Once considered places of sanctuary from violence, hospitals are now becoming desecrated by the ravages of a society where polite discourse seems to be easily forsaken in favor of gunpowder and lead. Surveys show that emergency department personnel are assaulted on a far-too-frequent basis.¹ Data also demonstrate that patients and visitors are arriving armed to the teeth.^{2, 3} How can we prepare ourselves to survive when the mean streets spill into our corridors and bullets fly?

There are steps that can be taken to prevent gun violence in the ED. It’s well past time to examine the risks and learn how to react if you find yourself in the middle of the nightmarish scenario of an active shooter in your department.

Prevent the Problem

Data are remarkably clear on two points. First, our patients and their visitors are armed. They arrive carrying knives, Tasers, mace, brass knuckles, and guns.^{2, 3} Second, and not surprisingly, the amount of firearms brought to a facility drops after metal detectors are installed.³

Surprisingly, however, data demonstrate that more than one-quarter of all shootings on hospital grounds involved a law enforcement officer shooting at a perpetrator.⁴ The most common reason for police shootings in hospitals and EDs was that a perpetrator disarmed a law enforcement officer and a second officer engaged with deadly force.⁴ The number of law enforcement-involved shootings is even higher in the ED—as many as one half of all ED shootings occurred in this manner.⁵

Given the effectiveness of metal detectors in reducing the number of guns brought to the ED, they should be standard equipment in all EDs.³ Given the frequency of law enforcement officers being disarmed, leading to shootings, the presence of armed security officers in the ED should be thoughtfully discussed and examined.

Hospital security and ED staffs need to coordinate when prisoners, forensic, or mental health patients are brought into the facility. Scalpels, pocket knives, or other sharp instruments might be taken by prisoners or psychiatric patients as weapons to use in escape attempts, so you should remove these items from your person prior to examining these patients.

Understand the Risks

It’s important to understand the patterns and risks of shootings in EDs. The definition that the FBI uses for an “active shooter” (the type of shooting highlighted in the news, including events like the tragedies at Sandy Hook Elementary School; Aurora, Colorado; or Orlando, Florida) is: “An individual actively engaged in killing or attempting to kill people in a confined and populated area.” Implicit in the definition is the use of a firearm.

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.

Be safe, understand the risks of ED shootings, and take steps to prevent them. But if all else fails, RUN, HIDE, and FIGHT!

Dr. Mell is assistant professor of emergency medicine at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina and the EMS Medical Director for Iredell County EMS in North Carolina.

References

1. Gates DM, C.S. Ross CS, McQueen L. Violence against emergency department workers. J Emerg Med, 31(2006):331–37.
2. Ordog GJ, Wasserberger J, Ordog C, Ackroyd G, Atluri S. Weapon carriage among major trauma victims in the emergency department. Acad Emerg Med. 1995 Feb;2(2):109-13; discussion 114.
3. Malka ST, Chisholm R, Doehring M, Chisholm C. Weapons retrieved after the implementation of emergency department metal detection. J Emerg Med. 2015 Sep;49(3):355-8. doi: 10.1016/j.jemermed.2015.04.020. Epub 2015 Jul 4.
4. Harnum JJ. Hospital gun discharge events 2011-2013. J Healthc Prot Manage. 2014;30(2):36-46.
5. Kelen GD, Catlett CL, Kubit JG, Hsieh YH. Hospital-based shootings in the United States: 2000 to 2011. Ann Emerg Med. 2012 Dec;60(6):790-798.e1.
6. Blair JP, Schweit KW. (2014). A study of active shooter incidents, 2000 – 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. 2014. Available online at: https://www.fbi.gov/about-us/office-of-partner-engagement/active-shooter-incidents/a-study-of-active-shooter-incidents-in-the-u.s.-2000-2013. Accessed June 13, 2016.
7. ACEP “Hospital Lockdown Policy [PDF].” Available at: https://www.acep.org/workarea/downloadasset.aspx?id=45256. Accessed June 13, 2016.