Active Shooter

Active Shooter
1. Perpetrator picks a highly concentrated group of unprotected people in a confined space (target-rich, threat poor)
2. Shooter attempts to kill or injure as many people as possible
3. Shooter is typically mentally ill with a carefully pre-planned strategy for inflicting harm on others
Hospital as a target (especially emergency departments)
1. Emergency departments frequently harbor the mentally ill for long periods while arranging disposition
2. Prisoners are often cared for in emergency departments (escape attempts are common)
3. Family members of patients with medical adverse events may target health workers as revenge

Maintain constant awareness of surroundings and disruptions
Plan for violent events in the hospital
1. Pre-planned strategy offers best chance of survival
2. Active Shooter situations are a rapidly developing "fight for your life"
3. Survival relies on individual decisions made in seconds (while police are at least minutes away)
Perpetrators with knives
1. Potentially more dangerous than with guns (especially within 25 feet of perpetrator)
2. Knives are more likely to strike their target
3. Learning to disarm a perpetrator with a knife requires significant training

Run First
1. Escape the situation if possible
2. Run as fast and as far as possible from the shooter
3. Evacuate mobile patients and staff immediately to safety if possible
4. Do not stay with patients who are not quickly evacuated
Hide Next (if unable to exit)
1. Find a safe place to hide
2. Close and lock door
3. Turn off lights
4. Silence phones, pagers, voceras, two way radios
Fight Last (if unable to run or hide)
1. Decide immediately whether fighting is only option
  1. Face time with perpetrators are less than 25 seconds
  2. If deciding to stay and fight, do so decisively and with all possible force
  3. All who decide to fight should attack the perpetrator in concerted effort
2. Fight if taken hostage
  1. Perpetrators kill 70% of hostages
  2. Do not die quietly, defend yourself

Run-Hide-Fight Approach may not be effective for hospital or healthcare setting
1. Vulnerable patients (sedated, incapacitated, intubated) and may be unethical to leave patients unprotected
2. Hospitals have maximal visibility, limited hiding places, limited stairway access
Overhead notification (e.g. Code Silver)
1. Established overhead notification of Active Shooter event (as well as an all-clear signal)
2. Operators should be trained to contact 911 and overhead announce in cases of Active Shooter
Prepare for Active Shooter events in hospital
1. Practice drills are important
Secure areas may be a better approach for hospitals
1. Apply mountable safety locks to fire doors to prevent Active Shooter entry
2. Further protect those in secured areas
  1. Dim lights
  2. Silence pagers, cell phones and monitors
  3. Temporize surgeries to allow for early completion
  4. Turn off non-essential equipment
3. All units should have emergency stabilization equipment to control bleeding
  1. Gauze and Tourniquets
  2. Medical providers and nurses should have training in stabilization
References
1. Swadron and Inaba in Herbert (2019) EM:Rap 19(5): 5-6
2. Kelen (2012) Ann Emerg Med 60(6): 790-8 +PMID:22998757 [PubMed]
3. Inaba (2018) N Engl J Med 379(6):583-6 +PMID:30089071 [PubMed]