Surgical Nursing

How I Heard

On Sunday, June 12, 2016, I was the administrator on call for Orlando Health Orlando Regional Medical Center (ORMC), the community’s only Level One Trauma Center. I was home asleep when the administrative supervisor called me a little after 2:00 am. The first words I heard were, “There has been a shooting and we are expecting about 20 victims.” I gave instructions to call hospital incident command system (HICS) for mass casualties and told them I would get dressed and be in as soon as possible. My next call was to the president of ORMC and the hospital’s chief operating officer to alert them of the need to go immediately to the hospital and implement incident command. As I drove in, I called the OR leaders, nurse managers and assistant nurse managers, as well as the PACU manager and told them to get to the hospital ASAP due to the shooting. I had to keep repeating, “This is not a drill. It is the real thing.”

Synopsis

I am the chief surgical services officer for our hospital and have oversight for surgery operations at both the Level One Trauma Center and the ambulatory care center. As a Level One Trauma Center, we always have the ability to run three operating rooms at night for emergencies. Based on the number of anticipated victims, we realized we would need the ability to activate more operating rooms than normal. We routinely run at least 5 operating rooms on Sundays with one trauma room, so I knew that by 6:30 am we would be in a position to have at least 6 ORs fully staffed and functioning. We already had 11 cases scheduled for the day without any add-on emergencies. On a typical Sunday at ORMC, we can do 17-20 cases.

Preparation

The biggest part of being prepared is planning to get resources as quickly as possible. The ED and the ORs were overwhelmed with victims and needed more staff to support the steady influx. We also realized quickly that due to the nature of the injuries there were supplies — such as chest tube trays — that we quickly would run out of. Calling a corporate incident command allowed us to be in touch with all of our sites for assistance both with staffing and supplies. As a Level One Trauma Center, we had a surgery team in house that was immediately available and 2 other teams on call within 30 minutes. This is not usually the case for a non-trauma community hospital.

Response

Upon entering the hospital, I noticed it was the same as outside — eerily quiet. I headed back to the ED, which was in full combat mode. Victims were arriving en masse, the trauma room was filling quickly, patients were being triaged based on the severity of their injuries and some were being taken to the operating room. It was controlled chaos at its best, but an overwhelming site to behold.

I then went quickly to the administrative suite where incident command was being established. Things were under control there so I made my way up to the operating rooms. The charge nurse at the desk was extremely busy booking cases and trying to get as much patient information as possible. Most of the victims did not have identification. Patients already were being wheeled up to the front desk. She had no time to call in staff. I started going down the list trying to reach any team members who would answer their phone and let them know this was not a drill, we urgently needed them at work. The leadership teams started arriving in short order and took over the job of calling staff. I went back to the admin suite to participate in incident command. My role as corporate operations chief for the system was now ready to begin.

The first victim was brought to the operating room at 2:44 am. By 4:00 am, we had 5 operating rooms actively running. Our goal was to get the most critical patients in the operating room as soon as possible, then find a way to do the rest of the cases that could not wait until Monday. By communicating with our nearby sister hospitals, Winnie Palmer Hospital for Women & Babies and Arnold Palmer Hospital for Children, we were able to get surgeons, PACU nurses and sterile processing personal to add to the team members who were on their way. At the busiest point in the day, we had 8 operating rooms running and 11 surgeons performing cases. By the end of the day, we had operated on 42 patients. We treated every Pulse victim who needed emergent surgery as well as the scheduled cases for that day.

Lessons Learned

It is imperative that you practice and drill for these types of incidents. It is very easy to take it for granted and think you are prepared. Your system must be tested to the limits in order to be prepared for the worst tragedy. At Orlando Health and the surrounding community, we do a city-wide drill each year with the goal of testing the limits of our resources. Even with that practice, it does not truly prepare you for everything that can happen.

Supporting the team during and after the storm is of utmost importance. No one can imagine the trauma that your team can go through in a situation like this. Having counselors available for several weeks afterward is essential.

What We Changed

We worked with our ED teams to institute what are called STAT NOW drills between the OR and the ED. These monthly drills better prepare us for trauma-related emergencies and mass casualties. The purpose is to teach the ED team how they can assist the OR in getting the patients into the operating room suite in a more timely fashion and allow the OR to focus on getting the needed equipment and instrumentation set up for the case. The ED team will don masks and hair covers before they leave the ED with the patient and instead of stopping at the front desk and waiting for the OR team to receive a report, they will accompany the patient directly into the OR. They will assist with moving the patient onto the OR table, attaching monitors as needed and whatever else they can do to allow the OR team to focus on getting the case ready to start.

Conclusion

In summary, the best laid plans need to be practiced over and over again. You need a robust system for reaching team members in times of mass casualty. Many team members no longer have land-line phones, their cell phones are turned off at night or they do not always answer cell phones or have them near at night. You need a method to get back-up supplies if there are multiple injuries of the same nature. For example, crushing chest injuries require more chest tube trays than you would normally have on hand. You need to prepare for an influx of family that requires support, especially if there are many victims and identification is difficult. Lastly, supporting your teams for days and even weeks afterward is essential to the overall health of your organization.

One unexpected outcome of the Pulse disaster was pride in our shared teamwork and in how the hospital handled the event and the number of lives we were able to save. Even those not working on the night of the shooting were proud that we could serve our community in this manner. We always thought we could do it and now we know we can do it.

Besides our concern for the patients and their family members, there was support for the team members who had direct involvement with the event and the horrific nature and volumes of injuries that presented to the ED that night. No one felt they were alone in this …..we all needed support from each other.

Key Takeaways

• If you do not have a disaster preparedness plan, then you need to develop one.The key to being able to respond appropriately and save lives is to practice, practice, practice.
• Developing a team with designated roles can provide leadership, guidance and assistance that would be unavailable if everyone was working independently.
• The clinical staff needs to be able to focus on taking care of the patients.
• After the disaster is concluded, you must take care of your clinical teams. The toll may not be visible immediately, but the trauma can last for years.