CODE SILVER: Responding to an Active Shooter as a Travel Nurse

It’s an all-too-frequent event in America: we turn on the TV or look at our phones and see that another mass shooting has happened. We see the photos of victims and watch footage of family members grieving. We learn the details: how it started, what happened, and how it ended. It’s inevitable that we begin wondering how we’d respond in a similar situation. Would we hide? Flee? Take a bullet to save another person’s life?

As a medical professional, an active shooting places you in a unique position. In nursing school, you may have taken the Nightingale Pledge. If you did, you recall it includes a promise to devote yourself to “the welfare of those committed to my care.”

The pledge means different things to different people, and that’s okay. When it comes to a crisis, none of us can know exactly how we’ll act. (Self-preservation is an instinctual survival act.) If you find yourself in the worst case scenario, preparation is key. Read on to learn how to protect yourself and help others.

First, some facts about active shooters in hospitals:

While the odds of a shooting in a hospital are low, a few high-profile shootings have made the news. One was the 2015 shooting of Dr. Michael Davidson, a cardiovascular surgeon. The assailant was the son of one of Davidson’s former patients. In another event, a Texas gunman fired shots due to frustrations over a long emergency room wait time. And just recently, three were killed at a shooting in Mercy Hospital in Chicago.

Typically, the shootings that do occur result from personal (and “directed”) conflicts, rather than random or ideologically motivated acts. A 2012 study found emergency departments are the most likely setting of gun violence (29%). From 2000 to 2011, of 154 hospital-related shootings, 41% on outside grounds, and 59% within the hospital. Hospital employees made up one-fifth of victims.

So, what if there’s an active shooter at your hospital? Here’s what you need to know.

Depending on your facility, you may hear the Code Silver or Code Grey to announce an active shooter’s presence in the hospital. Some facilities may also skip codes and use plain language to make an announcement, depending on the situation.

In most settings, the standard response to a shooter is Run, Hide, Fight. (See this guide from the Department of Homeland Security for a detailed explanation.) In this scenario, there are three tactics:

• First, if possible, run. Leave the building, and take shelter far from the event.
• Second, If there’s no safe path out of the building, find a place to hide. This should be a room without interior windows and with a lock on the door. If there’s no lock, barricade the door. Stay in place until you are instructed to leave by law enforcement agents.
• Third, if you do come in contact with the shooter, fight. Charge the shooter and recruit others to help you. Use whatever you can find as a weapon: a fire extinguisher (sprayed in the eyes or thrown), scissors, or even a pen.

In a hospital setting, you may decide to take on additional responsibilities. This may be especially true if you’re around vulnerable patients who need assistance and can’t run, hide, or fight. Here are a few things you can do to help:

• Activate all security doors to your unit.
• Barricade any unprotected areas/rooms, especially in areas where there are vulnerable patients.
• Stay on the phone line with emergency personnel (only if you can do it from a safe space, far from the shooter).

Your hospital will also be taking steps to prepare staff for the possibility of an active shooter on grounds. Consult with your supervisors and co-workers to learn more about the hospital's policies on the following:

• Prevention, communication, and response. What steps does the hospital take to keep threats at bay, including security personnel and other security measures? Who is responsible for communicating with authorities if a situation occurs? How will patients and staff know when the threat has passed? What areas are safe shelters?
• Assessment of risks. How has the hospital performed on past risk assessments? Were any potential vulnerabilities found? If so, what were they?
• Workplace violence training. Does the hospital offer employees any training on conflict resolution? What’s the protocol for reporting threatening behavior?

• Drills. Does the hospital offer any training on how to safely respond, protect patients, or manage casualties in the event of a shooting?

Additionally, you will want to take practical measures to prepare yourself for responding to an active shooter or other crisis. As a travel nurse, you face the challenge of new surroundings with every new assignment. Take time to explore each new hospital. You’ll want to learn about:

• Emergency exits and stairwells.
• Areas where there is a lot of exposure — you’d want to avoid these in an active shooter situation. (Glass atriums, cafeterias, open stairwells, fenced yards.)
• How to operate phone systems.

In the event you ever witness a shooting in a hospital, you will likely be asked to complete an incident report. These reports help managers learn from the incident and prepare for future events.

What if your hospital is facing a mass casualty situation due to a shooting nearby?

While some debate whether mass shootings are becoming more and more frequent, statistics show they’re becoming deadlier. The 2017 and 2016 shootings in Las Vegas and Orlando were the highest casualty events on record.

Most hospitals have mass casualty drills on a regular basis. With education, you can learn how to respond in a mass casualty crisis. For more, see our post on Triage in a Mass Casualty Scenario: What to Do Differently.

If you’d like to see more articles on Emergencies, click here.