Within the FBI itself, first aid training emphasizing hemorrhage
control has been extended to all 13,000 special agents.
causing almost 6,000 injuries and 699 deaths. 13
Relatively unsophisticated IEDs can have serious
effects, as was the case in Boston, where 264 victims
included 70 hospitalizations, 16 amputations, and
three deaths. 14 One estimate of the damage resulting
from the Boston attack placed the economic impact
at $400 million. 14
Unlike the threat of terrorist attacks envisioned
after 9/11, which were thought more likely to occur at
high-profile events in major urban areas or at installations of national infrastructure, these data indicate
that any community of any size is at risk. No single
preventive measure, such as hardening school buildings or training teachers in emergency response, will
substitute as a comprehensive response plan. Active
shooter incidents do not occur solely, or even predominately, in schools and institutions of higher
Community leaders, including law enforcement
officials, emergency medical and rescue service chiefs,
and hospital-based clinicians, all play key roles in
the survival of victims of intentional mass casualty
events. It is fortunate that the basic elements of an
effective response are already present in much of the
country, but the reaction to these events is as much a
problem of organization and cooperative effort as it
is a matter of police tactics and clinical acumen. It is
also a test of community leadership and of common
determination that knowing and dealing with a threat
is far superior to dismissing it as unlikely to occur in
one’s presence. These events, fortunately, are rare.
However, although the individual risk to citizens is
small, the demonstrable increase in active shooter
incidents in recent years and the disproportionate
potential effect of IEDs represent a continuing collective threat. It is within our power to address the
threat appropriately. 15 ♦
9. DHS Office of Health Affairs. Event summary: stakeholder
engagement on improving survivability in IED and active
shooter events. May 16, 2014. Available at: www.naemt.
Accessed June 22, 2015.
10. Attorney General Eric Holder delivers remarks at the
International Association of Chiefs of Police annual
conference. Justice News. October 21, 2013. Available at:
Accessed April 7, 2015.
11. Blair JP, Martaindale MH, Nichols T. Active shooter events
from 2000 to 2012. FBI Law Enforcement Bulletin. January
2014. Available at: http://leb.f bi.gov/2014/january. Accessed
June 22, 2015.
12. A study of active shooter incidents in the U.S. between
2000–2013. Available at: www.f bi.gov/news/stories/2014/
2000-and-2013. Accessed June 22, 2015.
13. Kapur GB, Hutson HR, Davis MA, Rice PL. The U.S.
twenty-year experience with bombings: implications for
terrorism preparedness and medical response. J Trauma.
2005; 59( 6):1436-1444.
14. McGuire C. Terrorism: the costs to an economy. Our
Marathon: The Boston Bombing Digital Archive & WBUR
Oral History Project. Northeastern University. Available
at: http://marathon.neu.edu/exhibits/show/terrorism-the-costs-to-an-eco/terrorism—the-costs-to-an-eco. Accessed
June 22, 2015.
15. Fabbri WP. The FBI’s view to improving survival in active
shooter event. JEMS. October 2014. Available at: www.jems.
sho.html. Accessed June 12, 2015.