By Gary Evans
A hospital is not a fortress barricaded against violent entry. Quite the opposite — its raison d’etre is to “admit” people and heal them. But it has become increasingly apparent that mass shooters and their violent ilk see healthcare facilities, much like schools, as soft targets.
A rundown of healthcare shootings in the last few years reads like a forensics report, so disturbing it might as well be illustrated with those old chalk outlines of bodies no longer used by investigators. Even as this report was being prepared on Nov. 17, 2023, a gunman entered the lobby of the New Hampshire State Hospital in Concord and killed a security guard before being shot dead by a state trooper at the scene.1 Motive, connections to the hospital, intended targets, and other details were still under investigation. Sometimes, these cases are not clearly resolved.
That was not the case last year in Tulsa, OK, where the killer stated his intentions in a note found on his dying body. Consider a brief post-mortem on this incident.
On May 19, 2022, the late Michael Louis went to St. Francis Hospital in Tulsa for back surgery. The orthopedic surgeon was the late Preston Phillips, MD, who was by all accounts well-regarded by staff and patients. According to police reports, Louis was discharged on May 24 but continued to complain of pain and call Phillips’ office. The surgeon saw Louis again on May 31, trying to alleviate some of the pain and help the 45-year-old patient.
At 2 p.m. on June 1, still agitated and complaining of pain, Louis bought an AR-15 semi-automatic rifle after purchasing a semi-automatic 40-caliber pistol a few days prior. In the afternoon of that first day in June, armed with both weapons, he entered the Natalie Medical Building, a five-story labyrinth of medical offices on the hospital’s campus building.
“[This building] has numerous offices, rooms, hallways and so forth,” Tulsa police chief Wendell Franklin said in a news conference after the shootings. “It is an exceedingly complex environment for an officer in a tactical situation to deal with.”2
Significantly, Louis entered through an unlocked access door to the 2nd floor from the parking garage. At 4:53 p.m., the Tulsa Police Department received a 911 call about a shooter in the medical building. The call was from a patient who had been on a telehealth visit with an unidentified physician when shots rang out. As more information came in, the police knew the shooting was on the second floor.
Police were on the scene within minutes. They entered through the 1st floor entrance and began shouting “Tulsa police” as they advanced up to the second floor. As they grew closer to Louis, they heard a single shot, as the shooter apparently attempted suicide and died shortly afterward in a hospital.
“We found the suspect and we rescued a female who was hiding under a desk at the suspect’s foot,” Franklin said. “She was there when the suspect took his life. She did not appear to be injured.”
Officers also located another deceased victim next to the shooting suspect. As officers continued to clear the building, they located Dr. Phillips, fatally shot in an exam room.
“We also found a letter on the suspect which made it clear that he came in with the intent to kill Dr. Phillips and anyone who got in his way,” Franklin said. “He blamed Dr. Phillips for the ongoing pain following the surgery.”
Three other fatalities included Stephanie Husen, MD, receptionist Amanda Glenn, and William Love, a patient of Phillips. In a prior social media post, Love said he was happy with Phillips care and spoke highly of him. “I had major back surgery in February 2021. Still doing follow-up appointments and making great progress to full recovery. All thanks to an excellent orthopedic surgeon.”3
Faced By a Gunman
Susan Strauss, PhD, RN, a consultant and trainer on healthcare violence, recently advised a webinar audience what to do when faced with a gunman.4
“Do not ever try to disarm the aggressor,” Strauss emphasized. “Do what you are told. Don’t make any sudden moves. Remain calm. Speak softly. Respect their personal space. Try to buy as much time as you can — one of the ways you do that is by asking questions. Remember that you’re going to focus your eyes on the person, not on the weapons. That might be hard to do.”
In asking questions, the goal is to get “yes” answers to simple, non-threatening queries like, “Can we sit down and talk about this?” It is critical not to argue, contradict, or in any way shame the armed perpetrator.
“You don’t need to be the hero here,” Strauss said. “Do not make physical contact with that individual. That could be a trigger. I know for me I tend to want to reach out and touch as a supportive gesture of compassion. Don’t do that. Do not say to them, ‘I understand just how you feel,’ because you don’t understand. Don’t ever say that.”
You might try to show empathy by saying something like, “I think if I was in your spot I would feel the same way,” Strauss suggested.
These tactics generally apply if an employee is in a threatening situation with an unarmed patient or visitor who is angry and potentially violent. If possible, flee and call for help. If the potential assailant is between you and the door, continue trying to de-escalate them and try to warn co-workers, if possible.
“Say you’re in a patient’s room and you are not by the door,” Strauss said. “You’ve got a family member that has come very close to you, is pointing his finger in your face, and you can tell it’s going to be bad. How do you warn other co-workers? How do you call for assistance? It is not always easy.”
Some rooms may include panic alarms or ways to silently alert staff, but the key moments with the aggressor require critical control.
“How do you remain calm and polite when you’re quite sure somebody’s going to bonk you one in the face?” Straus asked. “Establish eye contact, but you don’t want to stare. It’s a relaxed eye contact, and you may even look away briefly for a second or two so that they do not feel threatened by your eye contact. Of course, keep an even tone of voice.”
Try to begin moving away from the person, at least a safe distance — and all the better if you can get near the door.
“Never consider physical force as your first response,” Straus said. “In hospitals, you’ve got patients to consider. It’s not just you. It’s patients as well. You’ve got to create a process for this. Is there a way that you get them out of bed if they’re immobile? Then, do they go into a closet or a bathroom so you can close the door? These are all things that you’ve got to determine.”
Domestic Violence Comes to Work
Domestic or intimate partner violence frequently spills over into the workplace and should be addressed in hospital planning to protect staff.
“Over half (55%) of homicides of women are related to intimate partner violence, and half of those are due to firearms,” researchers reported. “Nationally representative data indicate that the share of women who report their physical or mental health to be poor is three times higher among women with a history of intimate partner violence compared to those with no history of it.”5
Since the broad majority of healthcare workers are women, domestic violence follows them to work in the form of stalking, harassment, threatening communications, and assaults. “The perpetrators use the workplace as a venue to harass their victim, to intimidate them,” Strauss said.
Depending on state laws, healthcare employers may be able to take out a restraining order on behalf of the employee. “But be sure you check with the employee to make sure that [restraining order] is not going to jeopardize her safety,” Strauss suggested. “How about escorting them to the parking lot and giving them parking spaces close the building?”
Granting these victims flexible worker hours may help, as will removing their name from the hospital directory, screening phone calls, and assigning them a new email address.
Thoroughly evaluate violent incidents of any type and consider forming a committee to review trends and address interventions like alarm systems and inadequate lighting.
”Do you have closed circuit video?” Strauss asked. “Do you have safe rooms? This is something that all hospitals should have, and it needs to be communicated where they are located. There should be at least one on each floor so that people can run to safety and get [behind] locked doors.”
In addition, review staff injury reports for signs of violence and check into complaints by patients and by staff. Assess risks and survey staff about the threats they perceive.
“I would do some qualitative research first by doing some [in-person] interviews and gathering whatever information you can,” Strauss recommended. “You can use that information in creating your staff survey.”
Vaughn Baker, CEO of Strategos International, warns that active shooter events set off a “normalcy bias” in untrained staff, who assume, for example, that the sound of gunfire is fireworks. Thus, training drills are critical to prepare for an event that is becoming less rare in healthcare settings. Instead of the familiar “run, hide, fight mantra,” Baker teaches a “nonlinear” approach with three components: lock out, get out, and take out. This includes locking the area you are in if possible, getting out if that is not possible, and fighting back as the final option.
Response Update
In a 2023 update of active shooter responses for hospitals, researchers warned, “Because active shooter events are now a common occurrence in the United States, all healthcare facilities must prepare to limit damage and death. Law enforcement officials now actively assist the hospital administration in planning and guidance in dealing with active shooter events. There is no one-size intervention that fits all healthcare institutions and one must take into account the size of the hospital, the different departments, geographical setting, patient access, available security and exits, and location of staff offices.”6
In terms of planning and training for an active shooter, the authors recommend:
- establishing a framework for dealing with active shooters, including all staff;
- creating multiple scenarios and practice routines;
- inviting law enforcement to help develop a robust program;
- creating a culture of reporting without reprisals;
- requiring employees to wear name badges with photo identification that can be reprogrammed to block a former employee from entering the hospital;
- ensuring employees can report suspicious activity or an individual;
- creating maneuvers to keep all doors closed and/or locked during active shooter events;
- developing a protocol for evacuation;
- educating employees on self-defense.
REFERENCES
- Duckler R. Bradley Haas, the security guard killed on Friday at the New Hampshire State Hospital, lived his life in service of others. Concord Monitor. Nov. 19, 2023.
- Officials provide updates after multiple people were killed in a shooting in Tulsa, Oklahoma. ABC 33/40. June 2, 2022.
- McBride J. Dr. Preston Phillips: Tribute to Tulsa shooting victim. Heavy. Updated Aug 5, 2022.
- Strauss S. The unthinkable: Violence in healthcare from bullying to an active shooter. May 2023.
- Rivara F, Adhia A, Lyons V, et al. The effects of violence on health. Health Aff (Millwood) 2019;38:10.
- Schwerin DL, Thurman J, Goldstein S. Active shooter response. StatPearls. Last Update: February 13, 2023.
A hospital is not a fortress barricaded against violent entry. Quite the opposite — its raison d’etre is to “admit” people and heal them. But it has become increasingly apparent that mass shooters and their violent ilk see healthcare facilities, much like schools, as soft targets.
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