Preparing for the Unthinkable: Physician Safety Paramount Following Shooting of Boston Surgeon

January 23, 2015

BOSTON, MA — Boston cardiac surgeon Dr Michael Davidson, fatally shot by an individual with a suspected grudge against the physician, is a grim reminder that doctors can be harmed by anybody with a grievance and a weapon. And even though hospitals take physician and staff safety seriously, attempting to prepare for any and all situations, sometimes there's not a lot that can be done.

In fact, the Brigham and Women's Hospital, where Davidson was killed on Tuesday, January 20, 2015, had previously worked with the Boston Police Department to prepare for an "active shooter." The Brigham had even created its own training video for staff, teaching them to assess when it's appropriate to run, to hide, or to disable the suspect, according to the Boston Globe .

Speaking with heartwire , Chris Van Gorder, president and chief executive officer of Scripps Health in California, said the dangers and risks posed to staff appear to be a situation that's getting worse rather than better. Van Gorder is in a unique position to comment on physician safety, as he's also a retired police officer, a reservist in the San Diego County Sheriff's Department, and a terrorism liaison officer with local law enforcement.

"This is one of those things that's very concerning to me, and frankly I'm sure it's very concerning to our physicians and our staff as well," said Van Gorder said of the Brigham shooting. While hospital shootings are rare—one study reported there were 154 hospital-related shootings between 2000 and 2011, resulting in 235 dead or injured victims, with hospital employees constituting 20% of the victims—other problems do arise.

"We've had situations with family members [where they'd] threaten staff and physicians," said Van Gorder. "We have regular incidents in our emergency department, where we're dealing with patients with behavioral health issues. . . . These individuals don't stop threatening people just because they're brought into an emergency room or hospital."

On the other side of the country, the Cleveland Clinic has its own fully commissioned police department, with officers certified by the State of Ohio. Started in 1987, the Cleveland Clinic Police Department is the third largest police agency in Northeast Ohio. Heather Phillips, the senior director of corporate communications, said that while most other hospitals rely on unarmed security officers, the Cleveland Clinic police consist of a mix of security and police officers with the authority to arrest individuals.

To heartwire , Phillips said the police and security officers undergo extensive "deescalation" training for all situations, but particularly when responding to the crisis-intervention team. "We also have a police crisis-response team that receives continuous training on the latest techniques and protocols when responding to a situation that may involve a weapon," noted Phillips.

Electrophysiologist Dr John Mandrola (Baptist Medical Associates, Louisville, KY) said that he has never been threatened directly by a patient or a family member, but following the shooting of Dr Davidson he conducted a small, informal poll of staff in the emergency department and found that most of them had been threatened at some point in their careers. A lot of the threats, they noted, are rooted in a refusal to prescribe opioids for patients who may be prescription hunting, Mandrola, a blogger for theheart.org|Medscape Cardiology, told heartwire .

Away From the Front Lines

While emergency-department physicians, nurses, and technicians are on the front lines, especially when dealing with mentally ill patients, other issues do arise with angry patients/family members, such as those who might threaten a staff member or even resort to physical assault. Van Gorder said safety is not an easy thing to guarantee in a hospital environment. "Healthcare is delivered person-to-person," he said. "You can't put barriers and screens all the time between a patient or even a family member and a provider. Sometimes these threats are not known in advance, like the situation in Boston."

In the shooting of 44-year-old Dr Davidson, Boston Police Commissioner William Evans said they responded to a 911 call at 11:07 am regarding shots fired at the Brigham and Women's Hospital. The suspect, 55-year-old Stephen Pasceri, was found by police in an examination room suffering from a self-inflicted gunshot wound. He was pronounced dead at the scene. According to the police report, their preliminary investigation suggests Pasceri had an issue about the medical treatment of his mother at the hospital. Marguerite Pasceri died November 15, 2014 and was a patient of Dr Davidson's, according to media reports.

Pasceri was not known to the police previously and was legally licensed to carry a firearm. His neighbors expressed shock at his actions, describing him as a " calm, pleasant sort of guy" with four kids, reports the Boston Globe.

Dr David Kandzari (Piedmont Heart Institute, Atlanta, GA), an interventional cardiologist, said he has been fortunate to never encounter a patient or a family member where he felt in danger. While not speaking directly to the circumstances of the Davidson shooting, Kandzari said that when there is a bad clinical outcome, such as a death, "it is essential to help patients/family to understand that events do occur and why."

Nearly 20 years ago, Dr Paul Teirstein (Scripps Clinic, La Jolla, CA) said that he was told if a procedure did not go well, the Las Vegas mafia would be after him. "Security investigated, and the patient called me to reassure me that the family member threatening me was nuts," Teirstein told heartwire . That procedure, he noted, turned out very well.

When Staff Are Threatened

When a staff member is threatened at Scripps, there is an in-place arrangement with law-enforcement agencies where the hospitals are located so that a call is placed directly to the police-department liaison. This sets in motion resources to investigate the threat, said Van Gorder. While they have an excellent process for dealing with known threats, the "unknown" threats are the scariest and most difficult, if not impossible, to guard against. Even if metal detectors existed in hospitals—which Van Gorder doesn't believe are feasible, given that these would need to be staffed by armed guards—hospitals are designed with multiple entrances and exits.

In 2010 at Johns Hopkins Hospital, the security staff came to a similar conclusion. The large Baltimore hospital felt metal detectors would be impractical, given that 80 000 patients and visitors pass through its doors each week and there are more than 80 entrances and exits. The hospital made this decision after a gunman had entered the facility and killed his mother and himself.

At Scripps, Van Gorder said they have already started a project known as rapid improvement events, where employees in the medical, security, risk management, and legal departments will work with law-enforcement advisors to determine whether there is anything they can do to improve security at the hospitals.

Security investigated, and the patient called me to reassure me that the family member threatening me was nuts.

While older hospital campuses might not be designed with "bomb threats" or "active shooters" in mind, newer hospital campuses have definitely tightened up security. For example, at the new Scripps Prebys Cardiovascular Institute, which is scheduled to open in early 2015, access to every part of the hospital is card-key controlled. Next week, the institute will participate in drills to deal with active shooters. It has already conducted such a drill at the new critical-care unit at Scripps Memorial Hospital in Encinitas, CA. And two years ago, Van Gorder formed the terrorism task force, which meets with law-enforcement agencies on a regular basis, to discuss how to protect staff from dangerous patients or how to respond if a threat is sensed.

"Instead of just calling and being told, 'It's not that big of a deal, call us if something happens,' law enforcement responds every time to make sure the hospital is secure," said Van Gorder. "As a sheriff in San Diego County told me once when we set up this task force, 'If somebody made a threat to a school, we'd have dozens and dozens of law-enforcement officers out there.' Hospitals are no less important to the infrastructure of the community. We have to respond the same way if there's a threat to the hospital."

At the Cleveland Clinic, each facility within the health system also has security measures to "deter, detect, and respond" to both known and potential risks, said Phillips.

"As part of this, we conduct regular emergency-preparedness drills throughout our health system each year," she told heartwire . "We implement our incident-command protocol with teams that can be immediately mobilized to manage a variety of crisis/issues, including kidnappings, bomb threats, outbreaks, plane crashes, public-health emergencies, and shootings. In addition, all of our employees are trained and drill annually on active shooter scenarios."

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