Violence has a cadence, a rhythm that disrupts the normal flow of life. When an act of violence erupts, the first sign is often a sudden, unexplainable shift in the environment—an eerie silence, a heightened energy, or a gut feeling that something is wrong. But when does that uneasy feeling cross the threshold into immediate danger? In this episode, we explore the critical decision points in an active violence situation in the healthcare/hospital setting, the moral and ethical dilemmas of medical providers staying versus escaping, and tactical strategies for survival. Finally, we break down the “run, hide, fight” approach and how to act decisively when every second counts.
Guest bio: Mike Shertz, MD is an emergency physician who spent 13 years as a Green Beret and a Special Forces medic. He is the founder and purveyor of Crisis Medicine, which teaches tactical casualty care to medical professionals. Check out this video that we did together in 2019 on how to place and remove a tourniquet and this one on how to pack a gunshot wound with combat gauze.
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We Discuss:
Recognizing an Active Violence Situation
- A sudden shift from baseline—such as a change in noise level or behavior—can be the first sign of danger.
- Instinct is key; if the hairs on the back of your neck rise, trust your gut and leave immediately.
- A change in “energy” or atmosphere often precedes an act of violence before any clear threats emerge.
- The difference between a “weird” situation and real danger is often felt before it is logically understood.
- Acting on instinct, even if it seems socially awkward, is better than ignoring warning signs.
Moral Dilemmas: Stay or Escape?
- If someone is actively shooting, the safest option is to leave immediately rather than become another casualty.
- The question of who you are willing to risk your life for is profoundly personal and varies based on individual moral beliefs.
- Tactical medicine prioritizes self-preservation—if you’re dead, you can’t help anyone.
- Some argue that medical professionals have an ethical duty to stay and care for patients, while others believe survival takes precedence.
- Heroism in an active shooter event is not an expectation, and societal norms are shifting away from glorifying those who intervene.
Perspectives on Risk and Response
- The question you must ask yourself is, for whom are you prepared to take a bullet? This depends at least partly on your moral compass.
- Josh Boucher (EMS Director): Personal safety is paramount; combat medicine teaches that care is secondary to survival.
- Ben Peery (EM physician, tactical medicine expert): His choice is to fight, believing that engaging the shooter quickly can have a significant impact.
- Jean Abbott (EM physician, ethicist): There is a public expectation for doctors not to abandon patients, but no absolute obligation to sacrifice oneself.
Tactical Survival: Run, Hide, Fight
- Run: If shots are fired, escaping should be the first priority. Do not stay to help; you are another target. Go to the nearest exit as rapidly as possible and get out. After you escape, don’t stay in the vicinity of the scene.
- Hide: If escape is impossible, find concealment or cover—cover being anything that can stop bullets. Look for a place you can squeeze yourself into, where no one would ever think to look. No matter how good your cover is, remember that there’s always better cover, and you should be thinking about how to get to that.
- Fight: If neither running nor hiding is possible, the only option left is to engage with full force. Use whatever weapons are available. Fighting can help you distract or startle the person just long enough so you can escape. Fighting back requires a level of violence and going to a dark place where most people have never been.
- Run, hide, fight is not a sequential process but dynamic. The best option depends on the situation.
Post-Shooting Medical Response
- Medical care can begin once law enforcement has secured the area, though risks may still exist.
- Penetrating trauma is the most common injury in these situations; hemorrhage control is critical.
- Improvisation may be necessary to manage wounds with limited resources.
- The scene may not remain stable, so situational awareness remains key even when rendering aid.
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