Hospitals and Mass Shootings

March 27th, 2018 by CHHS RAs

By CHHS Extern John Travers

Mass shootings are a recurring issue in American society and thus have provided impetus for hospitals to reexamine their ability to respond effectively after such events. The verdict seems to be a mixed bag as administrators, doctors and other professionals struggle to plan for the unthinkable. Dr. Jeremy Samuel Faust, an emergency medicine physician at Brigham and Women’s Hospital in Boston and an instructor at Harvard Medical School writes “In moments like these, doctors, nurses, and technicians lean on their training for most of the required actions. But … there are intricacies that could never have been predicted.” Although it is certainly true that some details can never be accounted for, especially in such an extraordinary situation, this does not mean that the issue does not warrant further investigation and the system greater improvement. So, what can really be done to help hospitals cope with mass shooting events? It is a more complicated question then most are aware.

The first and perhaps greatest impediment to improving hospital response to mass shootings is that very little data exists on the issue. The lack of data can be attributed to Representative Jay Dickey, a Republican from Arkansas who lent his time, effort and eventually his name to the Dickey Amendment. The Dickey Amendment stipulated that Centers for Disease Control (CDC) funds “may not be used to advocate or promote gun control.” This amendment, enacted in 1996, has been interpreted to be a bar on all studies related to gun control and subsequently gun violence. Thus, reports and statistics on gun violence can be scant as Congress refuses to appropriate money to research gun-related matters. Doctors across the nation have therefore called for funds to be unfrozen with regard to firearm research, declaring “we lack critical information on the epidemiology of firearm violence and on the effectiveness of various strategies to prevent it.” It is unknown at this time the outer limits of the Dickey Amendment because it is interpretative. Traditionally, it has been used creatively to stop any imaginable form of gun research. However, research has been done in the area of hospital surges which are of course an issue essential for improving responses to mass shootings. However, such studies often revolve around other base disasters. For example, the CDC had conducted research regarding hospital research as a result of communicable diseases. Although perhaps useful, such studies only have the strength of analogy and cannot really get at the heart of the mass shooting epidemic. The Dickey Amendment has come at a major cost as Americans have a unique gun problem in the western world, even if you were to exclude these waves of mass shootings. The first step to solving any problem is to understand the problem and to attack it intelligently and with precision. This is not and will not be possible until the CDC can be allowed to do research and publish findings on gun violence.  Due in large part to the Parkland School Shooting, legislators and medical experts have renewed their calls for the CDC to resume studies on gun violence. However, it is unknown as of now if these calls will yield results as several other measures to curb gun violence have already failed.

Lack of information does not foreclose the need for improvement in hospital response, and thus every hospital must prepare for such eventualities as best they can despite a lack of on point data. Doctor John Hicks, the medical director for emergency preparedness at Hennepin County Medical Center, notes that perhaps the greatest difference between effective and ineffective hospital response to mass shooting scenarios is if surgical response drills were made a priority in a given emergency room. He continues, “So just looking, you know, at the resources kind of top to bottom and figuring out from a space, from a staff, from a stuff standpoint, do I have the things that I need in place that if something like this goes down, you know, are we going to be prepared?” Therefore, what is most important is that the hospital be adequately prepped in how to handle a mass shooting event. Additionally, supplies need to be well-maintained and abundant enough to withstand an explosion in emergency patient populations. The Centers for Medicare and Medicaid Services (CMS) put out regulations on hospital emergency preparedness and a checklist to be used in trainings and real-life

Standard operating procedure has, in the past, dictated that EMS staff wait until law enforcement have cleared the threat or threats in a live mass shooting scenario. However, some in the medical community have called for a reexamination of this commonplace procedure in the interest of saving the most lives possible. Dr. John Hicks argues, that these typical formulations need to be reconsidered. He says, “too many times the active shooter incidents have been scenes where EMS has not been allowed to enter until law enforcement is content that the threat has been completely neutralized and that the entire building has been swept. And during that time, people die.” According to Dr. Hicks, a compromise between barring EMS entirely and allowing EMS unfettered entry into an active shooter scenario needs to be a made. He suggests creating what he called a “warm zone” or an area on the scene of an active shooter scenario that has been secured. EMS would be able to search these areas for injured. Additionally, Dr. Hicks advises that more effective communication needs to be a priority between EMS and law enforcement so that they may work as one rather than distinct operations.

It is clear that hospitals need to be ready at all time for potential mass shooter scenarios. However, it is also apparent that a hospital’s reaction to a mass shooting  needs to be planned for as meticulously as possible to prevent further loss of life. Reforms can and should be made in hospital preparedness and EMS on-site response, but it is certainly the bedrock of any positive reform that it be made on sound logical ground supported by evidence. Sadly, evidence for what would help first responders save the maximum amount of lives is scarce because of the Dickey Amendment. Thus, repealing the Dickey Amendment is the single greatest stride forward our country can make to ensure that hospital response is effective when the worst happens.

Update-

The Omnibus Spending Bill President Trump signed recently has language that some have stated opens the possibility to reexamine the Dickey Amendment. Former CDC National Center for Injury Prevention and Control Director Mark Rosenberg, says that this is a big positive step. He believes that this Omnibus Bill text shows Congress’ intent to fund studies on gun violence in the future. However, optimism should be tempered as it is up to Congress to fund the research which will likely be another partisan debate.  

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