Joanne Conroy, MD

Dartmouth-Hitchcock Medical Center

Demonstrating Leadership: A “Never Event” Can Show Who The Real Leaders Are

It was on a beautiful sunny afternoon in September, my sixth week on the job as CEO and President of Dartmouth-Hitchcock – a health system based in Lebanon, New Hampshire — when the pastoral innocence of our small community was shaken. On that Tuesday, September 12th at 1:24 pm, a middle-aged man walked into ICU room 17 of our medical center to see his mother, who had undergone successful treatment for an aneurysm. Once inside, he pulled out a gun and shot her four times, picked up his bag, placed the gun in it, and calmly exited the ICU.

A nurse who had worked in the ICU for only a month activated alerts for both Code Blue (an unresponsive patient) and Code Silver (an active shooter) simultaneously. A Code Silver alert automatically triggers calling 911. As the code team ran toward danger to help the mother, the rest of the building evacuated swiftly. Within minutes, local police were on the scene, responding to the 911 call. Within an hour, more than 150 state and local law enforcement officers from New Hampshire and Vermont were on our campus.

Meanwhile, thousands of employees followed the Code Silver procedures.  Many of our staff streamed down stairways and assisted patients out of the building. If a wheelchair was not available for transport, staff put seniors in rolling office chairs and swiftly moved them to nearby campus buildings. Other employees sheltered in place with their patients, locking and even barricading the doors, but with the calm professionalism that they display every day. The hospital’s Incident Command team – an organizational structure used to respond to emergency situations – set up immediately in an outlying building, establishing communications with the law enforcement who were on the scene.

Area schools were locked down and the leadership at nearby Dartmouth College alerted their students. Outside of our facility, the evacuees moved further into the wooded areas or into other campus locations. Nurses and physicians continued to care for patients under the shade trees, in hastily set up MASH-style units and in office buildings. They treated diabetics with hypoglycemia, removed stitches, dressed wounds, took vital signs and comforted patients and each other as best they could.  Local businesses drove as close as they could to the secured perimeter with water and food.

Our law enforcement partners took swift action. They were focused on securing the site and sweeping the building for the gunman and possible associates. They locked down the entire campus and apprehended the gunman almost 90 minutes later in his vehicle as he attempted to leave the area.  When the “all-clear” signal was called at around 5:15 pm, one patient – the mother – was dead, her son apprehended and – because our staff did exactly what they were trained to do – no one else was harmed.  This is our story of our lessons learned and the road to recovery we’re still on.

Managing active shooter situations are difficult. Law enforcement and health care providers have the same mission: to protect and help others.  Law enforcement must eliminate the threat and secure the facility. Health care providers, once the immediate danger has passed, want to return to care for their patients. There will be tension between these two groups regarding when you can safely return to the bedside to care for patients.  Some caregivers were sequestered in their barricaded conference rooms, outlying buildings or parking lots until the entire building was “swept” by local police and the D-H security team. It was an incredibly fast process to secure about 2 million square feet of our facility in four hours, but even that seemed too long for our dedicated clinicians and support staff trying to get back into the building or to return to their units.

You cannot predict how long it will take to return to the “new normal.”  The closer people were to the location of the shooting, the greater the emotional trauma, and the longer it will take them to return to a semblance of normalcy. In the 48 hours after the incident, we shut down several of our ICU beds so we could accommodate clinicians and support staff who felt they could not work. We flew in traveling nurses who helped with the ICU workload. Our Chief Nursing Officer, a Gulf War veteran, was a constant presence in the ICU and the Emergency Department over the next 72 hours. We escorted staff who felt unsafe to walk outside alone to their cars. We had psychologists, our Employee Assistance Program providers and members of our Chaplaincy department on-site for walk-in visits for more than a week. The next morning, senior executives greeted employees at every single entrance as they came into work, to thank them for their service and dedication to patients and each other under extraordinary circumstances. I hosted a Town Hall meeting on the main campus that was streamed online for our other locations to express my personal gratitude, to answer questions and to allow staff to vent their many emotions on what took place. One of the smartest things we did was to understand that everyone was going to begin the healing process from a different starting place.

People will experience an intense sense of vulnerability once the adrenaline wears off. There were requests for armed guards, Tasers, Kevlar vests, and metal detectors at all of our entrances. We know that there are areas in the hospital that are at increased risk, but that the statistics show that caregivers have less than a 5% probability of being injured in one of these events. But statistics do not comfort people. With the rise in anxiety from our incident, and with the background understanding of the national trend of assaults on care givers, we have increased our security presence but have held the line on installing metal detectors and arming our security team. A hospital is a place of hope and healing, and visible reminders of the potential for danger run counter to that belief.

Social media moves far faster than traditional communication and you cannot control it. Rumors were rocketing around social media, ranging from providers being shot to staff being held hostage. It seemed that people 100 miles away knew more about the situation than we did within the medical campus perimeter thanks to easy-to-download police scanner apps.  You must balance the need to communicate early and often with complete transparency and absolute accuracy.  Stay on message, and have someone monitoring social media and address rumors proactively.  We communicated with our staff by email several times that day, and every day that week.  There are, of course, many opportunities for improvement in our communication processes.  For example, we had no way to communicate with staff who evacuated outside into parking lots and may have left their cell phones in the building … no bull horns or outside speakers. Fortunately, when people who did have their phones and saw the “all clear” message returned to the building, everyone else followed suit. Of note, our second-year medical students were able to account for all of their classmates within 30 minutes using social media.

The outpouring of support was impressive.   We spoke with leaders at other medical centers who had experienced a similar trauma: a physician shot by a colleague, a physician shot by an angry son of a patient, a random shooting in an ED. They were all very helpful, sharing both their experiences and advice going forward.

The generosity from our community was inspiring. Not one patient complained about any inconvenience, whether they were cared for in a barricaded room or tended to under the shade of a tree near the parking lot. The next day when patients returned for their outpatient care appointments, they only asked the staff “How are you doing?”

We have many questions. Are we prepared if this were to happen in February, when it could be 5 degrees below zero? Could we better utilize our onsite critical transport equipment?  Should we have evacuated at all? How can we communicate more effectively?  How will we ensure people feel safe again?

One unexpected positive outcome was the increased sense of community and engagement among our providers and staff at Dartmouth-Hitchcock. People realized that they cared for their patients, colleagues and community more intensely than they expected.  We are trying to keep that kindled spirit alive because it so powerfully connects our organization to its purpose. One leader from another organization with whom I spoke shortly after the incident remarked that since I was new to the organization, it allowed me to demonstrate my leadership. Perhaps it did; but I was, instead, in awe of the demonstration of leadership by every Dartmouth-Hitchcock employee that day, and every day since.