I. Introduction
A subset of the firearm violence epidemic in the United States are public mass casualty shootings.Reference Grinshteyn, Hemenway, Bjelopera, Bagalman, Caldwell, Finklea and McCallion1 The number of public mass casualty shootings — generally defined as “incidents occurring in relatively public places, involving four or more deaths … and gunmen who select victims somewhat indiscriminately”2 — has increased every year for the last five years.Reference Cohen, Azrael and Miller3
In response, the medical community has published an increasing number of studies analyzing the epidemic.Reference Swanson, Mc, Ginty, Fazel and Mays4 In November 2018, the National Rifle Association (NRA) tweeted that “someone should tell self-important anti-gun doctors to stay in their lane.”5 More than 21,000 twitter users, consisting largely of members of the medical community, responded, sharing their experiences treating victims of firearm injury and dealing with the grief and despair of those victims' family members.Reference Haag, Ranney, Betz and Dark6
This online movement highlighted an important consequence of mass shootings that had previously received minimal attention. Multiple studies demonstrate that there are long-term consequences of mass casualty events on communities, victims and first responders.Reference Berger, Coutinho, Figueira, Fullerton, Ursano and Wang7 Studies around firearm injury also highlight the unique and devastating effect that it can have on communities and victims.Reference Greenspan, Kellermann, Vella, Warshauer, Tortorello, Schwab-Stone, Ayers, Kasprow, Santilli, O'Connor Duffany and Carroll-Scott8 However, few studies have looked at the specific phenomenon of mass casualty shootings (versus other types of shootings such as interpersonal violence or unintentional) and these events' effect on communities.Reference Ranney, Karb, Ehrlich, Bromwich, Cunningham and Beidas9 Even less is known about the lived experience of physicians tasked with treating the victims of mass casualty shootings. Filling this knowledge gap will allow institutions and policymakers to better identify and proactively support psychological sequelae commonly experienced by physicians providing care during these events.
II. Methods
A. Study Design
We performed a qualitative study that sought to understand the lived experiences of physicians who worked at hospitals that had a public mass casualty shooting. Our study protocol was approved by the Yale University Institutional Review Board.
B. Sample Selection and Recruitment
Eligible participants were physicians who worked at hospitals located in communities that experienced a public mass casualty shooting, as defined by the Congressional Research Service.10 All major public mass casualty shootings with significant media attention that occurred between 2012 and 2018 were included. Initial study participants were recruited via emails sent to professional listservs as well as advertised on the social media platform, Twitter. Eligible participants contacted the investigators to set up an interview. After the first few interviews, we used the snowball sampling technique to recruit additional participants by referrals from previously enrolled participants.Reference Valerio, Rodriguez and Winkler11 Our team concluded that we had thematic saturation (the point at which no new codes are being generated) after twelve interviews; we then completed five more interviews to confirm saturation.
C. Data Collection
We conducted semi-structured one-on-one interviews of eligible participants by telephone. The interview guide was created by the authors and circulated for edits among content experts. The guide was intentionally broad to accommodate the grounded theory approach. Verbal consent was obtained. Each participant was informed that their interviews would be audio recorded and transcribed with the removal of any identifying information. Participants were not compensated for their involvement.
Four authors conducted interviews from January to May 2020. The interviews consisted of broad, openended questions using a grounded theory approach. See Figure 1, infra. All interviews were audio recorded. Interviews began with basic demographic questions including age, sex, type of training, and years of practice. Questions then addressed the participant's experience during the event. The final set of questions involved the response to the event. These questions addressed the participant's personal reactions and how the reactions of the hospital, community, and nation at large affected their experiences.
Figure 1 Interview Guide
D. Data Analysis
Audio recordings were professionally transcribed. The transcriptions underwent review by the investigators with the audio recording to ensure accuracy of the data. The coding team consisted of an emergency medicine physician and a general surgery resident as the primary coders. Two medical students also participated in the development of the code book and themes as a part of the coding team. We used the constant comparative method of qualitative analysis to develop codes and themes.Reference Hewitt-Taylor12 The primary coders first read through transcripts and catalogued the transcript data by assigning conceptual codes to different sections. The entire coding committee reviewed these codes at multiple coding meetings, discussing the meaning of the codes and how they relate to each other. We then created a hierarchy of codes, grouping them into themes. These themes, with the subgroups of codes became the codebook for the study. This process was organized on Dedoose Version 8.0.35, a webbased qualitative research software.13
III. Results
A. Sample
A total of 17 participants with training in emergency medicine, trauma surgery, pediatrics and psychiatry were interviewed. Participant demographics including age, sex, gender, and years of practice are displayed in Table 1, infra. The mean age of participants was 48 years old, and over half were female (53%; 9/17). The mean number of years of practice was 14. Trauma surgery and emergency medicine were the most represented specialties at 35% (6/17) each. The participants came from eight different communities that experienced a mass casualty shooting. Each community was represented by 2-3 participants on average with three incidents being represented by one participant. Some participants had experienced more than one mass casualty shooting. Each incident in these communities involved significant media attention. The deadliest event occurred in Las Vegas, NV on October 1, 2017, which injured 413 people and killed 58 people. In the majority of events, the shooter used a semi-automatic rifle. Additional descriptions and details of all incidents included in this study can be found in Table 2, infra.
Table 1. Sample Characteristics
Table 2. Description of Mass Casualty Shooting Incidents
B. Themes
In discussing the experiences of physicians working in a community that experienced a mass casualty shooting, four major themes emerged: (1) The psychological toll on physicians: “I wonder if I'm broken”; (2) the importance of and need for mass casualty shooting preparedness: “[We need to] recognize this as a public health concern and train physicians to manage it”; (3) massive media attention: “The media onslaught was unbelievable”; and (4) commitment to advocacy for a public health approach to firearm violence: “I want to do whatever I can to prevent some of these terrible events.”
1. the emotional and psychological impact on physicians
The day of the shooting:
Participants described a variety of strong emotions in both their personal experiences and observations. Reactions to the sheer volume, type of wounds, selfless behavior of the victims, and the pressure on providers to succeed all emerged as themes. One participant described his experience of that day stating:
I just remember being on the phone with my [spouse] and sobbing and thinking to myself — not saying this to her — but thinking to myself, “Wow, I wonder if I'm broken.
[Participant #7]Many participants described feeling overwhelmed by the sheer volume of patients who were injured by firearms. See Figure 2, infra. One emotion commonly discussed was horror at the event itself, with a distinct feeling that this type of event was different from anything else they had seen in the past:
The impact of seeing this number of people — It's not just that they were shot. It goes beyond that … It's the fact that they were victimized in a very insidious, insidiously planned event … I think that's one of the hardest things.
[Participant #2]
Figure 2 Theme: Psychological/Emotional Responses (with exemplar quotes)
Participants also noticed a difference in the patients' wounds when compared to their typical practice due to the types of weapons used in the attacks. The nature of the mass casualty shootings and lack of readily available information also led several providers to feel afraid for their own safety. See Figure 2, infra.
The participants also described a heightened sense of pressure to ensure a good outcome for the victims of the shootings. One participant whose hospital only received one patient from a mass shooting described this feeling:
I think this situation was really different in the fact that I wanted him so badly to survive.
I wanted the one person that got to us to have the chance to live because none of the rest of them did.
[Participant #12]While not every participant described each of these emotions or responses, every single participant described at least one of these reactions to the mass casualty shooting.
Dealing with the aftermath:
Almost all participants described long term psychological consequences in either themselves or colleagues that persisted for many months:
I know we have colleagues, especially ones who were directly impacted at the shooting, who continue, to this day, to struggle tremendously with the psychological impact of that event.
[Participant #9]The impact of these events was particularly difficult for participants for a variety of reasons. First, participants described how their roles as perceived leaders within the healthcare system hindered processing their emotions in the immediate aftermath:
As physicians, we are so socialized to be the captains of the ship — to be the leaders — to never let them see you sweat, never let them see you cry. We would not let our guards down in front of the team at all.
[Participant #2]This reaction was compounded by the fact that many physicians continued to care for the victims of the mass shooting for days, weeks and months after the event:
Grieving a traumatic event, while also caring for others who've been traumatized is actually really, really difficult because it is effectively forced re-traumatization … Being healthcare professionals, we may find ourselves in a position where we are forced to relive the trauma even if we don't want to.
[Participant #14]This forced re-traumatization and compartmentalization, led several physicians to feel the weight of that day even more forcefully than they otherwise would have. See Figure 2, infra.
Despite these difficulties, participants also described several positive feelings. For many, the outpouring of support locally, as well as from around the country, brought their communities together. See Figure 2, infra. Several participants discussed the satisfaction they gained from taking care of patients that had been so horrifically injured, especially when they were able to achieve a good outcome:
I had worked really hard. I was really happy with the work I did. I was proud. Nobody who had arrived alive, died. I was proud of that.
[Participant #5]2. mass casualty shooting preparedness
Participants expressed the importance of being better prepared for a mass casualty shooting to meet the immediate needs of patients, physicians, and for the aftermath:
The chances of that happening to you on your shift where you work is pretty small. The chances of it happening to somebody on their shift is almost 100%…. With the increasing frequency, increasing amplitude, I think it would be wise for us to… recognize this as a public health concern and train physicians to manage it.
[Participant #3]Meeting the immediate needs:
Several participants noted that technology in their hospitals was not set up to serve them appropriately during the mass casualty event. See Figure 3, infra. There were failures in several systems including the electronic medical record, communications and notifications within the hospital, and inadequate and/or inaccurate communications from pre-hospital emergency services. This led providers to devise workarounds that did not always conform to what was normally accepted at their institutions:
Our internal communication system, our intranet crashed…what still worked was texting each other on our cell phones. We actually had to resort to that, rather than our usual method of communication because it wasn't prepared.
[Participant #2]
Figure 3 Theme: Mass Casualty Shooting Preparedness (with exemplar quotes)
The volume of injuries caused supply shortages in some instances. Physicians needed to change their clinical management practices to meet the demand, further compounding the stress placed upon physicians. See Figure 3, infra.
So, we ran out of chest tubes. So, what do you do? So, we used endotracheal tubes. Is that okay? Is that not okay? … People I think were reticent, worried, self-paced… You know the right thing to do, but you can't do it. That creates a great deal of post-traumatic stress injury and I think that could be in part alleviated by establishing some crisis standards of care.
[Participant #3]While no physicians expressed about potential liability or malpractice in the moment, a few noted that liability concerns from hospital administration hindered them in speaking openly about the decisions they had to make during the crisis.
This stress was further compounded by a lack of information and abundance of misinformation about the mass casualty shooting from both pre-hospital emergency services as well as the media. This lack of information led some participants to suspect there was an active shooter in the hospital or surrounding area, triggering fear for their own safety. See Figure 3, infra.
We just had no idea what was happening and there was a lot of fear for our own safety. The lack of information was really a problem.
[Participant #10]Barriers that normally exist between siloed specialties or professions — such as between the emergency department and inpatient surgery team — broke down as everyone came together to take care of the patients. Without that effort, participants felt that many more lives would have been lost. See Figure 3, infra.
Addressing the aftermath of a mass casualty shooting:
All participants in this study described at least some long-term psychological effects for either themselves or colleagues, including anxiety, flashbacks, and hypervigilance. The majority expressed concern about the development of post-traumatic stress disorder (PTSD) in the weeks to months following the mass casualty shooting — some continuing to describe symptoms years afterwards. Participants identified a wide array of direct support services available from their institution following the mass casualty shooting, including direct provision of therapy and counseling sessions. But participants from three of the eight incidents reported a complete lack of response or recognition. See Figure 3, infra. The importance of having organized, readily-available support systems for providers was repeatedly emphasized:
There has to be a more coordinated, institutional response to go to the people that have been involved in the care… and offer them services. Also, just to explain to them that this is hard… People are going to have some post-acute stress disorder, maybe even some PTSD down the road and to explain that dealing with these things or that after you experience something like this, it is not abnormal to have those feelings.
[Participant #12]Individuals who were trainees at the time of the mass casualty shooting were identified as particularly in need of organizational support. In the words of one participant who was a resident at the time of the event:
Since I was a trainee, a resident, we go on about our lives. We work really long hours. Then you are working the next day, then the next day. There isn't a lot of time to really go home and reflect. It's really important for hospital systems and residency programs to truly recognize the importance of including residents and trainees … Residents should not be forgotten because they are on the frontlines, you know? They're the ones that don't get much a break afterwards to really reflect and heal.
[Participant #12]Community and hospital recognition of providers' work was identified by some as an important source of healing. See Figure 3, infra. However, the unequal distribution of that recognition also caused some stress:
“The unsung heroes of the response were actually the medicine service … I think my medicine colleagues felt, at least for some time, that all of the glory was showered upon those on the guts and gore side … The actual making the system work side, they were not recognized at least externally to the hospital … Their contribution was underappreciated by the larger community. But, those of us that understand how the hospital functions could not have done what we did unless they did what they did.”
[Participant #3]3. massive media attention
All of these incidents were accompanied by a massive amount of media coverage. Many of the interview participants were asked by their departments to interact with the national news media. Participants described the logistical difficulties of dealing with media attention in the midst of an ongoing crisis. See Figure 4, infra.
The media onslaught was unbelievable during our incident. How are you going to manage those and who is going to manage those? We have a media relations department that did a very, very good job. The onslaught of media attention is extremely stressful to deal with … Managing all of that — how your security manages that — is all part of the post-incident phase. I think that we didn't realize how important that was until we had to go through it.
[Participant #4]This study suggests that physicians experience significant psychological symptoms from working during a public mass casualty shooting. Based on our findings, we propose that that these psychological sequelae could be mitigated with coordinated systematic plans from institutions for psychological support in the aftermath of a mass casualty event, improved guidelines and training in mass casualty events for health care providers, improved sensitivity and ethical standards from the media, and institutional support for healthcare providers engaged in firearm violence prevention work. Finally, more research needs to be done to better understand the psychological impact of these events on healthcare providers.
Figure 4 Themes: The Media and #thisismylane (with exemplar quotes)
Some, but not all, participants also expressed frustration with sensationalized and inaccurate information that was disseminated by the media, including descriptions of how people died. One participant even described how that experience inspired him to engage the local and national media in responsible reporting following a violent event. See Figure 4, infra.
4. commitment to advocacy for a public health approach to firearm injury
One physician who owned firearms for recreational use, discussed the change in their attitude towards firearms after treating patients that were victims of a mass casualty shooting:
I'm comfortable with [firearm] use. I will tell you, for me, my personal thoughts on weapons changed quite a bit as a result of this… It really changed my mind in terms of the idea of my personal enjoyment with weapons. I haven't shot any of my weapons since that event and I don't have the desire to.
[Participant #3]While not all participants decided to engage in advocacy, every physician we spoke with agreed that it is appropriate or even necessary for healthcare professionals to have a voice in the firearm violence debate. In addition to expressing frustration with the current political discourse around firearm injury, several participants saw the unique perspective of physicians as crucial for creating policy change surrounding firearm injury prevention:
I want to do whatever I can to prevent some of these terrible events. So, that's a lot of what I do now. I write, I publish, I teach around threat management and violence prevention.
I'm involved in state level activities and it's built over the years.
[Participant #9]IV. Discussion
In this qualitative study of seventeen physicians across five medical specialties working in eight different communities that experienced a public mass casualty shooting, four major themes emerged: (1) the intense psychological toll on providers, (2) the importance of and need for mass casualty shooting preparedness, (3) the onslaught of media attention, and (4) the commitment to a public health approach to firearm injury. These four themes have important implications for healthcare institutions, medical professionals, and policymakers.
This study suggests that physicians experience significant psychological symptoms from working during a public mass casualty shooting. Based on our findings, we propose that that these psychological sequelae could be mitigated with coordinated systematic plans from institutions for psychological support in the aftermath of a mass casualty event, improved guidelines and training in mass casualty events for health care providers, improved sensitivity and ethical standards from the media, and institutional support for healthcare providers engaged in firearm violence prevention work. Finally, more research needs to be done to better understand the psychological impact of these events on healthcare providers.
Very little research quantitatively describes the impact of these events on healthcare providers' mental health and resiliency. To our knowledge, the only study of physician mental health following a mass casualty shooting was a study of thirty-one general surgery residents working in Orlando, FL on June 12, 2016, during the Pulse nightclub shooting.Reference Havron, Safcsak, Corsa, Loudon and Cheatham14 The authors found a high prevalence of post-traumatic stress disorder (PTSD) and major depression that did not resolve over time, representing a large emotional toll upon healthcare providers involved in mass casualty shootings. Although our study did not formally screen for any psychiatric disorders, the vast majority of participants in our study expressed concern for or knowledge of development of acute stress disorder or PTSD in either themselves or their colleagues. They described institutional responses to mental health concerns that ranged from nothing, to individualized formal psychotherapy. Institutions may consider implementing protocols to address acute and longterm psychological sequelae after a mass casualty shooting, particularly for trainees. Future research is needed to better understand the psychological impact of these events, its relationship to mental illness and burnout among physicians.
Our findings are consistent with prior literature that details the need for improved guidelines and training in mass casualty shooting events for healthcare providers.Reference Glasofer, Laskowski-Jones, Willis, Philp, Sofer, Turner, Lockey and Rehn15 Participants expressed stress and uncertainty about whether the clinical decisions they made in response to the overwhelming demand for services were the right ones. Those participants with training in the military or prior work on mass casualty events were more comfortable with their clinical decision making and felt less stressed about their response after the fact. Development of guidelines that delineate “crisis standards of care” along with formal training and/or simulation in preparation for a mass casualty event may be beneficial.
Resource limitations, difficult triage decisions, and the need for rapid communication in emergency situations all raised concerns for providers. Multiple participants described resorting to texting on cellphones for rapid communication during the mass casualty event, which is not compliant with the Health Insurance Portability and Accountability Act (HIPAA). While the Department of Health and Human Services (HHS) has discretionary authority to modify enforcement of HIPAA violations (as it did recently to promote the use of telehealth during the COVID pandemic),Reference Cohen, Crespo and White16 they have not released general guidance on the use of texting during emergencies. Hospital systems concerned about HIPAA compliance during emergencies should incorporate a Privacy and Security Rule-compliant rapid communication network into their institutional policy. Institutions, hospitals and professional societies should work alongside policymakers to ensure that the technology regularly used in hospitals is prepared to encounter a mass casualty shooting.
Further, although many states and the federal government have taken steps to limit liability for ordinary negligence in emergencies, legal protections are patchwork and full immunity from liability is often not guaranteed.17 Medical negligence claims typically hold providers to a “reasonable” standard — meaning that a court will ask what a “reasonable” provider in the same scenario would have done. Often, demonstration that a provider followed emergency protocols for triage decision-making and resource allocation is sufficient to show reasonableness.18 While none of our participants reported that any medical liability claims were filed in these incidents, some expressed concern for the potential for medical liability. In the absence of an agreed upon “crisis standard of care” for the extraordinary circumstances encountered in a mass casualty shooting, the courts would be left without clear guidance on adjudication of medical liability claims. This underscores the need for the development of guidelines for “crisis standards of care.”
Direct interaction with and passive consumption of the media surrounding a mass casualty shooting was a central component of the lived experience for providers. Inaccurate and sensationalized reporting negatively impacted our participants by contributing to psychological suffering. The deleterious effects of misinformation and sensationalism during mass casualty shootings has been highlighted in prior publications, with specific recommendations for journalists and media outlets.Reference Meindl and Ivy19 Our work underscores the critical need for a change in reporting tactics from various media outlets to ensure ethical and accurate journalism during any mass casualty shooting.
Without prompting, multiple participants described how their experience led them to recognize the need for a paradigm shift in the firearm injury debate that focuses on preventing firearm injuries through proven public health strategies. As there has been a vacuum of effective leadership on this issue, medical professionals including physicians are increasingly taking the lead in crafting and promoting these public health policies as well as devising studies to better inform policymakers in the future.Reference Mozaffarian, Hemenway and Ludwig20
Limitations
There are limitations in this study. As with all qualitative studies, our findings are hypothesis-generating, and may not be generalizable, although we strove to identify outliers and dissenting opinions. Unique to this study, our participants were temporally removed from their experiences, some by many years. Therefore their recollections were subject to recall bias, though our interviewers were trained to prompt participants for concrete details and specific memories. In addition, their accounts are likely influenced by social desirability bias — the inclination to report answers, behaviors, or attitudes that adhere to social norms.Reference Tourangeau and Yan21 To mitigate this, all interviewers did not have a personal or professional relationship with the participants and all participants were assured of having anonymity. All interviews were conducted over the phone which increases the anonymity of the interview though may impact the way participants responded or understood questions. Finally, this research was conducted using snowball sampling with referral from one physician to another which may have biased the type of participants that were included within the study, in favor of those who may feel more comfortable speaking about their experiences. To mitigate this, we recruited multiple initial “nodes” of snowball sampling to ensure a variety of participants. Finally, our findings may not be transferable to other healthcare professions, such as nurses and pre-hospital providers, who also care for victims of public mass casualty shootings.
V. Conclusion
In this study we identify four themes which characterize the lived experiences of physicians working in communities that experienced a mass casualty shooting. The intense psychological toll imposed upon physicians called to action during an unprecedented tragic event in their communities, the need for mass casualty preparedness in the hospital setting, and complications arising from the relentless media attention were clearly front and center. Finally, the medical professionals in this study expressed hope that future firearm injury could be prevented. They believed that healthcare professionals are uniquely positioned to promote and devise public health strategies to curb firearm injury and hopefully prevent the next mass casualty shooting.
