Leveraging Bystander Emergence in Mass Casualty Incidents

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Luke Hodgson


Mass casualty emergency response plans are predicated on a number of assumptions, most of which were developed many decades ago. One assumption is that victims and bystanders will rely solely on emergency medical services to get to the scene, take control of the response, provide initial treatment, and transport victims to hospitals. In this sense, response plans expect bystanders to be the typical, passive definition of the term: “A person who is present at an event of incident but does not take part.”0F[1]

Many recent mass casualty incidents (MCIs) have been intentional, caused by an antagonist targeting a large group with violence to cause mass injuries and deaths. During those events, bystanders have been active on the scene by helping those around them, becoming what has been coined active bystanders or immediate responders.1F[2] Faced with both shocking injuries and the terror of a violent attack, many victims and immediate responders—mindful of the risk of further violence—are more inclined to treat one another and leave the area of the attack long before emergency medical services can arrive.2F[3]

While public safety agencies have acknowledged the actions of immediate responders following an intentional MCI, there remains little research guiding best use of these bystanders as a response resource. As the frequency, magnitude, and severity of intentional MCIs have increased, the role and ubiquity of the immediate responder has become more apparent. While extra helping hands may make a meaningful difference in terms of lives saved, professional responders must manage this emergent response to avoid unintended consequences. The incident management constructs, many of which can be traced to the civil defense era, have resulted in suboptimal responses when applied to these new circumstances. This thesis explores how response agencies can adapt policies, plans, and procedures to account for and encourage bystanders to become immediate responders.

Recent MCIs, particularly those caused by acts of violence, have featured immediate responder action that affected the response. After-action reports, media reports, and literature have shown undesirable side effects because existing policies and procedures did not account for immediate responder participation. The thesis examines case studies of MCIs and immediate responder behavior. The research also reviews the applicable policies, procedures, and approaches of emergency response agencies, and how such models have impacted the response outcome. The evidence shows the scale and scope of the problem and reveals the unintended consequences of immediate responder action. The thesis also discusses stereotypes about expected bystander response to determine if they are valid. The sociological theories and constructs that apply to MCI management and bystander behavior are then applied to inform alternative approaches to optimize immediate responder action.

Throughout this analysis, the thesis reviews a sample of five domestic and international intentional incidents since 2000: the 2001 World Trade Center attack, the 2004 Madrid train bombings, the 2013 Boston Marathon bombing, the 2016 Pulse Nightclub shooting, and the 2017 Las Vegas Route 91 Harvest Festival shooting. These events were chosen because they had a systemic impact on the health care system due to the quality of the incident or quantity of patients, and featured pronounced immediate responder action. The cause of the incidents, the nature of the scenes and injuries, and the response, with an emphasis on immediate responder activity following the event, are examined. Specifically, the research investigates the positive and negative outcomes of immediate responder emergence, and the analysis identifies patterns and correlations in incident conditions and immediate responder actions.

After-action reports, literature, and media coverage show that outdated MCI approaches cause less severely injured victims to transport themselves first, overwhelming the closest hospital.3F[4] Hospitals often misperceive this first wave of patients as representative of all injuries when, in reality, far more severe patients remain on the scene.4F[5] Bystanders also fail to use additional surrounding hospitals or specialty centers, which are designed for the traumatic injuries common in these events. Emergency medical services resources converge on the scene, not knowing that their services may be better used to redistribute patients already transported by immediate responders.5F[6] These findings expose misconceptions about bystanders and helping behavior that have contributed to this resource being discounted in emergency planning. The research herein challenges assumptions related to disaster syndrome, panic, and social breakdown that have prevented response plans from incorporating bystanders. In contrast to these myths, the thesis shows that immediate responders exhibit a sociological construct known as emergence following an MCI, and that they can be leveraged as part of a response plan.

Incident commanders currently struggle, however, to manage emergent immediate responders. Many of the structures used by public safety organizations for incident management are derived from military applications, which use a hierarchical command-and-control model to identify clear objectives, lines of authority, and divisions of labor. These constructs drive routine emergency response and are effective for managing small-scale incidents. However, the Incident Command System (ICS) and National Incident Management System (NIMS), which are routinely used by these commanders, are inadequate during large MCIs, especially those with immediate responder emergence. Successful leadership will require a diversion from the traditional applications, requiring commanders to adopt a method that takes into account the complexity and uncertainty. These MCIs call for a new paradigm for approaching incident management—one that incorporates sensemaking, probing, analysis, responsiveness, and agility.

This thesis considers two concepts that may provide a more effective means of managing today’s complex MCIs: operating at the edge of chaos and leadership through the Cynefin framework. This sensemaking framework allows the incident commander to understand the environment, recognizing that each of the elements of the system of MCI response may be in its own domain of complexity. Based on the findings of the sensemaking, incident commanders can allow emergent groups to function organically while orchestrating other aspects of the response, such as professional rescuer assignments. This model of management more closely aligns with the complex environment, thereby allowing for more effective incident leadership and advancement toward a resolution.

The thesis also proposes development for the person or team that manages immediate responders at an intentional MCI, proposing new skills that will allow the incident commander to think through the complex environment and guide resources toward resolution. Recognizing the benefits of immediate responder action, as well as the need to mitigate unintended consequences, the thesis examines means to develop a culture of helping behavior. Finally, recommendations for leveraging immediate responders to provide the best possible outcome for victims of, and responders to, intentional MCIs are provided. These include pre- and post-incident approaches. The recommendations are:

  • Using public safety assets at hospitals
  • Reconfiguring incident management processes to coincide with the unique demands of this type of event
  • Developing the incident commander to be able to analyze work in a novel, complex environment to effectively manage the incident
  • Delivering training to the public
  • Bolstering and standardizing Good Samaritan laws
  • Conducting further research to better understand and manage immediate responder action



[1] Lexico, s.v.“bystander,” accessed June 4, 2020, https://www.lexico.com/​en/​definition/​bystander.

[2] Isaac Ashkenazi and Richard C. Hunt, “You’re It—You’ve Got to Save Someone: Immediate Responders, Not Bystanders,” Frontiers in Public Health, December 5, 2019, https://doi.org/​10.3389/​fpubh.2019.00361.

[3] Erik Auf der Heide, “The Importance of Evidence-Based Disaster Planning,” Annals of Emergency Medicine 47, no. 1 (January 2006): 34–49, https://doi.org/​10.1016/​j.annemergmed.2005.05.009.

[4] Federal Emergency Management Agency, 1 October After-Action Report: Las Vegas Shooting (Washington, DC: Department of Homeland Security, 2018), https://www.hsdl.org/?view&did=814668; Annelie Holgersson, “Review of On-scene Management of Mass-Casualty Attacks,” Journal of Human Security 12, no. 1 (2016): 91–111, http://doi.org/​10.12924/​johs2016.12010091; Auf der Heide, “The Importance of Evidence-Based Disaster Planning.”

[5] Auf der Heide, “The Importance of Evidence-Based Disaster Planning.”

[6] Alejandro López Carresi, “The 2004 Madrid Train Bombings: An Analysis of Pre-hospital Management,” Disasters 32, no. 1 (2008): 41–65, https://doi.org/​10.1111/​j.1467-7717.2007.01026.x; M. G. Guttenberg, A. Asaeda, and A. Cherson, “Utilization of Ambulance Resources at the World Trade Center: Implications for Disaster Planning,” Annals of Emergency Medicine 40, no. 92 (2002).

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