Trauma Critical Care

How I Heard

Louise, above right: I was awakened abruptly by my cell phone ringing. The display read CARLOS and my first thought was, Oh no. Carlos Carrasco is the chief operating officer of Orlando Health Orlando Regional Medical Center (ORMC) and can handle any issue that arises. Carlos immediately told me there had been a big shooting downtown and we were getting about 20 patients. He was on his way to the hospital. I responded in a sleepy fog with, “Do you need my help?” At that time I thought that he could handle the situation due to previous experience telling me that alerts usually ended up being far less than originally reported. I asked him to call me when he got there and had assessed the situation. I laid back down thinking it was probably only five gunshot wound victims (GSWs) and I knew the team can and has handled that without a problem. As I lay in bed, my heart was pounding. I could feel it all the way to my stomach, something wasn’t right. I got out of bed and decided to call the Trauma Intensive Care Unit (TICU) because they receive all trauma alerts and respond to the trauma bay. Jessica answered the phone and when I asked what was going on she was calm and said, “Nothing, John is in charge and he just went to the trauma bay for an alert.” I got off the phone and turned on the news, but there was nothing about a shooting. Back to bed I went, my husband reassuring me Carlos would call me if I was needed. Just then the phone rang. It was an experienced trauma nurse from the TICU, and her words were, “Louise, it’s bad.” I responded with, “I’m on my way!”

Jim, above left: I woke up Sunday morning to so many texts and missed calls. The texts were short, “Are you OK?” “Please tell me you didn’t go out last night.” “Call me.” I listened to a couple of voicemails and they were from different administrators at work calling on their way in to ORMC telling me there was a shooting at Pulse, and they wanted to make sure I wasn’t there. I called the TICU and our clinical assistant nurse manager on duty told me what happened. I threw on some scrubs and headed in.

Synopsis

Louise: On a typical Saturday night, the TICU would get a few admissions — four would be a busy night. The TICU is a 16-bed unit with a sister 16-bed unit Trauma Step Down (TSU). The two units work closely together sharing a leadership team. Many nurses begin working on the TSU then, once they gain experience, transfer to the TICU. This strategy is to grow and retain nurses who have the highly specialized skills of critical care trauma, including burns. Typically, the TICU is a very controlled calm environment with the team of RNs, RRTs, nursing assistants and physicians working collaboratively together as a well-oiled machine. This night the TICU looked more like the trauma bay with supplies, equipment and team members working feverishly together.

Jim: On a typical day, I would start by rounding on the patients and their families in TICU and TSU. The sickest of our patients would have 1 RN to 1 patient. On June 12, we had 4 RNs working on 1 patient and transfusing cooler after cooler of blood products. Team members had the same look on their face — one that looked like they were all holding back a bucket of tears. I got a list of all of the patients who were in my units, and most of them were listed as “Doe’s.” I went room to room to round on all of the survivors in my units, and in the back of my mind I was praying to God that this was a nightmare. I spent a majority of the first week in a conference room with law enforcement trying to find family members for those who didn’t have family at the bedside.

Preparation

Jim: We were part of a community-wide mass casualty drill three months before Pulse. The scenario was an active shooter. My role was to ensure our units had the supplies necessary for the sudden influx of patients. Our units were very busy with real patients at this time, and as leaders we had to motivate the team to actively participate in the drill because there was a chance that an actual mass casualty event wasn’t going to occur during the best circumstances. Our teams were great and made the drill very successful. This drill happened on the day shift, but Pulse happened on the night shift. Fortunately we had drills on the night shift as well, so our night team was well-prepared and did an extraordinary job!

Louise: The team had prepared through drills both on a large and small scale, not only for the patient care but more importantly the triaging of the unit to open trauma beds, adjust staffing using team members from other units and get additional supplies needed for patient care to the unit.

Response

Louise: The team did what was practiced — the unit was triaged and nurses came from the Cardiovascular Intensive Care Unit (CVICU) to take patients back to their open beds. The Neurosciences Intensive Care Unit (NICU) shares the other half of the floor with TICU, and they responded by coming to help in the TICU. Their training and practicing went into play. I could only offer words of encouragement as the team was clearly shaken. “You all have this, you know what to do, you are doing great,” I told them. At that time, I asked our guest service team member to call in additional staff. Everyone came without hesitation. And due to preparation and great team members, the right people at the right time were there.

Jim: The TICU team called the other ICUs and had them come take patients from the unit to make room for the survivors with the most severe injuries. The other ICUs were wonderful and responded to the task by taking patients without even getting a report. Some of the nurses who were scheduled to work on Sunday morning came in early, while others came in on their day off. There was never a shortage of team members available to care for the survivors in the weeks following Pulse.

Lessons Learned

Louise: In debriefing with the team, we realized that our medication dispensing system could be put on emergency override to access all medication immediately by simply calling pharmacy. Patient care was delivered without a problem. But the days ahead were challenging due to an FBI investigation, identification of next of kin and reconnecting friends while ensuring the patient’s privacy rights were protected from onlookers and media. We realized our process of visitation ensured consistency and protected our patients especially in this highly emotional and publically visible situation.

Jim: I can never thank my team enough for what they do to care for our patients and their loved ones.

What We Changed

Louise: The biggest change was the process of identifying patients at the time of entering the ED. We have implemented a system we can use in collaboration with law enforcement and families. The Hospital Incident Command System (HICS) was important to keep goals and organization. We adapted HICS and now have HICS members as “runners” out on the front line to view the processes and be available to instantly provide help and answers that are communicated back through the HICS boardroom.

Jim: Everyone takes the drills seriously because you never know when it will actually come true.

Conclusion

Jim: June 12^th and the first week after were the worst days of my life. You never expect to walk into work having to go from room to room hoping to God that you do not know anyone in one of those beds. The reaction of the world (for the most part) was wonderful, and the survivors and their loved ones were the friendliest patients we have ever had in our trauma units! I am blessed that I had the opportunity to meet them and tell them that I am glad they are alive.

Louise: Our preparedness proved to be our best strength. In the face of such a tragedy, our teams could rely on processes they had practiced. Teamwork across department needs to be built into everyday processes, such as the TICU charge nurse responding to all trauma alerts in the ED. This allowed the TICU and ED teams to build relationships, just as the NICU team responded to help admit patients to the TICU. During the course of the event, it was important to have HICS in place, but equally important to have administration and senior leaders visible to the front-line team. Our leadership was rounding, ensuring the team had what they needed and offering encouragement and support. In the days and weeks that followed, team members were encouraged to take care of themselves and their coworkers. Counseling sessions were extremely helpful for everyone. The most feedback I heard from the TICU team was how other departments helped them. CVICU, NICU, blood bank, the housekeepers, guest services and our amazing chaplains were just a few they were thankful for.

Key Takeaways

Louise:

• Preparedness – Practice, drill and push your system to failure to identify weak areas.
• Teamwork – Across departments is key, build these interactions into daily processes. The relationships the front line teams build are priceless. Senior leaders need to be visible on the front line.
• Resilience – For the team to bounce back after tragedy, important pieces need to be in place beforehand. A culture of resiliency already needs to exist and its components of gratitude for what positives are accomplished, and collaborative and trusting relationships at all levels so team members know they can express their barriers to senior leaders. A strong culture that includes trust and respect for each other is crucial.

Jim:

• It’s important to seek out help from a counselor following an event like this. You can’t tell friends or family most of what happened and eventually it starts to gnaw at you, mostly when you’re alone. Counselors were instrumental in allowing me to deal with the emotions that still come to me to this day.
• You can’t teach people to embrace diversity and to be inclusive — it’s a part of someone’s character. I’m open about my sexual orientation. Team members and leaders at ORMC know I am gay and were worried that I was inside Pulse that night. The hugs and tears when I walked in to work that day were real, and forever I’ll be grateful to have worked with such amazing people.