Addressing the Active Shooter Challenge through In-situ Simulation

Author: Mark Mannenbach, MD. @MMannenbach

Commentary on: Mannenbach et al. An In Situ Simulation-Based Training Approach to Active Shooter Response in the Emergency Department. in Disaster Medicine and Public Health Preparedness

With an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for this low-frequency, but extremely high stakes event.  Engagement of all emergency department personnel can be very challenging due to a variety of barriers including perception of lack of time, likelihood of occurrence, or interference with actual patient care

Our department chose to utilize an in situ simulation training model as a component of active shooter education for our academic emergency medicine practice.  Although a variety of modalities can be utilized for this type of training, we felt that an in situ model allowed for our emergency department personnel to engage actively in the experience.  We did so with some hesitation as we felt that the experience may be “too realistic” for some members of the department.  However, we felt that this approach allowed for the greatest degree of engagement and ownership of the need for awareness and personal decision-making.

We were intentional in our inclusion of as many disciplines as possible for each scenario session.  Leaders from physician, nursing, security, registration, laboratory medicine, and radiology technology were chosen to participate in the planning process.

We utilized both mannequins and live standardized patients to specifically address the need for incorporation of real patients as a factor for emergency department personnel to consider as they processed their reactions and plans for the scenario.

These scenarios were conducted in care areas of our emergency department where actual patients were not present at the time.  The scenarios were also conducted at a time when the attending physicians were present for a mandatory monthly meeting to improve their involvement in the process outside of their usual clinical assignments.

Debriefing occurred after each of the brief 10 minute scenarios and included feedback and direction from physician and security experts in regard to the preferred approach of “RUN, HIDE, FIGHT” when faced with an active shooter situation.  Careful attention was paid by those overseeing the scenarios to allow for identification of the triggering of any emotional or psychological stress as a result of participation.

With this approach and planning, we were able to include nearly all of the attending physicians as well as many resident physicians, nursing staff, and other emergency department personnel over the course of several months.

The feedback from the participants was overwhelmingly positive in terms of increased awareness, educational value, and planning for an actual event.  Those involved felt that the scenarios created realism without undue stress.

Although our approach may not be translated exactly to other emergency departments, we hope that our approach and lessons learned can be applied by others and they are planning and preparation for these potentially devastating events.

As recent as this week, several reports have emerged about US emergency departments are not ready for "mass tragedy". Our article highlights the need to develop explicit training about events potentially leading to mass casualties.


Further details of our work can be found in an upcoming issue of Disaster Medicine and Public Health Preparedness.

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