Officers follow an ambulance as it arrives at the medical examiners office carrying the body of a police officer who was killed during a shooting at Mercy Hospital which left four people, including the gunman, dead Monday Nov. 19, 2018 in Chicago. (Armando L. Sanchez/Chicago Tribune/TNS via Getty Images)
Chicago Tribune—TNS via Getty Images
By Jamie Ducharme
November 28, 2018

A shooting at Chicago’s Mercy Hospital, quickly followed by a false alarm at Maryland’s Walter Reed National Military Medical Center, sent shockwaves through the medical community this month — and exposed the reality that hospitals, the institutions tasked with caring for the victims of violent incidents, are also at risk of enduring them.

The FBI defines an active shooter incident as “one or more individuals actively engaged in killing or attempting to kill people in a populated area.” Of the 50 such events that took place in 2016 and 2017, according to FBI data, only four occurred in healthcare settings, compared to 17 in “areas of commerce” and seven in schools. But the attack at Mercy Hospital, which left a doctor, a pharmacy resident, a police officer and the gunman dead, served as a stark reminder that medical centers must also prepare for the grim possibility of mass violence.

Hospital shootings, while still rare, have become more common over the last two decades, rising from just a handful in 2000 to more than 20 in 2015, according to research from Brown University; a 2012 Annals of Internal Medicine study identified 154 between 2000 and 2011. (Many hospitals shootings are the result of mental instability and suicides or escape attempts, according to the Brown data, which may not fit the FBI’s definition of an active shooter incident.)

To keep up, hospitals and researchers are intensifying their efforts to prepare for and prevent these tragedies, joining workplaces of all kinds in running active shooter trainings and partnering with organizations such as Stop the Bleeding Coalition, which promotes the use of tourniquets to staunch bleeding from a gunshot wound. But in this regard, hospitals face a unique responsibility as places where sick and injured people go to heal — thus making evacuation plans both more difficult, and more critical.

“Making sure that every hospital has a concrete plan in place to deal with these incidents, and that drills are carried out regularly for these incidents and that those drills are carried out with law enforcement and other community agencies, that would be the dream world,” says Jeff Solheim, president of the Emergency Nurses Association.

Brigham and Women’s Hospital (BWH) is one institution that has stepped up security. It publicly rolled out a new security campaign in 2017, two years after a man entered the Boston hospital and fatally shot a doctor who had treated his late mother. (Brown’s data shows that grudges of some kind motivated 79 of 241 hospital shootings recorded between 2000 and 2015.) The campaign focused on eliminating “piggybacking” and “tailgating” — non-authorized individuals slipping into secure areas by following staff members — and urged the hospital’s employees to either question suspicious individuals or report them to security.

Even hospitals that haven’t faced violence first-hand are taking action. “There’s no doubt there’s been an increased focus on it. It feels like there’s a lot more activity going on,” Solheim says, though he adds that some institutions could be more proactive. “[Hospitals are] adding active shooters into their disaster drills. Five or six years ago, we would never have thought about putting an active shooter in a disaster policy and procedure.”

Today, however, hospitals are doing just that. Children’s Health Children’s Medical Center Dallas, a pediatric hospital in Texas, began offering offering active shooter simulations for emergency department staff in 2016. Ninety-two percent of participants said they felt more prepared for such a situation, according to a paper published in the Journal of Emergency Nursing in August. The paper’s authors called ongoing active shooter classes a “definite recommendation” for both their hospital and others.

Even the scare at Walter Reed was triggered by this sort of preparation: The military hospital went into lockdown after its emergency alert system mistakenly sounded the alarm about an active shooter on campus. (Representatives from Walter Reed did not immediately provide further context.)

Mishaps aside, Paul Brennan, immediate past president of the International Association of EMS Chiefs, which is involved in drafting active shooter response guidelines for healthcare settings, says staff education and training, robust emergency alert systems and collaboration with local law enforcement and EMS are vital for hospitals trying to stay prepared. Many hospitals also have a workplace violence committee, he says, and many institutions are required to complete an annual “hazard vulnerability analysis.”

“Staff preparedness is key,” Brennan says. “If you’re not teaching and training your staff, and you’re not drilling, you’re not doing exercises, your staff is either going to forget, or they’re not going to be educated enough to respond well when something happens.”

No matter how well-trained, however, Brennan says hospitals face a unique set of challenges when it comes to active shooter scenarios. For one thing, they tend to be quite large, with fairly open campuses. “Very few hospitals have every single door locked, controlled, and someone there, with metal detectors,” Brennan says. “It’s really challenging to be 100% confident that you have everything covered.”

Perhaps more importantly, the thousands of people inside a hospital at any given time have vastly different levels of training, responsibility and mobility — making it difficult to apply standard advice to the medical environment, Brennan says.

Individuals facing an active shooting are typically advised to first try to run away from the gunman; hide if they cannot escape; and attempt to fight off the shooter only as a last resort. But in a hospital, patients may be either immobile or in the midst of treatment, leaving them unable to “run, hide, fight,” and raising ethical dilemmas for the doctors, nurses and other caretakers who may be forced to choose between assisting their patients and saving their own lives.

With these difficulties in mind, a paper published in the New England Journal of Medicine in August suggested an additional strategy for healthcare workers: “secure, preserve, fight.” In other words, hospital employees should first secure areas where life-saving patient care is in progress by electronically or mechanically barring entry to those zones; preserve patient lives by moving them to secure areas, even if that means ceasing non-critical care; and only fight off the gunman if absolutely necessary.

But Dr. Gabor Kelen, director of the emergency medicine department at Johns Hopkins University School of Medicine, says it’s not clear how well this strategy — or any — actually works. (Kelen co-authored the 2012 study on hospital shootings, two years after the son of a patient shot and injured a Johns Hopkins doctor before killing both himself and his mother.)

“There isn’t enough data and experience to know which of the strategies has the greatest yield, and which of these strategies fits to the psychological moment of even trained people,” Kelen says.

The dearth of data, Kelen says, emphasizes just how rare these incidents are. He stresses that the percentage of patients and healthcare workers who will find themselves in an active shooting situation is “infinitesimal,” and that most trainings are undertaken out of an abundance of caution.

“You make sure that hospitals are fire-proof and lightning-proof. I would put that in this category,” Kelen says. “I think the staff appreciates that there is some real attention to their wellness and the patients’ wellness. I do think that it remains important.”

Brennan agrees, emphasizing that most events hospitals train for will never come to pass — but it’s important to be prepared if they do.

“Hospitals traditionally are very, very safe, but it’s not a never event,” Brennan says. “Shootings are low frequency, but the results can be deadly.”

Write to Jamie Ducharme at jamie.ducharme@time.com.

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