What should you do when someone begins shooting up the emergency department? Don’t grab a phone to call 911 or help your patients. Flee instead: Run outside or to the protection of the radiation room. And maybe grab a fire extinguisher – yes, really — and get ready to fight for your life.
The best strategy of all is preparation via a frank, assumption-busting threat assessment at your ED, an emergency physician who’s investigated three major mass shootings told colleagues at the virtual American College of Emergency Physicians annual meeting.
Hospitals will find, for example, that rivals of injured gang members typically pose less of a threat than intimate partners of abused patients, said Howie Mell, MD, MPH, who currently works at a hospital in suburban St. Louis and who consulted on investigations of the Columbine, Aurora, and Virginia Tech mass shootings.
Mell was a firefighter and paramedic in the Chicago area for 8 years prior to his medical training.
When a shooting happens, he said, it’s crucial to escape the scene, not only for your personal safety but to be able to call for help and describe the threat to law enforcement. “If you believe there is gunfire, you should be moving towards an exit. I’ve seen a couple of hospital disaster plans that say, ‘Call 911 and then run and hide.’ That doesn’t work so good. Leave first, then dial.”
Some ED professionals tell Mell that they couldn’t abandon their patients in this scenario. He thinks differently. “It’s unfortunate, but I don’t honestly believe that we can protect our patients by our presence. I have very little problem with leaving, assuming that this doesn’t all go down while I’m in the middle of a life-saving procedure. [In that case,] I’m going to continue that procedure and then skedaddle. But otherwise, no.”
What if you can’t escape the ED and need to hide? Mell recommends running to the radiation rooms. These can allow “cover” – something that protects you physically from a shooter – as compared to less-effective “concealment” like a curtain or sheetrock wall that won’t stop bullets. Strong, lead-lined walls provide extra physical protection in radiation rooms, he said, along with their booths and a typical lack of external glass windows.
When it comes to hiding, he said, “this isn’t a kids’ game of hide and seek” where the goal is not to be found. Instead, focus on putting up barricades between yourself and the shooter. “This is a game of making that person work to come and get you,” he said.
If confronted by a shooter, he said, fight for your life.
“I happen to like fire extinguishers when it comes down to fights because you can spray a fire extinguisher into the person’s face, and then you’ve got a big heavy piece of metal that you can hit them with,” he said. “It’s disorienting to get hit full in the face with a chemical fire extinguisher. We’re not used to thinking that way as healthcare providers, but it may be the only thing you can do.”
Mell urged colleagues to launch intensive threat assessments in conjunction with local law enforcement. “Take a good look at what your lockdown policies are, where your risks are, where your vulnerabilities are,” he said. “Talk with your institution about putting in metal detectors, about having zero tolerance policies for hospital violence and truly enforcing them. We cannot tolerate violence in our emergency departments anymore. We have to start it with: ‘You can’t cuss at me, you can’t scream at me. You can’t physically intimidate me, you can’t bully me, you certainly cannot make contact or assault me in any way.'”
In a follow-up interview with MedPage Today, Mell recommended taking a look at policies on sedating aggressive patients: “Some places say we can’t sedate any patients until they’ve been evaluated by a psychiatric team.”
Hospital threat assessments should also analyze how violence occurs at the facility. “When it happens, who is it? Don’t build protocols to protect against the fictional possibility of gang violence spilling over into the emergency department and completely ignore intimate partner violence.” According to Mell, gang violence is rare at hospitals because that element knows law enforcement is there. Patients in police custody and intimate partners are more likely sources of violence.
Remember, too, that armed guards might seem like a good idea, but weapons in the ED can contribute to more violence, he said – and patients may get their hands on them.