The best strategy for addressing extreme violence, including a shooter, in the ED is preparation via a frank, assumption-busting—for example, rivals of injured gang members typically pose less of a threat than intimate partners of abused patients—threat assessment in conjunction with local law enforcement, according to Howie Mell, MD, MPH, an emergency physician who investigated the Columbine, Aurora, and Virginia Tech mass shootings. “Take a good look at what your lockdown policies are, where your risks are, where your vulnerabilities are,” he said. When shootings occur or are suspected in the ED setting, Dr. Mells says it’s crucial to escape the scene and then call for help, adding that he doesn’t believe providers can protect their patients by their presence in such situations. He also recommends running to a radiation room when escape from the ED isn’t possible, noting that strong, lead-lined walls provide extra physical protection and that radiation rooms tend to lack external glass windows. The goal of hiding, he says, isn’t to remain unfound but to put up barricades between yourself and the shooter. When confronted by a shooter, Dr. Mell urges fighting for one’s life. “I happen to like fire extinguishers when it comes down to fights because you can spray a fire extinguisher into the person’s face, and then you’ve got a big heavy piece of metal that you can hit them with,” he said.
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