On Jan. 28, 2013, Stanwood Elkus arrived for a doctor's appointment at the Newport Beach, Calif., office of urologist Ronald Gilbert, MD. This was the second time in a week that Elkus had attempted to see Dr. Gilbert. Previously, after staff members had prevented Elkus from entering the back office area as a “walk-in” patient, he had agreed to make an appointment, which he did using a false name and telephone number.

Elkus blamed Dr. Gilbert for a surgical procedure he had undergone 25 years earlier that had damaged his prostate and led to complications. Two other physicians actually performed the procedure, but Dr. Gilbert, then a young resident at a local Veterans Administration hospital, had recommended the procedure to Elkus.

On that January day, after Elkus filled out his new patient paperwork in the waiting room, office staff took his vitals and escorted him to an exam room. Shortly after, Dr. Gilbert entered the room and introduced himself to Elkus. The patient then shot the physician 10 times in the chest and neck, killing him.¹

For several hours following the shooting, my nearby office was on lockdown and ordered to “shelter in place,” during which we kept our staff members and patients safe inside. Other offices, however, did not seem to understand the shelter in place order or follow other safety training, and we saw physicians, staff members, and patients moving in the direction of the shooting. The shooter in this case surrendered immediately, but the outcome could have been very different had the assault continued.

PREVALENCE

One of the most difficult situations a physician will face in his or her career is being threatened with physical harm, most commonly by a patient or family members of a patient.² Violence in the medical setting is sadly not unheard of; according to the U.S. Bureau of Labor Statistics, more than 70 percent of all workplace assaults occur in the health care and social services industry.³ Reasons for this include feelings that health care services have become more impersonal, longer wait times, unmet patient expectations, increased patient agitation, lack of mental health support services, prescription drug abuse, and poor or non-existent security at health care facilities.⁴

Psychiatrists and emergency medicine physicians typically see the highest rates of violence,⁴ but family physicians are not immune. Primary care physicians often treat patients who are seriously ill or have challenging psychiatric conditions, which can result in heightened patient discontent.

This article discusses how to prevent, train for, and react to violent patient encounters. Mitigating workplace violence requires that physicians and their practices take preventive steps and craft and follow specific plans of action. Physicians must take the lead; their actions can be influential with other colleagues and staff members and their interactions with and knowledge of patients can provide vital information about potentially violent encounters. (See “Workplace safety tips.”)

Note that many of the recommendations are not evidence-based from a medical standpoint. However, they reflect best practices from law enforcement agencies.

PREVENTION

The first and most important tool in preventing a violent encounter is heightened awareness, which can help you spot behavior that may potentially develop into future violence, such as the following:

• Depressed moods,

• Changes in personality or performance,

• Unusual, odd, or bizarre behavior, including clenched fists, excess sweating, or altered breathing,

• Disciplinary problems,

• Paranoid ideation,

• Delusional statements,

• False or fictitious information,

• Actual threats of violence.

All physicians and staff should receive situational awareness training as part of their initial job orientation and receive annual mandatory refresher courses. Larger organizations may already have formalized training programs, but individual offices or smaller medical groups could ask their local hospital to share these resources. They could also obtain training through online sources, expert consultants, or local law enforcement agencies. (See “Additional resources.”)

In addition to learning how to identify potentially violent behavior, you will also need to learn how to defuse the situation, because failing to address it can allow the violence to escalate. One method is to maintain a firm but calm and reassuring demeanor as you speak with the individual. Allow the person to verbally vent his or her concerns. Acknowledge his or her statements and show understanding by repeating what you have heard, and empathize with the person's frustrations. All the while, remain vigilant for cues that the situation is deteriorating. You should be prepared at all times to alert others, identify an escape route, or plan for self-defense. Law enforcement officers are taught to never turn their back to a potentially violent person, and the same holds true in health care.

Putting appropriate security measures in place can also help prevent workplace violence. For example, practices should establish and enforce policies that limit public access to restricted areas, ensure locked doors always remain secured, and regularly change door keypad codes, if the practice has them. Front-desk staff should check in or question all visitors as to the purpose of their visits. All employees should wear uniforms or display name badges so they can be easily identified. And employees should be empowered to report what they believe are suspicious persons or activities without fear of reprisal. The instruction “If you see something, say something” is critically important in the workplace, because employees are often the first to observe potential problems. Also remember that sometimes attacks occur outside of the office, such as in the parking lot, so practices should ensure proper lighting and look for and address potential hiding places for perpetrators.

Lastly, employers and managers should regularly review security at their facilities for potential improvements, even consulting with experts if necessary to advise on new information or preventive methods.

PREPARATION

Even the best observation, de-escalation, and security procedures will not prevent every violent encounter, and physicians and staff members should be prepared for an actual incident. Although obtaining active shooter training is ideal, you should at the very least develop a written Emergency Operation Plan (EOP) with policies and procedures for dealing with violent encounters.

For example, health care facilities provide unique challenges during violent encounters because we have a responsibility to not only ensure the safety of ourselves and our staff members but also the safety of our patients, who may be of varying ages and abilities. You need to identify multiple evacuation routes, especially from patient-accessible locations. Your procedures must also specify how and when to evacuate patients or, if necessary, how best to shelter in place. The type of practice you have will dictate this planning; a practice with many older patients will make different decisions than a practice with many younger patients.

Remember that even if the violent incident does not occur in your office but elsewhere in your building or a nearby building, your office may still be affected. It is common in active shooter incidents for law enforcement officers to lock down an entire building or campus to prevent a perpetrator from escaping or to minimize casualties. The incident involving Dr. Gilbert led to the lockdown of three medical buildings, dozens of medical offices, and hundreds of staff members and patients.

At minimum, an EOP should answer the following questions:

• How do we report an active violent incident to the proper authorities, which may include calling 9-1-1 as well as notifying our facility's security personnel and office manager?

• When and how do we evacuate both staff and patients?

• What are the primary and secondary escape routes?

• What are the designated safe areas or “casualty collection points,” locations where the wounded can be triaged and provided first aid?

• How do we lock down the office?

• How do we contact emergency responders once they are on the scene?

Besides creating the plan, you also need to regularly practice and rehearse it using a variety of violent encounter scenarios. That way, if a violent incident does occur, staff members can immediately fall back on their training.

RESPONSE

The likelihood of being involved in a violent encounter at work is rare. Still, knowing how to appropriately respond will greatly improve your chances of survival. A frequently noted video, jointly developed by the U.S. Department of Homeland Security and the City of Houston, emphasizes the “run, hide, fight” response to a violent act.

Run. If possible, escape from the violence. Escaping effectively, however, means taking a route that has been pre-planned and practiced. Keep in mind that escape routes will vary based on your location within your office and the location of the violent action. Quickly gather others and be direct in your escape, but don't delay your escape by waiting for others. As you are escaping, keep others from entering the violent area. If you don't know the exact location of the perpetrator, avoid using a “main” or common entrance as your escape route unless that is your only option. When you are in a safe area, call 9-1-1 to alert the authorities to where you are and to provide any specific details you can about the perpetrator. The authorities may want to ask you additional information, so do not hang up.

Hide. If escape is not possible, you must do your best to conceal your presence. If you are hiding in a room, lock and, if possible, barricade the door to prevent entry. If time permits and you aren't compromising your safety, lock all of the doors, even for empty rooms. This will stall the perpetrator because he or she will not know which locked rooms are empty and which are occupied. Turn off all lights, and silence all mobile devices, even switching off “vibration mode” as it could make enough noise to be located. Remain extremely quiet, and if there are windows on or near the door, stay out of view. If possible, take cover behind large objects such as exam tables, file cabinets, or bookcases. Interior walls made of drywall or sheetrock will not provide sufficient protection if the perpetrator is using a firearm, and although most interior doors in commercial buildings are solid enough to protect against most handguns, they likely won't stop a rifle. Regardless of where you are hiding, you should still plan an escape, such as going out a back door or an exterior window, if close enough to the ground. If considering an exterior window, keep in mind that many commercial buildings have safety glass windows that require special glass breakers. These breakers should be placed in every room as part of proper planning.

Fight. If an assailant is entering the room in which you and others are hiding, or if the violence begins in your immediate presence and you have neither the time nor opportunity to run, then you must be prepared to fight. This is probably the most difficult scenario to prepare for or even think about as it is likely outside your normal character, but fighting back when no other option exists is critical to survival. As FBI statistics show, almost half of active shooter situations end before law enforcement officers arrive, and the potential victims stop the shooter themselves in a third of those cases.⁵ When fighting back, your goal is to incapacitate the individual. The survival mentality must become all-encompassing, and you should consider and use all resources available. This could include techniques learned in self-defense classes or items found in the typical medical office, such as fire extinguishers, chairs, bookends, scalpels, scissors, or liquid nitrogen. If you have firearms training and are permitted by law and your employer to carry a firearm, that is another tool to possibly stop a life-threatening attack. Use whatever options you have available, and be prepared to use them forcefully.

Although the “run, hide, fight” approach may be appropriate in most outpatient settings, these recommendations could be difficult to achieve in hospitals and other health care facilities where patients are physically or mentally incapable of moving. Also, hiding could be difficult in these facilities because most patient care areas are designed to be open to give nursing stations the maximum ability to observe patients. An alternative strategy is “secure, preserve, fight,”⁶ which calls for securing all access points to a wing, floor, or patient care area where life-sustaining treatment is being provided and providing only essential medical care during a violent incident. Successful use of this strategy requires significant pre-event planning, possible infrastructure improvements, and regular drills.

Once law enforcement officers arrive on the scene, keep in mind that SWAT (Special Weapons and Tactics) and MACTAC (Multi-Assault Counter-Terrorism Action Capabilities) officers are trained to immediately enter a location and find and engage a violent individual. These first responders' sole responsibility is to stop the threat, and they will not stop to provide medical aid or assistance to victims.

Physicians or staff encountering officers should expect them to be firm and direct in their commands, and they should do nothing to draw suspicion. Keep your hands high in the air and empty, and avoid making any sudden movements. Officers will direct you to evacuate the area, generally in the direction from which the officers came. You and other staff should leave all personal belongings behind; exiting with your purse or bag could heighten officers' focus on you as a potential assailant. Avoid pointing, yelling, or attempting to stop the entering officers as they may misinterpret such actions as hostile. When you exit the building, other officers will likely direct you to a safe location. Do not leave this location, as you may be an important witness who can help identify or aid in the apprehension of the assailant.

If you are barricaded in a room, officers may command you to open the door. Assailants have been known to impersonate law enforcement officers to trick occupants, so you should take reasonable steps to identify the person giving you a command. For example, you can listen for a police radio or have the officer slide his or her identification card under the door (all officers carry an ID card).

Once you determine that you are safe from the violent incident, you can provide aid to others, such as medical attention.

SURVIVAL

Every violent encounter is unique and unpredictable so there is no single approach that will cover every situation or every practice. However, the information in this article should give you a general starting point for addressing your individual situation. The steps you take now to prevent and prepare for violent encounters are not time wasted. They will improve your odds of survival should you ever have to face such horror.