Michael L. Cheatham, MD - Chief Surgical Quality Officer

How I Heard

Chadwick Smith, MD, the trauma surgeon on call and one of my partners, called me at 2:20 am. The call was unusually brief. There was none of the usual “I’m sorry to wake you up, but…” I answered and Chad calmly, but urgently, said, “I have 20 gunshot wounds coming. I need you.” My response was similarly brief. “I’m on the way.” Before I hung up, I quickly added, “Chad, call everyone.” Gunshot wounds have a much higher likelihood of requiring operative intervention, and I knew that we would need all the surgeons we could muster. I quickly put on some scrubs and headed for the car. My wife, Susie, had been awakened by the call and asked what was happening. As I recounted Chad’s call, I was struck by the surreal thought of having 20 simultaneous gunshot wound patients. We had trained for such an event, but I still couldn’t believe it was happening.

Synopsis

The Pulse nightclub tragedy highlights the importance of advance preparation and planning for successful mass casualty incident response. Physicians play a key role as both patient care providers and hospital administrators, providing medical guidance to the incident commander and serving as spokespeople to the public and media.

Preparation

In my 22 years at Orlando Health Orlando Regional Medical Center (ORMC), I have been actively involved in designing and implementing our hospital disaster plan. My interest in disaster response spans 40 years and has afforded me the opportunity to volunteer abroad in both mission hospitals and international disaster relief efforts.

Response

I started driving the 8 minutes to the trauma center, taking my usual route up Orange Avenue. As I left our neighborhood, I was immediately struck by the unusual number of police cars on the streets. I did not know the Pulse nightclub was the location of the shooting. I have driven by Pulse to and from work each day for more than 20 years. As I turned onto Orange Avenue, police cars were everywhere, and I drove through what was, in retrospect, a police roadblock. My mind was focused on our disaster plan and how we would respond to a mass casualty incident such as this. I was not paying attention to the road. I kept passing police cars until I came to a sea of flashing lights and parked law enforcement vehicles of all types. I was two blocks from Pulse and could go no further. A police officer approached my window and incredulously asked where I thought I was going. “There has been a mass shooting. I need to get to the trauma center,” I said, showing him my hospital ID badge. I was stating the obvious to him, but it would be an hour before I was told that Pulse was the location of the shooting. “You can’t go this way,” he said and pointed to a passing ambulance. “Follow them.” We took a circuitous route and approached ORMC from back roads. It was eerily quiet when I arrived at the hospital.

Joseph “Joey” Ibrahim, MD, our trauma medical director, had just arrived as I entered the Emergency Department and trauma room. It was controlled chaos with people running from patient to patient. Chad was directing the resuscitation of multiple patients. Joey was helping two of the surgical residents with an open thoracotomy. Chad asked me to go to the operating room where Josh Corsa, MD, one of our senior residents, was just starting a trauma laparotomy on one of the first victims. As I entered the operating room, I spoke with Sandy Mukerjee, MD, the anesthesiologist on call. We rapidly discussed the number of injured and how quickly we could open additional operating rooms. Sandy informed me they already had notified the on-call team and that he would open as many rooms as we needed.

We rapidly finished the first laparotomy, leaving the patient’s abdomen open with a temporary abdominal closure. I ran back down to the trauma bay. Chad informed me that additional patients were arriving and more of our partners were on the way. Joey had taken a patient to the operating room, and I asked Chad who he thought should go next. He showed me a young man with multiple gunshot wounds to chest and abdomen. He was markedly hypotensive, but had a palpable pulse. The nurses were rapidly transfusing emergency blood products. I grabbed his stretcher and said, “We’re going upstairs now.” As we entered the operating room, I told Sandy what I knew of his injuries. We moved him onto the operating table as the circulator and scrub nurse rapidly prepared the surgical instruments we would need. I checked his pulse again, but could no longer feel one. I instinctively started CPR as my mind raced, considering whether we had sufficient resources to continue attempts to resuscitate him. I considered the location of one gunshot wound directly above his heart. His end-tidal carbon dioxide level was less than 10 mmHg even with CPR. This is incompatible with survival and finalized my decision. I stopped performing CPR and announced the time of death.

On re-entering the trauma room, I was informed by Chad that two more of my trauma surgeon partners, Matt Lube, MD, and Will Havron, MD, had arrived. In addition, Marc Levy, MD, the on-call pediatric surgeon across the street at Orlando Health Arnold Palmer Hospital for Children, had offered to help. We now had more surgeons than we had available operating rooms. I recognized that it was time for me to “change hats” and focus on my role as a surgical administrator (half of my time is spent as a practicing trauma surgeon and half as a surgical administrator). My focus would now be ensuring that my surgeons had everything they needed to respond effectively to the increasing number of victims arriving.

I knew we needed to get our Hospital Incident Command System (HICS) up and running. As I hurried to our designated disaster response command center, I met up with Carlos Carrasco, ORMC’s chief operating officer. Together, we rapidly set up HICS with phones, job action sheets and position vests. Carlos always has had a low threshold for employing HICS as a method for practicing our administrative response to disaster incidents. This gives our “C-suite” multiple opportunities each year to practice our HICS roles. Mark Jones, the president of ORMC, arrived a few minutes later, and we updated him on what had happened in the first hour. Our mass casualty plan calls for the on-call nursing administrative supervisor to open HICS, but the reality was that he was too busy with the 36 victims who arrived in the first 36 minutes to be able to do so. We quickly assessed our resources and made plans to bring over operating room staff from across the street at both Orlando Health Arnold Palmer Hospital and Orlando Health Winnie Palmer Hospital for Women & Babies to augment our surgical capabilities while we waited for additional staff to drive to the hospital.

The remainder of our administrators arrived and staffed HICS soon thereafter. I assumed the role of medical director, serving as a liaison between the physician staff and HICS, and providing Mark Jones with the information he needed to make decisions as incident commander. It was during one of my trips down to the ED to check on Chad and our residents that I heard the overhead page for a “Code Silver” — an active shooter in the hospital. Gunshots were believed to have been heard in the ED (which in retrospect was likely gunfire echoing from the Pulse nightclub 2,100 feet away). This belief was supported by law enforcement’s initial conclusion that more than one shooter was necessary to inflict the carnage they had encountered in the nightclub. Our staff initially sheltered in place wherever they were working on patients, barricading the doors with chairs and portable x-ray machines. Recognizing that the ED was full of severely injured victims, however, many of our staff left the protection of the patient rooms and resumed moving from patient to patient, providing care. Heavily armed police officers and SWAT team members searched 1.5 million square feet of hospital and found no second shooter. But the belief that an active shooter could have been in the hospital had an emotional and psychological impact upon many team members.

The second wave of victims arrived just after the Orlando Police Department (OPD) SWAT team breached the back wall of the nightclub at 5:02 am and rescued the remaining hostages, killing the shooter. During the lull between patient waves, we had cleared the ED of the initial victims and resupplied the trauma room. We were then notified by OPD that a “third wave of 40 victims” should be expected. Carlos, Mark and I discussed in HICS whether we could handle an influx of another 40 victims. To this point, we had had sufficient resources to meet the needs of the victims. Another wave of patients might well push us beyond our capacity to provide “standard of care.” We considered transferring victims to the two Level II trauma centers in the area but recognized that this would delay patient care as they were each 25 minutes away. The earlier that one can stop a patient from bleeding, the better their chances for survival. We decided we would continue to accept patients, stop any life-threatening hemorrhage present, and then transfer patients to other hospitals for definitive care. Ultimately, this did not become necessary as there were no further survivors in the club. I remain thoroughly convinced that the proximity of the Pulse nightclub to our trauma center greatly improved patient survival as we were able to stop bleeding more quickly than would be possible if patients had been transported longer distances.

Throughout the morning, we had been issuing press releases from HICS detailing our response to the influx of victims. As the morning progressed, word came that a press conference was scheduled for 10:30 am and that a hospital representative had been requested to answer the media’s questions. David Strong, Orlando Health’s president and chief executive officer, asked if I would serve as the hospital’s physician spokesman. I switched hats again and relied on the media training that the hospital had put me through six months earlier. It would be the first of innumerable press conferences and television interviews that my partners and I would participate in over the next week.

Immediately prior to the press conference, David and I spoke with the mayors of Orlando and Orange County as well as the Federal Bureau of Investigation (FBI), OPD and Orange County Sheriff regarding the substantial number of family members and friends who were at the hospital requesting information. We discussed HIPAA and our ongoing attempts to identify the victims we had received. Although it was widely reported in the press that we received a waiver of HIPAA from the White House, this was not true. The Department of Health and Human Services has a statement on HIPAA in disaster situations dating back to Hurricane Katrina in 2005. This states that “[h]ealth care providers can share patient information as necessary to identify, locate and notify family members, guardians, or anyone else responsible for the individual’s care of the individual’s location, general condition, or death.”

As a result, after identifying all but four of our victims, we assembled several hundred family members and friends in a large conference room at 2:00 pm. We explained the purpose of HIPAA and asked those assembled if anyone objected to our reading a list of patient names and conditions. When no one objected, Joey Ibrahim read that information. This was one of the most difficult parts of the day, as each name was followed by gasps and cries of anguish from those assembled. Each victim’s family was provided with an Orlando Health team member who then escorted them to their loved one’s bedside. The worst part of the afternoon was when the remaining family members approached us and asked us to read the names on the “other list.” They believed that there was another list of survivors that we had misplaced or forgotten to read. These were the family members and friends of those who had died in the nightclub. We escorted these family members to another room where the FBI informed them of their loved ones’ deaths.

Although Joey Ibrahim was scheduled to be in-house as the trauma attending on-call that night, I stayed at the hospital as well due to the number of critically ill victims we had admitted. One patient required a repeat operation for ongoing hemorrhage, but the night was otherwise relatively quiet. My wife brought me dinner around 10:00 pm. It was the first time I had reflected on the day since I had arrived at 2:20 am. We sat in her car in the parking garage and just talked. The entire day remained a surreal experience.

Lessons Learned

What We Changed

The after-action report detailing our response to the Pulse nightclub shooting included almost 80 changes to our disaster plan. Only a few were related to patient care. The majority addressed how we will interact with family members, the media, and our law enforcement and governmental partners in future incidents. We also have expanded our plans for providing counseling and emotional support to our team members. Although each of these was addressed in our previous disaster plan, we realized the need to expand our capabilities based upon the significant impact each had upon our response to the Pulse tragedy. These are important considerations that are rarely addressed in most hospital disaster plans, let alone practiced during disaster exercises.

Conclusion

Many hospital disaster exercises focus solely on the intake of victims and their initial medical care. This represents only a small portion of the total hospital response that will be required. All hospital departments should participate in disaster exercises. Physician involvement in disaster planning response (both medical and administrative) is essential.

Key Takeaways