Introduction: A Lopsided Evolution

In the decades following the Columbine shooting, law enforcement agencies across the United States have made considerable progress in active shooter tactics. The days of delayed engagement and perimeter control have largely been replaced by a doctrine that emphasizes speed, aggression, and immediate neutralization of the threat. Officers now train to enter the structure as quickly as possible, even without backup, understanding that every second of delay means additional casualties.

But this tactical evolution has not been matched in the medical domain. While the operational tempo for law enforcement has increased, emergency medical services (EMS) and Fire have been largely left behind, relegated to the cold zone or standby staging. The result? A dangerous and unacceptable gap in care during the most critical minutes of an incident.

Medical integration in active shooter response remains fractured, underdeveloped, and inconsistently applied. Despite lessons learned on the battlefield environments of Iraq and Afghanistan— an numerous civilian after-action reviews—many jurisdictions still treat medical intervention as a secondary or post-clearance task. This cultural and operational misalignment continues to cost lives, and until the paradigm shifts, we will remain locked in a cycle of avoidable failure.

The Tactical Leap Forward

There’s no question that tactical doctrine has improved dramatically over the last two decades. After Columbine, the traditional model of perimeter containment and waiting for SWAT was quickly deemed obsolete. Incidents like Virginia Tech, Sandy Hook, and Pulse Nightclub forced a shift in mindset—one where solo or small team entries became the norm. Officers now train in active threat lanes, immediate action drills, and corridor-based clearance methods. Direct engagement has become the operational standard.

This evolution is necessary and commendable. It reflects a deeper understanding of active shooter dynamics, suspect psychology, and the time-sensitive nature of mass casualty events. But while the tactics have modernized, the surrounding support structure—particularly medical—has not.

In many jurisdictions, EMS and Fire is still staged blocks away “until the scene is safe.” The phrase “scene safe” is often misunderstood or misapplied, leading to unnecessary delays in patient care. While law enforcement moves with urgency, medical teams remain idle, waiting for a call that often comes too late.

The Medical Integration Gap

This disconnect is not a failure of individual medics—it’s a systems failure. EMS and Fire have not been fully integrated into the tactical mission because most response models are built around outdated assumptions. Chief among them: that the threat must be eliminated before medical intervention can begin. But evidence shows that the highest mortality risk in mass shootings comes not from prolonged shootouts, but from uncontrolled hemorrhage and airway compromise—conditions that require immediate treatment, not delayed care.

The National Academies of Sciences, Engineering, and Medicine (2016) report “A National Trauma Care System” emphasized that trauma care begins at the point of injury, not at the hospital bay. Yet in most active shooter events, there is no structured plan for medics to move with the assault teams, no defined Medical Rescue Team (MRT) doctrine, and no shared command structure to prioritize medical integration. Instead, EMS and Fire waits until law enforcement “calls them in,” often without knowledge of the tactical picture or safe routes.

The result is predictable: patients bleed out in hallways while rescue assets sit staged. Officers carry casualties over their shoulders because no medical team has been embedded. Life-saving interventions are delayed or improvised. These are not isolated failures—they are systemic symptoms of a broken model.

The CSR Framework: A Path to Integration

The Chaos–Stabilization–Recovery (CSR) framework was developed to address these gaps by integrating tactical and medical operations across three defined phases. Unlike traditional ICS, which often relegates EMS and Fire to support roles, the CSR model embeds medical assets directly into the tactical mission.

• Chaos Phase: Immediate response, entry, and threat engagement. MRTs should move forward with law enforcement elements, establishing hasty casualty collection points (CCPs) and rendering care inside the hot or warm zone.

• Stabilization Phase: Securing of corridors, establishment of security bubbles, triage operations, and coordinated patient movement. MRTs transition from immediate care to coordinated treatment and evacuation.

• Recovery Phase: Long-term medical transport, resource coordination, psychological support, and after-action planning. EMS resumes traditional MCI roles but remains embedded in the unified command structure.

The CSR framework does not view medicine as an afterthought. It places medics where they belong—at the tip of the spear, working alongside officers to preserve life while others neutralize threats. But this model only works when responders are open to change, when leadership commits to integration, and when training reflects the reality of what will happen on the ground.

MRTs: A Critical but Overlooked Capability

The Medical Rescue Team (MRT) should be as essential to active shooter response as the entry team itself. MRTs are not traditional ambulance crews—they are specialized units trained to move, assess, and treat casualties under austere and dynamic conditions. Their skill set includes:

• Rapid trauma assessment (MARCH algorithm)

• Hemorrhage control under fire

• Movement under cover

• Casualty extraction and triage

• Interoperability with tactical teams

Yet, despite the obvious need, many jurisdictions have no formal MRT capability. Where they do exist, they are often underutilized, improperly equipped, or poorly integrated into tactical planning. The MRT must not be treated as an add-on or optional resource—it is a life-saving asset that must be given equal priority to law enforcement engagement.

Training: The Key to Muscle Memory and Unified Action

Real integration is built through repetitive, realistic, and interdisciplinary training. Training is what transforms theory into action, confusion into coordination, and fragmentation into fluidity. It is the bridge between tactical evolution and medical integration. Without it, responders will continue to default to siloed operations.

Joint training between fire, EMS, and law enforcement must move beyond classroom lectures and tabletop exercises. It must include scenario-based repetitions that build muscle memory, mutual trust, and shared terminology. Every participant needs to understand not only their role but also the role of their interagency partners. The goal is not to train until you get it right, but to train until you can’t get it wrong.

Training must also be frequent and evolving. One annual active shooter drill is not enough. Like fire departments train ICS on every call, and law enforcement trains entry on every CQB iteration, medical and tactical integration must be practiced until it becomes instinctive. Integrated mission planning, shared command, medical force protection, and tactical casualty care must become baseline expectations—not enhancements.

A Paradigm Shift is Not Optional

We are at a tipping point. The data is clear. The failures are repeated. The solutions exist. What we need now is a willingness to evolve. Just as law enforcement moved from perimeter containment to dynamic entry, EMS must move from static staging to forward deployment. This shift is not theoretical—it is operationally necessary.

Agencies must commit to:

• Establishing and training Medical Rescue Teams

• Embedding MRTs in entry operations

• Creating joint SOPs that define roles across all CSR phases

• Conducting integrated, scenario-based training at scale

• Funding not just tools, but tactics and teams

The paradigm must shift from “treat after it’s over” to “treat while it’s happening.” This is the only way to reduce preventable deaths in the first minutes of crisis.

Conclusion: Integration Is the Next Tactical Evolution

The tactical doctrine has evolved. Now it’s time for the medical doctrine to catch up. Integration is no longer a luxury—it is the next necessary step in saving lives during active shooter and mass casualty events. The CSR framework gives us the model. MRTs give us the tools. Training gives us the confidence, coordination, and muscle memory to make it work.

Most importantly, we must remember: we are only as strong as our weakest link. If even one piece of the response—be it tactical, medical, or command—fails to function, the entire system suffers. This is not about territory. It is about teamwork. We either integrate and adapt as one, or we fracture and fail as many.