Hospital Active Shooter Management

Dr.Zubrato · Dec 7, 2013

EMRAP is a great source of up to date information for Emergency Medicine physicians, residents, and interns.
This month's subscription deals with Active Shooter management in the hospital setting, and I think you'll find it quite interesting, I found it completely refreshing to see unbiased attitude towards a real solution a soft target like a hospital faces.
Sorry about the quality, I have a copy printed out, and I'm not sure they would be cool with me posting an expensive large monthly subscription for free, so I have posted a few pages (not to bore you, and to avoid problems)
They've been riding in my scrubs all day, so sorry bout quality. The only way I was able to upload pictures this big to THR was as separate PDF files, Enjoy

Well, I'm only able to upload ONE so far due to "missing security token".
grumble grumble. part 2 coming soon

Dr.Zubrato · Dec 7, 2013

Dear Admins, I sent an email describing the problem more or less. Plz let me know what I can do to post the second page

TRX · Dec 7, 2013

The first page seems realistic and reasonable.

jr_roosa · Dec 7, 2013

They have specifically asked that the audio component be widely distributed and seem to have waived copyright. It's a 30 minute segment.

https://d140vvwqovffrf.cloudfront.n.../21baf2d6ff09c53304d0baf9b25048484b11717c.mp3

The interview was between a pediatric ER doc and the tactical medic. Very dark, but great info.

-J.

Dr.Zubrato · Dec 7, 2013

I was able to add the second part as a JPG, enjoy!
I'm not sure where you could find the audio part, as the actual subscription service audio is different than the podcast supplement which is free.

jr_roosa · Dec 7, 2013

I'm not sure where you could find the audio part,

That link should let you download it.

-J.

Dr.Zubrato · Dec 7, 2013

jr_roosa, Thanks for the link! I only opened it up after posting,lol. Excellent info and thanks for sharing!

jr_roosa · Dec 7, 2013

I emailed them too about the link and they are ok with it for this segment.

J.

osteodoc08 · Dec 7, 2013

Unfortunately, this is a very real threat. Especially when narcotics are easily taken via smash and grab out of an omnicell (common storage system in hospitals).

In my office we have morphine and Demerol injectables. It. Is kept in a lock box in a locked drawer, but is still an easy target. With my locale, there are more than a far share of "undesirables". The local pharmacies for the most part have all been broke. Into at one time or another the last 5 years.

The company I work for will not allow firearms so I typically carry a "defensive pen". I've discussed this situation with local police and staff. We have an action plan in place, but it's not really something that can be "trained" for other than what has been done. The threat is real and is probably more likely than the ethylene glycol poisoning. Heck, you just gotta get them drunk to save them.....

jr_roosa · Dec 7, 2013

The threat is real and is probably more likely than the ethylene glycol poisoning.

Actually, active shooters are so rare that ethylene glycol (antifreeze) poisoning is much more common! Some dude drinking a bottle of prestone doesn't make the national news.

it's not really something that can be "trained" for other than what has been done

I disagree, and the interview covers some of this. Specifically, medical providers are trained from day one to not do harm and to not abandon patients. In these situations, the urge to not do harm prevents people from aggressively protecting themselves when attacked. Also not immediately taking an opportunity to escape the situation will result in more casualties, and provide no benefit to the patients.

I typically carry a "defensive pen".

Good idea.

-J.

Dr.Zubrato · Dec 7, 2013

Having seen a violent, or manipulative drug seeking patient become violent, unfortunately his assessment was spot on when he said the majority of persons within the ER just accept it as part of the job. Most hospitals do not have a real AS policy, and the hospitals I've rotated through basically say we're there to help patients find the exits in emergency situations, and should be the last to leave, including students. Not so easy with patients in hospital beds that take up the whole hallway, so I guess you could say these plans have never been tested or thought through.

I'm not sure even I could do something to a pt who becomes violent, besides calling for security. A few minutes of discussion isn't going to change a lifetime conditioning of caring for patients in varying degrees of emotional status, and I'm not about to start hurting patients. If someone is there to steal drugs, my life isn't worth a vial of narcotics and I'm not about to put my life in danger to save a few bucks, more time and money should be invested into protecting those assets and putting more appropriate barriers between high risk patients and narcotics storage.

However, an active shooter scenario is quite a bit different because that person isn't there as a patient, and someone you're actively caring for. The discussion did not include CCW for hospital personnel, would have been nice but the knowledgeable EMT did mention to get any sort of self defensive training, whether it be firearms or hand to hand, such as disarming techniques.

Not wearing your ears around your neck is also good advice, but I'll be taking my chances I guess. My pockets are full as is, the clip holders suck because they catch on anything around you (not a great idea in the ICU/ER) and losing your stethoscope is a lot more common than being choked with one.

jr_roosa · Dec 7, 2013

I'm not about to start hurting patients

We had a patient almost kill a doctor in a room by strangulation at the ED where I trained. Somebody walked in just in time and saved her.

As medical providers, we are slow to recognize and react when a patient becomes a deadly threat. The interview also cites a case where the provider was being strangled and was hesitant to fight back because of the instinct not to hurt a patient.

-J.

denton · Dec 7, 2013

The hospital in Idaho Falls, ID has a branch police station adjacent to the ER, inside the hospital. That makes a lot of sense to me, especially after reading this.

osteodoc08 · Dec 7, 2013

Jr Roosa-

While my comment was more tongue in cheek, I've been in more physical altercations in working in the ER than had to deal with ethylene glycol poisonings.

Denton,

We also have uniformed police at our hospital. They can't be everywhere at all times, but at least they are armed.

I'll be damned if I stick around while someone is shooting up the place. Sorry. Self preservation is more important.

The most recent altercation a few weeks ago was when a male began beating his old lady. A male nurse and I literally jumped on the guy and subdued him. We had 7-8 people on him in no time. Security came, hand cuffed him and hauled to jail. Incident report done and signed and we moved on. It happens all the time. This doesn't even take into consideration all the damn drug overdose or "altered" patients we have to deal with that scratch, kick, punch, swing, spit, etc. Thats nightly. I don't mention that in bravado, but what are you supposed to do? Unless you've worked a true ER, it's hard to understand. I imagine it's the same as police, EMS, etc.

Then there is the whole chemical vs physical restraint debate.

It seems you can never do right, you're under appreciated if at all, you deal with the scum of society, etc.

I just pray and hope it never happens to me (shooting) and I can deal with whatever situation appropriately.

Dr.Zubrato · Dec 7, 2013

I hear you, and I don't doubt you've definitely been there.
I can't say it happens nightly here, usually the altered folks just come in to sleep it off, and I usually work the afternoon or night shifts. I guess violent folks are too busy sleeping then.
Everyone definitely moves on when something like that happens, like a coding pt, everyone in the trauma bay and team is involved in a split second, and by the time the adrenaline has time to hit you're already back to seeing the guy who came in for a flu.

I haven't seen very many police officers where I'm at, mostly one security guard per side (A or B) and one in the waiting room with a uniformed officer, and this is at a lvl1 trauma center.
And I definitely agree, I'm not sticking around if I hear shots, but if I were allowed to carry I would not leave my patients.

jr_roosa · Dec 7, 2013

While my comment was more tongue in cheek, I've been in more physical altercations in working in the ER than had to deal with ethylene glycol poisonings.

Amen. I meant as opposed to active shooters. The ED is one of the most violence-exposed workplaces out there, so much so that we just get used to it.

I've confronted verbally abusive patients by asking them in what other public place could they get away with swearing at and threatening the people who work there. It's just crazy what some people will say and do in an emergency department and not even think that it's inappropriate. Stuff that would get their heads knocked in if they tried it in a bar. This approach doesn't work with the intoxicated folks, though, and I'd say we have at least one or two people in restraints at any time in my ED.

The altered belligerent patient isn't such a big deal. Most of these guys have been down the road many times before and give up in the face of overwhelming force and a little sedation...they wake up after their nap and are usually apologetic.

I worry about the vengeful patient who returns to settle some kind of score or the guy who wants to go out in a blaze of gunfire. Fortunately the active shooter scenario is extremely rare, but we would be terribly exposed if it ever happened. We have unarmed security, and PD is only there if they have business.

I've worked in a free-standing ED out in the sticks, with maybe one or two cops on duty in the whole town. That place was pretty lonely at night.

-J.

Tom609 · Dec 7, 2013

Interesting conversation...thanks for posting.

IlikeSA · Dec 7, 2013

Thanks for posting!

denton · Dec 8, 2013

Years ago, the family was on a cross country trip, and my son's foot started to swell quickly and painfully. About midnight, we pulled in to an ER in Cheyenne. I commented that the place was about deserted. The doctor just laughed and said I should come back in a couple of hours when the bars close. He said they'd be plenty busy then. Makes sense.

Dr. Sandman · Dec 16, 2013

I work with a guy who is corcerned about the senario were a family gets a 6 figure bill and a dead grandma and a family member comes to the hospital to settle the score. There should be careful thought put into this senario.

Ps, if a guy comes into the ER waiving a gun and demanding drugs, I would be inclined to give that guy whatever he wanted and then send him on his way.

Hospital Active Shooter Management

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