objectively concerning or prohibited behaviors. Most of the attackers communicated a prior threat to their target or      communicated their intentions to carry out an attack. In many cases, someone observed a threatening   communication or behavior but did not act, either out of fear, not believing the attacker, misjudging the immediacy or     location, or believing they had dissuaded the attacker. Students, school personnel, and family members should be      encouraged to report troubling or concerning behaviors to ensure that those in positions of authority can intervene.….”

November 5, 2009: 13 are killed and more than 30 others are wounded when a U.S. Army officer goes on a shooting rampage at Fort Hood, TX

Greenville, TX: Mass shotting

10/16/1991: one of the deadliest shootings in U.S. history.


“George Jo Hennard drives his truck through a window in Luby’s Cafeteria in Killeen, Texas, and then opens fire on a lunch crowd of over 100 people, killing 23 and injuring 20 more. Hennard then turned the gun on himself and committed suicide……”

Civilian Public Mass Shooting in the US: Who died, how they died, and was the death preventable?


J Am Coll Surg. 2019 Sep;229(3):244-251. doi: 10.1016/j.jamcollsurg.2019.04.016. Epub 2019 Apr 25.
Incidence and Cause of Potentially Preventable Death after Civilian Public Mass Shooting in the US.


The incidence and severity of civilian public mass shooting (CPMS) events continue to rise. Understanding the wounding pattern and incidence of potentially preventable death (PPD) after CPMS is key to updating prehospital response strategy.


A retrospective study of autopsy reports after CPMS events identified via the Federal Bureau of Investigation CPMS database from December 1999 to December 31, 2017 was performed. Sites of injury, fatal injury, and incidence of PPD were determined independently by a multidisciplinary panel composed of trauma surgery, emergency medicine, critical care paramedicine, and forensic pathology.


Nineteen events including 213 victims were reviewed. Mean number of gunshot wounds per victim was 4.1. Sixty-four percent of gunshots were to the head and torso. The most common cause of death was brain injury (52%). Only 12% (26 victims) were transported to the hospital and the PPD rate was 15% (32 victims). The most commonly injured organs in those with PPD were the lung (59%) and spinal cord (24%). Only 6% of PPD victims had a gunshot to a vascular structure in an extremity.


The PPD rate after CPMS is high and is due mostly to non-hemorrhaging chest wounds. Prehospital care strategy should focus on immediate point of wounding care by both laypersons and medical personnel, as well as rapid extrication of victims to definitive medical care.


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