An active shooter event in an ED is unbelievably rare. According to FBI statistics, 160 active shooter events occurred in the United States between 2000 and 2013. Of those, four occurred in health care facilities (three hospitals and one nursing home); only one took place in an ED.⁶

More common, although still rare, are other types of shootings. As discussed above, the most common is an officer-involved shooting.^{4, 5} Across two studies of gun discharges in the ED, more than three-quarters of the events involved one individual seeking a specific individual to harm (eg, mercy killings, murder-suicides, domestic disputes, and/or suicide). Only 5 percent of events involved an individual looking to do harm to the “system” and not another individual. There were also two “accidental discharges” out of 47 events in one study.

Many EDs have lockdown procedures.⁷ These are states of advanced readiness or awareness that are deployed when an increased risk for a shooting is perceived by the staff. Unfortunately, these are more often directed at society’s perception of risk (eg, gang shootings, intimidating physical features of the patient) than toward the demonstrated historical risks (ie, prisoners, domestic violence, and suicide).

Ideally, lockdown procedures should be constantly in place. If they are to be deployed intermittently in response to local conditions, the available data on historical events and risk factors should be used to determine when to deploy these resources.^{4, 5} Nurses, physicians, and ED staff should be trained to recognize situations with increased risk of gun violence, either by the patient or by those around them.

Facing an Active Shooter

The overwhelming majority of gunfire in the ED isn’t the result of an active shooter. Most are targeted at a specific goal (ie, escape or avoiding capture) or a specific person. However, should there be an active shooter in the ED, the three steps to take are simple; Run; if you can’t run, hide; and if you can’t hide, fight.

• RUN: Leaving patients in the ED to evacuate is an anathema to ED personnel, but that perception needs to be changed. An active shooter should be considered in the same way one would consider a fast leak of a deadly gas: The only realistic option is to leave, FAST! This will sound harsh, and it’s meant to be: You cannot save your patients. Don’t try. It’s simply too dangerous. Always know two directions to exit the ED that don’t require key access or door codes. These devices may slow you during an emergency evacuation.
• HIDE: If you can’t run (eg, the shooter is between you and the door), then hide. Ideally, hide someplace that’s difficult to enter, difficult to see into, and is out of the path of the shooter. In many EDs the medication rooms, dirty or clean utility rooms, and/or stockrooms make good hiding spots. Radiology departments, with their multiple treatment rooms and lead-lined walls, may prove a good location as well.
• FIGHT: If you can’t hide, fight—but if you fight, understand that you’re in a fight for your life. The shooter wants to kill you; you must do anything you can to stop them. Again, much like leaving a patient to evacuate the department, fighting with the intent of severely injuring or even killing the shooter is anathema to the EM mindset. However, in this situation it’s your only hope. If you have to fight, don’t fight fair. Rally as many people as you can to join the attack. Use whatever is on hand (eg, sedative medications, fire extinguishers, chairs, crutches, even Mayo stands) to strike at or disable the shooter. The more surprising and widespread the counterattack, the more likely it is to succeed.

A free episode of EM:Rap features a discussion with a SWAT team paramedic describing what to do in detail if you find yourself in this situation: http://freeemergencytalks.net/wp-content/uploads/2013/12/EMRAP-2013-12-Active-Shooter.mp3.