Monday, June 23, 2014


Lately there have articles about crowds and managing them -- uncontrolled mobs going self-destructive or attacked by police in an attempt to control them or the reverse:  groups invested in protection, like hospitals, which go under attack by armed individuals.   Until now these situations have been seen as rare and tragic with no way of addressing them, but they become more and more common and the news of them is no longer suppressed.  Violence is just a phenomenon, so why can’t we analyze and manage it? 

One kind of mob is the riots that arise from social inequity until indignant stigmatized or economically trapped people demand some kind of action.  “Social psychologists have found that, rather than surrendering rationality and self-awareness, people in crowds define themselves according to who they are with at the time; their social identity determines how they behave. . . in Detroit in July 1967 after police raided an unlicensed bar . . . hundreds of patrons and local residents gathered in the street to protest. After more than four days of violence between the crowd and law enforcement, there were 43 people dead, 1,189 people injured, and more than 2,000 buildings destroyed.”   The presence of the police was a trigger that only confirmed to the demonstrators that they were having an impact, which united them in solidarity.

Manchester crash, 1985

Other emergency situations are quite different. Sometimes people simply don’t react -- they deny.   “When the hijacked planes hit the World Trade Center towers in New York on 11 September 2001, most of those inside procrastinated rather than heading for the nearest exit. Even those who managed to escape waited an average of six minutes before moving to the stairs. Some hung around for half an hour, awaiting more information, collecting things to take with them, going to the bathroom, finishing emails, or making phone calls.”  The extreme example might be “the aircraft fire at Manchester airport in the UK on 22 August 1985, when 55 people died because they stayed in their seats amid the flames.” 

There can be a simple inability to figure out what to do.  On some occasions people DO react and in very helpful ways, as at the Boston Marathon. “When Islamic extremists detonated four bombs on London’s transport system during the morning rush hour on 7 July 2005, killing 52 people and injuring more than 770, there emerged many remarkable stories of helpful behaviour amid the carnage and chaos. In the dark, soot-filled underground tunnels, where hundreds were trapped with no way of knowing if they would be rescued, there was little panic and a general sense that ‘we’re all in the same boat together’, as one survivor put it.”  Trapped coal miners work together to escape.

The formation of what might be called a “psychological crowd” merging individual with group can be good or bad.  “The Cairo-based journalist Ursula Lindsey remembers it like this: ‘Once you saw that crowd, you just felt the tide was on your side. You felt so right. It made people feel fantastic. People were high on it, seeing they were part of such a big group. It was an endless, mind-opening, affirming experience. You saw the evaporation of fear, this elation, because so many people were with you.”  It amounts to an expansion of identity to include everyone, a liminal situation where all parts of the person were united and joined to others on an equal and shared basis.  It is spiritual but also religious, a congregation.  What about leaders?  (Remember them?  They used to be around.)

Russell Brand opposing Euro-austerity

Efforts to understand and manage crowds at athletic events led to experimentally planting people IN the crowd who knew the layout of the venue and had been trained in likely group reactions.  They wore identification of some kind.  Once the crowd members got over thinking they were spies and recognized them as being on their side, they were surprisingly responsive, following directions meant to keep them out of bottlenecks and deadends, saving lives from crushing and suffocation.  It was guiding rather than suppression.

In war zones hospitals are now attacked without mercy or sanctuary, but the most common violence in civilian hospitals is individuals who are out of control, deranged and armed.  Studies showed that half arrived through the emergency entrance and almost one-fifth didn’t come armed, but grabbed the weapons of the security people, sometimes the ones who brought them in.  About a third were between 18 and 29 -- gender was unspecified: I suppose it was assumed they would be male.  

What do you do when confronted with an emotional but focused, determined, armed guy, possibly high?  Hospital advisors made short-lists, much like triage.

Three zones:  hot, warm and cold.  In the hot zone (an advancing person actively shooting) you have three options: run, hide or fight.  To determine which option you should use, consider:
  1. How close is the shooter?
  2. Is there time to get everyone out safely?
  3. Can the area be secured?
  4. Should we shelter in place?
  5. Should I prepare to defend myself and protect my patients?
This advice comes from George Economas, head of security at Johns Hopkins Medical Institution.  Once you've identified a place to hide, push heavy furniture or patient beds with lockable wheels to block doors that don't lock. Turn off the lights and move away from windows and doors. Hide in cabinets, closets, or anything that blocks you from view of the shooter. Turn your phones, nurse call systems, and pagers to silent. Call 911 and quietly provide as much information as you can, and leave the phone line open. Arm yourself in case you must confront the shooter.

“The last option is when you're cornered. Experts like Economas say there is evidence that you must . . . commit fully to disabling the shooter.  Economas recommends working as a team and throwing anything to distract, disorient or incapacitate: staplers, keys, tape dispensers, etc. If there's a fire extinguisher within reach, spray it at the shooter.”

In the cold zone take cover and stay there even after the emergency is over.  Hold hands up.  Make no sudden moves.  Responders must be able to identify you as a non-threat.

In the warm zone, there may be people who are wounded and need to be helped.  The list of risk-worthy conditions include:
  1. Massive hemorrhage control
  2. Airway management (basic)
  3. Respiration (bag-valve mask ventilation)
  4. Circulation risk (CPR, needle decompression)
  5. Hypothermia
  6. Head injury
  7. Everything else, decon etc.
  8. Documentation (what was done).
The focus is recognizing or creating cover corridors for moving them out.  Crash carts should have the equipment to address this sort of sudden trauma.  Remember movement makes one a target.

Sometimes nurses had such a strong need to respond to calls for help or screams or even shots fired, that they inadvertently interfered with the control responders: gave away locations, triggered automatic doors, exposed themselves to harm, became hostages.  Nurses are no longer clearly identified by caps and white uniforms.

Population pressure, international migrations, traumatized people, and hyper-mobility have particle-ized war into riots and flip-outs.  Many are not even reported widely.  But there still ARE leaders, often in the many school shootings where even the students are capable of aiming a heavy stapler at a shooter’s head.  But teachers are killed by underestimating shooter students.  The ubiquity of cell phones changes the dynamics, as does the familiarity with so many possible “scripts” as a result of watching news and narratives of violence.  

We’re short on stories like the ones during historical formal wars where someone picked up a flag and led a charge and even more lacking in stories about preparation, esp. ones that aren’t just walls or lockdowns.  Or what about stories about afterwards.  Survival is the issue, but on what terms?

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