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Great white shark attacks remain a relatively rare event, with 139 worldwide from 1990 to 2011, 29 of them fatal. In the U.S. there have been just 106 in the past 85 years, with 13 fatalities. Seventy-eight of those attacks happened in California.

Alex Peabody, the retired director for aquatic safety for the California State Park system, agrees that rescue swimmers should not be in the water during an attack. His parks are equipped with personal watercraft and patrol boats, although those were purchased to save swimmers caught in rip currents, not for shark attacks, which remain relatively rare in the Golden State.

Surviving an attack

Fins in the water, whether harmless basking sharks, ocean sunfish or the real thing, have always prompted an evacuation from the water.

But now, behind the scenes, a shift has taken place, away from skepticism and toward preventing and preparing for the worst, the possibility of a shark attack on a human.

In 2004, the evidence that great whites were here was undeniable, as a 14-foot, 1,700-pound female great white became trapped for weeks in a lagoon on Naushon Island.

Around that time, McFarland said, pages were added to the lifeguard manual telling them how to respond to reports or sightings of sharks in the water and how to rescue a swimmer or surfer who has been bitten.

Most recently, McFarland was on Nauset Light Beach with other lifeguards when a shark either attacked or became entangled in a buoy that marked the seaward limit of the protected area. He said its whole body came up out of the water.

"That was really disconcerting to me," said McFarland, who believed it was a great white. Research has shown that great whites have various attack strategies, but quite often bite with the intent of inducing massive blood loss and death. They wait for the victim to die, then return to feed.

Improved medical care is largely responsible for bringing the fatality rate in great white attacks down from 60 percent in the early 1900s to around 20 percent today. The majority of sharks spotted by shark researcher Greg Skomal's team have been in the 14- to 16-foot range, with only one estimated at around 18 feet.

Studies support the theory that humans lack the fat content great whites prefer and that most attacks are exploratory.

International Shark Attack File data showed that more than 70 percent of great white attacks on humans were done by sharks greater than 10 feet in length, largely because at that size they have shifted from eating fish to marine mammals.

The survival rate was estimated at around 80 percent for sharks between 10 and 15 feet in length and 70 percent for those between 15 feet and 20 feet.

Beyond that, the number of attacks are rare and survival drops to around 10 percent.

'Right up against the clock'

For lifeguards, stopping the bleeding is the first priority after they have the victim on the beach. The call to town emergency personnel has already been made at the first sign of an attack, rescue and beach officials said. En route, emergency responders are already looking for information from those on the beach so that they can determine whether to call for a medical airlift, Eastham Fire Chief Glenn Olson said.

The goal is to get the trauma victim into surgery within what is called "The Golden Hour," beyond which statistics say complications and even death becomes more likely.

Cape & Islands EMS president William Flynn said lessons learned in warfare have transformed pre-hospital trauma care from treatment at the scene to the point where they are now trying to stabilize the patient but still get them on their way as quickly as possible.

"It's a challenge. You try to get the patient moving and stabilized. You put direct pressure on any site (where there is major blood loss) and start IV therapy. You're right up against the time clock right off the bat," Olson said.

All too familiar

Unfortunately, it's a routine that Outer Cape rescue personnel are all too familiar with in handling car accidents along Route 6.

Olson said their relationship with medical air flight companies as well as lifeguards, harbormasters, the Cape Cod National Seashore and other agencies like the Coast Guard is honed by other emergencies that happen every summer.

"The fact of the matter is trauma is all treated the same way, especially in pre-hospital care," Flynn said.

Town and Seashore park beaches have all-terrain vehicles that can get patients off the sand and into rescue vehicles relatively quickly. On the more remote off-road trails, such as the ones leading from Orleans to Chatham, there are beach patrol vehicles that can get rescuers to the scene.

Orleans Deputy Chief Tony Pike said his department has already had a lot of experience with marine rescues in remote areas, like clamming flats. A July 7 rescue in Pleasant Bay in which a young girl suffered severe lacerations from a boat propeller was pretty close to what could occur in a shark attack, Pike said.

In that case, Orleans rescue personnel had to travel to the patient by boat and, when medical helicopters couldn't fly, coordinated with the Coast Guard in Chatham to bring in an all-weather helicopter to fly the girl to Boston.

It was all done within 40 minutes of getting the rescue call from the harbormaster, Pike said. But those kinds of rescues require a lot of manpower, Pike said, and some feel the towns are other agencies are more in a reactive than a proactive role regarding shark attacks.

Some have not had meetings to specially work out protocols for such an emergency but are relying on how they handle their current cases.

"This could all be potentially new ground," Pike said, wondering whether the future will bring more seals, sharks and problems.

"Where are we going to be one more summer down the road?"