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Illustration by Sam Ward

Hide. Hide. Hide.

When Michael D’Angelo, CPP, was tasked with creating an active shooter response plan for six Miami-area hospitals, he turned to the U.S. Department of Homeland Security’s (DHS) “Run. Hide. Fight.” training. At the time, D’Angelo was the manager of emergency preparedness and security for Baptist Health South Florida, which has hospital facilities in three counties. But when D’Angelo and a team of stakeholders looked at the verbiage of the DHS active shooter response program, they realized it didn’t suit the hospital environment.

The “Run. Hide. Fight.” training instructs people who find themselves in an active shooter scenario to flee the threat if possible. If not, they should take cover. As a last resort, they should be prepared to fight the gunman. “Most of the hospitals around the country are writing their active shooter policies based on the DHS guidelines, which have been out for three or four years now, but the problem is those are very cookie cutter,” explains D’Angelo, who is now the director of security at one of Baptist Health’s hospitals. “They give it to school systems, healthcare systems, everybody. It’s kind of that one-size-fits-all response plan to an active shooter.”

The recommendation to flee the shooter isn’t logical in Baptist Health’s multistory hospitals, D’Angelo notes. Complicated layouts combined with areas designed to provide clear line-of-sight create a dangerous environment for those attempting to flee a shooter.

Likewise, D’Angelo and his team agreed that telling hospital staff to fight an active shooter was too much of a risk. “Even though it’s prescribed as a last resort, we had that feeling that by talking about it, you almost plant this subconscious belief in the staff that they have some kind of obligation to end the incident, which is a difficult thing when it comes to clinical caregivers, because they’re taught to put the patient first for everything. So now you’re going to empower them with this belief that they are going to have to stop the shooter to protect the patient. And this is the one scenario where they have to put their own life before the life of their patient.”

In fact, D’Angelo says convincing staff to put themselves first in an active shooter scenario has been one of the most challenging aspects of creating a response plan. Staff can’t help patients if they themselves are injured, and tak­ing the time to hide slow-moving patients imperils everyone.

Ultimately, D’Angelo and his team agreed that the only applicable aspect of DHS’s recommendation was to instruct the staff to lock the doors, turn off lights and any unnecessary machines, and shelter in place until police arrive. They call it the “Cease to Exist” approach, and it has received buy-in from local law enforcement.

Baptist Health’s six hospitals sit in five different police jurisdictions, so D’Angelo and his team had to meet with each police department to make sure the plan fit in with each department’s active shooter response strategy.

“From law enforcement’s perspective, our plan seems to fit because their point of view is, we need you and your staff to be out of the way, not in the hallway, not running and distracting us, so we have as empty and clear a path to getting to the shooters as fast as we possibly can,” D’Angelo explains. “If anything, our response program speeds up their plan and effectiveness of ending the incident as quickly as possible.”

D’Angelo notes that local law enforcement has changed its active shooter response to provide more immediate assistance to shooting victims. In the past, fire rescue and paramedics would not enter the area until police had cleared the entire building, but the wasted time turned casualties into fatalities. Now, emergency response is coordinated so that fire rescue and paramedics follow behind police as they move from room to room, so that the police can focus on finding the shooter while rescue teams can safely attend to casualties. 

“We’re doing our best to get that point across to our staff that fire rescue is go­ing to come onto the scene with law enforcement as soon as possible,” D’Angelo explains. 

The discussion about having a proactive versus passive response to an ac­tive shooter goes hand-in-hand with the debate over whether hospital staff or security officers should be armed, D’Angelo notes. Baptist Health does not arm its security staff based on data: 50 percent of emergency room shootings in the U.S. involved a police or security officer’s firearm, which was either stolen to shoot victims or used by security to fire at an assailant, according to a Johns Hopkins report. “If I can guarantee a 50 percent less chance of a shooting taking place in my ER by not arming my security staff, then why would I do it? Based on raw data, I can’t see how having armed security forces is going to be the answer,” D’Angelo says.

Within the hospitals, there has been mixed response to the “Cease to Exist” approach. Some departments want to see more in the way of training and education, because they feel the staff should take a more proactive approach to a potential active shooter. D’Angelo reiterates that staff should help protect patients only if they can simultaneously protect themselves. “I guess nobody wants to address that real gray area of saying we leave the patients on their own, because some of them can’t help themselves, but you do the best you can to protect both of you if it’s realistic to do so,” he says. 

But for nurses with three or four patients, running from room to room and concealing each of them may be counterproductive.

There has been significant dialogue between Baptist Health leaders and staff about the “Cease to Exist” response, but D’Angelo says that Baptist Health prohibits active shooter drills. He describes one “disastrous” active shooter exercise a few years ago where, instead of causing chaos throughout the hospital, the code elicited almost zero response from the staff. 

“We quickly learned that the staff is alarm fatigued,” D’Angelo says. Infant abduction drills, fire drills, and [other mandated exercises] mean that every code is a drill until proven other­wise. “With something as significant as an active shooter, we absolutely couldn’t have that attitude. There’s only one way to guarantee that when staff hear that code, they will know that someone is actually shooting—and that is to prohibit exercising the code.”

D’Angelo acknowledges that Baptist Health is taking an unusual approach by not following DHS’s “Run. Hide. Fight.” program, but he notes that even DHS says it’s not a one-size-fits-all policy. “We took the time to look at it,” he explains. “If you automatically adopt the DHS policy and turn that into your in-house policy, you may be prescribing something to your staff that may be doing more harm than good.”​ ​