Active Shooter Response

Function

Different Types of Active Shooter Incidents 

While some active shooter incidents are spontaneous and driven by emotions, most are preplanned, where the active shooter may have had a grudge or previous ties and have plans for revenge. When a shooting incident occurs in a healthcare facility, the root cause is difficult to identify, but current evidence-based data defines the broad categories to identify the type of violence. Concerning the analysis of the shooter, this is beyond the scope of healthcare professionals and better profiled by law enforcement or investigative teams. The intersection of these services may occur if healthcare professionals on the scene have to describe their interactions with the shooter, if any patients were involved, or the mechanism of any gunshot injuries that determine the nature of the violence.[11][12][13][14][15]

Understanding the Problem

When an active shooter incident occurs in a healthcare facility, the healthcare professional on the scene should be able to identify the type of violence and who was involved. If a clinician’s patients were involved, then they may advise if the violence was personal, professional, or possibly pre-meditated. Today, law enforcement has classified active shooting incidents into 5 categories:

Type 1 - Criminal Intent

The shooter had no formal or legitimate connection with the workplace. The chief motive is theft. In most type 1 cases, a deadly weapon is used, and a high risk of fatal injuries is apparent to the worker. A typical type-1 scenario includes banks and retail businesses, such as gold and jewelry shops. Individuals who work alone or work in the late evenings are at high risk for harm in type-1 violence. In the US, the majority of workplace homicides are type-1. In many cases, a simple robbery or shoplifting incident becomes violent, resulting in death. Type-1 shootings are less frequent in hospital care settings, but some reported events of prescription drug robberies occur in hospitals and pharmacies.

Type 2 - Customer-to-Patient

In this scenario, the shooter may be a patient, employee, or customer. The argument may have started some time ago, and the violence usually occurs during working hours. Some jobs have a high risk for type-2. For example, some healthcare professionals like psychiatrists, social workers, and first responders are at higher risk of involvement than other hospital employees. A social worker may be required to tell a family that their children are being taken away, and the father or mother may resort to violence. Alternatively, a patient being treated by a psychiatrist may feel that the doctor is the one creating hallucinations and delusions and, in turn, harms them. Or an emergency clinician treats a gunshot incident, and the patient’s assailants arrive at the emergency room in anger or retaliation.

In 1991, Richard Worthington entered Alta View Hospital armed with a handgun, shotgun, and dynamite. His target was Dr. Glade Curtis. Richard entered the Women’s Center and took several hostages, including patients and nurses. In 2022, his son Alma Worthington was involved in a similar hostage incident in Utah.

Type 3 - Worker-to-Worker

In this scenario, the assailant is a former employee or current employee. The violence is often a result of workplace conflicts or interpersonal differences. The employee may have felt that they have been treated unjustly or unfairly. This type of violence accounts for about 7% of all workplace homicides. In such scenarios, the victims are usually managers or supervisors. These types of shooting incidents have been gradually increasing at the post office, where some workers have felt that they have been verbally and physically abused. In June 2017, Dr. Henry Bellow, a 45-year-old Nigerian family physician, had recently been terminated from his workplace and, armed with a gun, opened fire at the Bronx Lebanon Hospital in New York, killing a doctor and wounding 6 others.

Type 4 - Intimate Partner Violence or Domestic Violence

In most cases, the assailant is not an employee, but the partner is. The target is the female partner, and the perpetrator is usually a male acquaintance or spouse. Intimate partner violence in the workplace tends to occur when 1 partner has filed a restraining order or is in the process of separating. This type of violence is often lethal if occurring in the parking lot or areas adjacent to the facility. Typically, this type of assailant may arrive at the front desk or triage area asking for their person of interest in the request for information, such as where the person is, how long they have been at the facility, and why they are being treated. According to health privacy laws, responding healthcare professionals must maintain the privacy of their patients.

Type 5 - Ideological Violence

The assailant may have developed extreme ideologies and want to direct violence at masses of people, property, or an organization for their political beliefs. In most cases, the violence is perpetrated by religious zealots, environmental animal rights activists, or others who believe that the government is causing them harm. One or more assailants are involved; the victims are usually innocent. 

For example, in Colorado Springs, a shooting incident occurred at a Planned Parenthood facility. The standoff lasted more than 5 hours, and the police had to ram the front entrance with armored vehicles to capture the suspect.

Hybrid-Targeted Violence

Hybrid-targeted violence (HTV) is defined as the use of violence that targets a specific population or a group of individuals using a variety of unconventional and conventional weapons combined with tactics to ensure large kills. Individuals involved in HTV often target several locations at the same time. Some examples of HTV over the recent years include incidences at the following places:

• Gunmen attacked Westgate Mall in Nairobi in September 2013. The gunmen arrived during mid-afternoon from store to store in this upscale mall, killing at least 67 people and causing more than 200 injuries.
• The Beslan School siege massacre in 2004 lasted 3 days and resulted in at least 334 deaths and hundreds more injured. The perpetrators were heavily armed Islamic militants who took over the school, demanding the withdrawal of Russian troops from Chechnya. On the third day, the Russian forces stormed the Beslan School with tanks, rockets, and machine guns, killing most of the terrorists. Sadly, 186 children also died.
• The Mumbai siege took place in November 2008 when members of an Islamic terrorist group carried out coordinated attacks over 4 days in Mumbai. The terrorists killed 164 people, and hundreds were injured.
• In April 2013, 2 homemade bombs were denoted at the finish of the Boston Marathon, killing 3 people and injuring hundreds, some of whom lost their limbs. The perpetrators were 2 Kyrgyz American brothers, Dzhokhar and Tamerlan Tsarnaev. Over 3 days, they killed a policeman and then had a shootout with police. The older brother was killed, and the younger brother was captured.
• In 2015, 14 people were killed and 22 others injured in a terrorist attack in San Bernardino. The perpetrators were an Islamic couple, Tashfeen Malik and Syed Farook. The married couple targeted the San Bernardino Department of Public Health, where Farook was an employee. After the shooting, the couple left in a vehicle and were involved in a shootout with police; both were killed.
• In March 2017, gunmen dressed in hospital robes entered the military hospital in Kabul, killed 49 people, and injured dozens more. The gunmen had placed themselves strategically at the entrance of the hospital and went from floor to floor, killing everyone they saw.

HTV incidents are not novel, and not only in the US but in many parts of the world. In the majority of HTV events, the individuals are part of a terrorist group or those with fanatical ideologies. Tragically, over the past 2 decades, many international terrorist groups have tried to conduct HTV attacks in the US because of US foreign policy.

Characteristics of HTV

Unlike the active shooter incidents usually conducted by 1 or 2 individuals, in an HTV attack, many individuals are well trained, know how to operate a variety of weapons, and are willing to die. Most HTV attacks may involve small groups of attackers in different locations. Furthermore, these individuals also manage to communicate with others in the group. The key feature of an HTV attack is that attracting the first responders is involved so that more damage is inflicted. For example, in the Middle East, both Israelis and Palestinians have been known to engage in open-air violence in areas where they live together. Similarly, violence can be seen in parts of the Bronx in New York City or Compton in Los Angeles, as well as in other parts of the US.

In some cases in Iraq and Afghanistan, the attackers have complicated the incident by inducing fires, causing more harm. The big worry is that, eventually, an HTV attack may involve the use of chemical, biological, radiological, and nuclear agents (CBRN) agents. In Syria and Afghanistan, HTV attackers have been known to possess high-grade exposure, high-powered military weapons, and suicide bomb vests.

Differentiating Terrorist Attacks From Gun Violence

Over the past few decades, at least 10 dozen terrorist attacks were conducted on healthcare facilities in 43 countries. These attacks have resulted in 1217 injuries and 775 deaths. Terrorists now identify hospitals as viable targets. They are fully aware that by disrupting care, the terrorists can cause significant deaths. In addition, by attacking a healthcare facility, the terrorist can distract law enforcement and emergency medical services from going to the primary target area. Thus, individuals wounded at the primary site cannot be helped.[16] Whereas, in incidents of gun violence, the possession of arms does not typically belong to an organized group, in terrorist attacks, the organized group is recognized or has given themselves a name that shapes identity.

Issues of Concern

Shooting Incidents in Hospitals in the United States

Since 2000, 154 hospital-related shooting incidents involving 148 hospitals have been documented. The events resulted in 235 injuries, some of which included deaths. In the last decade, the incidence of hospital-related shootings appears to be increasing annually. Hospital shootings are known to occur in hospitals of all sizes. Over the past 2 decades, at least 51% of shootings have occurred in hospitals with less than 40 beds. However, as the number of hospital beds in a hospital increases, the number of shootings drops, perhaps indicating that small hospitals are easier to maneuver and have less stringent security.[17][18]

About 60% of shootings have occurred inside the hospital and 40% outside the hospital. The most common locations for the shootings include the following:

• Emergency department (highest)
• Outpatient clinic (second highest)
• Parking lot
• Patient rooms
• Intensive care unit (ICU)

Who is the shooter?

In more than 90% of cases, the shooter is a male. While many shooters have been young males, in some cases, shooters have been older adults. A majority of assailants in 115 shootings from 1982-2019 have underlying, undiagnosed, or misdiagnosed psychiatric diseases, though the correlation to hospital shootings specifically is unknown.[6]

What is the motive for the shooting?

• Grudge
• Treated poorly
• Revenge
• Ending the life of an ill relative with terminal cancer or severe dementia
• Ideology
• Political beliefs
• Suicide
• Prisoner escape
• Mentally unstable patient with false beliefs such as paranoia and delusions
• Complications from a medical procedure or surgery

Who are the victims?

In most hospital incidents, 1 active shooter and 1 victim are present. Only about 10% of incidents have more than 3 victims documented. Tragically, when multiple victims are involved, at least 60% to 80% have been innocent bystanders. The rest include physicians (3%), patients (13%), and nursing staff (5%). After the shooting, nearly 50% of the shooters committed suicide. Less than 10% of the time is the active shooter captured alive.

Relationship Between the Shooter and Victims

In many incidents, the shooter already knows the target or has some relationship with the target. Over the years, the following relationships have been identified between the shooter and the victims:

• Active personal relationship (32%)
• Estranged relationship (25%)
• Current or former patient
• Current or former employee
• No obvious relationship

Unlike non-hospital shooting events where close to 25% of victims have no prior relationship with the shooter, in hospital settings, more than 50% of the time, the shooter and the victim have known each other. Hospital shootings are not random and are often personal and targeted.

What are the behavioral indicators of potential shooters?

• Individuals with a personal grievance
• Individuals who have a fascination with weapons and have a large collection of weapons
• Individuals who have recently enrolled in weapons training and visited gun ranges for target practice
• Fascination with explosives and constantly talking or watching related videos
• Individuals who are angry, volatile, and find fault in everything
• Individuals with rigid beliefs that someone is out to get them

What weapons are used by the active shooter?

In most cases, the active shooter will use a firearm. In rare cases, the active shooter may use other weapons or improved explosive devices that cause more injuries and act as an impediment to law enforcement and emergency responders. Some of these improvised explosive devices may detonate immediately or may have delayed fuses. Thus, no attempt should be made to go near or handle these devices.

The Hospital Environment and the Shooting Incident

Most healthcare facilities have a large number of visitors, patients, and important medical staff, and thus, any shooting incident can result in mass casualties. Thus, hospitals are soft targets for someone determined to cause mayhem and chaos. For example, a shooting in the emergency room can paralyze the hospital since this is the core area where patients are resuscitated. Injured individuals may have nowhere else to go without a viable emergency room. Challenges such as these are discussed within the team that creates the abovementioned contingency plans. The following points may be identified in several thought exercises, drills, or simulations.

Challenges in Hospitals With an Active Shooter

The presence of an active shooter in a hospital can be challenging in many ways, including the following:

• The hospital is often a large complex with many sections. One may have difficulty knowing where the incident is occurring. How is the message communicated, and to whom?
• Should clinicians leave their patients when an active shooting is occurring?
  • What happens if the clinician is in the middle of a procedure or surgery?
• How can visitors be informed of an active shooter, and what safe places are available?
• How can patients who are bedridden, old, or incapacitated be evacuated?
• What if the shooting is in a mental health ward that usually has locked doors?
• Most high-security wards require a password to exit or enter, which allows staff to leave. How would the patients evacuate?
• If many patients are injured, which patient should healthcare workers save first or evacuate? 

Areas of High-Risk

Many critical places are considered when an active shooter is present in the hospital.

• The emergency department usually has many patients waiting to be seen or admitted. Emergency medical services personnel have effectively managed the triage process.
• Intensive care units: Evacuating patients in the ICU is difficult as many are critically ill, and some may be hooked to machines and ventilators. Specialized protocols have to be designed.
• Other areas of concern include the laboratories where chemical spills and exposure to a microorganism may occur.
• Magnetic resonance imaging, MRI, suite: This imaging suite has a machine with high-powered magnets that can create a missile effect. Any iron-containing item can be quickly drawn into the MRI with a sudden force that makes it airborne. This effect has resulted in many accidents and can readily jeopardize the safety of staff, patients, and MRI equipment. As previously reported, a delivery person walked into an active MRI with an oxygen tank. The magnet created a missile in the oxygen tank, resulting in the rupture of the canister and the death of the individual. Several reports exist where guns have been pulled out from the hands and holsters of law enforcement officers, hitting MRI machines and, in some cases, resulting in an accidental discharge.[19][20] 

Clinical Significance

Workplace Evaluation

Evaluating the workplace is important before any preventive measure. Each hospital area must undergo assessment, planning, and exercise to ensure the healthcare facility is adequately prepared. After the initial assessment, the process is continuously refined and tested depending on the facility’s risks. The risks of an urgent clinic in a high-income location near a large body of water are not similar to those of a community hospital bordering 2 states near a desert. Accordingly, the first facility may not undergo continuous quality improvement like the second one. The preparedness of the staff is assessed if emergency management is anticipating incidents or has experienced several incidents recently.

Exercises in the emergency room must always consider the number of patients and visitors present. In contrast, in the mental health unit, one assailant is likely responsible, and the intended victim may be a staff member. Furthermore, one must consider many exits and entrances in the emergency room, whereas, in a place like the ICU, one entrance and exit are usually present.[21] Utilizing principles of triage has promising results when multiple people are involved, with many emergency department patients expecting clinicians to take an active role.[19][22][23]

Active Shooter Response Options

Different active shooter response options have been developed over the years, with the predominant response types coalescing into several simple principles: Run, Hide, Fight. The ALICE (alert, lockdown, inform, counter, evacuate) Training Institute, US Department of Homeland Security, Ready.gov, and the Federal Emergency Management Agency (FEMA) are several entities that have created active shooter response training. The key principles are highlighted below in order of emergency response: 

1. Figure out: If gunshot noises or overhead announcements are heard, determine if evacuating or hiding is possible. If part of the staff, follow the identified channels of communication or designated team leaders.
2. RUN: Follow the identified escape route, moving quickly and encouraging others to follow. Trained personnel should be able to help. If no personnel are nearby, follow fight-or-flight instincts. Employees or former active shooters are fully aware of exits and entrances in their healthcare facility. The following is recommended:
   • Avoid all known or obvious escape routes, as they may be booby-trapped.
   • If possible, exit the area immediately and in groups on a single line.
   • Do not use elevators as they may be disabled.
3. Call out: Use the facility’s emergency lines, and the team leaders should activate a code to lock down the area or the whole facility. The team leaders are typically physicians, advanced/senior practitioners, law enforcement, and additional emergency personnel such as soldiers, security guards, or paramedics. Below are the necessary details if none of the above leaders are available:
   • Name of the shooter (if known)
   • Location of shooter
   • Number of shooters
   • Physical description of shooters
   • Number and types of weapons
   • Number of potential victims
   • Follow the dispatcher’s or police’s instructions
4. HIDE: Hiding places include a room that can be locked with objects to hide behind. Avoid places that could trap or restrict movement. Areas are sometimes designated with signs. Cover the windows and doors and obstruct the exits or entrances if violence escalates. Keep noise levels low and remain close to the ground. The team leaders managing the incident should provide the same instructions.
5. FIGHT: This is the last resort tactic if all other options fail. The goal is to act aggressively, defend oneself and others, yell, scream, and try to survive. 
   • Try to interrupt the focus of the shooter.
   • Try to interrupt the rhythm and momentum of the shooter.
   • Try to interrupt the shooter from accessing any weapons in the vicinity.
   • If a face-to-face encounter occurs, the individual should be taught to push the gunman’s weapon down, not sideways or up.

When law enforcement officers arrive, do exactly as they instruct since they have no idea who the shooter is.

Planning

Planning to counter an active shooter involves an interprofessional team with a multidimensional approach. No one approach always works, and the threat is continually assessed.

• Establish a framework for how to deal with an active shooter in the facility.
• Notify everyone in the facility, but identify leaders in each department. If everyone is involved, no one may take charge.
• Utilizing emergency management guidelines, teams should ideate through multiple scenarios.
• Invite law enforcement to help develop a robust program and understand the risks.
• Develop a culture of reporting without reprisals.
• Use simulation-based training modeled on current research.[24][25]

Facility initiatives

• Develop a method of recognizing the problem and have a reporting system that involves leaders from every department, from the chief attendings to the students.
• All security measures should be activated, including the following:
  • Employees must wear a name badge and photo identification.
  • Employees should be able to report suspicious activity or an individual without fear of reprisal.
  • All badge or card access readers must have the ability to be reprogrammed to block a former employee from entering the hospital.
• Establish staff reporting stations.
• During an active shooting event, all doors are closed and locked.
• Have an effective means of communication for all workers in the hospital.
• Develop a protocol for evacuation.
• Workers must be aware of emergency escape routes.
• Ensure safe locations if an escape route is blocked.
• Employees should be educated on self-defense and harm reduction.

Use of Bystander Intervention

One way to stop an active shooter is with assistance from bystanders. In almost every case of an active shooter, law enforcement takes a few minutes to arrive at the scene. Most experts in law enforcement indicate that using bystanders to counter the active shooter is not recommended and is usually the last choice. However, if the bystander has a weapon, they may confront the shooter. 

Instead of fighting the active shooter, experts say that bystanders should try and help any injured victims. Some have suggested that bystanders try to stop any source of bleeding. Most clinicians not trained in emergency medicine or surgery would have no idea how to stop bleeding. One also needs the right equipment, lighting, and assistance to stop hemorrhage. Unless a surgeon or emergency room clinician is present, no attempt is necessary to stop internal bleeding. Instead of focusing on bleeding, one should ensure that the injured victim has a patent airway. Since most shooting incidents occur in a matter of minutes, the next step is to call 911 or the operator to get medical help.

Special Considerations

Some patients cannot move, and a designated healthcare professional should remain if the patient is on the ventilator or acutely ill. Patients in the neonatal intensive care unit, ICU, dialysis unit, or the surgery recovery room usually cannot be moved, and moral dilemmas may occur as to whom to take and whom to leave behind. For example, one cannot leave an infant on a ventilator and escape. The hospital should have a policy because litigation is always threatened.

Medical Considerations

First aid

During an active shooter incident, some individuals may be killed instantly, while others may sustain injuries from the shooter or when attempting to escape. Some may jump from a building, others may break down windows to escape, or others may crawl through hazardous terrain. First aid kits must be available to provide oxygen, stop bleeding, and provide relief in extreme environmental conditions such as hyperthermia, hypothermia, or in situations of traumatic limb injuries. These first aid kits are placed in all departments and identified in the contingency plan. Further, these kits are periodically rechecked to ensure the supplies are current.

Communications

When an active shooting incident occurs, time is of the essence. In many cases, valuable time is lost because of panic and confusion. Thus, all communications regarding an active shooter should be clear, concise, and actionable to prevent the situation from escalating. The best way to foil an active shooter is by protecting the targets; this also applies to medical care.

Lucid language messaging 

Law enforcement suggests that communication with the masses about an active shooter is relayed in simple language. Code words should not be used for patients but rather between staff or intradepartmentally. Similarly, alerting all patients in a department should not occur when communicating among clinicians simultaneously. The alert time is delayed to not alarm a large group of people. The communication should provide accurate information about the shooter and location and clearly instruct where and how to proceed. 

Immediate support

Immediate medical care depends on the number of victims, the proximity to nearby facilities, and the protocols for sending staff. Emergency cases are prioritized, and less acute patients are treated accordingly. If victims of an incident are sent for treatment, the psychological impact is both short- and long-term. Experts in mental health suggest that one should address the immediate psychological trauma. 

Psychological first aid should be offered immediately, and the responders should try to limit the negative or distressing news that can instill more fear and panic. Psychological first aid is ideal for any individual experiencing an overwhelming emotional response to a violent event. The individual may or may not have a prior mental health condition. The aim is not to cure any emotional disorder but to limit the panic so that evacuation can proceed safely.[26]

Long-term support

Loss to follow-up is as high as 69% in gun violence survivors. Outpatient follow-up in survivors of gun violence has been studied in a unique model called the Trauma Quality of Life clinic, with an improved rate of compliance in addressing the needs of this population.[27] Survivors have a higher risk of reinjury, differentiated by race disproportionately. Current results of studies indicate that the population is also at risk for substance use disorders. Hospital-based interventions could be aimed at underlying risk factors.[28][29] The role of primary care clinicians is also being studied, including training at the resident physician level, which increases preparedness.[30]

Other Issues

The key points are the following:

• Hospitals are not immune to violence and shooting events.
• Hospitals are complex structures with many departments with special patient populations, and each department has different responsibilities in patient care.
• Hospitals must develop preventive measures against all possible scenarios to counter the threat of an active shooter. This prevention is termed a contingency plan that can be tailored to a specific area of improvement.
• Regularly conduct drills to understand what is working and what needs improvement.
• Provide precise training to keep personnel and create a task force to counter active shooter violence.
• Know the principles of first aid during an active shooter incident.
• Make sure that critical supplies have been repositioned in high-risk areas.
• Develop a method of communication to alert everyone when an active shooter incident occurs.
• Continue to audit the system with facility leadership.

Enhancing Healthcare Team Outcomes

Responsibilities of Employers

In the past, most workplaces in the US had no plans to deal with active shooter incidents. However, the number of shooting incidents has caused most healthcare facilities to initiate measures to prevent or decrease the risk of active shooter incidents. OSHA has also made recommendations for employers in all government and healthcare facilities.[31][32][33][34] Some of the OSHA recommendations include the following:

• The workplace must offer employees a safe and free place from physical hazards.
• The workplace should employ best practices and industry standards to ensure worker safety.
• The workplace must follow all state and federal guidelines regarding safety.
• Educate and create awareness among healthcare professionals about the possibility of an active shooter.
• Incorporate preventive measures from past shooting events

Healthcare facilities that are not compliant with OSHA recommendations are liable for any injuries or deaths that occur during an active shooter incident. Several lawsuits have been filed against facilities with inadequate security or negligence.[18][35][36][37]