Terror in Tulsa

The day was like any other to the physicians and staff who bustled about the Warren Clinic, the office space of an orthopedic medical group on the campus of Saint Francis Health System in Tulsa, Okla. Shortly before 5 p.m. on June 1, spine surgeon Preston Phillips, MD, was in an exam room with a couple, talking to the husband about his chronic back issues. As they discussed treatment options, the door cracked open and Michael Louis, 45, slipped inside the room. Mr. Louis, who was carrying an AR-15-style semi-automatic rifle and a .40-caliber semi-automatic pistol, stared at his intended target. He fired several rounds into Dr. Phillips, but miraculously spared the couple’s lives.

Dr. Phillips had performed spine surgery on Mr. Louis on May 19. In the weeks that followed, Mr. Louis experienced pain and called Dr. Phillips’ office multiple times over a period of several days to complain and ask for relief. On the morning of the shooting, he called once more before arriving several hours later to hunt down Dr. Phillips.

Members of the Tulsa Police Department who swarmed the Saint Francis campus minutes after receiving calls about shots being fired discovered Mr. Louis in the clinic’s lobby, dead from a self-inflicted gunshot wound. A letter found on his body said he blamed Dr. Phillips for the pain he experienced after surgery and noted his intent to kill him and anyone who got in his way. Mr. Louis legally purchased the semi-automatic rifle from a local gun store hours before the shooting and had bought the semi-automatic pistol at a pawn shop on May 29.

As officers began to clear the office complex, they came across the bodies of the shooter’s other victims — sports medicine specialist Stephanie Husen, DO, receptionist Amanda Glenn and William Love, who was visiting the clinic and was reportedly shot while barricading a door so others could escape.

In the days that followed the shooting, shattered members of the Saint Francis Health System tried to cope with the senseless tragedy and mourned the loss of their fallen colleagues. Healthcare professionals across the country expressed their dismay that a patient who was distraught over the amount of postoperative pain he had to endure would kill four innocent people and were left to worry about their personal safety amid increasing incidences of workplace violence.

National Ambulatory Surgery Center in San Jose, Calif., had its scheduled in-service staff safety training, which includes what to do in the event of a mass shooting, the day after the Tulsa attacks. “Everyone was in shock from what had happened,” says Clinical Nurse Manager Marisa C. Ynchausti, BSN, RN. “The tragedy made for a very engaged day of training because of the fresh appreciation that something like that really could happen anywhere. Everyone was very attentive and understood they needed to know what their roles would be in that kind of situation, what tools are at their disposal and where the proper exits are.”

Staff members were told to run if they could, hide and shelter in place if they had to and to not fight the aggressor, says Ms. Ynchausti. The facility also recently ran a realistic drill on how to respond if an armed assailant attacked (see “Be Prepared for an Active Shooter”).

The Tulsa incident immediately reminded Ms. Ynchausti of a frightening incident that took place last year when a man barged into the center’s front offices where she was working alone. The man was mumbling and incoherent and said he was looking for the doctor caring for his friend, who had cancer and needed immediate medical attention. Ms. Ynchausti said the doctor didn’t work at her facility and offered to call 911 for the man’s friend. She also paged two colleagues, who quickly arrived on the scene. The man left when he saw he was outnumbered. After the frightening incident, the surgery center’s staff came up with a code word that would alert others if a colleague needed help without arousing the suspicions of the intruder.

The Tulsa shooting made Ms. Ynchausti realize that her scary encounter with the agitated man could have been much worse. “Workplace violence is a very real issue, and it’s occurring more often,” she says. “We realize it could happen anywhere.”

That’s the frightening reality healthcare workers continue to face. In 2013, the son of a patient who was receiving care at the Ambulatory Surgery Center of Good Shepherd Medical Center in Longview, Texas, went on a stabbing spree, killing a nurse and a visitor. Two years later, a man shot and killed cardiac surgeon Michael Davidson, MD, at Brigham and Women’s Hospital in Boston. The shooter reportedly blamed the surgeon for his mother’s death. In October 2021, nursing assistant Anrae James was shot and killed by an off-duty co-worker at Thomas Jefferson University Hospital in Philadelphia. Two days after the Tulsa tragedy, an assailant stabbed a doctor and two nurses in the emergency department at Encino (Calif.) Hospital Medical Center.

Ali H. Mesiwala, MD, FAANS, a board-certified neurosurgeon at DISC Sports & Spine Center in Newport Beach, Calif., says the Tulsa shooting is eerily similar to the murder of spine surgeon David Duffner, MD, on Valentine’s Day 2020. Dr. Duffner was gunned down in his Southern California clinic by a patient who complained that failed surgeries had left him reliant on painkillers. “The surgeon was killed for reasons related to the patient’s incomplete pain relief and dissatisfaction and frustration over his postoperative care,” says Dr. Mesiwala. “In both cases, it seems the patients were suffering from pain that could not be treated with an operation.”

These tragedies highlight the insidious psychological effects of pain and reinforce the need to set clear patient expectations about likely outcomes of surgery — especially when it comes to back and spine procedures that rarely leave individuals completely free from discomfort. Of course, as Dr. Mesiwala points out, sometimes even the most clear-cut guidance on what to expect during recovery isn’t enough. “Regardless of how much time a surgeon spends with patients, they might have unrealistic expectations about what surgery can accomplish,” he says. “When their pain does not respond or is not substantially reduced, they become distraught, frustrated and desperate.”

That’s why it’s becoming increasingly common for facilities to lean on psychological evaluations of patients, says Edgar L. Ross, MD, director of Brigham and Women’s Pain Management Center in Chestnut Hill, Mass., and an associate professor at Harvard Medical School in Boston. “For elective surgeries, especially orthopedic procedures, a pre-op psychological review is becoming the norm, if not a standard of care,” he says. “A psychological evaluation can also be used to plan for post-op pain management.” Dr. Ross says that such evaluations can help providers identify certain types of patients — such as pain catastrophizers  — who are at higher risk for chronic opioid use, non-compliance with rehab, long-term chronic pain and poor satisfaction with the care they receive.

Regardless of how much time a surgeon spends with patients, they might have unrealistic expectations about what surgery could accomplish.
— Dr. Ali H. Mesiwala

Drs. Mesiwala and Ross have had to calm frustrated and visibly upset patients. “Every healthcare professional will sooner or later encounter a situation like this,” says Dr. Ross. He adds that strategies such as actively listening to their concerns, staying relaxed, avoiding the tendency to get defensive or argumentative — and even getting help from resources such as patient relations experts — go a long way toward defusing tense situations that arise when patients clearly aren’t happy with the care they receive.

“The key aspect of a productive response is to never abandon patients,” says Dr. Ross. “Even if a referral is needed to continue contact after surgery, reach out to the patient periodically.” The toughest thing to do professionally, says Dr. Ross, is to stay engaged and let the patient vent as much as they need to. “All healthcare professionals will experience complications, miss something important or make a wrong decision or judgement call,” he says. “It’s how they handle these situations that is most important.”

Dr. Mesiwala agrees that hearing the patient out, listening without judgment and giving them an opportunity to vent uninterrupted are of paramount importance when it comes to de-escalating tense encounters. “While I’ve never been in a situation where I felt physically threatened by a patient, we have had occasions where patients were angry and desperate regarding their postoperative pain
control or frustrated over access to care,” he says. “We found that bringing the patient into a private room to have a discussion with several staff members and letting them vent helped to calm them down.” Ultimately, says Dr. Mesiwala, taking time to hear the patient out and addressing their concerns can go a long way toward preventing devastating outcomes.

“ The shooting in Tulsa was simply a tragic, horrible event ,” says W. Michael Hooten, MD, a professor of anesthesiology in the division of pain medicine at Mayo Clinic in Rochester, Minn. “It’s difficult to even think about, and my heart goes out to those who lost their lives and of course those who will be affected forever by that occurrence. The human loss is incalculable.”

Dr. Hooten is immediate past president of the American Academy of Pain Medicine (AAPM) and a former chief resident of psychiatry at Yale School of Medicine who has researched workplace violence in the setting of pain management facilities. He co-authored a study on the subject based on a survey of providers that was published in Mayo Clinic Proceedings and co-led a panel that discussed the findings in a special session at the AAPM’s 2019 annual meeting. The survey sought to understand the rate of workplace violence in the setting of pain management, as well as the drivers and key clinical situations that seem to be most associated with it.

“We were very surprised by how many providers received threats in the workplace from patients,” says Dr. Hooten. “Some individuals who responded to the survey experienced physical violence — the rates were very high. What we learned from our research is that in the setting of pain management, this is a more common occurrence than you might think. However, it is underrecognized and underreported.”

Dr. Hooten and his co-authors identified two areas where threats of violence and actual violence typically occur. “The first involved clinical situations surrounding the ongoing provision of opioids — particularly a change in treatment, whether it’s discontinuation or dose reduction,” he says. “Another flashpoint seemed to be whenever there was ongoing litigation surrounding health care, such as workers’ comp cases.”

Dr. Hooten’s study was not designed for the more granular task of asking each individual respondent for more information about their experience. “That type of work is still needed,” he says. “What we can say, at least in general, is that pain is highly distressing. Understanding how distressed individuals can become is critical. I think you can see types of behaviors emerge, either threats of violence or actual violence as you saw in Tulsa.”

A threat surveillance system driven by awareness and communication among providers is key to head off threatening patients before grievances and anger over clinical issues turn into attacks, according to Dr. Hooten. “There are at least a couple key factors that I think are really foundational for building and developing a surveillance system,” he says. “Number one is just to raise the awareness and the level of vigilance among staff members. That not only includes doctors and nurses, but the individuals answering the telephone and checking patients in at the front desk because this is often where threats are delivered.”

Dr. Hooten says threats that occur, regardless of the perceived level of severity, must be quickly communicated to everyone in the immediate area. “That at least provides an opportunity for early intervention to see if the threat can be mitigated,” he says. “Explicit threats to individuals’ lives should be immediately reported to law enforcement.”

There is a risk of unanticipated consequences when surveilling and managing potential individual threats. “We don’t want to necessarily allow it to fracture our clinical relationships with patients,” says Dr. Hooten. “That’s why these threats need to be assessed. Awareness should lead to assessment, and then there should be various levels of interventions. Human behavior is complex. This is what we’re dealing with.

“Threats and violent events occur intermittently,” he continues. “But if awareness and communication are raised, hopefully these types of tragic events can be mitigated in the future.”

The first responders were gone, the victims removed. Cliff Robertson, MD, MBA, walked through the Warren Clinic the morning after the shooting to see the tragic scene for himself as he tried to process the nightmarish events of the previous evening. The CEO of Saint Francis Health System prayed over each area where the victims lost their lives and in the quiet aftermath of tragedy tried to steel himself for the trying times ahead. Later that day, during a press conference called to answer unanswerable questions, he would stand in front of stunned colleagues of the victims and acknowledge the shooting would change the health system forever.

“It’s up to us to not allow this horrible event to make us want to turn our backs on the reason we’re here,” he said while choking back tears. “We were all called into this profession to care for others and our community. While it’s human nature to want to walk away right now, we can’t do that. We won’t do that.” OSM