Johns Hopkins shooting shows need to prepare

A recent shooting incident at Johns Hopkins Hospital in Baltimore shows the need to prepare for gun violence, but it also illustrates the limitations of any prevention program, security experts say.

Fifty-year-old Warren Pardus was speaking with the surgeon treating his mother when he pulled out a semiautomatic pistol and shot the doctor in the abdomen, according to reports from the Baltimore Police Department. He then ran into his mother's room, and the immediate area of the hospital was evacuated, police say. After a two-hour wait, a police robot entered the room and found Pardus and his mother dead from gunshot wounds.

The surgeon, David B. Cohen, MD, underwent emergency surgery for a gunshot wound to his abdomen, and Johns Hopkins reported he was in stable and fair condition the next day. Cohen is an orthopedic surgeon specializing in spinal work. Witnesses told the Baltimore Sun that he had been discussing the 84-year-old mother's prognosis when Pardus yelled, "You ruined my mother," before shooting. Witnesses told the newspaper that the mother had been left paralyzed after surgery intended to make her more mobile. (For the Baltimore Sun report, go to http://articles.baltimoresun.com/2010-09-17/news/bs-md-ci-shooting-hopkins-20100916_1_mother-hospital-staff-east-baltimore.)

A spokesman from Johns Hopkins declined comment because of the ongoing criminal investigation.

More incidents to come?

Risk managers can expect to see more such incidents in the future, says Sean Ahrens, CPP, BSCP, CSC, senior security consultant with Schirmer Engineering in Glenview, IL.

"With the increased pressure being put on emergency departments and the increased stress that people feel from a variety of factors, we may be seeing more situations in which people lose control of themselves and act out violently," he says. "This isn't going to happen every day, but it has always been a problem in health care facilities; and I'm afraid it's going to get worse in the near future."

In many ways, the shooting was typical of how gun violence happens in a health care setting, says Timothy Dimoff, CPP, founder and president, SACS Consulting and Investigative Services, Akron, OH. It is common for violence to be precipitated by patients or family members receiving bad news, and those situations should always be assessed carefully, he says.

"There are cases where you can identify that you have the potential for a violent situation, whether it is with a gun or with a violent outburst. When that happens, then you can start notifying security that you have a situation where someone is upset," he says. "You need training for hospital staff and physicians, so that they can try to recognize those situations before it escalates."

Good response at hospital

Johns Hopkins apparently did a good job isolating the situation so that no other staff and patients were at risk, Dimoff says. He sees two lessons to be learned from the Johns Hopkins incident. First, he says it is a reminder that hospitals should train staff to help recognize disgruntled patients who could become violent. Verbalizing their anger, by shouting or raising their voices, is an important warning sign, Dimoff says.

The second lesson is that staff must work cooperatively with hospital security in such situations. Staff and physicians should be trained to alert security to such situations early, rather than waiting until the person becomes violent. By giving security a heads up, officers can move closer to the scene and respond more quickly when trouble erupts, Dimoff says. They also can make themselves known to the person, which often discourages violence.

Homicide is relatively unusual in a health care setting, says William Dunne, MS, NREMT-P, director of the Office of Emergency Preparedness and administrative director of Security Services for the UCLA Health System in Los Angeles. Violence is not unusual, but it rarely goes so far as murder, he says.

"The statistics show an overall increase in violence in health care facilities in the past few years, but I also think there is an increased sensitivity to it also," Dunne says.

Dunne says the key to addressing violence in health care facilities is to create a culture of safety, rather than depending on more officers and more physical solutions, such as technology and infrastructure design.

"Those factors certainly can play a role, but it is more important to create a team in which people are always on the lookout for people who might act out or those who are acting suspiciously," he says. "That kind of culture will help you mitigate these situations, so that either they never become violent or you minimize the impact when it happens."

Shows limits of planning

The shootings show some of the limitations of preparations for violence in a health care setting, notes Roberta Carroll, ARM, CPCU, MBA, senior vice president, Aon Solutions, Chicago. There is every indication that Johns Hopkins was well prepared and had trained staff for violent situations, she says, but sometimes there is no way to prevent them.

Metal detectors, for instance, are an impractical solution for health care facilities, she says. They would have to be used at every entrance, and most hospitals have many. They also would have to be staffed around the clock by trained personnel.

"And besides, you don't want your hospital to look like an armed fortress," she says. "It is reasonable to expect hospitals to take precautions and do what they can to avoid violent situations, but unless you want to lock down your hospital like a prison, you can't completely eliminate the chance that someone is going to walk [in] with a gun."

Johns Hopkins alerted employees and students at the hospital and the university campus soon after the shooting, says Earl Stoddard III, PhD, MPH, public health program manager with the Center for Health & Homeland Security at the University of Maryland in Baltimore. He is a former Hopkins student and still on the school's e-mail list, so he received an e-mail about the incident within 10 minutes, he says. Hopkins also used the social networking site Twitter to send out alerts.

"Their flash messaging to both employees and students in the surrounding school buildings was quick," he says. "Their overall planning seemed to have worked well. Their emergency operations plan, which includes the scenario of an active shooter, was put into place quickly. They also worked well with the city police response."

An active shooter makes evacuation of an entire facility difficult or inadvisable, Stoddard says. An emergency plan should include provisions for notifying staff to stay and shelter in place, rather than risk leaving their workspaces and running into the shooter, Stoddard says.

"At Johns Hopkins, a nurse on the floor recognized immediately that something was wrong and got everyone out of the immediate area, then called security, which locked it down," he says. "That isolated the danger. In that regard, it appears their plan was very successful."

Conduct annual security evaluations

Stoddard advises hospitals to conduct security evaluations each year. A first step should be reviewing violent incidents from the previous year, along with near-violent incidents in which people feared someone would become violent. That information can reveal a great deal about the level of risk and the type of risk faced in your facility, he says.

"The risk is going to be different with every facility, but hospitals serve different populations, they have different stress loads, and nothing is ever the same. By looking at your own experiences, you can know how much attention to pay and how much of your resources to devote to this issue," he says. "Staff training and a constantly evolving security plan are key to managing these problems."

Stoddard points out that the training should include all employees of the facility, not just clinical staff. While clinical staff may be the most at risk, anyone working in the facility can become a victim if someone becomes violent, he says.

"Everyone should be expected to have an understanding of the emergency plan and security procedures," Stoddard says. "When an incident happens, it may not be a security person who responds and makes a difference in the first few minutes. It might be a clinician or someone in accounting, so everyone needs to know the plan."

Sources

• Sean Ahrens, CPP, BSCP, CSC, Senior Security Consultant, Schirmer Engineering, Glenview, IL. Telephone: (847) 953-7761. E-mail: sean.ahrens@aon.com.

• Roberta Carroll, ARM, CPCU, MBA, Senior Vice President, Aon Solutions, Chicago. Telephone: (312) 381-1000.

• Timothy Dimoff, CPP, Founder and President, SACS Consulting and Investigative Services, Akron, OH. Telephone: (330) 2515-1101. Web site: www.sacsconsulting.com.

• William Dunne, MS, NREMT-P, Director, Office of Emergency Preparedness and Administrative Director, Security Services, UCLA Health System, Los Angeles. Telephone: (310) 206-3281. E-mail: rdunne@mednet.ucla.edu.

• Earl Stoddard III, PhD, MPH, Public Health Program Manager, Center for Health & Homeland Security, University of Maryland, Baltimore, MD. Telephone: (240) 777-2323. E-mail: estoddard@law.umaryland.edu.