1. Introduction: The Flawed Legacy of “Outside the Wire” CCPs

For decades, tactical medical doctrine taught that Casualty Collection Points (CCPs) should be placed outside the immediate threat area—safely staged behind the wire, out of danger. This logic was grounded in traditional firefighting and EMS practices, where responders waited until law enforcement cleared the scene before approaching. The idea was to protect medical teams and prevent additional casualties.

But in active shooter and high-threat environments, this approach is no longer viable. Waiting for the scene to be declared "safe" can take minutes—or hours. In those moments, people bleed out. The outdated belief that CCPs should be far from the point of injury results in fatal delays, operational confusion, and a fractured response that fails the most critical patients.

Modern tactical medicine must evolve. Under the CSR (Chaos, Stabilization, Recovery) model, CCPs are no longer safe havens parked blocks away—they are lifelines located inside the hot zone, co-located near the point of injury. To save lives, real-time care must begin inside the building, not outside of it.

2. The CCP as a Tactical Lifeline

A Casualty Collection Point is not a mobile emergency room, nor is it a safe zone where prolonged treatment is delivered. Its function is narrow, specific, and vital:

• Triage: Rapid evaluation using START/JumpSTART or MARCH to assign priority.

• Immediate Treatment: Hemorrhage control, airway management, needle decompression.

• Evacuation Prep: Packaging, labeling, and streamlining patients for transport.

The CCP is a transitional node, not a destination. It exists to apply lifesaving interventions, stage casualties for handoff, and rapidly move patients toward definitive care. In a hot zone, security is limited, supplies are minimal, and the clock is merciless. Providers must think in seconds, not minutes. The CCP should reflect that urgency—it is a point of action, not a place to pause.

3. Tactical Setup: CCPs Within the Hot Zone

Modern tactical response doctrine recognizes that proximity equals survivability. The closer the CCP is to the point of injury, the faster patients receive treatment—and the better their chances of survival. This requires a bold shift in mindset: the CCP must be inside the operational environment.

A successful hot zone CCP includes three critical elements:

• Security: Provided by law enforcement. Officers secure entry points, maintain perimeter integrity, and protect both casualties and medical responders. This is not optional—it is foundational.

• Command & Control: A unified presence from EMS, fire, and law enforcement creates seamless coordination. Tactical medics, MRTs (Medical Response Teams), and supervisory staff operate under a shared communications plan with clear command hierarchy.

• Proximity to Point of Injury: Whether it’s a school hallway, office lobby, or warehouse corner, CCPs must be as close to the wounding mechanism as safely possible. Seconds save lives. Waiting outside costs them.

Programs like ALERRT, ASHER, and ATIRC support this internal CCP model. They promote joint training between disciplines and emphasize the importance of integrated tactical medicine during the chaos phase of a response. CCPs aren’t static—they move with the fight. They adapt to the structure, to the shooter, and to the casualties.

4. Triage and Evacuation Within CCP Operations

Inside the CCP, triage is dynamic. Casualties shift from green to yellow, yellow to red, depending on evolving injuries, blood loss, and interventions. Static classifications are dangerous—MRTs must reassess frequently, updating triage tags and communicating changes in priority.

The CCP follows a “Tag – Treat – Move” model:

• Tag: Rapid assessment using RPM or MARCH criteria. Assign appropriate color coding and evacuation priority.

• Treat: Apply hemorrhage control (tourniquets, wound packing), airway adjuncts, and tension pneumothorax relief. Treatment is focused, not exhaustive.

• Move: Prepare patients for extraction, categorize based on urgency:

  • Urgent – Requires evacuation within 2 hours to survive.

  • Priority – Evacuation within 4 hours for optimal outcomes.

  • Routine – Can tolerate 24-hour delay.

  • Convenience – Non-life-threatening or deceased.

From the CCP, casualties are transferred to a staging point—ideally just outside the structure—where ambulance transport is coordinated. The flow must be clean: CCP → Staging → Ambulance → Trauma Center. Confusion or congestion at any point in this pipeline reduces efficiency and increases mortality.

5. Addressing Tactical Barriers and Civilian Hesitance

Despite its operational validity, internal CCP implementation faces resistance. Many agencies are hesitant to enter hot zones due to perceived legal risk, fear of secondary threats, or lack of proper training. These concerns are understandable—but solvable.

Proper training in integrated response is the first step. MRTs must train alongside law enforcement to understand tactical movement, scene security, and casualty rescue under fire. Scene commanders must emphasize task-based risk assessment—not blanket "scene safe" declarations that delay lifesaving interventions.

Another barrier is fear of transporting armed or dangerous suspects alongside innocent casualties. This risk can be mitigated through suspect segregation, secure transport units, and direct communication with receiving facilities. The presence of a suspect does not negate the need for timely treatment—it simply requires planning.

The greatest legal and ethical liability is not entering the building—it’s allowing preventable deaths to occur while waiting for perfect conditions.

6. The CSR Advantage: Coordinated CCPs Save Lives

The CSR model—Chaos, Stabilization, Recovery—provides the ideal framework for internal CCP integration.

• Chaos Phase: Law enforcement engages the threat; MRTs enter with a rescue task force to establish CCPs and begin triage.

• Stabilization Phase: Unified command solidifies operations, coordinates transport, and reinforces the CCP with additional assets.

• Recovery Phase: Medical and command staff debrief, coordinate reunification, and support long-term care transitions.

When CCPs are embedded in the hot zone early, care begins minutes sooner. Survivable injuries become actual survivals. Real-world examples, from Parkland to Uvalde to Las Vegas, demonstrate that the gap between wounding and treatment determines outcome. Internal CCPs close that gap.

MRTs must not wait for the shooting to stop. They must be trained, equipped, and integrated to move with law enforcement. The goal is not chaos mitigation from the perimeter—it’s damage control at the point of injury.

7. Conclusion: “If You’re Not in the Building, You’re Not in the Fight”

Outdated CCP doctrine belongs to a world that no longer exists. In the modern active shooter threatscape, every minute of delay costs lives. If we continue placing CCPs outside the wire, we will continue losing people who could have been saved.

The CCP is no longer a concept—it’s a battlefield necessity. It must be close, coordinated, and aggressive. MRTs must be mentally conditioned to work under threat. Command staff must build policies that reflect operational reality. And agencies must train together—not separately—to ensure rapid, integrated execution.

If you’re not in the building, you’re not in the fight.

The new CCP is not just inside the structure—it’s at the crossroads of tactical precision and lifesaving efficiency. Get in. Treat. Get out. And save lives.