Preparing for the Worst

Image Source: Common Sense

Author: Aaron C. Tyagi, MD
Sparrow/Michigan State University
Chair, RSA Social Media Committee
Originally Published: Common Sense July/August 2017

We in the world of emergency medicine like to think of ourselves as ready for anything. I have often heard the mantra that we are ready for anything that “walks, rolls, or crawls through the door.” Our world is one of relatively controlled chaos. That is to say, when we receive the chaos, it has started somewhere else, far off and distant and we receive a microcosm of it in the form of a patient. That patient is delivered (for the most part) calmly to our home base. However, what happens when the chaos starts at our home base?

Code Silver. It’s something no health care provider ever wants or expects to hear in his or her hospital. But it was something that became a reality for the patients and staff of Bronx-Lebanon Hospital at 2:50 PM on June 30th, 2017.[1] A disgruntled employee, a former physician at the hospital no-less, entered his former place of employ, traveled calmly to the 16th and 17th floors with an AR-15 neatly hidden under his coat. He was wearing a white coat, the symbol physicians traditionally wear to signify healing, and opened fire on his former colleagues. His brutal attack left one dead and six wounded requiring various levels of inpatient hospital care.

There seems to have been a relative up-tick in the number of active shooter events of late, from one event in 200 to 20 in 2015.[2] This has naturally sparked all levels of debate and, more importantly, action. Multiple agencies have enacted policies and protocols to provide some level of preparedness for if and when these situations arise. Such agencies as the Department of Homeland Security (DHS), FEMA, the FBI and others have collaborated to establish such protocols.

The event at Bronx-Lebanon, however, brings things closer to home for us in the health care field. A hospital is thought of as a place of healing. A Code Silver or active shooter scenario is a nightmare for everyone and especially so in a hospital with an even further vulnerable population.

In 2011, the Presidential Preparedness Directive 8 set out guidelines for how health care facilities (HCFs) can approach better equipping themselves for such events. It details a five-point approach: Prevention, Protection, Mitigation, Response, and Recovery. Many, if not all of us who have trained in the modern era of emergency medicine training are familiar with the NIMS modules required as part of our EMS training during residency. This was extended to HCFs. For example, under this directive, HCFs were encouraged to establish Incident Command Systems (ICS) to help manage crisis situations.[3] Additionally, training modules were incorporated to better equip other non-physician and EMS personnel in HCFs to be prepared to deal in these situations. The three key tenets of this training are to recognize a potentially volatile situation, learn the steps to increase your likelihood of survival and survival of others, and how to effectively aid law enforcement during this time.

The staff at Bronx-Lebanon were fortunate enough to have just undergone a Code Silver preparedness drill in the week prior to the incident, which many of the staff credit with their capability to respond in the commendable fashion they were able to. They incorporated their training and that, accompanied by their natural instinct to help those in need, helped a bad situation from becoming worse.

For those interested in further reading and resources on how to best prepare for active shooter scenarios, there are a number out for public access. I have included links to the Joint Commission’s website that itself has multiple resources listed. I have also included two preparedness manuals, one from the Health care and Public Health Coordinating Council and one from FEMA, the DHS, DHHS, and the FBI. I encourage all to look through these resources and make sure that your HCF has a Code Silver plan and that you and your staff are well versed in it.

• https://www.jointcommission.org/emergency_management_resources_violence_security_active_shooter/
• http://www.calhospitalprepare.org/sites/main/files/file-attachments/as_active-shooter-planning-and-response-in-a-health care-setting_1.pdf
• http://www.calhospitalprepare.org/sites/main/files/file-attachments/as_active-shooter-planning-and-response-in-a-health care-setting_1.pdf

References:

1. https://www.nytimes.com/2017/07/07/nyregion/bronx-lebanon-shooting-doctor.html
 
2. https://ovc.ncjrs.gov/ncvrw2017/images/en_artwork/Fact_Sheets/2017NCVRW_MassShootings_508.pdf 

3. http://www.calhospitalprepare.org/sites/main/files/file-attachments/hc_eop_and_active_shooter.pdf