Author(s): Angelo Verzoni. Published on January 3, 2017.

Wide Open

Why it's important for health care facilities to train employees on procedures that address active shooter events


As mass shootings like the one that left more than four dozen dead at an Orlando nightclub in June have become more frequent in the United States, hospitals have begun to anticipate and train for treating victims of similar events, according to a recent article in U.S. News & World Report. But what happens when the hospital itself—or any other type of health care facility—is targeted by a would-be shooter?

That’s a question Michael Marturano has dedicated much of his time to over the last several years. Marturano is safety officer for St. Luke’s, a health care system in Duluth, Minnesota, a job he took on in 2002 when the organization’s administration saw a greater need for emergency planning following the 9/11 terrorist attacks. For years, his primary concern focused on terrorist-led chemical and biological attacks, Marturano told NFPA Journal in a recent interview, citing the anthrax scare that swept the nation in the weeks after 9/11. But around 2010, in the wake of events such as the 2007 shootings at Virginia Tech, the concern began to shift to the possibility of a shooting in a hospital.

Marturano went to the St. Luke’s administration with a bold new idea: Hold an active shooter drill for hospital staff, complete with law enforcement involvement and a gun loaded with blanks. “That’s the only way people are going to really understand how they will respond,” he argued, likening the need for such training to the need to conduct regular fire drills. The administration agreed, and in 2012 the first active-shooter training was held at a St. Luke’s clinic. Since then, Marturano, an NFPA member, has taken his education efforts to other St. Luke’s facilities and beyond, leading trainings for anywhere from 30 to 150 staff members at a time at more than a dozen health care facilities throughout Minnesota and Wisconsin.

NFPA Journal spoke with Marturano about the importance of preparing health care facilities for situations involving active shooters, some of the challenges involved with the training, and measures health care workers can take to stay safe in active shooter events.

What makes health care facilities so vulnerable to attacks from shooters?

We’re wide open. We don’t run you through a metal detector on your way in. Surgery’s locked down, the birthing center is locked down, but the other 80 percent of the building is pretty open. You’ve got sales people coming in, family members coming in, you’ve got meetings with a lot of community folks, and they need to get in.

How common are shootings at health care facilities?

In the United States, there haven’t been hospitals that have been targeted in mass shootings, but there have been incidents overseas. In the U.S., you’re basically looking for disgruntled employees or murder-suicides. That’s the biggest risk nursing homes have—a murder-suicide with grandpa ending grandma’s life and then taking his own, and you hope it stops there. There have also been cases where a family member was not happy with the care that a doctor or nurse gave a loved one and they went in and shot them. I see that as more of the risk right now—the murder-suicide, the disgruntled employee who was fired, the family member who’s not satisfied with the care.

How prepared are health care facilities to deal with active shooters?

St. Luke’s is well prepared. However, other facilities I’ve done trainings at were not prepared at all. Most of them didn’t even have a plan. So we’ve shared our plan with them. I’ve developed a template, and I say, “Here’s a template. You can follow it, you can come up with your own, or you can use it as a guideline.” That’s why people are asking me to do this, because they just aren’t prepared.

What should health care workers watch for that might indicate a shooting is likely to occur?

We start with awareness. If you’re at the front desk, what do you need to be aware of? For example, if somebody’s standing or pacing outside your door and they’re looking in the windows and it’s 80 degrees outside and they’ve got a coat on, that’s not normal. If you look at your patient list—and you know most of your patients unless they’re new—and you’ve got Bob and Carol and Ted and Alice coming in today and that’s not one of them outside, maybe you need to call 911 because at that point you’re still able to function.

What do you mean by “still able to function”?

If you wait until something happens, you might not be able to pick up that phone and make a call. If someone walks in and pulls out a gun, there’s a very good chance you’re going to lose your fine motor skills. You’ll probably go into auditory exclusion. You will perhaps experience tunnel vision and time dilation—something can seem like it took forever but it was only five seconds. The police chief I worked with last week at a vet’s home was actually in one of these situations—he’s allowed me to use his story to illustrate these points. He was a member of a SWAT team that responded to a call at a residence. A guy came out and started shooting. All the chief could do was bring up his gun, put it on the target, and pull the trigger—he wasn’t able to move out of the way. Forty-two shots were fired in total between police and the gunman and the chief never heard a shot. All he heard was his M-16 going click, click, click as it ejected a round and loaded another. He thought it was a 10-minute gun battle, but it was over in about three seconds. The chief wasn’t injured but the shooter was killed. So if somebody with 17 years of law enforcement experience and eight years of military experience can lose fine motor skills, go into auditory exclusion, and experience time dilation, what are you going to do if you never think about this until it happens? By listening to the training and the drills, you’re much better prepared.

How do you get people to overcome, or at least manage, that physiological response?

That question is a hard one to answer because I really don’t know how somebody’s going to respond. Working through it, though, doing drills, two to three scenarios like that, is what does it. In the case of the police chief, it was muscle memory that got him through this. He said if it wasn’t for his training, which taught him to bring his gun up, put it on target, and pull the trigger, he would probably be dead. If I could, I’d do trainings quarterly in all my clinics, but we, like most organizations, don’t have the capacity. I read an article that said if you really want somebody to get good at responding to active shooter situations, you really need to do training quarterly for the first year or two and you need to do it twice a year thereafter. The more you can work through it, the more drills you do, the more you can work through the issues you may have had the first time. You’re trying to build muscle memory.

Let’s say a shooter enters the building and begins firing. What now?

Your options are run, hide, and fight, and that’s basically it. Run-Hide-Fight is one of the more well-known programs recognized by the federal government. Let’s start with run. The first thing is awareness—where are the exits? If you come in the same door every day, your homework assignment as you’re walking around the building is to find all the exits and go out those exits and see where they go. When you’re running, you have to call 911. You need to call a number to let people know where you are and that you’re safe. You need to let others know why you’re running out of the building. Your other homework assignment when you’re walking around the building is to look for doors that lock. Put a dot on the door or something so if people are running down the hallway and they see that symbol they know that door locks from behind. For hide, if you can’t lock the door, can you move your desk in your office up against it? Maybe you need to rearrange your filing cabinet so you can easily push it against the door if you have to. I show people how to use their foot up against the door to keep the door shut, how to use a belt on a door that opens out, how to use a transfer belt—which is a belt that nurses and other staff use to assist patients with walking—on fire doors to keep them shut, how to use anything from your clothes to your shoelaces to your lanyard on your name badge to secure a door.

NFPA 101®, Life Safety Code®, requires that doors not be locked so as to prevent egress. Does this present a challenge in your training?

If you’ve got to lock a door to save patients or yourself, you do it—you do whatever you have to do. I wish we could make it easier. I can’t put a deadbolt on fire doors because of the code, but in this particular case, what’s the difference if I put a chain on the door or I take my belt off and tie it around? That takes time. If I can’t get it done fast enough, then I’m dead and everybody behind that door’s dead. Why couldn’t I just put a deadbolt on it? So I’m wrestling with that. I’m talking to some of the fire marshals around here. They get it, but because of the way the code’s written, we don’t have that option. We need to sit down and think about what we need to do.

What about the fight scenario?

This is a measure of last resort. The message there is just because a door has a lock on it doesn’t mean it can’t be breached. Once you’re in there, what do you fight with? And this is the fight of your life, for your life. What can you fight with? Your name badge, your shoes, your belt, your pen, your wedding rings. Pee in a cup and throw it in their face. Hydrogen peroxide, alcohol hand sanitizer. You’ve got to make a plan. Go into a room and you look around and you give yourself 10 seconds to figure out what you can fight with. We’re training you to win.

Beyond the human side—training people how to respond—what structural changes can be made to save lives in these situations?

Just breaking the field of view. As an example, if you’ve got somebody who comes in with a long gun and there’s a countertop that’s 12 feet long and it’s wide open, they have nothing stopping them from just making a sweep with that firearm and continuing to shoot. So we talk about creating barricades. We talk about if you have to get up and run a long distance, what can you do to break up that view? We talk about changing the culture on locking doors. We talk about where to put up cameras.

Patients are obviously a high-risk group in emergency situations, with some of them immobile. Does your training address patient safety?

Yes, and that’s a tough one. You want employees to know that they need to go home tonight, that being a hero and shielding somebody with your body doesn’t do anybody any good because if the shooter has any kind of decent handgun or rifle, they’ll get two people with one shot. You can’t sit there and try to round up patients when the shooter is nearby because you’re a target yourself, and we don’t want you to be a target. The most important thing you can do is get to a phone and call 911. If there’s a mass notification system in the facility, you need to be able to access that, too, so if the shooter is on the first floor, the folks on the other floors can get themselves and patients behind doors and to safety.

ANGELO VERZONI is staff writer at NFPA Journal. Top Photograph: Thinkstock