Hospital Emergency Preparedness for Mass Casualty Events: NEJM Insights

I have two jobs that most people think cannot coexist. I am a trauma surgeon, and I am a Dallas police officer. I have been doing both for over two decades. That dual life has given me an unusual vantage point on a problem that the American medical and law enforcement communities spent years trying to solve together: how do we keep people from bleeding to death before help arrives?

That question is what drove the creation of the Hartford Consensus. And it is what the Stop the Bleed campaign was built to answer. I have been part of both from the beginning, and I want to explain clearly what they are, why they matter, and what we still need to do.

The Problem We Had to Confront

For a long time, the medical community treated active shooter events and mass casualty incidents primarily as a law enforcement problem. Get the shooter down, then let EMS in. In theory, that sequence makes sense. In practice, it costs lives.

Hemorrhage is the leading cause of preventable death in trauma, both on the battlefield and in civilian settings. When a person sustains a penetrating wound to an extremity and loses blood for two, five, or ten minutes before a medic reaches them, the outcome is often determined long before any surgeon gets involved. Research I have been part of, including a post-mortem evaluation of potentially survivable hemorrhagic deaths in a civilian population, confirmed what many of us already suspected. A meaningful percentage of people who die at the scene of mass casualty shooting events did not have to die. Their injuries were survivable. The bleeding was controllable. What they lacked was someone nearby who knew what to do and had the tools to do it.

That finding is not an abstraction to me. It is the reason I have spent much of my career working at the intersection of surgery, law enforcement, and emergency preparedness.

What the Hartford Consensus Actually Is

In April 2012, a group of surgeons, emergency physicians, and law enforcement professionals met in Hartford, Connecticut, after a series of high-profile mass casualty shootings had exposed serious gaps in the nation’s response capabilities. The American College of Surgeons convened that meeting. I joined the Hartford Consensus Working Group and have remained part of it since.

The goal was straightforward: take what military medicine had learned about hemorrhage control in combat, apply it to civilian mass casualty events, and build a system that could scale across the entire country. The military’s experience with tourniquets and wound packing in Iraq and Afghanistan had been transformative. Survival rates from extremity wounds improved dramatically when medics applied those techniques quickly. We knew the same tools could work in a school, a concert venue, or a shopping mall. We just had to build the infrastructure to get them there.

The Hartford Consensus introduced a structured framework called THREAT for coordinating the response to active shooter and intentional mass casualty events. The framework addressed the full chain of survival, from threat suppression through hemorrhage control, rapid extrication, medical assessment, and transport to definitive care. It put hemorrhage control at the center of that chain rather than treating it as something that happened only after law enforcement had fully cleared a scene.

Over the following years, the Hartford Consensus produced a series of policy papers published in the Bulletin of the American College of Surgeons, the Journal of Trauma and Acute Care Surgery, and other peer-reviewed journals. I coauthored several of those papers alongside colleagues including Dr. Lenworth Jacobs, Dr. Norman McSwain, and Frank Butler. We briefed the National Security Council. We presented to Congress. We worked with the Department of Homeland Security and the Department of Justice. The effort was genuinely collaborative, and it produced real policy change.

Stop the Bleed: What We Are Actually Asking People to Do

Stop the Bleed is the public-facing campaign that grew from the Hartford Consensus. The White House launched it in October 2015, and the American College of Surgeons has championed it since. The training is practical, accessible, and fast. A person with no medical background can learn the core skills in under an hour.

The program teaches three techniques for controlling severe bleeding: direct pressure, wound packing, and tourniquet application. That is it. Three techniques, taught clearly, practiced on a training mannequin, reinforced with simple language anyone can remember under stress.

Tourniquets were the piece that took the most cultural adjustment. For years, civilian first aid training told people that tourniquets caused harm and should be avoided. That guidance was outdated and, in high-blood-loss situations, dangerous. Military medicine had demonstrated definitively that correct tourniquet application saves lives and that complications, when they occur, are rare and manageable. One of the foundational arguments the Hartford Consensus group made repeatedly was that this evidence needed to reach civilian training programs. It eventually did, and Stop the Bleed is part of how that change spread.

I have taught Stop the Bleed skills to law enforcement officers, nurses, teachers, business owners, and high school students. The people who take this training leave with a real capability. They are not pretending to be paramedics. They are learning one specific, high-value skill: keep blood inside the body until someone with more training arrives. That skill can mean the difference between a patient who survives and one who does not.

What My Work in Dallas Confirmed

I became a Dallas police officer in April 2010. That was a deliberate career choice, not an accident. I wanted to understand law enforcement from the inside, because so much of the trauma I was treating in the operating room originated at scenes where officers made rapid decisions with incomplete information and no medical support nearby. To help build better systems, I needed to understand those scenes directly.

Over the years, I served as Deputy Medical Director, then Chief Medical Officer of the Dallas Police Department. I have been a Tactical Physician embedded with SWAT since 2004. I have also served as Medical Director of the Texas Tactical Peace Officers Association. That operational experience shaped every policy recommendation I have made in the academic and government settings where I also work.

The events of July 7, 2016, in Dallas reinforced everything the Hartford Consensus had argued. Officers were struck by gunfire during what should have been a routine assignment. The response that night drew on training protocols, on bleeding control techniques, and on the kind of coordinated medical and law enforcement response that takes years of preparation to build. I have presented about that night at conferences across the country and internationally, not to relive it, but because the lessons from it belong to everyone who responds to mass casualty events.

What I took away from that experience and from my broader career in tactical medicine is consistent with what the research shows. Preparation is what saves lives. Not just preparation in the abstract, but specific, practiced, repeatedly reinforced training that people can execute under extreme stress. The surgeon matters. So does the officer with a tourniquet on their belt. So does the bystander who knows how to pack a wound.

The Law Enforcement Health Connection

One piece of the officer safety picture that does not get enough attention is the medical vulnerability of law enforcement personnel themselves. I published research on population-based estimates of trauma-related deaths for law enforcement, and the data are sobering. Risks for officer death from traumatic injury are higher than many people assume, and the trends over the analysis period were not moving in a positive direction.

That finding informed my work with the U.S. Department of Justice Officer Safety and Wellness Working Group, which I served on for over a decade. Officers face a medical threat environment that is distinct from what civilian trauma systems are built to address. They are often injured in locations and circumstances where standard EMS response times are longer, scene safety is unclear, and the treating team has to make decisions while still managing an active threat. Building hemorrhage control capability into law enforcement training directly addresses that gap. An officer with a well-applied tourniquet on a wounded colleague, applied in the first two minutes, changes the clinical picture dramatically by the time an ambulance arrives.

I served as Medical Director of the Pre-Hospital Trauma Life Support program from 2017 to 2021. PHTLS trains tens of thousands of providers annually, including military medics, paramedics, and first responders worldwide. The curriculum teaches evidence-based hemorrhage control as a core competency. That reach matters. Every provider who completes PHTLS training carries those skills into the field, and the field is everywhere.

What Progress Looks Like and What Still Has to Change

The Hartford Consensus and Stop the Bleed have produced measurable results. Tourniquet use in civilian prehospital settings has increased substantially. Bleeding control kits are now placed in schools, government buildings, and public venues in cities across the country. Tens of millions of people have been trained since the campaign launched. The conversation about bystander hemorrhage control has moved from a niche surgical policy debate to mainstream public health.

That progress is real. It is also incomplete.

Distribution of bleeding control kits remains uneven. Communities with fewer resources have less access to training. Protocols for how law enforcement, EMS, and medical teams coordinate at active shooter scenes still vary too much from jurisdiction to jurisdiction. And the research on long-term outcomes, on which patients were saved by bystander intervention and which interventions made the difference, is still being built.

I was part of a paper published in the New England Journal of Medicine in 2018 that addressed active shooter response at healthcare facilities specifically. That setting presents a distinct set of challenges. The victims and the responders can be the same people. Staff who are trained to care for patients may suddenly need to apply hemorrhage control to a coworker or to themselves. The healthcare facility that is a destination for trauma patients can, in the worst moments, become a source of trauma patients. Preparation for that scenario requires a different kind of readiness than standard disaster planning.

The path forward is the same as it has always been: training, standardization, and sustained commitment. Stop the Bleed needs to reach more communities. Tactical medical support needs to be better integrated into law enforcement agencies that still lack it. And the research base needs to keep growing so that the protocols we train reflect the best available evidence.

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