Responding to Active
Shooter Incidents:
In the community and in the
hospital
Christopher Lake, Ph.D.
Executive Director, Community Resilience
[email protected]
Active Shooter
Incidents
Come In Two
Flavors
 Hospitals must be prepared to be first-receivers
 Hospitals must be prepared to react to an
Active Shooter on Campus
Two Scenarios
From The Left
and Right
Coasts

Orlando Florida – Pulse Nightclub Shooting
 San Bernardino California – Inland Regional
Center
 ISIS sympathizer enters club and begins shooting indiscriminately
 Approximately 100 people shot; 41 DOAs at the scene
 44 People with serious injuries transported to single hospital
PULSE
NIGHTCLUB
 Patients arrive in 2 separate waves the majority received no EMS
treatments
 First wave, came within minutes of the shooting (self-evacuated and
transported via private auto to the closest hospital)
 Second wave, approximately 2 hours later (after gunman was killed)
 9 patients die in the Emergency Department
 74 surgeries took place in the first 72 hours
 307 units of blood utilized during the trauma resuscitation phase
 For the most part, “No Triage, No Triage Tags,
No Ambulance Transportation”
Triage and
Transport
 First aid comprised of direct pressure on open
wounds
 Transported mostly via pick-up trucks and
police cars
 Transport delayed because of possible bombs
at the site
 Close enough to hear the gunshots
 Creates confusion, people report that the shooting is at the hospital
(Code Silver)
 PD Dispatch alerts hospital to expect 50+ patients within 30
minutes
Orlando
Health
 Only 2 mins later the first patients arrive via private auto and
physically carried by others
 Everyone when triaged with START, is either RED or BLACK
 Everyone needs surgery and blood products
 Media begins to swarm at the hospital
 Family members and “significant others” of the victims flock to
the hospital
 All patients come to one facility
 3 building complex that houses public health programs and a
state-run facility for individuals with developmental disabilities
INLAND
REGIONAL
CENTER
 14 people killed and 22 others seriously wounded as ISIS
sympathizers begin shooting at a Christmas celebration
 Patients transported to 2 hospitals – 50 mins. after the shooting
occurred, by EMS/Paramedic
 2 Level One Trauma Centers within 15 miles of the shooting
 Injured police officers arrive several hours later
 As patients arrive at Loma Linda University Medical Center, the
hospital learns of a “credible” bomb threat
 Patients extracted by SWAT Medics and
brought to FD Triage area
Triage and
Transport
 Paramedic level care on scene
 Ambulance transport to LVL 1 Trauma centers
 Extraction of patients delayed by 30-50
minutes because of possible bombs at the site
 Receives 5 critical patients in the initial wave with 15-30 minute
notification
Loma Linda
University
Medical Center
 Activates Emergency Operations Plan which included: HICS, Lockdown and MCI Surge components
 Shot Officer arrives which added new elements of anxiousness
and stress
 45 minutes after the last patient arrives LLUMC learns of bomb
threat, via PD
 EOD units respond to the hospital and begin room by room search
 LLUMC now has to institute uniform command center, Bomb
Threat protocols and Joint Information Center with PD
 Prehospital care is often delayed by fear of secondary devices
 Patients experience hemorrhagic shock as they bleed for
significant time periods before first aid is rendered
 Limited information or no notice notification of the MCI event
Common
(Healthcare)
Factors
 Patient triage systems (START) proves inadequate as all patients
are either RED or BLACK with similar wounds and same
mechanism of injury
 Hospitals received threats of their own
 Media converge to the hospitals
 Family and loved ones gather at the hospitals
 Hospital staff (on and off duty) are starved for accurate
information
 Multiple parts of the hospital EOPs needed to be implemented
simultaneously
 It won’t happen here!
 All the patients will go to the trauma center
 We’ll have adequate warning
Common
Myths About
Mass Casualty
Incidents
 You can dictate the terms of the victims you receive
 “We will only take “greens” and a few “yellow””
 We won’t have additional complications during the crisis





Communications Failure
Electrical / Power Problems
Bomb Threats, Fire, Flood
Crowd Control Issues
Security Issues
 We have all the resources we will need
 We will transfer all the critical patients immediately
Mass
Shootings Can
Occur On Any
Given Day
(It’s not just Orlando, San Bernardino, Dallas – an
event with 4 or 5 critical patients will be a service
disruptor for any rural community)
Orlando shooting: 5 people dead after 'disgruntled'
ex-employee opens fire, police say
_________________________________________________________
OCSO FL News @OrangeCoSheriff
OCSO working shooting scene that has stabilized. Multiple fatalities. Situation contained.
Sheriff will brief as soon as info is accurate.
Yesterday…
June 5th, 2017
•RETWEETS837
•LIKES250
________________________________________________________________
Five people died after a "disgruntled" former employee opened fire inside a
business in Orlando Monday morning before turning the gun on himself,
police said.
Officers responded to a call about an "active shooter" at a business off
Forsyth Road in Orange County, near Full Sail University, about 8 a.m.,
Orange County Sheriff Jerry Demings said in a news conference.
Plan, Practice,
Drill
Learn from real-life events and incorporate the
lessons learned into your facilities plan.
PLAN
Example:
We know that a common factor is delayed prehospital care which results in increased cases of
hemorrhagic shock so…
Why don’t we teach “Stop the Bleed” to
everyone?
Practice all the time
Use minute drills, group discussions and table top exercises to refine
your facilities emergency operations plans (EOP). Practice doesn’t
need to be formal or large scale.
Always include multiple elements of your EOP in your practice
discussions and exercises
PRACTICE
Disasters don’t happen in a vacuum. You will need to activate
multiple parts of your EOP including:
 Incident Command
 Surge Plans
 Communication Plans
 Crowd Control
 Lock Down
Exercise and drill multifaceted events
Always have a triage component, using a majority of critical patients
 Who gets treated first?
 Who get transferred first?
 What level of patient care can we provide?
DRILL
Always have a communications component
 What information will you relay to staff in the hospital or off-duty?
 What will you tell the public?
 How? Social media, Press Releases, Press Conferences
Very few hospitals in America have a true mass casualty protocol; We
need to develop these comprehensive plans
 Life, Limbs and Eyesight – First Priority
Rural Critical
Access
Hospitals…
What to do?
What to do?
What to do?
 Step One is ALWAYS…
STOP THE BLEED
 Re-TRIAGE based on your hospitals capabilities
 Remember triage is an ongoing process of reassessment which may
change the patient’s category
 Treatment - appropriate based on the knowledge, skills, abilities
and resources your facility has immediately available
 CAB (Circulation, Airway, Breathing)
 Tourniquets
 Airway and Oxygenation
 Transfer Patients to Highest Available Level of Care
Adapted from US Army Combat Medic Advanced Skills
Training (CMAST)
Patient
Transfer
Priorities
 URGENT
 PRIORITY
 ROUTINE
 CONVENIENCE
Patient condition(s) that cannot be controlled at rural hospital
 Cardiorespiratory Distress, as a result of trauma
 Shock not responding to IV therapy
 Prolonged unconsciousness
URGENT
Evacuation Required ASAP
and no later than 2 hours to
save life, limb or eyesight.
 Head Injuries with signs of increasing ICP
 Burns covering 20% to 85% TBSA
 Decreased circulation in extremities
 Open chest and/or abdominal wounds with decreased BP
 Uncontrollable bleeding or open fractures with severe bleeding
 Severe facial injuries
 Burns on hands, feet, face, genitalia or perineum, even if less than
20%TBSA
 All Penetrating Wounds (if possible)
PRIORITY
 Closed-chest injuries
 Brief periods of unconsciousness
Evacuation Required within
4 hours or the patient’s
condition could deteriorate
and become an urgent or
urgent surgical case.
 Soft tissue injuries and open or closed fractures
 Abdominal injuries with no decreased BP
 Spinal injuries
ROUTINE
 Simple fractures
Evacuation maybe
considered prudent
based on CAH’s
resources within
24 hours; for patients
requiring additional
care.
 Open wounds including chest wounds without
respiratory distress
 Psychiatric cases
 Terminal cases
Convenience
Transport of the
patient is a matter of
convenience rather
than necessity.
 Insurance Concerns (out of network)
 Physician Concerns (My normal doctor is at XYZ
hospital)
 Family Concerns (My family all lives in ______)
 Transportation Concerns (I have no way to get home)
 Etc.
When an
Active Shooter
or Hostile
Event is
occurring in
the hospital
Motives
Other or Unknown
164 Hospital
Related
Shootings
Mentally Unstable Patient
Ambient Society Violence
Prisoner Escape
Euthanizing Sick Relative
(2000-2011)
Suicide
Grudge
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
NV Hospitals have experienced their share of hospital shootings.
North, South and Rural have all experienced shootings in the last
10 years.
Shooting
Motives in
NV Hospitals
The motives have found to be:
Ambient Society Violence (Gang Activity)
Prisoner Escape Attempt
Euthanizing Sick Relative
Suicide
Grudges
 Emergency Departments (29%)
Where do
most events
start?
 Parking Lots (23%)
 Patient Rooms (19%)
The overwhelming majority of shooters are male.
No Profile of
an Active
Shooter
Exist…
While there is no profile of a “typical” healthcare active shooter,
often times there are observed warning signs including:
 Pathway Behaviors – planning, preparations, etc.
 Fixation Behaviors – accompanied by social deterioration
 Identification Behavior – “pseudo-commando”
 Leakage Warning Behaviors – they tell someone else their plan
 Last Resort Behavior – The subject feels trapped and justified
 Directly Communicated Threats.
According to a study in the Annuals of Emergency Medicine, of
154 hospital-related shootings between 2000-2011…
In hospital
shootings,
who are the
victims?
 The most common victim was the perpetrator (45%)
 Hospital employees composed 20% of the victims but
 Physicians (3%) and nurses (5%) victims were relatively infrequent.
23% of Emergency Department shootings occurred when the
security officer’s gun was taken by the perpetrator.
As with all hazards identified in your hospital’s “Hazard Vulnerability
Analysis” (HVA) you must Plan, Practice and Drill to prepared for the
anticipated hazard.
Plan, Practice,
Drill
All plans shall be accompanied by a policy and procedure based on
new CMS Conditions of Participation.
Policy should provide the management / governance of what to do
and why. Procedures should explain when a policy is put into effect
and how to accomplish the require tasks.
All plans, policies and procedures should be updated every year and
after each real event or exercise.
Plans should include all of the following:
 Preferred method of reporting an active shooter or hostile event
 An evacuation plan
Plan
 Emphasize the “Run –Hide – Fight” methodology
 Emergency escape procedures and safe, lockable areas to hide
 Lockdown procedures for individual units and buildings
 Integration with the hospital’s Emergency Operations Plan
RUN –HIDE FIGHT
RUN
RUN
The best method to reduce injury and loss of life during an active
shooter or hostile event incident is for as many people as possible to
immediately evacuate, or be evacuated, from the area where the
event is located or where the suspect is attempting to enter.
If it is safe to do so, the first course of action for everyone is to
run.
HIDE
If running is not a safe option, staff should hide in a safe a place. The
safest places might be where the walls are thickest, the doors lock and
there are few windows. Additionally, if you cannot run or your patient
cannot run (i.e., mobility issues), barricading maybe the only option.
HIDE
One easy way to remember what to do in a panic situation is to memorize
this rhyme:
Lock the door,
turn out the lights.
Turn off your phone,
stay out of sight.
FIGHT
Confronting an active shooter or hostile person is not a job requirement of any
healthcare worker, but may be necessary in rare circumstances to save your life.
FIGHT
The decision to fight or not is a personal choice.
Approximately 1/3 of all active shooter incidents are disrupted and stopped by the
potential victims deciding to fight their attacker. If neither running nor hiding is a safe
option, as a last resort and when confronted by the attacker, adults in immediate
danger should consider trying to disrupt or incapacitate the shooter by using
aggressive force and improvised or ad-hoc weapons.
Your actions could save many lives.
Recently at a Las Vegas medical center:
“The best-laid
plans of mice
and men…”
A patient reports a suspicious person to a hospital employee (a valet
car parking attendant)
The attendant, walks inside and relays the concern to the first
employee seen with “house phone” access. This happens to be the
hospital’s information desk.
The information desk is staffed with volunteers…
Do all volunteers get training on all aspects of your Emergency
Operations Plan???
It Gets Better!!
The volunteer doesn’t know that they are to call security and advise
them of the concern, instead he pushes the “Panic Button” and
overhead pages “Code Silver” based on what they remember being
told to do.
Do you review your policies and provide refresher training to all
employees every-year?
Staff runs to the area identified, security comes and the suspicious
person is located, talked with and there is no problem or threat.
The hospital declares “Code Green” all clear and life should have
gone on, with all well in the world…
Remember the “Panic Button”?
While the hospital has declared the situation “all clear” nobody
realized the panic button was pressed and that law enforcement
was responding…
Murphey’s Law
To make matters more interesting, a physician was talking with his
sister when the “Code Silver” was paged. He jokingly tells his sister
that there’s probably an active shooter or something…
The sister calls 911 and things get interesting…
Here Comes S.W.A.T.
Law
Enforcement
The sister, told the 911 operator about her brother, the doctor, who
works at the hospital on the 4th floor and is hearing an “active
shooter”.
Remember, this is now a secondary report. First a “Panic
Button” and now a second-hand account of an “Active Shooter”
with a new, more specific location within the hospital.
Police and SWAT teams take over the hospital, restrict access and
begin a sweep of the fourth floor.
You don’t have a plan if your staff, volunteers and providers
aren’t trained.
The moral of
the story
All personnel must receive initial and annual refresher
training on all emergency plans, policies and
procedures.
(effective Nov. 15, 2017)
Table-top exercises and minute drills are excellent ways to
practice, get employee involvement and not be too disruptive to
the hospital’s daily operations.
Practice
SurvivorSkills should be discussed frequently at the unit or
department level. These peer-to-peer discussions do not need to be
formally planned, do not take much time to complete and could
make the difference in the outcome of an active shooter event
(either at work or if your employee is involved in a situation while
off-duty).
Hospitals should conduct drills and exercises that re-enforce the RunHide- Fight principles…often
These drills should also include elements of the plan that are required of everybody:
 How to report an event
 How and where to run
 How and where to hide
Drill
 When and why to fight
 How to lock-down units and floors
 What services stop until the “all clear” is given
 How to interact with law enforcement
 Where to meet / how to check-in
Mass shootings occur frequently in society.
A rural hospital may either be the first receiver of multiple critical
patients or the scene of the incident.
Hospitals must Plan, Practice and Drill for each scenario.
Everyone should know how to “Stop the Bleed”.
Conclusions
Everyone should know how to Run –Hide –Fight.
Initial training (and annually thereafter) must be given to all new
and existing employees and individuals providing services under
arrangement (i.e. physicians) and volunteers consistent with their
expected roles. 42 CFR 485.652(d).
Questions ???