I have the pleasure, although it's not the 7.30 talk, it's a little later, of talking about a subject that might be a little touchy, because an active shooter in our world is not the best thing in the world. But before we get anywhere, a little housekeeping, A, I have no disclosures, B, make sure everybody signed in at the desk. If you didn't sign in, you don't get any credit. If you don't fill out your evaluations, none of us come back, and if you put that I was late, I'll come find you. Fill out your CME sheet. The concierge service of TCAA is available for your anything pleasure. Bathroom breaks, tickets only. Don't leave. All right. On with the show. As Dr. Kaufman mentioned, one of the things, okay, I become the poster child for a few other things besides alarm clocks, is having your tourniquet with you. Because if it's not with you, it does no good. And one of the things that we know, I'll keep pulling them out of pockets here, is most hospitals, when I took a poll, have somewhere between two to 12 tourniquets available at all times. I don't know how many your hospitals have. Mine has 12. I have 50 in my truck. No joke. I have four on me. Usually two, but four right now. But the fact is, unless you're prepared, the equipment does you no good. So think about that for a moment. All right. If, God forbid, you're in an active shooter scenario, practice, reality, it's not where you want to find yourself. But it is where you are. And one of the things that happens, doesn't matter if you're in Las Vegas, Orlando, Roanoke, Virginia for Blacksburg for the Virginia Tech shooting where I was at, it's all of a sudden where you find yourself. So you've got to kind of get your act together right before you do it, during it, or way before. And that's what this is all about. Because just because you're in that level one or level two or level three trauma center doesn't mean you guys are ready. Doesn't mean we're ready. So you have to prepare. And preparation is probably one of the hardest things we have to do in the medical field. Because we do our day-to-day activities, and we go about our business. But preparing and scheduling that preparation, or unscheduling that preparation, is really where the rubber meets the road. Excuse me. So if you want to put your plan up on the board and get an idea of what not to do, this is what not to do. Because having no idea of what to do or putting it together at the last moment is a terrible idea. And I will tell you that all the major hospitals that have dealt with active shooters, dealt with mass casualties, planned it, practiced it again and again and again. So fear has two meanings. Because you can forget everything and run, which is very likely. And statistically, if you go back through mass casualties, especially active shooters, 60% of Americans will run. 20% will freeze. And 20% will help. Where do you fit in? Well, in the medical world, we'd like to think we are part of the 20% that will always help. And in a hospital active shooter incident, ooh, all bets are off. Think about that. You have to know what your hospital is ready and capable of doing. If it's not ready and it's not capable, then why are we in business? You have to ask yourself, what do we have on hand? Who do we have available? And are we ready and practiced? Because if you do tabletop exercises and you do other exercises to get this under your belt, if you will, you all of a sudden start to have a little bit of stability in your system so that, God forbid, an active shooter does happen in or out of the hospital, you have a chance, a chance of helping the maximum number of people the best way. One of the things that's available and TCAA is putting together, and I'm on the disaster committee, is putting together after action reports so that people can learn from others, successful success, maybe failure. Because we all need that information to be able to do a better job. None of us are perfect. None of us can just pick up a book. There is no one book that tells you how to do this. So all of a sudden, you rely on others and others' experiences, and God knows we've had enough of that in America lately, to help us get better and do better. Even with local law enforcement, state agencies can help. Because these are the people who do this for a living. And I would encourage each and every one of you to reach out to your local law enforcement. Our SWAT team comes through our hospital yearly. They know where the OR is. They know where the ICU is. They know the layout of our hospital. And they practice there. Have them do a walkthrough. These are the people who are going to come to your assistance, God willing, in 5, 8, 12, or 15 minutes. Think about that for a moment. Somebody starts shooting in your hospital. How long does it take to get help? Well, we have armed police security in our hospital. Yeah, they're a little older. They're out of shape. You're the dumpy guy in the corner. But the fact is, help is coming when? Let that sink in. So if you can, tag on to somebody else's training. Because as people are doing this training, you can learn from them. You can learn how to set it up. You can learn how to run it again. You can learn, again, mistakes and successes, and bring it back to your institution so that you are capable and able to deal with this. No one is ever 100% ready. I promise you, no one has enough success stories for in-hospital or out-of-hospital shooters to make it 100% right. But we all want to be perfect, don't we? I do. So Google is your friend. There's a lot online. Hopefully, TCAA is your better friend, because we're putting together a fact sheet with after-action reports and best methods for these kind of disasters, pending. It's coming. There are other resources, the ACS, the CDC. And when it comes to your own personnel, as was just mentioned, stop the bleed. Because people in the hospital don't necessarily know how to treat these kind of patients. The med-surg nurse or doc or resident has sometimes no clue, whoa, that's surgery. Surgery does that stuff. We'll know everybody does that stuff, hence why we should have tourniquets and stop the bleed equipment all over the hospital. Disaster training. Basic and advanced disaster life support is something we strongly advocate. Because it doesn't matter what the disaster is, yes, this is an active shooter talk. But you have to be ready for anything. Then probably the highlight of my entire career in life is dealing with administration. Any administrators in the room? Before I lose my job? Okay. Administration needs to be as ready as you are, as ready as we are. Because they have to learn emergency operations, they have to learn incident command, and they have to learn all about what we do. Because you never cure a patient administratively. You cure them or fix them by what we all do. Last but not least, supply chain. I mentioned I took a poll on two or 12 tourniquets available in emergency rooms. Imagine what you needed for the Pulse nightclub. Imagine what you needed in Las Vegas after that shooting. How many of everything do you need on hand? You could be overprepared and have 100 or 200 of everything. Well, that's kind of not practical. But if you have 10 on a shelf of something, can you get 10 more? Can you get 20 more? How many ET tubes are available? How many chest tubes? How many tourniquets? One of the things that we all have to know is, whether it was Columbine, Las Vegas, Pulse, any of these, is that patients will find their way to you regardless of EMS. So whether they get driven in, flown in, walked in, just like all the videos from Las Vegas, I don't know if everybody's aware, 78 or 80% of all patients that arrived, arrived by personal vehicle to the emergency rooms in Las Vegas. Think about that for a moment. What happened to your triage? Oops. All of a sudden, the game changes. You have to prepare for that. Because you and I depend on EMS to do that work for you before they get to you, the primary triage. Well, in Las Vegas, that did not happen at all. When I had Virginia Tech, it did happen. But most of these things, that's not the way it's going to be. You have to do a complete assessment of your hospital from top down. Because number of beds, number of personnel, amount of equipment, where do we do triage, where do we do decontamination? God forbid something else goes on with an active shooter. You have to have an honest assessment of everything in your hospital. And I will tell you, being the guy that has to do that for my hospital, that the hospital looks at you like you have four heads, six eyes, the color of your skin is blue, and they're like, what the hell are you talking about? You have to have an honest assessment. They have to have an honest assessment of themselves as well. In the Orlando, when Pulse Nightclub happened, Mark Jones gave a great talk, a few of them actually, to the press, and this is one of my favorites. Make sure you do your drills. Make sure you do your drills at inconvenient times. That's an important part. Don't always schedule them. Do them when people least expect them, because that's more reality. Make sure you do your drills when it's uncomfortable, and we would also add how important it is for those drills to push yourself to the point of failure so that you're really clear as to what the weak points of your plans are. Ladies and gentlemen, sometimes we have to fall down before we get up, and when it comes to an active shooter, we better know where our weak points are, or else we're not ready. Because if we always plan under the best circumstances, and I'll be honest, when the Virginia Tech shooting happened, it was 8.30 a.m. on a weekday. I was fully staffed. I had more doctors coming out of my you-know-what than I could ask for. It was great, but what happens when it's 2 a.m.? What happens when it's 5 a.m.? What happens when it's 6 p.m.? Shift change. Oh, God. Shift change. Oh, oh. Nothing ever happens in a hospital good at shift change. We all know that. So what you want to do is take an honest assessment of your hospital, get a lot of advice. But this is important, because you don't base your decisions on the advice of those who don't have to deal with the results. That's my kind of administrative headache, because these are people who are making life and death decisions from an office that don't deal with patients. Let that sink in for a moment. So when you guys are out there seeking advice, look to the people who have boots on the ground, been there, done that, and all of a sudden you have credible information. Supply chain. This is one of those things I got voluntold to be on the supply chain for my entire hospital. Yeah, that's a whole lot of fun, let me tell you, sitting through those meetings. But the fact is, I have a brand new respect for the way things, gauze pads, band-aids, endotracheal tubes flow in and out of our hospital. And I would encourage each of you to find out a little bit more about that. Because if it's in a warehouse and it's on a shelf, how quickly does it get back to your emergency department? How quickly does it get back to your ICU? How quickly does it get back to your OR? All of a sudden you realize the world does not revolve around each of us. The world revolves around supply chain. Because we are nothing without the equipment we need to work with. The other thing that I would encourage everybody to do is figure out what do you need? Because if your hospital is very well stocked, you're an 800-bed hospital, and your emergency room and your operating room has everything and plenty of it, that's great. I work in a 260-bed hospital, it's the county hospital, and it isn't great. We don't have room. We're an old hospital. We're building a new hospital. We break ground in two years. We don't have enough shelving space for half the things we need. So we're constantly rotating and moving equipment around. But find out what you think you need. Because if you think you're going to need 1,000 Foleys for an active shooter, you're probably wrong. You might need more gauze. You might need more ACE band-aids. You might need more tourniquets. You might need more combat gauze. You might need more endotracheal tubes, NG tubes. Probably not. But take a good, hard look at what you have on hand and what you think you need. So one of the things that I also encourage is learning the honest art of triage. If you've been in the military or you're firing a mess, you probably have a good idea of triage. I will tell you that doctors and nurses, excuse the expression, suck. We've run these drills so many times, it's laughable. But how bad people triage, because we do it with emotion. You cannot do triage with emotion. You can't. Little kid, fireman, uh-uh. They're all the same, plain and simple. What I do, I don't do tags, never did, never will, because tags are fallible. They fly off at the worst times. No offense to our helicopter crews, but when they come off and rotor wash finds the tag, which it always does, the tag ends up, oh, about three blocks away. So I use a Sharpie pen. That's how we do triage. Sharpie pen right across the forehead or the right shoulder. I have taped down both of my legs so I know what's coming in on one leg and I know what my resources are on the other leg. It's kind of fun to watch because when I run around like a chicken without a head, I have these wide tapes on my legs and people are like, what the hell are you doing? I'm keeping track of everything because that's my job if I'm the triage officer. And whether you have a radio or you have somebody whispering in your ear of what's constantly available or not available, you gotta know because the triage person is going to change their triaging based on resources. How many reds can you put in the OR at one time? I have 11 ORs. Does that mean I can put 11 patients in the OR at one time? No. There will be black tags. You have to know your resources. I also keep a scribe right next to me. The poor soul who gets stuck doing that is never having a good day. Because we use specific order sheets, which I'm happy to share. I didn't bring them with me today, but I'm happy to share them. We have order sheets of what you do and do not offer to each patient. CAT scans. We don't do that stuff unless you absolutely have a head injury. X-rays. There's not one x-ray that's going to make a difference acutely in a mass casualty. Antibiotics, medications, thoracotomies. Who do you do it to? Who do you do CPR for? All that is on the order sheet and you have to respect the order sheet. When you do black tag somebody from an active shooter, that means you are out of resources or the person will not survive. I wish you all luck. That is about the worst day of your life, but the good news is after you've done triage once, you start again and go back through. Because if you all of a sudden have resources or an operating room, that black tag becomes a red tag. So all is not lost, but you have to be willing to know who and who cannot potentially survive. I also differentiate our reds because I learned the hard way after doing this enough that there's a red operation now, wheel them right into an operating room, and there's a red that you have to do a critical intervention and then they can delay. That's a really important fact to not hit the funnel and stuff it all up when you're pushing reds through your system. And I would encourage everybody to understand that differentiation because a red now, operation now, will save their life versus they need a chest tube, they need another tourniquet, they need something, but not an operating room. This minute is a huge differentiation. Secondary triage will happen at every single point of intake, wherever you put your greens, the walking wounded, they're over in another building, wherever you put your yellows, they're in the endoscopy suite or in the auditorium. Somebody has to continue to re-triage. You have to practice for the worst-case scenario. I know that's probably common sense, but if you don't practice for the worst, how can you be your best? Know your capacity and capabilities medically and surgically. I really don't put too much to what my administrators can do, other than running the Emergency Operations Center, Incident Command, that they do, but it is so important for the people with the boots on the ground. You have to know your capabilities, you have to know that your phone tree works to get more people in. Minimize paper. Who's on EPIC? Who's on Cerner? Who's on God knows what? Oh, good. I got good news and I got bad news. Yes, we spend 30% of our time sitting with an electronic piece of junk charting. In a disaster, you will use it zero. I was on the EPIC committee in Wisconsin to try and come up with how to do mass casualty. We haven't done it yet. That's seven years in the making. Cerner does not have it yet. McKesson doesn't have it yet. No electronic system has it yet, so we do paper. Think about that. Do any of us have paper anymore in the hospital? For a disaster, I hope so. That's what we keep it for. All right, you got to know your policies. You got to know how to do these things. You have to know that the hospital is ready. It's a Joint Commission rule. It's a Medicare rule. You got to have all these things updated and you have to know how to practice with them. You have to activate your incident command every once in a while. We just went and had our entire hospital Wi-Fi system, everybody laughs about this, go down and I called the incident command open and of course the first person asked me, which was the one of the vice presidents, why are you doing this? There's only four people who can open incident command. The administrator on call, the head of the emergency department, the head of trauma, myself and God. And that's it. But you have to realize when it's appropriate and they have to practice it because it can't take two hours to get it up and running. You have to have your credentialing because of neighboring physicians, neighboring nurses, neighboring respiratory techs. By the way, everybody's a respiratory tech. We practice this too. You know what this is? This is called a bag. This is called breathing and it's amazing how medical students can make people breathe on a ventilator because we ran out of ventilators. So bags come in really handy. You have to do your drills. Tomorrow be a great time to start so I expect you all to go home from this meeting and do a drill. Okay, that's not gonna happen I'm sure for half of you, 10% of you, 90% of you. You've got to practice. You've got to do your drills. Really important. So where were we? Columbine 1999. High death rate. A lot of reasons why. But law enforcement learned a very valuable lesson is what's called active shooter drills and active shooter response for law enforcement. I'm part of a SWAT team, the state police SWAT team and we practice this stuff and teach it all around the state constantly. One of the things that we know is active shooters, sorry, the active shooter response means that law enforcement is going to walk over each and every injured person to stop the shooting. They will not offer aid and one of the things that Columbine helps cement, I've been doing tactical medicine which is the medical component of law enforcement for years. Those are the people who will help and integrating medics, docs, nurses, PAs, NPs, whatever into local responses from SWAT teams really can save lives. We proved that at Virginia Tech. Everybody remembers the kid who tied the light cord around his leg, big picture of that in the newspaper and there was a tourniquet on his leg that was put on by one of my tactical medics. So all of a sudden Columbine taught us a lot. We improved communication because at Virginia Tech I knew nothing, nothing. That's because every radio frequency was different. Look at your own town, look at your own city and find out how are you going to get information about an active shooter and then institutional planning. Medical care begins sooner, stop the bleed. As bystanders now in the Pulse nightclub, people save lives by helping. Those are the first responders, not the medics. Tactical medical personnel as I spoke about, field communications are not always accurate or not always timely. I can tell you from Virginia Tech we thought that there were three shooters. We thought it was going to go on for six hours. It didn't. It was all misinformation. How long does it take you to set up? It took us 27 minutes to go from beginning to set up for Virginia Tech because we practice, practice, practice. I thought that was fairly amazing but you have to look at your own hospital and figure out how quick you can do it. How many ED beds are available? How many stretchers are available? How many ORs can you make available? How many ICU beds can you make available? What do you do with all the patients who are in them right now? Threat assessments. What situations and circumstances are you dealing with? And then are we dealing with lots and lots and lots and lots of people like Las Vegas? Are we dealing with one or two? You may not know until they show up at your door. In hospital, here's the good stuff. Having lived through this as well, how accurate is the information going out? Where is the shooter? How many of them are there? We at the County Hospital in Phoenix have the gangbangers. They don't like each other. They don't like, well they respect us to a point, but they don't like each other. So they'll try and kill each other in our hospital. So where is that threat and where can we isolate it to? Do not, do not be a hero. None of us have a Superman cape. We all want to be one, but don't be a hero. The good news is most victims of shootings in hospitals are known to the shooter. The vast majority. And the other good news is it's a very low proportion of active shooter incidents occur in hospitals, but about 14 a year and 60% of those are in the hospital. 40% are in the parking lot or in the clinic away from the hospital. ED is 29%. Any ED people here? Yeah, good luck guys. Good luck. Parking lot 23%. Patient rooms 19. Offices less than 5. Typically these are male shooters for some reason. I don't know why. The good news is though, docs are second. Okay, that's a flippant thing to say, but honestly nurses are not usually the intended victim. It is usually a patient who is the victim. So what do you do? Evacuate or stay in place? One of the things that everybody teaches in an active shooter scenario in the hospital is barricade. Get a door locked. Can all your doors lock? Most hospitals cannot. Oops. Now what? Think about that for a moment because the reality is it could happen. Not that it will happen, but it could. So you have your hospital maintenance or environmental services or whoever, they have to figure out how to be able to let you barricade in place. We always profess people will not get medical care during an active shooter. Common sense, but think about it. You're not gonna be in the middle of a hallway taking care of somebody because then you're a target. Hemorrhage control if able. I'm gonna go back to the be prepared. The tourniquets on my leg. Okay, hold on. There they are. Every day at work. This is with me. I'm made fun of, I know, but there's two tourniquets with me. Not because I'm paranoid, but because every once in a while you actually have to use them and I've used needles to decompress people in the hospital and I've used a tourniquet. So you have to have it with you because if this stuff's down in the emergency room and you're up on the floor and something happens, not gonna do you much good. Again, don't be a hero. So typically, as I said, the intended victims are typically the patient, family, friend, or enemy. Statistically, they're not random acts. People don't just walk in and start shooting in hospitals, thank God. The question is for any people who are enjoyers of the finer arts of shooting, understand people have to reload. That may be the time to intervene. A fire extinguisher is your best friend and one of the things we teach in our hospital is to whoever, wherever you're running, grab a fire extinguisher. It can be a great weapon against the person who is shooting. But if they are having a malfunction, which happens, if they are reloading, which happens, just like at the Waffle House, everybody just saw that on the news down in, was that Florida? Tennessee. Thank you. The guy was reloading or something and somebody intervened. March 15th, 2018, UAB. One employee, nursing supervisor, who was the intended victim. Shooter died of a self-inflicted gun wound. September 2017, up at Dartmouth. Guy shot, who would shoot their mother? That's not nice. But he shot his mother in the ICU. Bet that's set up for a good day that day. November 2017, a doctor was shot and killed in a shared love interest. Situational awareness. You've got to be aware of what's going on. You have to be aware. You got to know where the exits are and get the heck out of Dodge. Communication over the loudspeakers. You have to practice this stuff. Patient gear gets put on hold and your safety is paramount because you don't want to become the patient. Do not activate the fire alarm. Do activate your active shooter system that every hospital does have. You have to be smart and if you have to defend yourself, what weapon do you have? A fire extinguisher? A IV pole? Something. It's okay. This is your life we're talking about. The Department of Homeland Security talked about run, hide, and fight. It's a flawed system. Doesn't always work, especially in a hospital. Out in public, maybe. In a hospital, nope. Oops, wrong way. Oops, I missed one slide. One of the new ones that we talk about is secure, protect, and fight. And that was put out by Ken Maddox, Ken Giannaba, and Alex Eastman. Because all of a sudden, and it's in your handbook, I think, maybe not. But secure, preserve, and fight because you secure the areas and some places are potentially lockable. You can lock them down. Preserve life of yourself and of your patients. Turn off pagers. Turn off cell phones. Turn off monitor alarms. Turn off the damn monitor because you want it as quiet as possible so the shooter may keep going. And then fight as a last resort because that may be what you have to do. I hope none of us are ever in that situation, at least I hope I'm not in it again. But it's not a place you want to find yourself, but it is a place you want to prepare. Thank you and have a fabulous day. Don't forget to set your alarm tomorrow.

active shooter

hospital setting

preparedness

emergency equipment

communication

evacuating

situational awareness