Active Shooter Incidents in the Health care Setting—Implications for the Surgeon

Abstract

The incidence of active shooter incidents in the U.S. continues to increase, with 48 incidents reported in 2023, representing a 60% increase from 2019. Such attacks typically occur in soft target forums, defined as having minimal to no defenses. Historically, this has included schools, offices, public areas, but increasingly includes health care facilities, such as hospitals and medical offices. All physicians play critical roles in the response to any mass-casualty incident, including active shooter events. The surgeon plays a particularly special role both in leadership and treatment given the unique medical skillset capable of rendering life-saving aid to victims of a mass-casualty incident.

Introduction

The term “Active Shooter” has unfortunately become more and more common in modern times. The Federal Bureau of Investigation (FBI) defines an active shooter incident as a situation whereby “an individual [is] actively engaged in killing or attempting to kill people in a confined and populated area.” ¹ There are other violent attacks that occur in healthcare settings but with a different weapon (ie, knife, chemical, and explosive)—these are not included as such attacks do not meet the definition of an active shooter incident (ie, the use of a firearm). The overall incidence of active shooter incidents is increasing in the U.S.—Kelen et al (2012) identified 154 active shooter incidents within U.S. hospitals (occurring in 40 states).^2–4 The most recent report provided by the U.S. Department of Justice and FBI reported 48 active shooter incidents in 2023. ¹ While only a single armed individual is required within this definition of an active shooter incident, the federal definition of “mass killing” includes “three or more killings in a single incident” (not including the active shooter). ¹ It is worth noting the distinction that an active shooter incident implies an ongoing scenario while a mass killing (shooting) does not. Additionally, incidents with one or two fatalities may not be included in the statistical recordings thus underestimating the actual number of U.S. active shooter incidents. Of note, this number was reduced from 4 to 3 within the past year. ⁵ The overwhelming majority of active shooters are male; however, there is not a distinct profile to aid in predicting future events. ⁶

Active Shooter

The motivations for such atrocious acts of violence are varied—some of these may include grudge, revenge, perception of poor treatment, suicide, ideology, desire to end life (terminal disease, dementia), complications from surgery, chronic pain, and mental instability. Such attacks tend to occur at soft targets, that is, facilities that lack hardened, defensive means. Attacking a law enforcement facility would likely be difficult, whereas attacking a soft target (lacking defensive measures) such as a school, office, or health care facility is easier to infiltrate. Perhaps more relevant than the distinction between a hardened and soft facility is the underlying motivation of an active shooter. A national push for preparedness efforts began in March, 2011 with the Presidential Policy Directive (PPD) 8. ⁷ This directive represents a paradigm shift for national preparedness in response to a series of natural disasters, terrorist attacks, and increased domestic terror incidents (including active shooter incidents). ⁷ The PPD-8 delineates 5 core mission areas: prevention, protection, mitigation, response, and recovery. ⁷ These mission areas align with any type of emergency situation and co-align with the pre-incident, incident, and post-incident environments. ⁷ Leadership and coordination occurs via the National Incident Management System (NIMS) and the Incident Command System (ICS), which provide a framework for the overall organization, leadership, and communication within and among organizations. ⁸ Together, these mission areas guided by the ICS framework offer an effective means to navigate the 4 phases of disaster management: preparedness, mitigation, response, and recovery. The result is a flexible, scalable, adaptable, and sustainable response. ⁹

Targets

Identification of healthcare facilities as soft targets and subsequent active shooter incidents at hospitals is increasing. Among the 48 active shooter incidents reported in 2024, two (4%) occurred in the health care setting. This number of reported incidents is likely low due to the reporting criteria that qualify an incident. ¹⁰ Mass murder incidents historically mandated a minimum of four victims or casualties; however, active shooter incidents do not require this threshold (currently three).^5,10 Health care facilities such as hospitals are unique in that a vulnerable population (ie, patients of various mental and physical health levels) are present within, along with the expectation of safe sanctuary. This marks a prime target for the terrorist motivations of the active shooter. The active shooter incident is typically pre-planned and usually demonstrates a comprehensive knowledge of the target facility. ⁴

The motivation(s) for an active shooter within a healthcare facility may arise from animosity between the active shooter and a physician due to a health-related outcome or perhaps from a financial/billing issue. ⁴ Law enforcement classify active shooter incidents into five categories: 1) type 1 (criminal intent), 2) type 2 (customer-to-patient), 3) type 3 (worker-to-worker), 4) type 4 (intimate partner violence / domestic violence), and 5) type 5 (ideological violence). ¹¹

Numerous reports of physicians (and other healthcare employees) attacked by active shooters exist (type 2 active shooter incident).^2,3,6,12,13 Surgeons in particular are often targets of active shooters, perhaps most commonly due to some perceived post-operative issue and/or perception (ie, blame for pain/suffering and poor surgical outcome). ⁶ In addition to potential target selection by active shooters, the surgical work environment demands a special examination due to both increased patient vulnerability and a unique operating theatre to navigate under such an incident. ¹⁴

The current article aims to explore the unique involvement and environment of the surgeon in the context of an active shooter incident. The surgeon (and surgical team) should be acutely aware of their unique environment, and both educated and prepared to offer life-saving services in the event of such an attack. Firearms attacks result in penetrating injuries with subsequent need for surgical intervention. This highlights the unique ability for surgical personnel to be trained and aware for the active shooter response.

Terrorism and Counterterrorism Medicine

The increased incidence of both domestic and global terrorism has catalyzed the development of the field of counterterrorism medicine as a subset of disaster medicine. ¹⁵ This also includes technical medical responses to chemical, biological, nuclear, radiologic, and explosive (CBRNE) threats. The active shooter medical response falls within the classification of counterterrorism medicine, and an increasing number of texts and articles support best practices and protocols for such response.^15,16 The evolving combination of tactical and medical continues to form, in contrast to earlier medical responses that were required to delay until tactical (law enforcement) personnel advised for clear entry. This pause in medical response necessitated by the risk to emergency responders has been labeled the therapeutic vacuum. ¹⁷ While it is understandable that emergency responders would not immediately enter a hot zone, this delay is believed to yield a higher casualty rate than if a medical presence were on site as quickly as possible. ¹⁷ The evolution to establish tactical emergency responders allows more rapid medical care even in an active “hot” zone that may include providing care under fire. ¹⁷ This carries a multitude of conditions, as appropriate education, training, protection, and availability of tactical medical personnel are all required.^17–21 Equally as important is the mandatory communication that must transcend all participating personnel and organizations as established via the National Incident Management System (NIMS) and Incident Command System (ICS). ⁸

An active shooter incident (often) falls within the category of a mass-casualty incident—this largely depends on the number of patients involved, the surge characteristics of presentation, and the resources of the responding healthcare facility. The response ability of a small rural emergency room will differ from a level I trauma center. ²¹ This is particularly relevant to the surgeon given his/her familiarity with this concept in both the emergency and operating room arenas.

The classification of a facility as a soft target may affect a healthcare facility as well, a somewhat unusual concept as compared to more traditional soft targets represented by schools, offices, and public areas.^3,6 The hospital as a (soft) target incurs an entirely new level of complexity and repercussions, as now the responding center is also affected by the terrorist act of an active shooter.^{3,6,12,13,22,23} There is a growing amount of literature discussing the hardening of targets (ie, hospitals) to make facilities less vulnerable to an active shooter; however, this is a difficult process based on the complexity of health care facilities/hospitals, the number of egress points, the 24/7 hours of operation, and simply the overall openness and availability to the public. ²⁴ Additionally, any space characterized by a density of people (such as the emergency room) or the presence of highly vulnerable populations (intensive care units, ²⁵ operating rooms, pediatric areas) mark a high risk area for an active shooter attack. ²³ There have been reports describing the intentional attack of healthcare facilities for the sole purpose of targeting first responders. ²⁶ This particularly malicious intent to attack first responders and a healthcare facility exemplify the degree of damage that terrorists seek.

Surgeons are commonly involved in the leadership, organization, and treatment aspects of active shooter (and other mass-casualty) incidents. ⁹ The hospital, and individual areas such as the operating room, must have specific protocols established prior to an event. ¹³ Protocols must be understood from the start as there is not time or access to examine and/or learn such a protocol once activated. Protocols must be rehearsed and ideally with simulations and/or drills.^{4,6,12–14,22,23,26,27} The same is true for outpatient ambulatory surgery centers. The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations) and the Accreditation Association for Ambulatory Health Care (AAAHC) require emergency operations plan to be in place, which include disaster scenarios to include active shooter incidents.^28–30 Guidance from these organizations is present although primarily represent outlines for recommended actions. The Joint Commission notes reports of 39 shootings from its accredited health care facilities that unfortunately resulted in 39 deaths. ²⁸ The Joint Commission offers basic guidance for the creation of an emergency plan. The AAAHC emergency drills toolkit for example requires purchase (even for members) and provides a simplistic outline (assess, plan, inform, perform, evaluate). ²⁹

Some type of hazard risk assessment or hazard vulnerability analysis, whether basic or formal, aids in the general assessment of current status of a facility and how to improve. ³¹ The key is to put forth some effort to evaluate what can be done to optimize the safety of staff and patients. The most formal and complex plan serves no purpose if the staff are unaware and do not understand the protocol when activated. Proper education, training, and drills are paramount. Leppert et al (2020) uniquely reviewed the challenging questions that surgeons must face while performing surgery in the event of an active shooter incident—should the operation continue, be stopped? There are many unique characteristics of each and every healthcare facility that will specifically guide protocols. In reality any active shooter plan is going to occur amongst chaos and so simple is best.

Active Response

Run-Hide-Fight

The core response most commonly taught for active shooter incidents is the RUN-HIDE-FIGHT paradigm. This is well described throughout the literature and within various educational resources.^32–34 Briefly, this protocol depicts the suggested order in which an individual should respond in an active shooter scenario; however, the order may change based on the precise situation each individual is in. RUN refers to the priority to safely flee the scene if able. Hide refers to the suggested action if an individual is unable to flee safely. A multitude of best practices follow each of these actions. A person hiding should turn off cell phones and any devices that may make noise and alert the active shooter. Additionally, one must consider appropriate hiding spots, such as a dead end area that does not offer an alternate escape should a person be detected. The final action is to FIGHT—this is reserved as a final action should an individual find themselves within close proximity to an active shooter and without the ability to flee.

The RUN-HIDE-FIGHT paradigm is simple but paramount in an actual situation. While there are other variations of recommended actions, these all essentially suggest the same actions. An active shooter event will be chaotic and thus the most basic methods should be taught and reinforced. This preparedness must exist at all levels, from the individual, the facility, the community, and the hospital. It is important to understand that until law enforcement arrives, this is a survival situation, and one must do what is necessary to survive, whether within one’s comfort zone or not. This point stresses the importance of situation awareness and protection, but also reinforces the ability and opportunity to alert law enforcement as quickly as possible.

Law Enforcement Coordination

Planning a healthcare facility’s active shooter plan should incorporate law enforcement within this stage. This offers them the opportunity to see and understand that specific facility layout, with entry and egress points. This also reinforces the surgeon and his/her staff in the understanding of facility layout. A solid communications plan is critical—this includes both internal communication to staff (and later to their families) as well as external communication to law enforcement and other authorities as needed (medical).

Patient Protection

The protection of patients is somewhat controversial with regard to the duties of the physician; however, the majority of studies support care of the patient in an active shooter scenario as the responsibility of the physician.^6,14 This seems particularly true for patients in the intensive care setting, for pediatric patients, and for those undergoing surgery in the operating room.^6,14 Inaba et al, (2018) suggest a modified approach (secure, preserve, fight) to account for physicians’ moral and ethical duty to not abandon a patient. ⁶

Responsibilities in the Operating Room

Active shooter protocols in the operating room align with those of medical offices and other healthcare facilities, except for the added complexity of having patients who are sedated and/or actively undergoing surgery. Leppert et al (2019) discussed the dilemma a surgeon faces while performing surgery and hearing notification of an active shooter within the facility. Recommendations were twofold: 1) waiting for additional information as available and/or 2) aborting an operation when safe as this option allows the patient to be awakened and moved as well as the ability to prepare for an incipient mass-casualty event. ¹⁴ Core protocols such as locking/blocking doors and covering windows should be performed immediately as per standard active shooter protocols. ¹⁴ Each healthcare facility should incorporate ICS/NIMS protocols such that an Incident Commander can coordinate, inform, and direct actions throughout the hospital. ¹⁴ The simple presence of an effective communications plan and method is one of the most important strategies.

Prevention

The Federal Emergency Management Agency (FEMA) offers a comprehensive guide to implementing active shooter incident planning into healthcare facility emergency operations plans. ⁸ A multitude of preventive measures can be employed by healthcare facilities in efforts to harden entry. This may include security officers (both number and strategic placement), electronic key card access, metal detectors, x-ray screening of bags, photo identification cards for employees, and promotion of situation awareness of staff. ⁶ The presence of individual first aid kits (IFAK) and defibrillators placed in strategic, well-marked locations may prove useful should they be needed. The American College of Surgeons has promoted the Stop the Bleed campaign which aims to teach direct and immediate wound pressure to laypersons. ³⁵

The use of artificial intelligence (AI) has been employed to help detect firearms in public places as well. A select number of companies (ZeroEyes) offers immediate firearm detection capabilities based on automated optical AI firearm detection. ³⁶ This software layers over existing digital cameras—if a gun is detected, images are instantly shared with a 24 hour / 7 days a week manned by U.S. military and law enforcement veterans for confirmation. If the operations center staff determine that a threat is real, they dispatch alerts and actionable intelligence to first responders and local staff as quickly as 3 to 5 seconds from detection. This serves as a tremendous force multiplier and offers a greater time for all phases of response.

Preparedness for an active shooter incident mandates education of the individual as well as staff. Additionally, individuals must understand what they should do and why. For example, turning off or silencing a cell phone while hiding may seem obvious to avoid detection; however, this simple but critical concept must be reinforced. Simple familiarity of workplace environments and surroundings should be noted by all staff to ensure faster decision-making in a chaotic environment. The military teaches the OODA (observe, orient, decide, act) loop process as a strategic mechanism to determine the optimal solution and decision for a given problem. ³⁷ United States Air Force Colonel John Boyd’s OODA loop yields the conceptual framework that drives behavior and decision-making within a dynamic environment, originally developed to aid Air Force fighter pilots in making rapid decisions during air-to-air combat.^37,38 Successful utilization of the OODA loop involves executing the process faster than an adversary, resulting in the disruption of the adversary’s OODA loop and thus a gained advantage. The same holds true with an active shooter incident whereby an individual must make rapid and effective decisions based on his/her environment to survive. The OODA loop cannot be entirely studied as environments are dynamic; however, education, preparation, and practice will maximize this effect.

Training

Education and preparedness must occur at all levels, including the individual, the facility, and the community. The process begins simply with the basic action of initiating the learning process. There is great variation among medical facilities in the emergency operations plan established. At the minimum, a facility should have a plan and organize a lecture by qualified law enforcement personnel. Staff should familiarize themselves with their work environment with respect to egress routes, types of doors and locks, and perhaps most important an optimized sense of situational awareness.

True preparedness for an active shooter incident mandates practice and drills. ¹² The reality is that most institutions will never do this. Drills in a hospital setting require significant planning and coordination between clinical staff, administrative staff, and law enforcement personnel. Much of the education is simply the acceptance of the unknown but guided by specific protocols and methods such as the RUN-HIDE-FIGHT paradigm. Continuous threat assessment should help to identify existing and potential risks and weakness of a facility. The surgical community has promoted the THREAT concept, identifying key actions implicit in saving lives: threat suppression, hemorrhage control, rapid extrication to safety, assessment by medical providers, and transport to definitive care. ³⁹ This concept is analogous to recommendations and actions promoted by tactical military battle aid such as taught within Tactical Combat Casualty Care (TCCC). ³⁹

The surgical environment and operating theatre mark a particularly unique environment for an active shooter incident. The surgeon will be looked to for direction during such an event, which includes a myriad of conflicts. First, the immediate danger of the active shooter must be addressed. Second, the surgeon and staff must consider the appropriate action to care for a surgical patient who may be in various states of anesthesia, likely immobile, potentially requiring ventilation, and so forth. Leppert et al (2019) offered a comprehensive review of these issues and highlighted the critical importance of facility-wide communication in accordance with the ICS/NIMS guidelines. ¹⁴

The surgeon must be aware and prepared to respond both in and to an active shooter incident. Additionally, the surgeon carries added responsibility due to his/her unique ability to provide life-saving surgical care in such a mass-casualty scenario. Surgeons and staff must collectively remain vigilant and aware of their surroundings, to include recognition of a patient or family member who exhibits concerning actions and/or comments.