II. Background
- Active Shooter
- Perpetrator picks a highly concentrated group of unprotected people in a confined space (target-rich, threat poor)
- Shooter attempts to kill or injure as many people as possible
- Shooter is typically mentally ill with a carefully pre-planned strategy for inflicting harm on others
- Hospital as a target (especially emergency departments)
- Emergency departments frequently harbor the mentally ill for long periods while arranging disposition
- Prisoners are often cared for in emergency departments (escape attempts are common)
- Family members of patients with medical adverse events may target health workers as revenge
III. Management: General
- Maintain constant awareness of surroundings and disruptions
- Plan for violent events in the hospital
- Pre-planned strategy offers best chance of survival
- Active Shooter situations are a rapidly developing "fight for your life"
- Survival relies on individual decisions made in seconds (while police are at least minutes away)
- Perpetrators with knives
- Potentially more dangerous than with guns (especially within 25 feet of perpetrator)
- Knives are more likely to strike their target
- Learning to disarm a perpetrator with a knife requires significant training
IV. Management: "Run. Hide. Fight."
- Run First
- Escape the situation if possible
- Run as fast and as far as possible from the shooter
- Evacuate mobile patients and staff immediately to safety if possible
- Do not stay with patients who are not quickly evacuated
- Hide Next (if unable to exit)
- Find a safe place to hide
- Close and lock door
- Turn off lights
- Silence phones, pagers, voceras, two way radios
- Fight Last (if unable to run or hide)
- Decide immediately whether fighting is only option
- Face time with perpetrators are less than 25 seconds
- If deciding to stay and fight, do so decisively and with all possible force
- All who decide to fight should attack the perpetrator in concerted effort
- Fight if taken hostage
- Perpetrators kill 70% of hostages
- Do not die quietly, defend yourself
- Decide immediately whether fighting is only option
V. Management: Hospital
- Run-Hide-Fight Approach may not be effective for hospital or healthcare setting
- Vulnerable patients (sedated, incapacitated, intubated) and may be unethical to leave patients unprotected
- Hospitals have maximal visibility, limited hiding places, limited stairway access
- Overhead notification (e.g. Code Silver)
- Established overhead notification of Active Shooter event (as well as an all-clear signal)
- Operators should be trained to contact 911 and overhead announce in cases of Active Shooter
- Prepare for Active Shooter events in hospital
- Practice drills are important
- Secure areas may be a better approach for hospitals
- Apply mountable safety locks to fire doors to prevent Active Shooter entry
- Further protect those in secured areas
- Dim lights
- Silence pagers, cell phones and monitors
- Temporize surgeries to allow for early completion
- Turn off non-essential equipment
- All units should have emergency stabilization equipment to control bleeding
- Gauze and Tourniquets
- Medical providers and nurses should have training in stabilization
- References
- Swadron and Inaba in Herbert (2019) EM:Rap 19(5): 5-6
- Kelen (2012) Ann Emerg Med 60(6): 790-8 +PMID:22998757 [PubMed]
- Inaba (2018) N Engl J Med 379(6):583-6 +PMID:30089071 [PubMed]
VI. References
- Clumpner and Claudius in Herbert (2013) EM:Rap 13(12):2-3