Emergency Department

How I Heard

Dr. Bondani: Saturday, June 11, 2016, was a particularly slow night in the ER. As the overnight attending physician, I started my shift at 11:00 pm. As the evening progressed into the early morning hours, I was discussing with the other attending, Gary Parrish, and the 4 residents what to do for dinner and whether anyone could head home early. Weekends are known for limited choices in the hospital cafeteria, so we decided on a nearby sub shop. We had just placed an order for delivery when the ambulance bay doors opened for an incoming patient. In the distance, we heard dozens of sirens and saw a slew of police cars flying down Orange Avenue past the hospital. Several of us wondered aloud about what might be going on. I mused for only a minute about what could be requiring such police response and then continued evaluating patients already in our department. About 5 minutes later, we received a call from the ambulance bringing in the first patient and were updated by police and EMS to expect more than 20 total victims.

My Role in the ER

As an attending physician, I am responsible for overseeing the resident physicians in providing emergency medical care. I discuss all cases with the residents, see all their patients and supervise/teach all procedures.

Synopsis

The ORMC Emergency Department consists of 75 beds divided into 6 different areas. At night, we typically have about 40 patients, including some who are admitted waiting for a bed upstairs. We have 4 resident physicians working each night. At least one of these is a third-year senior resident in charge of the trauma bay patients. On this particular night, it happened that all 4 residents working were third- years. In addition, because it was June and the end of the residency year, all residents were graduating in two weeks. It was fortunate we had such experienced resident physicians when the event first unfolded. On a busy Saturday night, we can see 6-12 trauma alert patients. On the night of the Pulse tragedy, we received 38 in less than 1 hour. It was by chance that the event started around 2:00 am, as the second emergency medicine attending had not yet left. I never ended up eating the sandwich I ordered. To this day I wonder what the sandwich driver thought of the whole situation as the deli he works at is located across the street from Pulse.

Preparation

Our emergency department participates in several hospital-specific and community-wide tabletop drills and exercises each year. The largest of these exercises typically involves around 500-600 volunteer “patients” distributed throughout the city, with our facility usually receiving around 60-80. The community-wide event is held every April during the daytime, but in November 2015, approximately 7 months prior to the Pulse, we held a nighttime event. The purpose of that nighttime exercise was to better familiarize evening and overnight staff about how a mass casualty response should look if it did indeed occur.

Response

When the first victim rolled in, the senior ED resident and I were there to meet him. I vividly remember the resident and I exchanging shocked glances at the size of the bullet wound on his back. That was our first indication of the enormity of the situation we were facing. He had arrived with very little warning -- only two minutes passed between hearing the EMS call and them rolling the patient through the trauma bay doors. He was sitting up, conscious and apprehensive. The trauma team had not had time to make their way into the Emergency Department so the resident and I were performing his initial evaluation. When we asked the patient to lean forward so we could assess his back for further gunshot wounds, we were not expecting to see a crater big enough to fit an entire hand inside. It was in that moment we began to grasp the severity of what was ahead.

Only a minute or two earlier the call went out over the Emergency Department loudspeaker. “X-ray, RT, trauma room, 1 minute.” I made my way from the back of the department toward the trauma room, mentally preparing for resuscitation. “Gunshot wound,” the nurse informed me as I walked into the room and grabbed my personal protection – a gown, gloves and facemask – standard attire for each trauma resuscitation we performed.

It started out as a pretty routine trauma alert with the trauma team trickling in and all of us tackling our assigned tasks. Each trauma alert is a well-choreographed dance, one we had all performed countless times. I recognized one of the transporting paramedics as he occasionally worked in the emergency department as a side gig. He chimed in, “At least 20 more headed your way.” Within minutes of his announcement, more patients started arriving. The next 4 to arrive would be some of the most critically injured. Normally the senior resident and I would handle all of the trauma alerts ourselves, however, with now 5 patients arriving all within a few minutes of each other, we called the rest of the residents and the second ER attending to the trauma bay to assist in resuscitations.

Two of the first five patients were without vital signs on their arrival and we quickly initiated CPR, prepped for intubation and set up for chest tube insertions. The wounded were arriving rapidly -- two or three at a time in the back of police pickup trucks and ambulances. Staff in the ambulance bay would pull them from vehicles and place them on a stretcher, then wheel them into the emergency department. Patients quickly began lining up in the hallway, waiting their turn to be assessed and resuscitated in the trauma bay. It rapidly became apparent that we were going to need to start triaging and prioritizing our efforts. This was one of the hardest things for us to come to terms with as a team. We were accustomed to putting full efforts into each and every patient, but this was impossible due to the sheer numbers of injured.

As each patient entered the trauma bay, our team descended upon them, placing IVs, assessing injuries, calming nerves. Many required emergent procedures – chest tubes, central lines and intubations. Some were taken almost immediately to the operating room or intensive care unit while others were stabilized and moved to rooms in the general ER to make room to triage new patients. The rest of the first wave of patients passed in a blur of activity with only a few snippets standing out in my memory -- a young woman crying out for help from her ER stretcher, a young man struggling to breath begging us to help him, a high heel peeking out under a white sheet. After the first wave cleared, we started reassessing patients, repeating bedside ultrasounds, rechecking vital signs, reprioritizing those still in the emergency department.

Prior to receiving the second wave of patients, I was standing in the trauma bay with staff and two of the surgical attendings when we suddenly heard “Code Silver” announced over the intercom. This means there is an active shooter on campus or in the hospital. I remember turning to one of the other physicians and saying, “I didn’t come to work to get shot tonight.” We made the decision to barricade ourselves into the trauma bay and continue resuscitating our patients. We placed a heavy portable x-ray machine in front of each set of doors and continued with our efforts. Over the next 20 minutes, we were unsure of what was going on outside the trauma bay doors. The scene of mass violence was only a couple of blocks from the ED, and the scope and number of shooters was unknown. It was a reasonable assumption that such violence could spread to the ED, so we all breathed a sigh of relief when it was announced overhead that the code silver was canceled.

The second wave of patients began with an injured police officer. Amidst radio calls of “officer down, officer down” we prepared for the task of resuscitating one of our own first responder community. He had received a gunshot wound to the head but was extremely lucky that his helmet stopped the bullet and he was left with only a small contusion to his forehead. Watching him walk out and high-five the staff remains as one of the few bright spots of the morning. We started up our process again, assessing and stabilizing each patient as they presented to our department and trauma bay.

The entire event lasted only a few hours. By the time the next shift arrived at 7:00 am, only a handful of patients remained in the emergency department. The trauma bay was cleaned and prepared for the next patients who were unlucky enough to grace its stretchers. Half-empty supply shelves and stray blood splatters were the only indications of the turmoil of the night before. But those of us who were there will never forget the chaos and anguish of those early morning hours.

Lessons Learned

What Went Well…

Dr. Parrish: As with most scenarios involving the rapid intake of mass casualties into an Emergency Department/Trauma Center, there were a number of highlights that stand out as successes, and a number of challenges that we encountered. Some of the successes:

• Teamwork – Teamwork is ubiquitous in the healthcare industry, but the incredible, inexhaustible teamwork witnessed that night was breathtaking and memorable. From law enforcement to emergency medical services to the emergency department and trauma bay to the operating rooms, post-op, intensive-care units and general floors, teams that are sometimes fragmented came together seamlessly. Due to our close proximity to the nightclub and the rapid influx of a large number of patients during the first wave, it was imperative for those caregivers who were immediately available in our academic center to provide care for patients, even if it was outside their normal area of expertise, comfort level or technical training.
• Early Activation of Incident Command – Even with little information on the exact number of patients and nature of injuries, the emergency and trauma physicians had a low threshold for activating the mass casualty intake plan and incident command. Because the actual number of patients received well exceeded the initial estimates by law enforcement and EMS, the lead time and minutes saved proved to be helpful.
• Early Notification and Availability of Surgical Colleagues – The on-call trauma surgeon, Chadwick Smith, immediately made the decision to request back-up assistance from, not one, but multiple trauma surgical colleagues. Fortunately, those colleagues were able to be physically present in the institution within minutes, including back-up from an on-campus pediatric trauma surgeon. Coupled with support from anesthesiology colleagues, operating room staff and the blood bank, this allowed multiple operating rooms to be simultaneously up and running within minutes.
• ED Throughput – Ordinarily, in the setting of a rapid influx of patients into an emergency department, the most difficult job is finding adequate treatment space. The capacity to receive patients is largely dependent on the ability to move patients out of the department, especially to ORs, specialty units, general floors or alternate treatment areas. On any given night, this can be a challenge in many emergency departments, including ours. That, however, was not the case the night of the Pulse massacre. Largely due to the items mentioned above, we were able to treat patients rapidly and move them upstairs with remarkable efficiency.
• EMS Offload and Triage – The initial wave of primarily critically ill patients was transported by a combination of ambulances and a law enforcement pickup truck. As the number of patients rapidly increased, our medics and techs saw the need to move outside to assist with offloading vehicles and transporting patients inside. This allowed EMS vehicles to rapidly return to the scene, just blocks away, to efficiently retrieve more patients.
• Communication with EMS – Although a number of systems are in place as part of our mass casualty intake plan to communicate with emergency medical services, the one that worked best the night of the Pulse was mobile-to-mobile text and phone communications between the ED attending physician and an Associate EMS medical director, Dr. Chris Hunter. That allowed the ED attendings to be in direct communication with EMS medical control throughout the event to ensure we were in complete agreement.

Some of the Challenges We Faced…

These challenges are not unique to our department and are shared by other institutions and agencies that have faced similar scenarios, but help bring to light some of the hurdles we encountered.

• Little Time to Prepare – Ordinarily, emergency medical personnel who transport patients to the emergency/trauma unit will notify us while they are inbound and provide a brief clinical history, thereby allowing our trauma unit to prepare more accurately for the patient’s arrival. Because of the extremely close proximity of the Pulse nightclub to the ED, there was no time for advanced reports from any responders with the exception of the first patient. The short transport time was, no doubt, beneficial for critically injured patients, but made planning and allocating resources difficult for receiving personnel. This experience differed from our community-wide mass casualty drills, where planning is easier due to advance EMS notice of the number and type of patients inbound.
• Electronic Medical Records – During normal hospital operations, an electronic medical record offers institutions clear advantages in documentation, order entry, data retrieval, patient tracking and subsequent data queries. However, during the rapid intake of multiple complex patients, typical methods for utilizing electronic records may be a potential obstacle in providing immediate medical care. Tracking patients through the department (and the institution) can be a challenge if depending solely on electronic systems. In addition, subsequent data queries that are necessary for analysis of the response may be lacking their usual depth and accuracy.
• Staff Notification – When mass casualty incidents occur during normal waking hours, there is usually no problem communicating with staff, who typically hear of the incident through social or online media, conventional media or word of mouth. More often, during those daytime events, there may be a large response from caregivers who want to help, with overstaffing by unneeded personnel. However, if the incident happens during nighttime hours, it may be more difficult to contact key individuals. Due to the ubiquity of mobile devices as a primary means of communication and the ability to effectively silence those devices at night, we had difficulties notifying staff by text, calls and emails. In some cases, repeated calls were necessary.
• Communications – Although our protocols call for the use of multiple means of communication (beepers, landlines, mobile devices, encrypted walkie-talkies, computer software, etc.) during a disaster event, it is nevertheless a challenge to maintain a two-way flow of information from EMS and law enforcement operations on the scene to the Emergency Department staff and on to the incident command center. Smooth information exchange between first responders, field command centers and receiving facilities is vital to better allocate resources and personnel. As mentioned earlier, direct phone communications between the ED physicians and EMS medical control were helpful the night of the Pulse shootings, but may not always be available.
• Code Silver – With active shooter or other violent threats, especially those that occur so close to the receiving facility, there is always concern that active violence could come to, or be on, the hospital property. This threat is especially true of the emergency department’s often chaotic environment, where active shooters have historically gravitated. Whether the threat is real or perceived, it has the potential to add additional fear, anxiety and stress to an already tense situation, and potentially disrupt the influx of backup support staff reporting to the institution to help.
• Patient Identification – With a rapid influx of patients, particularly if they have critical injuries or altered mental status, accurate patient identification is challenging. Although a mechanism is in place at our institution to begin the immediate care of unidentified patients, that system works best with one or several patients. With a much higher number of patients, it is likely patient identification will be more difficult and time consuming, and require the assistance of local, state or federal law enforcement officials. Accurate identification is imperative for the family reunification process that must soon follow. After the Pulse tragedy, a cloud-based system was developed where caregivers, law enforcement and families can share identifying information to help identify decedents and patients.
• Family Reunification – Immediate and organized management of families and loved ones during the rapid influx of patients is crucial. Families and friends gravitated to the trauma center to search for news of the possible injured, particularly if they were unable to contact them. Managing anxious families is emotionally draining and is personnel and resource intense, particularly if early details of the event, including patient and decedent identities, are lacking.
• Managing the Post-Incident Phase – The largest emphasis for most mass casualty planning exercises tends to be the management of patients from the scene to the hospital or alternate site and, more recently, through the surgical and inpatient hospital areas. However, we found it was just as important to have an organized plan for managing the post-incident phase – transparency in providing information to the media and public, awareness of HIPAA laws, local and state regulations, caregiver support, management of well-intentioned dignitaries, and the management of gracious gifts/donations. Forethought and planning would help accomplish these in a moretimely manner.

What We Changed

• Improved notification process – Several software vendors were reviewed after the incident and the institution is in the process of selecting an improved and more reliable method for the initial notification of hospital staff and physicians.
• Improved tracking in the Emergency Department – A dedicated method was designed to track patients in the department, including movement within and transfers out of the department. This required the addition of a dedicated paper “flow” form and dedicated secretarial staff to track and follow patients through their department stay.
• Improved documentation – A simpler, more concise, one-page paper mass casualty intake form, separate from our everyday electronic medical record, was developed to facilitate better patient care documentation in a more concise and user-friendly manner.
• Improved patient identification – A confidential, online database was developed that could be shared easily between patients’ families, law enforcement, healthcare providers and others in order to facilitate quicker and more-reliable patient identification and family reunification.

Conclusion

When patients present in the truckloads, as they did in our trauma bay in the early morning hours of June 12, 2016, an emergency department may be inundated with ill or injured patients without notice or preparation. If that happens, teams will need to trust their instincts, their training, their experience and one another. Normal practice patterns will likely be insufficient to care for such a large surge of patients, and healthcare providers will need to turn to their ingenuity, creativity and resourcefulness to do what they think is best to care for as many patients as possible. It is also likely providers will need to make some difficult life and death decisions -- some they may not be comfortable with -- but ones they will have to live with for weeks, months or years to come.

Key Takeaways

• Have a dedicated and familiar emergency preparedness plan. The importance of a team of dedicated and knowledgeable individuals to develop and sustain an organized mass casualty plan cannot be understated. Developing relationships and leveraging preparedness with community leaders, law enforcement, medical examiners and EMS is imperative. The plan should be as close as possible to standard daily patient care activities, as the more a plan varies from standard work, the more difficult it will be to activate in the event it is needed. If a plan is in place, and is practiced regularly and with vigor, then regardless of the nature of the event or the time of day, staff and providers will be hardwired on what their institution’s response should look like.
• Maintain a low activation threshold and have good notification.Responding emergency medical and trauma staff should be familiar with the aforementioned plan, and observe a low threshold for its activation. The plan should be activated early, even before definitive information on numbers of patients or nature of injuries is available. Delaying activation until accurate details of a mass casualty event are available may cause a critical gap in the staff response. When the decision is made to call for help, a robust notification system must be in place to contact additional staff and receive feedback on their availability.
• Expect the unexpected. Even when institutions conduct regular training exercises and are familiar with preparedness plans, the controlled chaos that is typical of a true mass casualty intake will likely result in some unexpected occurrences. For us, one of those occurrences was the threat of an active shooter in our department at a time when patient influx and medical care were most intense and additional staff was needed. When these events occur, let experience, flexibility and creativeness be your friends and your guides.
• Don’t underestimate the emotional impact. These tragic, horrifically violent, high-profile events, especially occurring so close to the receiving facility, leave an enduring impact on hospital staff. Don’t underestimate the lasting influence these have on your staff, your department, your institution and your community. Stand on the shoulders of others who have been through similar events to help guide your staff and counselors in developing a roadmap for caregiver recovery.
• Don’t forget about the rest of the story.Although the focus of our preparedness planning most often emphasizes the initial care of patients involved in a mass casualty event, there is a great deal of planning that needs to be done for the post-incident chapter, after the last patient has been admitted or discharged, and the dust has settled. That is often the time when institutions may be caught off guard and may be underprepared and overwhelmed.