Volume 7 Number 1

Medical responses to intentional mass violence: an integrative review of emergency responses and victim-centred insights

Aldon Delport, Amy-Louise Byrne, Amy Johnson

Keywords tactical medicine, intentional mass violence, emergency response, coordination, high-threat medicine

For referencing Delport A, Byrne A, Johnson A. Medical responses to intentional mass violence: an integrative review of emergency responses and victim-centred insights. JHTAM. 2025;7(1):8-27.

DOI 10.33235/JHTAM.7.1.8-27
Submitted 17 March 2025 Accepted 3 June 2025

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Author(s)

References

Abstract

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.

Introduction

Global incidences of intentional mass violence (IMV) have become more lethal. While trends are challenging to track, where data is recorded, there has been a surge in the lethality of recorded attacks.2 Incidences in 2024 resulted in high fatalities and casualties requiring medical intervention across several significant events, including the 2024 Moscow Crocus Hall Theatre attack, the 2024 Bondi Junction attack and the 2025 New Orleans New Year’s Eve attack.3–5 These events reflect a pattern of attacks targeting populated civilian spaces, driven by complex multifactorial influences of global politics, conflict and social (mis)alignment, contributing to a broad cross-section of motivations for violence.2 Injury burden during these attacks is significant, time-critical and often complex. As such, emergency responses to IMV must be swift, coordinated, and effective to preserve lives.

While not exclusive, a significant cause of IMV is terrorism. Terrorism itself is difficult to define but is generally understood to be an act of violence on civilians, to cause fear and disruption, to coerce or effect societal change, underpinned by extreme ideology (usually political/religious), and more recently, hybrid or fringe belief systems.6,7 The increasing complexity of terrorist motivations is reflected in the 2024 decision to raise the Australian National Terrorism Threat Advisory System to ‘Probable’, meaning there is a 50% likelihood that an attack is actively being planned or may be conducted over the next 12 months (between 2024–2025).8 

The threat level change was implemented shortly after the Bondi knife attack in New South Wales (NSW), where six people lost their lives during a single assailant mass casualty incident.5,9​ IMV has become a serious and urgent concern for governments, law enforcement and emergency medical responders alike. Responding to the medical needs of victims is often complex and interdisciplinary.7 Despite the impact of these events, there remains limited systematic understanding of how emergency medical services respond to and manage IMV incidents. This article thus looks at the characteristics of emergency medical responses to IMV.

Defining intentional mass violence

There is a lack of consensus around the definition of IMV, and it is often used synonymously with terms such as mass murder, terrorist attack and mass shooting, and frequently in the context of extremist and terrorist attacks. Such terms are frequently used interchangeably to capture events where groups of innocent people are killed in one place at one time.10 Turning to the literature, definitions can be broadly described as centring on the means/weapons used (for example, mass shooting), while others may focus on the locations (geographical spread) and motivations (terrorist or extremist attacks).

With this in mind, and recognising the need to define IMV, this review has adapted the definition below from the works of Fox and Friedel10 and Fox and Levin.11

Intentional mass violence is the killing of four or more victims by one or more assailants, not including the assailants, in a single geographical location during a time-moderated event (<24 hrs), independent of motive or means.

IMV will always lead to injury or death of victims.10–12 From a medical perspective, those who respond to such violence are tasked with rapid assessment, treatment and transportation of multiple victims, often under ongoing threat. The way in which emergency services respond and the characteristics of the response impact the outcomes that victims may experience, including prolonged time to treatment for preventable deaths.13 As such, this review aims to better understand the characteristics of emergency medical responses under IMV conditions.

Methods

This integrative review used the work of Whittemore and Knafl1 to systematically search, explore and synthesise the literature. A constant comparison method was used to identify, define and refine patterns and themes within the data.1 Exploring co-founding influences allowed for a deeper understanding of the issues related to medical responses and IMV, thus allowing the literature to be integrated back to the current social location. The review includes stages for problem identification, literature search, data evaluation, data analysis and presentation.1

Problem Identification

The research question was:

“What are the characteristics of emergency medical response to intentional mass violence events in Australia, the United Kingdom, the United States of America and Western Europe?”

The PRISMA checklist was used to guide the article and inform the literature review processes, ensuring rigour and reliability.14

Search strategy and sources

A librarian was consulted to identify the most appropriate literature terms and databases for the review. Pilot searches were performed using combinations of the predetermined search terms by the lead researcher and the librarian. Initial pilot searches in Google Scholar, involving analysis of the first 100 article titles per search, informed the selection of five key databases for the review: Embase, Scopus, PubMed, Informit, and ProQuest. Search terms were identified from keywords in the research question. Multiple synonyms for each keyword were identified and expanded further into broader terms. Finally, additional narrower terms were incorporated to ensure that all possibilities were accounted for. Search terms were organised into a table, and all three reviewers agreed on the selected terms (see Table 1).

 

Table 1. Table of search terms

delport table 1.png

 

Data evaluation

Inclusion criteria

The integrative review examined peer-reviewed English-language literature and after-action reports from 2014 to 2024, focusing on Australia, the United States of America, the United Kingdom, and Western Europe due to their comparable emergency response systems. Literature was included if it addressed enablers, barriers, response models, and the professions were involve with both terrorist and non-terrorist IMV incidents. To ensure that reports reflect a homogenous understanding of IMV, only literature specifically focused on events with “four or more victims killed by one or more assailants, not including the assailants, in a single geographical location during a time-moderated event (< 24 hrs.), independent of motive or means” was included.

Exclusion criteria

The review excluded literature focusing on third-order effects (such as mental health, victim support and recovery), attacker profiles, conflict zones, genocide, serial killings, familicide and training programs. While chemical, biological, radiological and nuclear (CBRN) are recognised means of attack sometimes employed by terrorists, they present a unique set of characteristics that are outside the scope of this review and were, therefore, also excluded. Grey literature was excluded to ensure peer-reviewed accuracy.

Selection of sources of evidence

Database searches were imported into the web-based software Covidence.15 The selection process involved two stages of screening. Initial title and abstract screening were completed by two reviewers, followed by full-text screening, where articles were independently reviewed in pairs. Rejections were categorised based on wrong intervention, outcome, study design (non-empirical), setting, country of origin and language. Citation searches were then conducted on included articles to identify additional relevant literature. New discoveries were assessed using the same categorical criteria, with inclusion decisions made by consensus. Quality assessment was conducted using the Critical Appraisal Skills Programme16 checklist, evaluating the research questions and aims, methodology, research design and pertinent ethical issues. Any conflicts were resolved through reviewer discussion and consensus.

Data analysis

The data analysis process was completed on a purpose-built Excel spreadsheet by two reviewers. Items for charting were selected using the research question and the inclusion/exclusion criteria as a guide. A third reviewer verified and validated that the data extracted was accurate. Through a constant comparison method,1 codes, categories and themes were generated, defined and refined through an iterative process until consensus was reached.

Presentation

According to Whittemore and Knafl1 conclusions from the integrative review can be tabulated or diagrammatic, where evidence is supportive of the conclusions drawn through a logical chain. The results aim to capture a wide berth of contextual information, thus facilitating a deeper understanding of the phenomenon of interest.

Results

Database searches yielded 2009 articles (2002 from databases, seven from citation searching). Following screening and quality assessment, 14 articles met the inclusion criteria and quality standards for final analysis (see Figure 1). Table 2 provides the extraction results.

 

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Figure 1. PRIMSA Flowchart

 

Table 2. Data Extraction

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delport 2.8.png

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The review generated two major themes with associated subthemes in relation to the characteristics of emergency medical responses to IMV. These are: response-centred characteristics (zones of care, ongoing threats, triage, communication and unification); and victim-centred characteristics (wounding patterns, time, survivability). Importantly, while the review has delineated the characteristics by response and victim centric, these occur concurrently and interweave, with all elements being essential to the medical response of IMV.

Table 3 demonstrates the themes, subthemes and the supporting data, while Figures 2 and 3 provide a conceptualisation of the interconnecting nature of the themes.

 

Table 3. Theme and subthemes

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Figure 2. The emergency response web; Characteristic of emergency medical responses to IMV—Conceptualised

 

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Figure 3. The expanded emergency response web; Characteristic of emergency medical responses to IMV—Conceptualised

 

Response-centred characteristics

The literature explored and discussed factors around the response to IMV; this included communication and unification, ongoing threats, zones of care and triage. Importantly, and as depicted in Figure 3, these elements are interconnected, often interweaving with victim-centric characterises (discussed below).

Communication and unification

Multi-faceted communication is central to a successful medical response to IMV. The start of an IMV incident is marked by a rapid surge of incoming calls at respective service call centres, often with conflicting data and perspectives,17 leading to extreme consequences.

Inconsistent incoming reports at call centres during the 2015 Paris complex coordinated terrorist attack and the Manchester Arena bombing in 2017 degraded situational awareness through a delay in deconflicting information.17,18 Hunt18 states that an inability to deconflict incoming data quickly could lead to dispatching responders into dangerous areas where attackers might still be active.18 Indeed, rescue services responding to the attack in Paris near the Rue Bichat were fired upon during the response. While the response team was close to the incident as it unfolded, it highlights the dangers of responding to IMV during an active incident with less than accurate information on the potential location of the threat.19

An additional layer to the communications problem is the need for a shared mental model. Wurmb et al20 point out that a multiagency response with a shared mental model and role clarity for each response service is essential.20 For example, threat suppression is the responsibility of the responding police services, while victim rescue is the responsibility of the responding emergency medical services. Indeed, multiple services and role players will respond to high-consequence incidents, but each service will have responsibilities unique to their capabilities. To avoid misunderstandings or disorganisation, Wurmb et al20 suggest a unified command system. On-site unified command allows for the sharing of information between role players in real-time, which leads to a common understanding of the changing threat picture. Unification in this way leads to efficient and threat mitigated use of appropriate resources to address time-critical problems with minimal delay.21

A second facet of communication and unification exists at a more granular responder level. On-scene communications are subject to network scalability in communication systems.18 Similar to the number of incoming call data at call centres, communications networks will experience a surge of radio traffic as outgoing dispatch information and initial on-scene reporting peaks in the initial phases of the incident.18 Hunt18 points out that responders turned to civilian open communication infrastructure for on-scene communication during the Manchester Arena bombings and the Westminster Bridge attack in 2017. Notwithstanding operational security concerns, civilian infrastructure is already subject to strain when facilitating surging call volume to emergency call centres. Lesaffre et al19 recommends communication system backups and alternatives to improve scalability in the first 60 minutes of a response, while Hunt18 suggests using open-source encrypted text-based communications portals and dedicated communications liaisons as a backup.   

Overall, communication and unification between multiple-responders, in call-centres and on-site is essential for successful response to IMV. The need for ongoing communication and unification is essential, especially as the threat of ongoing violence remains high.

Ongoing threats

According to the data, ongoing threats can be separated into three broader categories. Active attackers, follow-up attacks and unknowns. Active attackers, as the name suggests, means that the attackers are in the process of targeting and attempting to kill and injure civilians.22 This type of threat has implications for responders, as demonstrated by Lesaffre et al’s19 report of rescue personnel being shot at when arriving on the scene at Rue Bichat during the 2015 Paris attack. This level of threat will naturally hinder medical responses.

The threat of follow-up attacks is more insidious. While it’s reasonable to assume that responders are at risk of opportunistic threats during their response, follow-up attacks are more intentional. Follow-up attacks are intended as an ambush for responders.23 One example of a follow-up attack occurred during the 2015 Bataclan Theatre siege when an attacker confronted by the first responding police officer detonated a suicide vest, attempting to kill the police officer and additional civilians.23 Follow-up attacks are a very real threat for responders, and the heightened awareness of danger impacts medical responses to victims.

Similarly to follow up attacks, unknown threats are not immediately apparent. Unknown threats could be elements of the incident that remain undetected but pose a significant hazard to the responders.24 During the 2015 San Bernadino terrorist attack, the terrorist placed an improvised explosive device in a backpack and left it in a conference room. The device remained undetected until well into the response. The presence of the device exposed every responder who entered the conference room to danger,24 again highlighting the ongoing and often perilous environment within which the response occurs.

Detecting ongoing threats requires that individual responders maintain a high level of individual situational awareness that can only exist if responders are trained to detect them. Autrey et al21 (somewhat concerningly) pointed out that this is not the case for most medical responders.21 It is thus necessary to restrict some responders to zones of care that match their ability to detect and mitigate ongoing threats.

Zones of care

Zones of care, also called zones of operation, are areas demarcated by on-scene commanders and act as guard rails for responders based on their responsibilities and the threat picture within those zones. Zones of care are mutable. Mutability is influenced by ongoing, emerging and unknown threats. The communication cycle is crucial in ensuring a unified understanding between different response agencies of the zones of care.18,24

Zones of care are separated into colour coded areas: Green, or the outer safe zone (also referred to as the cold zone); yellow, an inner zone where there is a requirement for threat mitigation and specialist capability, also referred to as the warm zone; and the red zone, an area of danger and exclusion for most responders. It is also referred to as the hot zone and is reserved for specialist police tasked with threat suppression and, in some cases, embedded specialised medical personnel.17,24 In some cases, victims that are ambulatory will extricate themselves from the warm and hot zones as described by Carli and Telion.17 If responders are properly trained, an opportunity exists to exploit the warm zone in small teams to rescue victims. However, when responders are not trained and equipped to enter these zones, they will be required to remain in the cold zone until the threat has been suppressed and an all clear has been announced.21,23

An inability to exploit the warm zone leads to a “therapeutic vacuum.” Due to the delays in emergency response caused by this “therapeutic vacuum” and ongoing threats, victims with time-critical and reversible injuries may die.21

Triage

Triage refers to the systematic assessment of victims, often based on injury profile and requires an assessment of the interplay between multiple predetermined physiological parameters to determine the urgency of care required for each victim. The fundamental premise of triage is to prioritise care for those most in need.25 Gates et al26 pointed out that most victims of the Boston Marathon Bombing were transported to the hospital by ambulance with minimal on-site triage performed.26 Similarly, Hunt18 reported that triage during the Manchester Arena bombing incident was disruptive and impractical, costing both personnel resources and time.18

While triage is common in emergency medical practice in both pre-hospital and hospital contexts, current models such as Simple Triage and Rapid Treatment (START) and Sort-Assess-Lifesaving Interventions-Treatment and/or Transport (SALT), which are both based on the sort and sieve principle, do not hold up in real-world conditions due to their complexity.27 Indeed, Wurmb et al20 suggest that triage in IMV should favour exsanguinating haemorrhage over complex physiological parameters as a primary metric to facilitate rapid transportation. While the suggestion is simplistic, with no consideration for other time-critical preventable causes, it underscores the need for a simplified, uncomplicated triage system that prioritises rapid transport to definitive care for victims of IMV. Triage is an important process of IMV emergency medical responses to ensure the optimisation of resources within the chain of survival. However, current triage systems are inadequate for the complexity of IMV, and there is tension between established systems, the need for rapid rescue and evacuation and their utility within the complex milieu of response to IMV.

Victim centred characteristics

The literature detailed important factors of emergency medical response that are victim centric. These factors included the assessment of wounding patterns, time, and survivability, which are interrelated. Each aspect is an essential element of the emergency medical response and a key driver for the responder.

Wounding patterns

Common in the literature was the assertion that wounding patterns reflect those seen in war zones because of the weapons and tactics used by attackers on civilian populations. Depending on weapon choice, low velocity penetrating trauma, ballistic trauma, explosive injury and blunt force trauma are all common.17,24 While wounding patterns can be homogeneous, they are often dictated by the complexity of an attack.18 When additional layers of complexity are added to the attack, wounding patterns will conform. For example, vehicle ramming attacks followed by stabbing sprees translate into blunt force trauma and low-velocity penetration trauma in a single incident. The more complex an attack is, the more diverse the injury patterns will be.18 This complexity ensures that emergency medical responses to violence occur in complex and dynamic contexts, and the expected wounds are also complex.

Contextual, environmental, and situational aspects of an attack, particularly in explosive events, also affect wounding patterns. Peleg and Rozenfeld29 described the compounding effects of blast injury in confined spaces where the blast wave is contained, compared to open settings.29 Similarly, Gates et al26 argued that injuries at the Boston Marathon bombing were consistent with secondary blast injuries more common with lower-order improvised explosives. Furthermore, Gates et al26 pointed out that the high number of lower limb and specifically below knee injuries and amputations were consistent with improvised devices being placed on the ground.

With wounding patterns reflecting those common in war zones, the emergency medical response to IMV must focus on treating injuries most likely to benefit the victims in situations analogous to war zones. The literature commonly references preventable causes of death, with the highest priority given to exsanguinating compressible haemorrhage as the number one determinant of survivability.17,23,26,27 Thus, responders at all levels must first and foremost be highly skilled in efficiently assessing and arresting compressible haemorrhage, followed by treating other preventable causes of death resulting from complex attack methods observed in war zones.

Survivability

Survivability centres on delivering the greatest good to the most victims possible. In IMV incidences, there will likely be a high number of victims.17,23 The literature suggests that early intervention is critical to achieving survivability.  Due to proximity and access, bystanders will often be the first to assist victims.26 Gates et al26 provided an example where the initial treatment of casualties was performed by bystanders, some of whom were medical personnel based at the event for athlete support.26 Indeed, in active events, particularly in the immediate threat (hot) zone, it is unlikely that ambulance crews or rescue teams will be able to render assistance until the immediate threat has been mitigated, leaving only bystanders to assist victims. However, untrained bystanders are unlikely to infer benefit unless bystanders have rudimentary trauma first aid training that can adequately address compressible haemorrhage and other preventable causes of death.24 This has led to increasing implementation of civilian training in haemorrhage control in much the same way as they receive Cardiopulmonary Resuscitation (CPR) training, although no such program has been implemented in Australia.

Victim survivability may be supported when contact teams, such as law enforcement tactical groups or special forces tasked with threat suppression, have access to embedded physicians or paramedics. Embedded physicians within French special forces during the Bataclan Theatre siege were the first and only providers of care to victims during the active stage of the siege.19 However, these embedded specialist models are not widely used due to limited personnel resources. Additionally, embedded specialists exist for the benefit of the response teams and are not mandated to care for victims beyond team members who may be injured during suppression operations.24 Carli et al17 argued that despite the best efforts of embedded special forces physicians, the confined and uncontrolled conditions during the siege may have led to deaths from potentially survivable injuries. The articles by duRAID23,29 demonstrated this by describing how access by special forces physicians to victims was prevented in some cases due to the large volume of casualties, some of which were obscured in “tangles of bodies”.23

Similar models of care are used elsewhere; some will include occasional teams of police officers assigned to protect and escort adequately trained emergency personnel, such as firefighters and paramedics, into the warm zone.24 While the concept is established and referred to as a Rescue Task Force (RTF), it requires training, resources and readjusting of safety expectations for responders who participate in these teams.21,24 The use of these teams infers survival benefits but not beyond the borders of the warm zone in an active event; victims in the hot zone may not receive care even when an RTF is available.24

Carli et al31 asserted that exsanguinating haemorrhage is a major contributor to victim death; however, this extends beyond the initial wounding. Data extracted from the selected literature indicates that early interventions should centre on preventable causes of death, specifically compressible exsanguinating haemorrhage.23 Other preventable causes include simple airway compromise and tension pneumothorax (in simple terms a collapsed lung secondary to trauma). Interventions focusing on these three preventable death causes align with damage control resuscitation principles. Damage control resuscitation is a system of trauma care refined in recent wars in Iraq and Afghanistan.31 These three causes of death can be addressed at the basic life support level, provided adequate resources and training are available.21 However, the caveat is that those providing the care even at the most basic level will require the training and resources to be effective.32 Much of the selected literature indicates that resources were a confounder to addressing the preventable causes of death.21,32 An additional confounder is time, the pathologies described as preventable causes are time critical and need to be addressed as a matter of priority. Shackleford et al27 asserted that time is inversely proportional to survival for victims of IMV.

Time

Time in IMV is a pervasive domain that links critical aspects of the response. Indeed, time dependency binds the emergency medical response and extends through from threat mitigation to survivability and, ultimately, resolution. Attacks are difficult to predict and occur unexpectedly and at any time, often with high casualty rates.28,29 Some data from the selected literature indicate that variables related to time, such as traffic patterns and staffing levels, have negative consequences.28 Considering the preceding assertions, it is clear that once an attack starts, victims of an attack are captured within a multivariate timeline over which they have little control.

Even so, response times are typically short, however, once emergency medical responders are on site, there are barriers to accessing victims.18 Rapid responses without the capacity to exploit the inner zones of care infer no survivability benefit for the victims.28 The inability to exploit the inner zones of care is the result of the most pervasive barrier, the threat.21 The threat of the ongoing attack, the threat of the unknown and the threat of follow-up attacks on responders are all barriers to exploiting zones of care for survivability optimisation. Because of the threat picture, medical responders who are not trained to operate beyond the boundaries of the warm zone must typically remain at the outer boundaries of the zones of care to ensure relative safety.21 The concept of the therapeutic vacuum, as described under the heading, zones of care, is inextricably linked to time and moderated by threat.

Discussion

The aim of this review was to identify the characteristics of emergency medical response to intentional mass violence in Australia, the UK, the USA and Western Europe. Characteristics are not mutually exclusive and are bound together in a co-dependent milieu that spans the initial violent incident through the response and treatment and optimised survival of victims.

To our knowledge, this review represents the first concept-ualisation of the characteristics of emergency medical response to IMV. The conceptualisation is a visual representation that demonstrates the complexity between response-centred characteristics and highlighted operational problem sets associated with a response to IMV and victim-centred characteristics that ultimately affect survivability. The conceptualisation shows that while the characteristics can be split, they are intertwined, with each characteristic having a close effect on others. Indeed, emergency medical responses need to be dynamic and, yet coordinated and unified, as depicted in this complex conceptualisation.

Task and training within these characteristics are, however, not universally recognised, and models of response do, of course, vary. One of the response-centred characteristics identified in the review is the preference and need for a simplified triage system based on preventable causes of death. Vassallo et al25 addressed this need by introducing the Ten Second Triage (TST) system, categorising victims by severity based on preventable causes rather than physiological parameters.25 While TST has been adopted and implemented in the UK, it does not appear to be widely used in other countries, including Australia. Understanding the (non)adoption of such recommendations is an area of future research, but raises questions about the training, resourcing and support required for such interventions.

Similarly, falling under the victim-centred survivability characteristic, the need for bystander training has been championed by the Hartford consensus following the Sandy Hook elementary school shooting and has resulted in the Stop the Bleed program in the USA, which focuses on civilian training for compressible haemorrhage in mass shootings.33 Along these lines, in the UK, the Citizen First Aid Program provides guidance for civilians on how to treat preventable causes, specifically exsanguinating extremity trauma with the use of tourniquets or improvised tourniquets.34 Again, no such trauma-focused public initiatives could be identified in Australia at the time of writing. Could this indicate a significant capability gap for Australia, or could it be reflective of the relatively small incidences of IMV? Furthermore, what measures are Australian response services taking to prepare for IMV, drawing from past incidents and analogous response systems in the UK, US and Western Europe? Is Australia prepared? The answer may simply be, we do not know. Given the continued threat of IMV, and the recently raised threat level in Australia, consideration of any interventions which save lives is worthy of investigation.

A significant finding of this review is that no contemporary literature that met the inclusion criteria could be found for the Australian context. The UK, USA and Western Europe, on the other hand, are well represented in the literature. Again, while IMV is more common in areas outside of Australia, it is not immune to violence, and how lessons are being learned, responses improved, and models adapted is an important consideration for Australia.

The federal government provides broad guidelines for response to major incidents through the Australian Government Crisis Management Framework (AGCMF). This document provides a higher-level framework for the roles and responsibilities of officials. IMV falls under the non-specific definition of ‘human-induced events’, which offers no pointed guidance for medical response to IMV (and also includes cyber-attacks and space junk incidents).35 Within the AGCMF, the National Health Emergency Response Arrangements (NatHealth Arrangements) refer to The Domestic Plan for Mass Casualty Incidents of National Consequence (AUSTRAUMAPLAN). The AUSTRAUMAPLAN was superseded by Australia’s Domestic Health Response Plan for All Hazards Incidents of National Significance (AUSHEALTHRESPLAN) in 2021.36 Again, this plan provides a broad framework for activating, resourcing and coordinating health resources for all hazards but provides no guidance on the specifics of front-line operations.

At the operational level, it is the responsibility of each response agency within each state to ensure that they are adequately resourced and trained to respond to a range of mass casualty incidents. Each state provides a broad mass casualty incident plan, which then refers to the individual State Ambulance Service as the responding agency tasked with operationalising its capability within the boundaries of the State mass casualty incident plan36 These plans do provide guidance for organising on-site activities, but, like those further up in the hierarchy, the guidance is ambiguous enough to allow flexibility or, equally likely, obscure specifics. Indeed, given the geographic isolation of Australia, responses need to be dynamic and fluid.

Limitations and delimitations

This review has some limitations, Firstly, only English language articles were used, and only Western countries were included for analysis. This was chosen to create a homogenous group with similar medical capabilities and response; however, this may have inadvertently excluded other response systems and tactics.

Secondly, IMV is ill defined in the literature, and much cross pollination around terms, such as terrorism and attacks, has occurred. The reviewers have attempted to mitigate this risk by describing a definition of IMV at the outset.

Lastly, this review used only peer-reviewed literature. As an integrative review, the quality and peer review of sources is important, however grey literature may have held important characteristics which have not been accounted for. This review is the starting point for a wider study which will broadly review literature and insights on the topic.

Conclusion

The fact remains, there is limited research on Australia’s response, capabilities and readiness for IMV. It is unclear how Australian response agencies are addressing the unique characteristics laid out here, in part owing to the dearth of reporting and research relating to the specifics of responses to those incidents. The wider socio-political influences around Australia’s responses to IMV, beyond medical responses, are needed and will be the subject of future inquiry.

Orcid numbers

Aldon Delport 0000-0001-8546-8996
Amy-Louise Byrne 0000-0002-8679-8310
Amy Johnson 0000-0003-4228-6265

Conflict of interest

The authors declare no conflicts of interest.

Funding

The authors received no funding for this study.

Author(s)

Aldon Delport *1, Amy-Louise Byrne2, Amy Johnson3
1School of Health, Medical and Applied Sciences, CQUniversity, Rockhampton, Australia
2 Senior Lecturer and Postgraduate Research Coordinator School of Nursing, Midwifery and Social Sciences, CQUniversity, Sydney, Australia
3 Senior lecturer and Head of Course for the Bachelor of Arts School of Education and the Arts, CQUniversity, Rockhampton, Australia

*Corresponding author email a.delport@cqu.edu.au

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