By Gary Evans, Medical Writer
It keeps happening.
Violent attacks on healthcare workers in 2022 included a gunman who shot two physicians, a receptionist, and a visitor at Saint Francis Health System in Tulsa, OK, on June 1. One of the doctors was a surgeon the gunman targeted after complaining of pain from a back procedure. The shooter, who bought a semiautomatic rifle early that day, killed himself on the scene as police arrived. With four healthcare workers killed, the Tulsa attack is one of the worst ever in a healthcare setting.1
On Oct. 22, 2022, a gunman visited his girlfriend in a labor and delivery room at Methodist Dallas Medical Center. He accused of her of infidelity and killed a nurse and a social worker who entered the room. He was shot in the leg by a security guard and taken into custody.2
In addition to the long-documented physical assaults and verbal aggression, these incidents underscore the relatively rare but real risk to healthcare workers of an active shooter in the building.
“Healthcare is the second leading incident location of frequency that these incidents occur,” Vaughn Baker, CEO of Strategos International, said at recent webinar sponsored by the Association of Occupational Health Professionals in Healthcare (AOHP).3 “Not just active shooters, but for any incident of violence, assault and otherwise. In fact, statistically, people who are in the healthcare field are No. 2, behind taxicab drivers, as far as who’s most likely to be involved in an incident of assault.”
Low Risk, High Consequence
While active shooter events in general seem to happen frequently, the odds are exceedingly low that a healthcare worker will be killed in such an incident.
“Your odds [of dying] as a result of workplace violence by an active shooter event are 184,000 to 1,” Baker noted. “Every single year, between 800 and 1,000 people lose their life as a result of homicide in the workplace. Your odds of losing your life at work as a result of workplace homicide are very, very low. But that doesn’t mean we shouldn’t prepare for it.”
Factor in this question: “What would the consequences be if it did occur, and we were not ready for it?” Baker asked. “The consequences of not being prepared are too great.”
There is a lot of talk of preparedness and policies, but unless staff are trained for an active shooter incident, the response could just be general panic. For those who have never experienced or studied theses shootings, the rapid gunfire is startling. In the Virginia Tech shooting in 2007, 26 shots were fired in 52 seconds by the attacker, Baker noted.
“Think about it — in less than a minute, how many people lost their lives,” he said. “If our plan is simply to call 911 and wait, that’s a plan that’s going to fail. The average response time by law enforcement is four to nine minutes.”
Thus, preparation is necessary. The first step is conducting a facility risk vulnerability assessment. “We look into things like access control and visitor management,” Baker explained. “What are your processes there? Have you identified safe rooms within your building? How do you prepare those safe rooms where people could go in an event they find themselves in the middle of a violent intruder event?”
High-Risk Terminations
After the assessment, create a workplace violence program manual. Many facilities mistake this for an anti-bullying or harassment policy, Baker said, but a violence plan should address specific incidents that raise risk, like “high-risk terminations” of employees with a checkered behavioral history. Firing these workers creates the potential for a violent reaction, particularly if there is a history of alcohol and drug abuse, frequent conflicts with colleagues, financial stresses, or marital problems.
One of the worst workplace attacks involved a high-risk termination, although the worker at a Virginia Beach Municipal Center quit via email before he could be fired. He had several confrontations with colleagues in the immediate days preceding the May 31, 2019, attack. Twelve people were killed and four injured.4
“This guy had been an engineer there for 15 years,” Baker said. “They thought they were going to have to terminate him and had police there. They thought he might get physical and violent, but when he resigned by email, the police officers left.” Instead, the man came at the end of the day, right before closing time, and began shooting indiscriminately.
Domestic abuse demands a separate policy to prevent it from spilling over into the workplace. “An example of that would be a female [employee] who is afraid of her significant other,” Baker explained. “She’s so afraid that she ends up getting a protection order against them, and she moves. He does not know where she lives but guess what he does know? He knows where she works.”
Educate healthcare employees and encourage them to share when they are victimized at home in a domestic violence situation. “We want to educate our employees that we can help them through our employee assistance programs. HR and supervisors can assist them,” Baker said. “If you look at the statistics, one in four women report being a victim of domestic abuse at some point in their life.”
Normalcy Bias
Active shooter events often set off “normalcy bias” in potential victims, a process of rationalization and disbelief that delays reaction and response.
“Normalcy bias gets more people hurt and killed than any other phenomenon in active shooter events,” Baker noted. “It is the mental state of denial that individuals enter into when facing disaster or impending danger. Normalcy bias leads people to underestimate, minimize, or even rationalize the crisis away.”
Normalcy bias is common in many crisis situations but has been particularly reported in active shooter events. An attack at Wedgwood Baptist Church in Fort Worth in 1999 is perhaps the most compelling example, as many did not flee from an ongoing youth celebration because they thought the shooter was part of a skit. Even a man who was shot twice said that the man was using a paintball gun.5
“Even though he’s been shot twice himself, he still cannot accept the crisis, because he’s so biased to the normal taking place, he can’t accept what’s really happening here,” Baker said. “It was reported that multiple attendees of this event ran toward the gunman, yelling and waving their arms saying, ‘Shoot me, shoot me!’ They wanted to be part of the skit as well.” Seven people were killed before the gunman then sat in a pew and shot himself in the head.
Another common example is the assumption the gunfire sounds like fireworks, even if the shooting occurs at a time and place that fireworks would not normally be set off. At Virginia Tech, some of the victims thought the shooting noise was coming from an ongoing construction project right next to the building.
Threat Recognition Training
With as many of these attacks that have occurred, one would think the normalcy bias would start shifting toward immediately suspecting a shooter. That has not happened, but people can be trained to recognize normalcy bias and err on the side of threat recognition.
“There’s two categories of people in these crisis events — those who are untrained and those who are trained,” Baker explained. “Psychologically and physiologically, untrained people do not respond — they react based on their instincts. They experience normalcy bias, and when they finally accept the crisis, all they can do is panic.”
This can manifest as frozen in place or running toward the danger instead of away from it. In contrast, trained healthcare workers accept the crisis and consider their options. “Trained people respond based on their training,” Baker said.
Ideological attackers are people who are motivated by extremist world views that may be religious or political. Most attacks in the United States are perpetrated by “traditional” mass shooters, who typically hold a life-long self-perception as a victim.
“Many of these attackers blame others for all of their long list of failures and their long list of personal problems,” Baker said. “It’s always somebody else’s fault. That’s how these guys think.”
Thus, they want to go from victim to victimizer, and they pick soft targets to maximize the body count and possibly aspire to records set in previous attacks. “Many of them do not plan an escape strategy, even though they spent days, weeks, and months planning the attack itself. They don’t plan their escape because their escape strategy is to shoot themselves,” Baker said. “Many of them do this. If our attackers are going to show a high level of preplanning and commitment, we should do the same.”
Instead of the familiar “run, hide, fight mantra,” Baker teaches a “nonlinear” approach with three components: lock out, get out, and take out.
“It depends on, first, where you are in relation to the attacker at the time you perceive the threat,” Baker explained. “Two, what environment are you in at the time you perceive the threat? No matter where you find yourself, the three options must be considered.”
- Lock out: “How can I lock out the area I’m in?” Baker asked. “If you find yourself in a cubicle area, you can already answer that question. You know you have to ‘get out’ of that area — there may be an office right across the hallway that you can lock. Lock out is usually appropriate for an office or storage room — somewhere that has a door that can be secured in some way.”
- Get out: “If you’re in area that can’t be locked out, maybe there’s another area you can go to lock out,” Baker said. “If you happen to be next to an exit door to get out of the building altogether, that is an option as well. But if you’re on the second or third floor or higher, I would not recommend using the ‘get out’ option to get out of the building altogether. Why? Because you’re going to have to go down the elevator, a few hallways, stairways — you’re going to be exposing yourself to the attacker. If you run across the attacker at that point, you just put yourself in a really bad position.”
- Take out: “Take out” is fighting back. “I want you to understand why it is important to fight back. Who in your life is worth living for? That’s why you fight back — that’s the motivation,” Baker explained. “I tell you the same thing I tell my wife: If you ever find yourself in a situation where it’s time to fight back and take out — because you don’t have a choice — remember ‘take out’ is a last resort. I say you may get beaten, but you better get beaten doing something. Don’t get beaten doing nothing, begging for your life in the fetal position underneath a desk. It’s time to fight. You, one, two, three, or four people willing to fight for their lives — that’s a formidable force and that’s not a theory. We’ve seen multiple incidents that were stopped by people willing to fight back.”
REFERENCES
- Hanna J, Watts A. Gunman who killed 4 at Oklahoma medical building had been a patient of a victim, police chief says. CNN. June 2, 2022.
- Bleiberg J, Stengle J. Police: Boyfriend at Texas hospital for baby’s birth kills 2. AP News. Oct. 24, 2022.
- Association of Occupational Health Professionals in Healthcare. Workplace violence active shooter response. Oct. 24, 2022.
- Chavez N, Simon D. It was a normal Friday at the Virginia Beach Municipal Center. Then someone started shooting. CNN. June 3, 2019.
- Vernon C. Wedgwood survivor speaks to crime victims. Palestine Herald-Press. April 21, 2012.
Violent attacks on healthcare workers in 2022 included a gunman who shot two physicians, a receptionist, and a visitor at Saint Francis Health System in Tulsa, OK, on June 1. In addition to the long-documented physical assaults and verbal aggression, these incidents underscore the relatively rare but real risk to healthcare workers of an active shooter in the building.
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