The Journal of High Threat and Austere Medicine

Board games have been developed as a low-cost method to facilitate disaster education. Incident Command System (ICS): The Game is a free board game that aims to teach disaster response in an easy and engaging manner. In this board game, two to five players collaborate in real time to manage mass-casualty scenarios while making critical decisions under pressure. The game presents 20 different disaster scenarios (such as natural disasters, bombings, mass shootings) and the START (Simple Triage and Rapid Treatment) or SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) triage methods. In playing the game, participants practice rapid triage, resource allocation, teamwork, and effective communication. ICS: The Game fills a niche by providing cost-effective immersive learning and can create a more well-rounded disaster training program when combined with other methods, such as lectures and full-scale simulations

Background Intentional mass violence is an ongoing and serious global threat. Incidents often result in multiple casualties requiring urgent medical care, with victim survival often heavily dependent on the coordination and effectiveness of emergency medical response.

Aim The review explores the characteristics of emergency medical responses to intentional mass violence in Australia, the United Kingdom, the United States of America and Western Europe.

Methods This integrative review followed a systematic process of problem identification, searching the literature, data evaluation and analysis.¹ Embase, Scopus, PubMed, Informit and ProQuest databases were searched.

Results A total of 14 articles were included for review. In relation to emergency medical responses to intentional mass violence, two major themes, and associated subthemes were generated. These were: response-centred characteristics (zones of care, ongoing threats, triage and communication and unification); and victim-centred characteristics (wounding patterns, time and survivability).

Conclusion A conceptualisation of the characteristics and their interdependence was synthesised. The conceptualisation illustrates that while characteristics could be categorised, they are not mutually exclusive but instead are bound together in an interdependent response web.

It is unclear how Australia responds to intentional mass violence incidents, with its unique characteristics, beyond the non-specific systems currently documented in Australian response arrangements.

More work is needed to define terms and ensure Australian response arrangements are tailored to address response challenges related to intentional mass violence.

This study analysed armed assault terrorist attacks in developed countries from 2010 to 2020 using the Global Terrorism Database, cross-referenced with open-source data. The primary aim was to determine the typical duration of the active threat phase and assess correlations between incident resolution, weapon type, duration and casualty numbers.

Fifty-eight incidents met inclusion criteria. The median active threat phase lasted six minutes. Attacks involving firearms—especially high-velocity weapons or mixed modalities—were linked to higher casualty counts and longer durations. Incidents resolved through perpetrator suicide or law enforcement threat suppression were associated with fewer fatalities, potentially reflecting faster access by pre-hospital teams when the attacker’s status was confirmed.

These findings reinforce that active threat phases are typically brief but highly lethal, underscoring the importance of minimising the ‘therapeutic vacuum’—the delay before casualties receive medical care. The study advocates for rapid threat suppression and earlier deployment of medical teams, even within residual risk environments. Embedding pre-hospital providers alongside law enforcement for point-of-injury care and casualty evacuation should be further explored.