Mass Shootings: How Hospitals Can Prepare for the Worst

No one can predict a tragedy, but you can try to plan for it

On June 12, the deadliest shooting to date in the United States occurred at the Pulse nightclub in Orlando, Fla., leaving 49 dead and 53 injured. As the wounded were taken from the building, they were rushed three blocks away to the Orlando Regional Medical Center, where emergency responders worked tirelessly, struggling to keep up with the constant influx of patients.

Sadly, this was not the first mass shooting in the United States, and it is unlikely to be the last. In 1999, 13 people were killed in a high school in Columbine, Colo. In 2012, 27 people were killed in an elementary school in Sandy Hook, Conn., less than five months after 12 were killed in a movie theater in Aurora, Colo. In 2015, less than three months after nine people were killed at a community college in Roseburg, Ore., another nine were killed in a church in Charleston, S.C. Mass shootings — defined as when four or more people are victims of a shooting — are disturbingly common in this country, with 126 instances in the past 50 years.1

While policymakers struggle to determine how to decrease the frequency of mass shootings, healthcare professionals must deal with the immediate impact of these tragedies. Regardless of preparation, whichever hospital is closest to the site of the shooting is forced to instantly formulate a plan that will enable them to help large quantities of people at an extremely fast rate.

Many hospitals already have an “all hands on deck” policy in place for emergency situations that requires all available surgeons and/or nurses to be brought into the hospital and prepared to treat patients within minutes. No matter how much help is brought in, though, there is no guarantee that it will be enough. In these situations, a system of triage is often used to identify the most critical patients for expedited treatment by using the ABCDEs of trauma: airway, breathing, circulation, disability, and exposure. Although this system has been effective in saving lives, it can still leave patients waiting in the hallway who would, in normal circumstances, be rushed back immediately.2

In light of the increase in mass shootings in recent years, hospitals have been forced to increase their preparedness for these incidents. Beyond readying their medical staff to handle these situations, many hospitals have hired individuals to specifically address emergency management. Further, there has been an increase in counseling and spiritual services provided to the staff members who are forced to cope with these situations.3

No matter how much a hospital plans, though, nothing can truly prepare an organization for the chaos that comes with a mass shooting. Wade Fox, DO, FACEP, FAAEM, and regional director of CEP America, knows this firsthand: He headed the emergency department at Mercy Hospital in Roseburg, Ore., where victims of the shooting at Umpqua Community College were brought in 2015. “You can do drills, you can have manuals, but no hospital is ever ready for that,” he said. “As doctors, you get through your college, medical school and residency, and you just kind of power through. You work hard — harder than most — and you do stuff that other people can’t do, and you do it by sheer force. When you get into situations like this, though, that stuff doesn’t work anymore, so you have to have some other techniques.”

Fox stressed that nothing a healthcare organization does can truly prepare its staff for a mass shooting. However, he told ADVANCE about what he found helped his hospital the most, and what he believes other hospitals need to do — before a tragedy forces them to do it.

Designate a Leader

In sudden emergency cases, a designated leader needs to be ready to guide the team — even if it means stepping away from working directly with patients. “You always have to have one person to rise up and take control of the situation,” Fox said. “That’s something all hospitals should think about: If something happens, who’s going to be that person?”

At Mercy Hospital, that person was the trauma coordinator. “She commanded control of the situation,” Fox recalled. “She assigned doctors, nurses, techs, and ancillary service providers to specific rooms, and she made it very clear: ‘If you don’t have a specific, defined role or job in this room, you need to get out.’”

While it might seem harsh, Fox stressed how helpful those direct orders were for the emergency department staff. “In the ED, when we have a big, exciting case, it draws attention, and people kind of overrun one room,” he explained. “You get a lot of non-essential people in the way. So we got divided into separate rooms, and when the first person came in, not everyone ran to that one room. We stayed where we were, because we knew the next person would be a minute behind them.”

Know Who Will Represent the Hospital

“As soon as the shooting hit the news and social media, people just started showing up in droves,” Fox said. “Parents were screaming and crying, asking, ‘Where’s my kid? Are they here?’ One of the senior administrators came down and basically took the job of managing them and keeping them in the waiting room.”

In cases like these, though, hospitals have to expect more visitors than family members. “The amount of reporters who came is still mind-boggling to me,” Fox said. “It’s important to have somebody whose job for 48 hours is to have a suit on and do interview after interview after interview.”

There are multiple reasons for delegating hospital staff — typically administrators — to represent the hospital in communications with the public. Beyond ensuring that the ED is able to focus solely on serving the patients, this decision will protect the ED staff. “I still can barely talk about it,” Fox admitted. “I was in zero position to talk to the media about it then.”

Have a Plan to Quickly Reach Staff

At Mercy Hospital, the on-site assistant for the ED was able to instantly connect with every healthcare professional employed by the hospital — and the turnout was better than ever expected. “If they were in town, they came,” Fox recalled. “A lot of people showed up and stood way back and said, ‘Hey, I’m a cardiologist. I don’t know how to do any of this stuff, but I can put in a vascular access, so if you need that, I’m here.’ We had a great turnout.”

Fox emphasized the importance of finding a way to connect with as many people as possible, as quickly as possible. It could be a page, a call or even a mass text — whatever will reach the most people, because that’s the only way to ensure that your hospital is able to help the maximum number of patients.

Provide Support

Although the aftermath of mass shootings is heavily covered by news sources, the emotional impact on the health professionals who help these victims is rarely discussed. “A lot of people really, really struggled. There were people who quit their jobs over this,” Fox said. “In law enforcement, they have pretty sophisticated programs in place for this. If there’s a shooting, officers go on three or four days of paid leave until the situation gets resolved. I think most hospitals don’t really think about that.”

CEP America, the national physician partnership to which Fox belongs, was able to provide Fox and his colleagues with many counseling opportunities — a privilege that many healthcare professionals don’t have. In addition to hospital leaders providing support for their staff, though, it’s crucial for healthcare professionals to support each other.

“Reaching out doesn’t take a lot, but it truly means a lot,” Fox said. “I think we as a collective specialty need to think about ourselves and each other. We need to spend more time taking care of ourselves. We need to think about these things and be reflective because… well, this really, really affected me.” He paused. “Maybe it still does.”

Sarah Sutherland is a staff writer at ADVANCE. Contact:


  1. Berkowitz, B, et al. The math of mass shootings. The Washington Post. 2016.
  2. Campbell, K. How healthcare centers respond to mass shootings. WNCN. 2016.
  3. Leonard, K. Hospitals increasingly anticipate mass shootings. U.S. News & World Report. 2016.

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