California Healthcare News first published this article, Here Comes the Flood, on October 8, 2019.

“For as in the days that were before the flood they were eating and drinking, marrying and giving in marriage, until the day that Noe entered into the ark.” 

—  Matthew 24:38 (King James Version)


         Once upon a time the world existed without the system of interconnected computer networks to link devices across the globe. Information was sparse and communication slow in this modern day antiquity, a time when people relied upon encyclopedias and regular mail instead of Wikipedia and the act of composing and sending electronic messages, typically consisting of alphabetic and numeric characters, between two or more users of mobile or laptop devices.

         Equally barbaric was the need to develop film upon returning from a trip and waiting, sometimes days, before viewing these photographs for the first time.  In health care, radiology was still a physical department, and “the x-ray” referred to a large machine that produced a large film that a real physician on site had to review before rendering certain diagnoses.  It was a time when “telemedicine” meant speaking with your doctor on a telephone, and sometimes with a rotary dial.

The Age of Enlightenment

          Advancements in technology over the past few decades have changed the ways in which society approaches communication, eclipsing even the most progressive science fiction from Yesteryear. Too much enlightenment, however, can create fundamental shifts across society, the full extent of which may remain unknown for decades. Today, identities blur with avatars, propaganda is fake news, and anyone can learn about Monowi, a village in Boyd County, Nebraska with a population of one. 

         In health care, this new world order has spread knowledge and expertise across the entire population so that anyone can render a medical diagnosis, and just about everyone identifies with some mental illness/acronym, including but not limited to ADD, ADHD, OCD, ODD, PTSD, SAD, corresponding treatments known as CBT, CBD, ECT, IOP, PHP, or a multitude of support groups almost always ending in the letter “A”.  The speed with which this health care conglomerate identifies and treats psycho and somatic conditions applies proportionally to dissemination of fear and chaos, whether the subject of concern is a natural disaster, a tragedy in the air, and sometimes actual or threatened gunfire at an elementary school in Anytown, USA.

Crisis in the Modern Age

         First responders and others who follow shortly thereafter may benefit from the dissemination of any information, irrespective of its accuracy.  The rest of the population, however, relies far too often on conjecture and speculation, often fueled by anxiety and fear.  For decades the brick and mortar behind any hospital institution served as the focal point for a public health crisis.  Today, any number of health care services may start and finish from locations beyond the hospital walls, although nothing can pull the plug on technology faster than an active shooter. 

         As a preemptive strike to avoid being struck, in 2017 the Healthcare & Public Health Sector Coordinating Counsel published its third report, 115 pages long, on how to plan for an active shooter in a church, movie theater, mall or health care setting.  Response plans include (a) Run, Hide, Fight, (b) Avoid, Deny, Defend, (c) The 4-As (accept, assess, act, alert) and (d) “ALICE” (alert, lockdown, inform, counter, evacuate).  The report includes preventing the disruption of patient care, too, but a condition precedent still remains the need to not get shot.

         In any industry, adequate preparation is expensive.  For the financially strapped health care system, preparing for, and experiencing first hand, an active shooter event goes beyond costs but also includes patient acuity — in the maternity ward to behavioral health to emergency departments to post-surgery to the intensive care unit.  In many instances, evacuation is not an option.  Those fortunate enough to avoid gunfire still must be mindful of gas, and specifically oxygen, nitrous oxide, nitrogen, carbon dioxide, medical air, medical test gas mixtures, medical culture growth mixtures and waste anesthesia gas disposal, none of which should ever be in the line of fire.  A magnetic resonance imaging suite can also complicate matters by disarming an officer or even discharging his or her weapon in the middle of the event.

A Gun and a Pulse

         As the entire nation remains on heightened alert, it takes little more than a gun and a pulse to shut down an entire hospital.  According to the Federal Bureau of Investigations, there were approximately 16.4 active shooter incidents each year between 2007 and 2013, 20 each of the next three years (2014-2016), 30 in 2017 and 27 in 2018.  Because the helplessness of certain victims often overshadows the limited number of casualties, could there be such a thing as too much preparation?  Florida’s Marjory Stoneman Douglas High School Public Safety Act (“MSDHSPSA”) tests this notion by requiring schools to conduct active shooter drills as often as other emergency exercises, such as those preparing for the next fire or earthquake.

         While it is hard to believe that an active shooter drill could someday resemble the all-too-familiar “fire-drill crawl”, the complete participation in which sometimes requires the brandishing of a weapon, the rise in school-yard attacks in the last two years makes such tragedy feel almost commonplace.  This indifference may offset some initial elevated anxiety, but it can also marginalize the tremendous amount of energy and financial resources necessary to prepare for the unthinkable, and to a lesser extent, unbelievable.  The role of the media and its use of the Internet as a means to spread the word creates the illusion that each active shooter event occurs in Everytown, USA, which in turn adds unnecessary fuel to the heated debate in the United States over gun control, which can also remove from the spotlight the challenges health care faces in preparing for such an event, whether it happens or not.  This creates what some may refer to as a “dilemma,” a luxury health care cannot afford.

Here Comes the Flood

         As receptive as travelers on the world wide web can be when it comes to the reporting of tragic news, most still choose to ignore that below the surface of the virtual universe there is a land not indexed by standard web search-engines, but instead existing on darknets and overlay networks that require specific software, configurations or specialty knowledge.  While the “Dark Web” is not the cause of active shooter events, many espouse theories that ultimately blame the Internet for both. 

         If overexposure to threats like these causes a level of detachment from society while making murder less malum in se, society can only speculate on the full impact the Internet may have on a generation that knows nothing about a world without “www” or a  moral compass to offer directional assistance online. The behavioral side of health care refers to this as in vivo exposure therapy or “flooding”, a psychotherapeutic technique used to treat phobia and anxiety disorders by exposing the patient to painful memories with the goal of reintegrating repressed emotions with current awareness.

         Health care cannot afford to drown in the unknown or wait for any partisan response to deploy life preservers if necessary. Historically at least, survival is something at which health care is especially adept. Without an immediate solution to a crisis that is unclear, with a scope that remains unknown, the best health care can do is educate, prepare and have faith.  After all, in addition to Noe and his family doing well by such a strategy, so, too, did all of the animals Noe swore to protect.