Discussion

It is evident that the “Run, Hide, Fight” concept is effective in responding to active shootings in non-medical settings. For instance, during the active shooting in the bowling alley in Lewiston, Maine, 1 witness reported that “Between the lanes there’s some swinging doors where they keep all the mechanical stuff out back, so we kind of all just ran that way. We barricaded in there and another parent was in the room with me. She had a phone, she called 911.” ^{Reference Hoffman and Cohen18} Another witness reported that “[I] thought it was a balloon. I had my back turned to the door. As soon as I turned and saw that it was not a balloon, he was holding a weapon. I just booked it down the lane and I slid basically into where the pins are and climbed up to the machine and was on top of the machines for approximately 10 min until the cops got there.” ^{Reference Hoffman and Cohen18} “Hide” was necessary in this case because there was barely any exit route at the time for a “Run.” ^{Reference Hoffman and Cohen18} However, this study identifies a crucial gap in addressing the effectiveness of the “Run, Hide, Fight” concept in hospitals. There are limited data on the overall effectiveness of the “Run, Hide, Fight” concept, and all the current data are not targeted to hospitals. It has never been shown to be applicable to hospital scenarios and does not address major gaps given that hospitals are filled with individuals who may be disabled, bedbound, or unconscious without the ability to flee or fight. ^{Reference Sanchez, Young and Baker22} The “Run, Hide, Fight” concept seems to be effective in hospitals only if that population matches with the population affected by active shooting in other public settings. To demonstrate, toward the end of June 2023, there was an active shooting at Fraser Canyon hospital in British Columbia, Canada. A witness there at the time reported that “All of a sudden I heard gunfire start from the emergency room, and then I panicked and I ran.” ^{Reference Zeidler23} It was a normal, regular day for anyone where the witness went to the hospital’s emergency room for persistent cough when she heard gunfire sounds while sitting in the waiting area. Afraid that the perpetrator might come out to the waiting room area, she ran out to the parking lot where she parked her car until police secured the scene. ^{Reference Zeidler23} From the incident in Maine and in this case, the concept seems effective in both scenarios because they can ambulate and care for themselves. However, not everyone situated in the hospital has that ability.

The “Secure, Preserve, Fight” concept as a response protocol for active shootings in health-care facilities is an alternative approach to address the flaws that come with the “Run, Hide, Fight” concept. ^{Reference Inaba, Eastman and Jacobs17} The rationale behind this recommendation is that the “Secure, Preserve, Fight” concept prioritizes securing the area as the first step. ^{Reference Inaba, Eastman and Jacobs17} Thus, this approach protects both healthy individuals and ill patients who are unable to escape due to their physical condition and addresses the ethical dilemma that health-care professionals may face. Unfortunately, this appears applicable in theory only. At this time, there are no reliable and accurate data to support the effectiveness of the “Secure, Preserve, Fight” concept when used in hospital settings. Furthermore, while patient safety is a priority for health-care professionals, personal safety is paramount. ^{Reference Giwa, Milsten and Vieira24} Health-care workers may still face ethical dilemmas of choosing between remaining with and protecting their patients who cannot escape or prioritizing their own safety in such a terrifying situation. ^{Reference Inaba, Eastman and Jacobs17}

While emphasizing the duty and codes of ethics of health-care professionals in placing patients first which, at times, involves accepting risks to themselves for patient care, there needs to be an emphasis on the fact that these codes do recognize that this duty is not absolute. ^{Reference Giwa, Milsten and Vieira24} It is not shameful to consider self-protection in this horrifying situation. Similar to facing epidemic and pandemic situations, it is not wrong to be scared of the unknown with life-threatening potential. Health-care professionals should be allowed to accept significant, but not disproportionate, risks when performing their role. ^{Reference Giwa, Milsten and Vieira24} Thus, once again, like epidemic and pandemic situations, health-care institutions should be involved in ensuring not only the patient’s safety, but also their employee’s safety. ^{Reference Giwa, Milsten and Vieira24} This includes implementing both administrative and engineering measures for active shootings such as frequent simulation training and bullet-proof windows and glass walls.

The implementation rate and effectiveness of the “Run, Hide, Fight” concept is heavily reliant on frequency of training and preparedness for actual events. ^{Reference Mannenbach, Fahje and Sunga25} To demonstrate, 1 study showed that 92% of 204 hospital staff who participated in simulations felt more prepared for responding to active shootings as well as reported 70% improvement in knowledge retention and application. ^{Reference Sanchez, Young and Baker22} The above data suggest simulation training and drills as fundamental for the effectiveness of this concept, especially ones with a multidisciplinary approach to help address all potential barriers as viewed by different disciplines. ^{Reference Mannenbach, Fahje and Sunga25,Reference Pyle, Gennett and Linvill26}

As a result, an established official program is needed for the hospital setting by starting during the onboarding process and with an annual refresher course. ^{Reference Darais11} Darais ^{Reference Darais11} reported that 52% of hospital employees agreed that virtual training is most helpful. Also, 47.8% of hospital employees claimed full scale exercises and live training to be the most helpful, while 46% suggested classroom/verbal training, and 30.5% selected written training. ^{Reference Darais11} Simulation is suggested by many studies to be effective in improving the skills and mental preparedness of health-care workers for active shootings. ^{Reference Darais11} Once the official training and refresher courses are initiated, it is crucial to set up frequent simulation training sessions just as there are frequent mock codes done in the ED and ICU settings. Repetition will aid in further promoting psychological preparedness and improving skills for response. The goal of training is to help hospital staff to be better psychologically wired and mentally prepared for responding to active shootings within the hospital.

For engineering measures, it is best to model countermeasures that are used by more common active shooting target locations, such as schools. A study by Zhu et al. (2022) ^{Reference Zhu, Lucas and Becerik-Gerber27} recommended the implementation of enhanced building security in a virtual school setting. The security countermeasures include installing barriers in areas surrounding the building, isolating unsecured areas from secured ones, increasing security access, using frosted windows, and staggering interior doors. ^{Reference Zhu, Lucas and Becerik-Gerber27} The study suggested that these countermeasures promoted hiding behavior as opposed to running behavior. ^{Reference Zhu, Lucas and Becerik-Gerber27} This may be beneficial not only for schools but also for health-care facilities because the population in both settings are not as equipped to run as the general population. Thus, hiding strategies in tightly secured areas of the building are likely to work better for school and hospital settings.

In addition to that, an agent-based simulation model by Bott et al. (2022) ^{Reference Bott, Frantz and Dietz28} showed that the presence of school resource officers and concealed carry weapon holders helps significantly reduce casualty rates during active shootings. Recently, there is a discussion if citizens, including employees during their work hours, should start carrying firearms for self-defense. This discussion took place after many active shooting events including the 2012 shooting at Sandy Hook Elementary School in Newton, Connecticut. ^{Reference Gajanan and Mansoor29} Although it sounds like a good proposal to fight a gunman with a gun, there may be more safety risks and complications than benefits. First, it takes intensive training for firearm use, and following this recommendation means that people will have more exposure to firearms where it can then turn into a potential weapon of harm at any point in time. Second, there will be an increased rate of injuries from firearm accidents because of malfunction or negligence such as in the firearm locking mechanism. Last, this would prove to be a disadvantage during active shooting due to the challenge for authorities to differentiate between perpetrators and victims who may have firearms for self-defense. Furthermore, perpetrators can then use this opportunity to pretend to be a citizen with a firearm and slip away from the crime scene. As a result, I personally do not believe that this suggestion is suitable for helping solve this problem.

Currently, there is a lack of adequate quantity of reliable data on both the “Run, Hide, Fight” and “Secure, Preserve, Fight” concepts for objective comparison on which concept is more suitable and effective for hospitals. This is especially true for the “Secure, Preserve, Fight” concept because it is a recently developed concept. Both concepts may not be effective in hospitals at all and a new proposed concept is needed. Also, there needs to be further discussion on personal safety if the “Secure, Preserve, Fight” concept is deemed more applicable for health-care settings. ^{Reference Fins30} Workplace violence in health-care facilities is on the rise. Health-care professionals should not be responsible in accepting disproportionate risks to benefit patient’s safety and care. ^{Reference Fins30} Thus, the future step identified from this study is to increase the number of valid and reliable research in this topic. In this case, randomized control trials would be impossible due to the nature of the event, but simulation study would be feasible. Then, future studies should consider a balance between health-care staff safety and the safety of patients and their families and visitors because there will be questions such as “if protecting our patients is a legal obligation?” and “if yes, are our lives less important?”