Mark Jones & Kathy Swanson (Retired) - Hospital Presidents

How I Heard

Mark Jones

When my phone rang early in the morning of June 12, 2016, it was my colleague, Carlos Carrasco, the chief operating officer of Orlando Health Orlando Regional Medical Center (ORMC). He explained there had been a shooting at a downtown nightclub with multiple gunshot victims and they were headed to ORMC’s Level One Trauma Center. Unfortunately, it’s not uncommon for us to receive a patient with a gunshot wound, or several for that matter. But I could tell in his voice something was different. He was calm, but he was clear — I needed to get to ORMC quickly. The decision had been made to activate the Hospital Incident Command System (HICS). 

Heading toward the hospital, I saw red and blue flashing lights ahead.  The closer I got, the brighter the lights became, until it was almost blinding. I had never seen so many first responders assembled in one place. I was still about a half mile from the hospital, but the roads were closed. Officers redirected me, but still, all roads led to closure after closure. It was then that I realized the “downtown nightclub” was Pulse — a club located just three blocks from ORMC, a club I pass every day on my way to work. 

While I drove, different scenarios played through my head. As it turned out, none of them were on the scale of what we would be dealing with that day.    

Kathy Swanson

I remember waking to a phone call from Dr. Jamal Hakim, Orlando Health’s chief operating officer. He calmly asked me, “Kathy, do you know what’s going on?” and then suggested I turn on the television. News channels were reporting live from the scene, and the scene was our hospital. I could see ORMC in the background. I could hear an unusual sense of panic in the reporters’ voices. I knew something exceptionally awful had occurred. But still, it all felt a little surreal. 

When I arrived on campus, Mark Jones was serving as incident commander at ORMC. I stopped at Orlando Health Winnie Palmer Hospital for Women & Babies to check-in on my team there. I could see they were genuinely scared. There was a feeling of fear that permeated the hospital.  

And, there were far more questions than answers. The team desperately wanted information and assurance — not just for themselves but for our patients and their families. Adding security precautions became a top priority. 

It wasn’t until a few hours later, when I went into incident command, that it really hit me. Just a few steps into the board room, I saw a look on Mark’s face. That look cemented the gravity of what had transpired. I’ll never forget that moment. Mark and I have been colleagues and friends for more than 30 years. We’ve been through incident command responses multiple times, but I could see it in his eyes — this time was different. 

Synopsis

HICS provides hospitals and health systems with the tools needed to respond to any type of emergency, either internal or community wide. 

The incident commander is responsible for leading the HICS team, which has 22 individuals evenly assigned to Team A (first shift) and Team B (relief shift). Each HICS team member is selected to fill a very specific role, including safety, security, operations, logistics, medical and more. These 22 people will work in tandem until HICS is no longer in effect.  

The HICS team is most often assembled in times of a natural disaster such as a hurricane. In situations like those, the HICS team is generally well-informed upon arrival and they are ready to implement plans. June 12^th would prove to be very different. The team was responding to something we had never experienced before. 

Over the next 36 hours, the HICS team would be tested to new limits as they responded to lead our team through one of the nation’s largest mass-casualty events. 

The HICS team documented five operational objectives:

1. Provide a safe environment for guests, patients and team members
2. Maintain and replenish supplies during the incident
3. Offer assistance to guests/families using Family Assistance Area
4. Maintain appropriate staffing for quality care during incident
5. Manage communication

Although seemingly simple in theory, each of these objectives held great weight. It would take incredible collaboration and discipline to fulfill these objectives. 

As incident commander, you are trained to remain calm. The pressure is intense. You take on the role knowing everyone is watching to see what you will do and how you will respond. Later they may evaluate and speculate about why you did what you did, but in the moment, you are the chief. You are leading a team of leaders. Together, you do what you need to do. You trust your gut, trust your team and rely on your training. 

Preparation

As the region’s only Level One Trauma Center, ORMC has a heightened responsibility to care for our community in a time of crisis. Drills are essential in helping us identify potential areas of weakness and risk. Our team deliberately designs complex, real-life scenarios that will push even our most experienced team members to their limits. 

In March of 2016, the annual Mass Casualty Intake Drill took place. For the first time, the drill simulated a mass-shooting scenario — a worst-case scenario that would ultimately play out as a tragic reality just three months later.

As incident commander, you have significant responsibilities related to the drills. You must prepare your team. No matter how inconvenient and disruptive the drills can be, they are critical to being ready to respond in a crisis situation. 

For drills to be successful, they must be:

• Frequent. Said simply, practice, practice and practice AGAIN.
• Taken seriously — no matter what. No excuses.
• Spontaneous, as much as possible. There will never be a “good time” to drill. The spontaneity of it is, in fact, part of the drill.
• Authentic. Maintaining the integrity of the drill as a real-life event — from start to finish — is crucial.
• Routine. Develop a plan, practice the plan, stick to the plan.
• Led by a decision maker. The incident commander is the authority throughout. Decisions — even in a drill — must be calculated, calm and non-emotional. The ability to maintain an overview creates trust among the team in a real-life scenario.
• Evaluated. Acknowledge the learnings. Hold teams accountable for ongoing process improvements to ensure systematic success.

Undoubtedly, lessons learned from the mass casualty drill in March contributed to the positive clinical outcomes and overall organizational preparedness on June 12th. There is no drill that could have prepared us for the emotions we would experience. But when faced with the unthinkable, our team knew what they had to do. We drew confidence from our training. And when the community needed us most, we were as ready as we could have been.

Response

Mark Jones

When I arrived at ORMC, I was met by Carlos and Dr. Michael Cheatham, ORMC’s chief surgical quality officer. They briefed me on the situation at hand. Things were unfolding quickly. The emergency department and trauma bays were receiving an influx of patients. And worse yet, it was believed that more victims, potentially even more severely injured, would soon follow. 

Recognizing the extreme circumstances, and the need for reinforcements, the decision was made to activate the Hospital Incident Command System (HICS) at 3:14 am.  Before long, the HICS team had assembled in the ORMC board room, which serves as the Incident Command Center.  Around a long, wooden table are a dozen black leather chairs — each assigned to a particular member of the HICS team. In front of each person was a phone with a designated phone line. 

I would remain in the command center for the next several hours. As incident commander, I was physically separated from the unfolding events just a few hallways away. To remain focused on the details that needed to be worked through, I was intentionally insulated from the events themselves. Although it was an adjustment to the traditional incident command plan, I sent Carlos into the field as my eyes and ears. At that time, what I needed more than anything was information and perspective from a key operational leader. This turned out to be one of the best decisions for the team.

On the video screens in the command center, I was seeing what the world was seeing. The images showed our hospital with ambulances lined up and people rushing in and out. Outside, I could see multiple vans lined up. These were from the medical examiner’s office and were waiting to take the bodies of those who died shortly after arrival. 

I watched as the stretchers came out from behind a privacy screen, one after the other. There were nine in total. White linens were draped over the nine young men and women. It was an image I’ll never forget.

By 6:30 am, I was ready to be among our clinical team. It was important to see for myself what was transpiring. Following protocol, I designated a member of the incident command team to temporarily assume my role as incident commander and then left the room. 

I made my way toward the trauma bays. The effectiveness of our team’s efforts had gotten the patients upstairs and the bays were empty except for a single team member. She was on the floor, gathering the victims’ personal items. She was doing her best to keep personal items sorted, placing them into clear plastic “belonging bags.” Along the wall were dozens of bags lined up side by side. Bags filled with articles of clothing, jewelry, wallets and cell phones.

I returned to incident command deeply affected by what I had seen. But there was so much more to be done throughout the rest of the day.

Kathy Swanson

As Mark and I began our incident commander handoff, we were both becoming keenly aware of the devastation and the world-wide response that was unfolding. The conversation was all business, an uncommon occurrence for two colleagues who had worked together over three decades. Listening to Mark’s handoff, I knew this night would be unlike any other I had ever experienced.

Once our handoff was complete and the new incident command team was in place, I briefed the team on the tasks and priorities ahead. One of the top priorities continued to be patient/victim identification. I remember receiving the list of patients and all of the names started with “Jane” or “John Doe” followed by a different city and state. This unique identifier that unknown patients received would be linked to each one, once we established their true identity. I had never seen a Doe list so long, and I began to realize what a daunting task we had that would carry us through the night. After the briefing was complete and the team got organized around the priorities, I said to myself, and then to the team, “We’ve got this.” 

Our team knew there were hundreds of distressed family members and friends waiting for answers. Yet, as desperate as we knew they were, this was not a process we could afford to rush because we could not afford to be wrong. We had a system in place to request identifying marks — tattoos, birth marks, etc. — but this wasn’t enough to distinguish the patients as efficiently as we needed. We had to be more creative with our identification process, so we requested photos from the families. 

Amy DeYoung, ORMC’s administrator for allied health professions, watched her inbox flood with pictures from loved ones who were clinging to hope. The photos showed young men and women with vivacious smiles and eyes full of life. It was difficult to see these young people during such happier times knowing full well, that if the individual was under the care of our team, they would likely be unrecognizable. 

As we continued the task of identifying patients, ensuring adequate staffing, ordering supplies and completing all of the other tasks necessary for ongoing operations, someone delivered a police officer’s helmet. You could see the bullet hole in the helmet from a shot earlier that morning. The officer survived, thanks to the helmet. This gesture gave us all a fresh sense of determination.

Through the night, various physicians would come into the command center and just sit quietly awhile before returning to their duties. In the middle of the night, I temporarily turned over incident command and called for the patient care coordinator to accompany me on rounds. I needed to check on the staff and see how they were doing. I went to the ED, trauma ICU and other units, and the staff was amazing — concerned only about the patients and how their colleagues were doing. Many of them had been there the night before and were back again to provide care.

The board room walls were covered with photos of young men and women we had not been able to identify.  One by one, we worked diligently to identify each and every patient. With each positive identification came tears of joy and also heartache. Joy for those who would learn their loved one had in fact made it out of the club and was under our care, but heartache for those whose hope dwindled a little more each time their loved one’s name was not called. It was heartbreaking, but we remained focused on the tasks at hand.

In the early morning hours of Monday, questions started being asked. Are we canceling elective surgeries? Are we on trauma diversion? What are the plans for daily operations today? We discussed it as a team and decided we were not going to compromise our responsibility to the communities we serve and the patients who place their trust in us. We were not on diversion, we were not canceling cases. It was going to be a full Monday schedule as planned. Most of the victims of the shooting were going to need multiple surgeries, so I met with the chief surgeon and we prioritized each patient’s return to the OR. We were able to accomplish this without disrupting the regular elective schedule.

As the night became morning, we had made great progress. Only one photo remained without a name, one young man who represented the last of the survivors. A room full of families stood anxiously as our team worked to identify this last patient. They understood the grim reality that if this was not their son or brother or friend, their loved one had not survived the shooting.

This image, this one last photo hanging on the board room wall, is something I will always remember. I can still picture his face clearly to this day. 

Lessons Learned

• Drills had prepared us well for clinical excellence. While we were well-equipped to deliver outstanding patient care, we struggled to meet the needs of the families and friends who turned to our team for answers and access, comfort and consolation.

   

• The HICS team is intentionally secluded from the field. However, during a time of crisis, what the team needed most was a trusted liaison directly interfacing with them. This person is vitally important to conveying accurate, first-hand information to those in incident command.

   

• Implementing a process for families and friends to submit photos of their loved ones proved beneficial to our team as they worked urgently to identify patients.

What We Changed

• Following the Pulse shooting, Orlando Health leadership reevaluated security protocols for our hospitals and increased protective measures for patients, guests and team members. This included minimizing risks by adding metal detectors at the hospitals’ main entrances and more officers patrolling the campus as well as reducing access points in and out of the hospitals.

   

• Going forward, we plan to expand our outreach even further to include additional departments for specialized support, such as Community Relations and the Orlando Health Foundation.

   

• Social Media proved to be especially critical for real-time, ongoing support. We will continue to utilize social media as an additional communication tool, allowing for controlled messages.

   

• With the high demand for ongoing updates, media became a critical resource. Early on, it was evident we needed a dedicated spokesperson who could convey operational and clinical updates to the media. The world was waiting on answers and they looked to Orlando Health to provide them. Recognizing the need to delicately balance our operational needs and clinical updates with great compassion, we turned to Dr. Cheatham. Without hesitation, he accepted this role and did an outstanding job of balancing clinical updates with great compassion. Going forward, we will pre-identify multiple spokespeople to help share the responsibility. They will each receive media training, which will include many learnings from our team’s response to the Pulse tragedy.

Conclusion

Much of what happened on June 12, 2016, and in the days that followed took our team members well beyond the scope of their job descriptions. 

Reflecting upon what contributed to the successful response from our team, we are grateful for the culture that we’ve worked so hard to build over many decades.

Our organization believes strongly in creating a workplace of trust, transparency and empowerment. On the morning of June 12^th, our team members and physicians responded in a spectacular way, but what makes us proud is that they perform and work collaboratively like this on a daily basis.

Our culture thrives when our teams make the right decisions in the right moment for each patient. They know exactly how to respond to any situation, when to ask for help and when to ask for leadership support. While our incident command team played a critical role in making high-level decisions, the front-line team made the right decisions as patients entered the Emergency Department in large numbers. We had the right people in the right roles. The team knew they were empowered to make judgment calls. They were encouraged to trust their intuition. When there simply wasn’t time to seek approvals and follow protocols, the team knew they could do what they needed to do to act in a patient’s or family’s best interests. 

Our culture and our planning proved beneficial when our community needed us most.

Key Takeaways

• Trust your gut. As incident commander, you must remain in control. You are tasked with protecting your organization while remaining mission-minded. When the script makes sense, follow it.When it doesn’t, rewrite it. Set ground rules and be prepared to enforce them. At the end of the day, you must own the decisions you make.
• Drill. Drill. Drill. But don’t just drill for the sake of drilling. Rather, drill to improve. Drill to the point of failure, allowing failure to expose weaknesses. Through drills, encourage your teams to test themselves and the systems that are in place. Drill often — even more than what is required. You will be glad you did.
• Remember. Even though it can be difficult to think about the incident, don’t try to forget it. Use the experience to motivate yourself, and propel you and your team forward.