Emergency Department

How I Heard

The night shift rarely calls me, so when my phone rang around 0230 on that Sunday morning, I was definitely startled. It was the charge nurse calling to tell me she had received a heads up notification on more than 20 trauma alert patients who were gunshot-wound victims. I told her I was coming in and hung up so she would be free to prepare for the influx of patients. Until that point, it had been a fairly quiet Saturday night and she had considered sending some staff home early. Fortunately, she hadn’t. As the night unfolded, we would need every one of them — and more.

While I got dressed, a million things were going through my mind. Would I need to call in more people? Would I know any of the victims? Where were my kids? I was on the road by 02:45 and called the department for an update. That’s when I learned it was a shooting at a club. I assumed it was a club downtown and was surprised to see so many police cars speeding by me as I approached the hospital from the opposite direction.

Synopsis

The ORMC Emergency Department consists of 75 beds divided into 6 areas. At night, we typically have about 40 patients, including some who are admitted waiting for a bed upstairs. We have a shift that ends at 03:00 and we usually go down to one attending physician at that point. Since we were alerted to the shooting event around 02:00, staff lingered to hear more about what might be needed.

My role is ensuring that our processes flow as intended, and readiness is my primary focus. I work with the ED physicians, respiratory therapists and the trauma team to make sure we have necessary equipment such as ultrasound machines and video laryngoscopes. Our volumes and arrival times are pretty predictable, so we base the schedule on historical census data. We usually see 3 or 4 trauma alert patients a day. On a busy Saturday night, we can see 6 to 12 trauma alert patients. This night, we received 38 in less than 1 hour.

Preparation

Every year we participate in the community-wide exercise drills. We plan in advance who will work real-world patient care and who will be in charge for the exercise. I typically take on a supervisory role for the drill, helping with unusual requests and communicating with incident command. I also stay at the 30,000-foot level to look for safety issues. We want staff to gain experience in the charge nurse role, decontamination lead and moving patients through the system. The leadership team attends the debriefing, and I obtain information from the staff for the after-action report. The goal is to improve each time. 

Because we are a Level One Trauma Center, mass casualty incidents (MCI) are very real in our department. Frequently we receive alert messages regarding multiple-vehicle car crashes or industrial accidents. These test us even more than the annual drill. When we get multiple trauma patients at once or we receive mass casualty alerts, we start planning immediately. Generally, we anticipate receiving about half the number of patients that the alert predicts. We first focus on moving admitted patients upstairs and discharging patients who are ready to go home. This event, however, was definitely different.

Response

The Orlando Police Department called and notified the charge nurse about multiple trauma alert patients. The staff that was going home at 03:00 stayed and the charge nurse called me. The staff then began readying the trauma area by lining up stretchers in the bay and outside in the drive so that we could triage patients. Then we all started calling colleagues whose numbers were in our cell phones. These were people we knew would come in, that past experience told us we could count on. Finding their numbers in our cell phone contacts list was easier than digging in the book or online with the phone list.  

As the patients started arriving in police vehicles, physicians determined who was alive and should go into the trauma bay, and who already was deceased. The trauma team also was triaging in the trauma bay, assessing who needed to go immediately to surgery. The critical care physicians came down to help as well. Patients who seemed a little more stable were moved into the department to make room in the trauma bay for more critically injured patients. The decisions made at this time were very difficult for everyone involved. We had never before worked a real disaster where we classified people as red, yellow and black. The team had trouble not being able to do everything for everyone.

When I arrived, I saw patients everywhere — on stretchers in hallways, in the nurses’ stations and all over the trauma bay. I walked the department to survey the area and figure out where to start. One of the assistant nurse managers tried to give me the charge nurse radio. I told her to keep it so I could manage flow and handle unusual situations like I do during the drill. I called another assistant nurse manager to come and work the waiting room. I realized that I needed another secretary to come in and help with patient tracking. I went outside to the decontamination area and saw the nine deceased patients who had arrived to us with no signs of life. Their shoes stuck out from under the sheets. Back inside, patients were moving in and out of the trauma bay. I helped nurses transfuse blood, give meds and comfort patients.

Information came to us in bits and pieces, which made it difficult to formulate a clear picture of what was actually happening. We received word that the gunman was locked in a bathroom at the club, so we prepared for a second wave of patients. Then we heard on the radio that there was a gunman in the hospital.  A Code Silver was activated and law enforcement officers came into the Emergency Department and told us to get down on the ground. Law enforcement officers also were sitting with some patients who were considered suspects. There was a lot of confusion with the combination of severely injured patients, some who were intoxicated and others who did not speak English. The stress of a possible gunman in the building added to the confusion and chaos.

Eventually, the Code Silver was resolved with no gunman located, and the shooter at the club was neutralized. We heard we were receiving more patients and that a police officer had been shot. Injuries for the second wave of patients were not as critical as the first, and the officer had been shot in his helmet! He walked to CT and we saw that he had a very minor injury to his head. He actually high fived me on the way out!

Once we heard we were not receiving any more patients, I walked outside. As the sun was coming up, I remember thinking that families were going to wake up to the worst news of their lives. While outside, I met a family frantically searching for their daughter. We did not know any patients’ names because they had all been registered as Doe patients. A nursing assistant and I went room to room and found their daughter. We were on lockdown, but I brought her mother back to see her. The patient was crying hysterically about being in the bathroom with the shooter. She was injured and went to the operating room. 

By this time, the dayshift had arrived and the night shift was leaving. I gathered them in the break room and thanked them for their heroic work. I told them we would all be processing this event together in the days ahead. I was never more proud to work with this team of professionals than that night. 

Lessons Learned

More administrative help: Although clinical help flocks in, we also needed more administrative help. Because the administrative supervisor was in the ED and the ED charge nurse was calling staff in, there was a delay in activating the MCI alert. The patients came in so quickly that no one thought to activate the mass casualty alert right away. This delayed notification of the event to the rest of the hospital and made it difficult to initially get blood products because the blood bank was not aware of the magnitude of the event at first.

I also learned that we needed a better way to track patients. I assigned a secretary to log in each patient and document where they went. Incident command was preparing their press releases and needed accurate counts of deceased, patients who went to the OR and those in the ICU. 

Another administrative person is needed to track patient belongings.  We had cell phones ringing in the trauma bay, which was very upsetting to staff as we knew families were trying to reach their loved ones.

And a leader needs to coordinate with law enforcement. We had many different agencies investigating, and they all needed workspace and help navigating the system. 

Time to decompress: As the night shift was leaving at 07:00, I did not consider the same team was scheduled to work again that evening. I stayed all day at the hospital helping reunite families and put the department back together, but did not consider giving the team the night off. There was plenty of other staff who did not get called in and could have covered for them.  

Staying in touch with the staff:  I also learned how important it is for the leadership team to continually check in with staff. Four days after the event, a nurse let us know that the team was not OK. We arranged a big debriefing that evening with our employee assistance counselors and quickly shuffled schedules and coverage for the department so everyone who needed to could attend. The team was surprised at how quickly we pulled this together and commented on how comforting it was to be together and share.   

Starting the healing process: In the Emergency Department, we usually do not know the outcome for our patients. It was not until I was in a debriefing with a trauma ICU nurse that I realized all the patients we sent upstairs survived. The injuries were so severe and there was so much blood loss, I did not think there would be many good outcomes. I spent the week after visiting patients with front-line staff so they could see the results of their hard work. This made it real for us and refueled us. The patients were thanking us, but I had to tell them that seeing them was a gift for us. I believe this started the healing for the team. 

What We Changed

• When we receive an MCI alert, we put the MCI plan on standby if it sounds like an event that may overwhelm our system.   This lets all the necessary departments know that something in the community is brewing.   Initially we were over triaging and putting it on standby for every notification.  It took a little time to develop the thought process about an appropriate response.  We do not want to exhaust the system with constant alerts. 
• We redesigned our disaster book to make it easier for the secretary to pull the roster and begin making calls.  One of the first notifications is to an additional secretary to handle some of the administrative duties mentioned earlier.  We developed a tracking tool to monitor the location of patients and their status.
• There were so many requests for interviews and presentations, I had to keep a roster of who went to what event or interview.  It was difficult because the main participants were on night shift and many events happened on short notice during the day.  I tracked the events and tried to be as fair as possible with the gifts, tickets, meals and events for team members to participate. 
• We think ahead about staffing and who should be working when.  When a particular shift has had an especially trying shift, we try to arrange their schedule for proper time off to refuel.

Conclusion

This event not only changed individuals, but the department as a whole. The annual MCI exercise was taken more seriously than ever before. The team has grown closer and become more accountable to each other. Some had to leave the department. Many sought counseling and attended the debriefing sessions. For the first few months, we activated an MCI alert for every event we were notified of. Some staff didn’t want to be in charge or trauma for a while. 

Way before this event, our leadership team had developed a style of open communication and caring. This enabled the team to freely let us know what they needed. Our positive working relationships allowed everyone to work together to accomplish a giant mission not only before but during and after the event. There were no egos, no disrespect, only a unified goal of taking care of a large influx of critically injured patients in a very short period of time. I am most proud of how this multidisciplinary team takes care of each other as they care for patients. We never say anymore, “What a crazy day or night.” 

Key Takeaways

• Have a plan, exercise the plan and change it to improve your readiness. Leaders should stay at the 30,000-foot level so they can think globally about what needs to happen next.


• Give staff respite. Have different members from leadership check in with the team to assess their resiliency. Make sure to have a debriefing with front-line staff to discuss what went well and what needs to improve.


• Share the recognition. When the community recognizes you, to share it with all departments. We were voted Central Floridians of the Year by the Orlando Sentinel, and that plaque is traveling to each department that played a part. You have to emphasize to everyone how important their work is. We sent food to our environmental workers as they saw and cleaned up more blood than they ever imagined. We also sent food to the operators who fielded thousands of calls during and after the event. It is hard, but try to include everyone. It strengthens and encourages the team to continue on because their work really matters.