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What is the Healthcare Provider’s Role in an Active Shooter Incident?

Debra Cascardo

Debra Cascardo, MA, MPA, CFP, and a public member of the American Board of Disaster Medicine (ABDM), has written several articles on disaster preparedness but believes that one particular type of disaster now demands special attention – the active shooter incident. Recently, the American Board of Physician Specialties® (ABPS), of which the ABODM is a Member Board, sat down with her to discuss the healthcare provider’s role in these random acts of violence.

ABPS: We know that organizations across the country, like schools, government facilities, and companies, have developed plans to address active shooter incidents. How would a medical organization’s plan differ from any of these?

Cascardo: As with all disaster preparedness, an effective response starts with advanced planning and training. Whether the emergency is a natural disaster or is manmade, a medical facility should have comprehensive policies and procedures in place to continue clinical care during the emergency while protecting patients’ health information. Every medical organization should have a section in their plan called Active Shooter – Emergency Preparedness Compliance Plan. That’s because, during an active shooter incident, our natural reaction is fear and anxiety. There’ll be gunfire, alarms, shouting, patients in disbelief, or panicking. What training does is allow the medical staff to act despite all this chaos. With proper training, the staff will act automatically according to this training rather than react with denial or helplessness. 

ABPS: Given the healthcare professional’s duty to care for patients, should a disaster plan for an active shooter situation be essentially the same for all medical organizations?

Cascardo: A medical facility’s plan would ultimately depend on factors such as size, type, and location, and whether there is security on the premises or law enforcement nearby. But every facility should take into account certain principles when creating a plan, and incorporate those that are most relevant. First, a plan should seek to maximize the protection of life. Secondly, medical staff should strive to evacuate as many people as possible out of harm’s way. Third, the plan must allow for decisions to be made based on staffers’ personal assessment of the situation. Related to this is the recognition that a decision to engage or fight the shooter may have to be made. And, finally, the ideal plan should emphasize the duty to care for patients and the best action to take to protect the most lives.

ABPS: As someone who has studied this issue in great detail, would you be able to recognize a potential active shooter? In other words, does a potential shooter fit a certain profile?

Cascardo: There is no known profile, but there are common warning signs. These include: behavior associated with the planning and preparation of an attack; an angry or emotional undertone; any behavior that suggests a desire to be a “pseudo-commando” and is closely associated with weapons or other military or law enforcement paraphernalia; and communication to a third party of an intent to do harm to a target through an attack.

ABPS: Any final thoughts on how medical organizations can best prepare for an active shooter situation?

Cascardo: The “active shooter” section of a health care facility’s policies and procedures manual should include goals, objectives, and courses of action. While these would be shaped by assessments at the start of the planning process, they would be updated by ongoing assessments. And, all stakeholders should provide planning input, from executive leadership and nursing to emergency management and local law enforcement. A facility should also share a draft of its plan with the local police and local fire department and ask for suggestions on how it could be improved. Finally, it’s imperative that practicing physicians, regardless of their specialty or practice location, be properly trained in disaster medicine because a manmade disaster like shooting incident can happen anywhere.  

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Far too often, medicine is led by less than 5% of non-practicing physicians taking away and replacing the voice of the 95% of physicians practicing and placing patient safety and care first on the front lines every day. The American Board of Physician Specialties has raised the standards in physician board certification not only in the quality of their boards of certification, but in hearing and allowing for the voice of those active physicians caring directly for patients. Having been a part of the ABPS over the last 28 years has allowed me to grow as a woman leader in a field often wrought with challenges. It helped me and others raise the bar of the standards of care in my specialty, Emergency Medicine, through their Board Certification in Emergency Medicine (BCEM). ABPS also helped raise the standards of care for 21st century medicine through their certifications in other specialties, particularly in Integrative Medicine & Disaster Medicine. Having physician voices heard matters to medicine and is essential in the betterment of patient safety and care.

Sarah E. Gilbert, MD, FAAEP
Sarah E. Gilbert, MD, FAAEP
Emergency Medicine
On October 18, 2007, President George W. Bush released Homeland Security Presidential Directive 21 (HSPD-21), calling on our nation, among other initiatives, to “collectively support and facilitate the establishment of a discipline of disaster health”. It is a great testament to the wisdom and foresight of the American Board of Physician Specialties that it immediately set to work and created, within the short span of only one year, an educational blueprint and set of certification examinations, both written and oral, for a new subspecialty of disaster medicine—and it is why I chose to be part this vital initiative and this wonderful organization. This is but one of the many innovative programs initiated by the American Board of Physician Specialties over the years, and why I am proud to support its work on behalf of our nation’s public health.

Art Cooper, MD
Disaster Medicine
When the American Board of Physician Specialties offered to host the American Board of Integrative Medicine, ABPS became a landmark organization working to move medicine into the twenty first century. Certifying physicians who have completed rigorous academic training in Integrative Medicine ensures that the field of Integrative Medicine will continue to develop academically, clinically, and professionally. The leadership of ABPS continues to impress me - they are diligent in constantly innovating to provide certifications for physicians who want to advance their careers and their areas of expertise. I am honored to be a part of this organization.

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Integrative Medicine
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Chris Kunis MD
Internal Medicine
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Jerry Allison, MD
Emergency Medicine
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Richard Paula, MD
Administrative Medicine
The American Board of Physician Specialties has provided me with the opportunity to demonstrate mastery of internal medicine through board certification. As a hospitalist, board certification is an expected credential, and hospitals recognize the American Board of Physician Specialties (ABPS) as one of the three standard credentialling bodies for Internal Medicine. Additionally, the ABPS has helped me develop leadership skills as a Board member and Committee Chairperson. ABPS has also helped me sharpen critical thinking skills as a test question developer and reviewer. The Allopathic (MD) and Osteopathic (DO) physicians in the ABPS are lifelong learners and frequently pursue multiple board certifications. I enjoy the camaraderie of my peers in ABPS.

Loren Jay Chassels, DO
Internal Medicine
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