EMS World Expo Quick Take: This is not a drill — Active shooter in the ED

Key takeaways and lessons learned from the 2018 mass shooting event at Mercy Hospital and Medical Center in Chicago


In early November 2018, staff at Mercy Hospital and Medical Center in Chicago completed a hospital-wide, OSHA-mandated active shooter training. Personnel at the 292-bed, Level II trauma center were taught procedures such as "run, hide and fight" to protect themselves and their patients in case the unthinkable were to happen. 

One week later, on Nov. 19, 2018, the unthinkable happened

Juan Lopez, the former fiance of Dr. Tamara O'Neal, showed up at Mercy's emergency department with a gun and threatened to kill O'Neal in the hospital parking lot. O'Neal called 911 and police were dispatched to the scene.

The Nov. 19, 2018 fatal shooting at Mercy Hospital and Medical Center in Chicago reflects the importance of preparedness, quick decision-making and flexibility for active shooter MCI response.
The Nov. 19, 2018 fatal shooting at Mercy Hospital and Medical Center in Chicago reflects the importance of preparedness, quick decision-making and flexibility for active shooter MCI response. (AP Photo/Amanda Seitz)

Lopez shot and killed O'Neal in the parking lot, then entered the ED and fatally shot Pharmacy Resident Dayna Less as she came off the elevator. Chicago police entered the ED and, while searching a hallway, Officer Samuel Jimenez was fatally shot by Lopez. A Chicago Police SWAT team came into the hallway shortly thereafter and ended the attack by killing Lopez. The duration of the attack, from O'Neal's 911 call to the threat being neutralized, was about 15 minutes. 

University of Chicago Flight Nurse Teri Campbell, RN, MSNC, PHRN, and Chicago Fire Department Ambulance Commander Beth Ciolino, EMTP, hosted the session "Active Shooter in the ED: Chicago's Mercy Hospital" at the virtual EMS World Expo on Sept. 17. In addition to describing the events of the shooting and playing audio of O'Neal's 911 call in combination with corresponding radio traffic, Cambell and Ciolino explained the unique aspects of an internal disaster within a hospital, lessons learned from the tragic event and positive takeaways of how personnel responded effectively to the mass casualty incident at Mercy.

Memorable quotes about active shooter protocols and response

Here are some memorable quotes on active shooter response:

"SOPs, SMOs, policies, procedures: They are our guidelines, they are our marching order, but sometimes we also have to be flexible and we have to be able to do the right thing at the right time." — Teri Campbell

"One of the best things we can do is empower our people. So if you are a blue or a green, help a yellow exit." — Teri Campbell

"Right, wrong or indifferent, just make a choice ... Every minute of indecisiveness and indecision that you have adds 10  minutes to the overall scene time." — Beth Ciolino

"We don't have guns, we don't have vests, I have no desire to go down hallways and look for somebody, a perpetrator who could be shooting at me ... It is a police scene and until that scene is safe and secure as deemed by the police department, the fire department will work in direct contact with them, but just underneath the authority of where are areas we can go to." — Beth Ciolino

Key takeaways on internal hospital MCI preparation and response

While hospital staff members followed their training, hiding and moving patients to other areas of the hospital, police, fire and EMS personnel worked in conjunction to stage, command, communicate and evacuate, as well as triage, treat and transport patients. The Chicago Fire Department had a total of 19 ambulances, 9 fire suppression vehicles, 9 auxiliary vehicles and 16 fire and EMS chiefs at the scene of the shooting. There were 22 patients: three red, 13 yellow and seven green. First responders needed to coordinate to ensure their own safety while rendering care as quickly and efficiently as possible.

Here are 5 takeaways from the presentation on active shooters. 

1. Safety first

Ciolino made it clear: "At no time would I argue at all under any circumstances should any fire department chief or any fire department be in charge of an active shooter ... It is absolutely a police scene." 

Police, fire and EMS personnel must communicate to establish the parameters of the hot zone and warm zone to work safely and effectively during a dangerous and dynamic incident. Ciolino explained the benefit of Chicago Police and Fire Department personnel training closely together, improving their readiness to coordinate during a violent MCI event. 

Ciolino added that having SWAT team members who are also EMTs and rescue task forces that pair police with fire-EMS personnel are two ways departments can balance the needs of personnel safety and faster treatment of trauma patients. SWAT officers can begin rendering aid once the immediate threat has been neutralized, and rescue task forces can work together in warm zones to treat life-threatening injuries and move patients, with police providing protection for the fire-EMS members providing care. 

"We learned in school shooting that way too many kids died waiting for the 'scene to be safe' for us to go in and start treating victims," Ciolino said. 

2. Make a decision and make things work

Campbell and Ciolino explained that while policies and procedures are important in guiding one's actions during an MCI, flexibility is needed to react in a dynamic and highly time-sensitive situation. 

"You can have a plan, you can have a backup plan, you can have an SOP, you can have an SMO, you can have policies and procedures — sometimes, you need to be flexible and you need to make these things work," Campbell said.  

With the entire ED evacuated and ED staff traumatized, it was clear patients would need to be transported to other hospitals in the area, and Campbell explained that there were not enough private critical care ambulances in the city to transport that number of patients. 

"The Chicago Fire completely and absolutely stepped up to the challenge, despite this not being in their SOPs," Campbell explained. "Many of the Chicago firefighter-paramedics are also nurses, so they were able to put patients in the ambulance and they were able to manage ... the equipment that is more commonly handled by critical care transport or by nurses." 

The fire department commandeered city buses to evacuate patients not needing medical transport, and 22 patients were transported to the four trauma hospitals closest to Mercy. 

Ciolino said it's important to not be "flat squirrels on the road" unable to make a quick decision when needed. 

"You guys need to be quick with your decision-making and figure out a plan of action and just start going that way so at least things start to get mitigated," Ciolino said. 

She also noted that an incident like the Mercy shooting "ain't your granddaddy's MCI" — an active shooter event doesn't allow for valuable time to be spent on things like shoving triage tags into little plastic pouches. Absolute priority should be placed on transporting red patients as soon as possible. 

3. Lessons learned from the Chicago ED active shooter

Campbell and Ciolino listed lessons learned from the Mercy Hospital shooting that informed preparation for future major incidents, including a "nursing wish list" of guidance and resources that Mercy ED staff members wish they had had during the shooting. 

  • Nurses explained that security guards staffed by the hospital were unarmed and didn't have a great relationship with other ED staff, as they wouldn't always intervene when a patient or family member caused a disturbance. After the shooting, Mercy hired armed police security to bolster the existing security force. 
  • The lack of a "safe word" in place led some staff who were hiding to continue hiding and barricading themselves as police and SWAT were doing a sweep of the hospital. A "safe word" would have confirmed that the police were who they said they were, especially as the sounds of the gunshots echoing from different directions led to the belief that there was a second shooter. 
  • EMS crews initially staged too close to the scene, which was problematic especially considering the space that would be taken up by the 19 rigs that responded. EMS crews should make sure to stage a sufficient distance away from the scene. 
  • Chicago Fire and Chicago Police dispatchers were receiving duplicate requests and ended up sending more resources than necessary. This led to the Chicago Officer of Emergency Management and Communications to change SOPs to have fire and police dispatchers sit face-to-face in a separate room for any large-scale incident, giving them the ability to closely communicate with each other. 

4. Positive takeaways from an active shooter incident

Campbell and Ciolino also gave credit where credit is due for what went well during the response to the shooting: 

  • A perimeter was established immediately, allowing all responders to be aware of where the hot zone and warm zone were. 
  • Ciolino noted that the staging area manager was very effective and "did a fantastic job of being the first person in charge standing there and mitigating everything from the beginning."
  • The incident command post and forward fire command were both established quickly, with forward command being quickly re-established during the ongoing threat. 
  • Chicago Fire and Chicago Police, having trained extensively together, worked well together and cooperated to secure the building for four to six hours after the shooting. 

5. The unthinkable can happen anywhere

Between 2000 and 2011, there were 154 shootings on hospital grounds, and active shooter events have seemed to be increasing over the years, according to Campbell. Fifty-nine percent of hospital shootings occurred inside hospital buildings, and Campbell noted that something especially concerning was that 23% of shootings in EDs involved a gun being wrestled away from a security officer. 

Campbell noted that although the Mercy shooting was an act of domestic violence targeted to one of the hospital's doctors, it didn't mean such an event couldn't happen again at Mercy or any other hospital. In 2016, OSHA mandated violent intruder training for all hospitals to address the growing threat of mass violence. 

Ciolino also pointed out that the "abundance of resources" available to Chicago public safety officials, such as vehicles and the availability of hospitals, does not reflect reality for all public safety departments, especially in rural areas where the nearest trauma center may be dozens of miles away. Other hospitals and departments will need to factor in these limitations when preparing for a potential violent MCI. 

Following the shooting at Mercy Hospital, the ED managed to return to operations the very next day, and "shockingly, no emergency room staff employees quit the ED," Campbell said. Crisis counselors were made available to staff, and Campbell noted that many hospitals have peer support lines, where personnel who experience traumatic events can speak with those who work in the same field and who "understand your language." Personnel can debrief with those who have similar experiences that one's friends and family may not have. In the long-term, it is important to have the appropriate tools and support to recover from an incident, and for lessons learned to lead to changes that will improve preparedness for the future. 

Additional resources on active shooter training, response

Learn more about training for an active shooter incident and emergency response with these resources:

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