Neil Osterweil

October 30, 2015

BOSTON — "Avoid, deny, defend, treat" — these are the four key principles for coping with an active shooter in a hospital, a situation that everyone must prepare for, said a disaster preparedness expert here at the American College of Emergency Physicians (ACEP) 2015 Scientific Assembly.

"Unlike shootings at a school or a mall, we still have stuff going on," said David Callaway, MD, director of operational and disaster medicine at the Carolinas Medical Center in Charlotte, North Carolina. "We still have the septic patient, we still have heart attacks, we still have grandma with her busted hip who we have to take care of."

The grim reality is that from 2000 to 2014, there has been a steady increase in hospital-based shootings in the United States. They have been increasing in frequency and complexity, they involve more weapons and more improvised explosive devices, and the shooters are targeting more victims and attacking more subtargets, Dr Callaway said.

Boston, host of the ACEP meeting, has experienced the horror of a hospital shooting. In January, Michael Davidson, MD, a 44-year old interventional cardiologist, was shot and killed at Brigham and Women's Hospital. The shooter committed suicide after killing Dr Davidson.

Sadly, Boston is far from alone. From 2000 to 2011, there were 154 hospital-related shootings in the United States; 59% took place inside the hospital and 41% occurred outside on hospital grounds, according to a recent study (Ann Emerg Med. 2012;60:790-798). Those shootings occurred in 40 states and resulted in 235 injuries or deaths.

Motivations for the shootings included grudges, revenge, suicide, ending the life of an ill spouse or relative, and escape for prisoners brought in for medical care. The case fatality rate was 55%. The victims were primarily the shooter and the intended target, and 91% of the shooters were male.

Since that study was published, another 39 hospital-based shootings have occurred, Dr Callaway reported.

Workplace Violence

Studies have shown that healthcare workers are increasingly at risk for workplace violence; 60% of all workplace assaults occur in a healthcare setting. And 46% of all assaults or violent acts that result in lost works days are committed against registered nurses, Dr Callaway said.

The first response to the presence of an active shooter or the sound of gunshots is generally disbelief: "Oh, that was firecracker," he explained. But it is imperative for those in the vicinity of a shooter to accept the situation and deliberate quickly on the available options — run, hide, fight — and then take decisive action, he said.

The first priority for those on scene is to avoid danger by removing potential targets from the shooter's vicinity by running, hiding, and calling 911 when it is safe to do so.

This denies the shooter access to potential targets. More than one-third of all active shooting incidents end within 5 minutes, and police generally arrive on site quickly, so lives can be saved if the potential targets can hold out until help arrives.

Those on site can take action by hiding in secure locations, if available, locking or blockading doors with a gurney, chair, desk, or IV pole, for example, turning off lights, and silencing phones.

Those in hiding can prepare to defend themselves by strategically positioning themselves near entrances and arming themselves with ad hoc weapons, such as the metal regulator on an oxygen supply tank, a fire extinguisher, or even a hard plastic telephone handset.

According to the US Federal Bureau of Investigation, 13% of active shooting incidents that occurred from 2000 to 2013 ended with unarmed civilians subduing the shooter.

Treating Victims

Dr Callaway cited a 2011 report that states that it takes police an average of 60 to 90 minutes to determine whether a shooting scene is secure from any obvious perpetrator threat (EMS World. 2011;40:42-48).

"Are we really going to wait for the scene to be secure before we start treating?" he asked.

Waiting is usually not an option, especially when there are critically injured victims. For this reason, hospitals and other healthcare facilities need to have in place careful, detailed, site-specific plans for what to do. The plan should include steps aimed at balancing the need to immediately treat victims and other patients in urgent need with operational concerns related to timing, staffing, restricted access, and crime scene investigations.

The facility plan should also include steps for integrating first-care providers, such as bystanders, families, and other patients; nonmedical first responders, such as hospital support staff and administrators; and medical first responders, such as emergency medicine providers, trauma surgeons, and critical care unit staff.

Although there is no single right answer, emergency plans should focus on maximizing the protection of lives, Dr Callaway said.

Bryan Wexler, MD, director of the division of disaster medicine and emergency management at WellSpan York Hospital in Pennsylvania, said that his institution, like many others, is working to develop a comprehensive active-shooter response plan that incorporates the main hospital and the various affiliated offices and services.

"We have a trauma facility that has a lot of capability, but we are also responsible for and have obligations toward our smaller community hospitals, which have variable levels of responsibility for the community and variable levels of capability," he told Medscape Medical News.

"The other issue we are facing is making sure that our licensed sites — outpatient family practice units and specialty services that have multiple groups under one umbrella — also have a plan in place," he added.

Dr Wexler reported that his institution, like many others, has received bomb threats and encountered armed assailants and threats of violence, but has not yet had a shooting incident.

Dr Callaway and Dr Wexler have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2015 Scientific Assembly. Presented October 26, 2015.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.