Emergency Medicine Residency

How I Heard

I woke to the sound of our dog barking around 3:00 am or 4:00 am. Although, I live less than a mile from the hospital, I couldn’t hear the sound of the sirens and helicopters the same way our pet Yorkie could. I had been scheduled to work the overnight Emergency Department shift on June 11-12, 2016, but due to a family event, I switched with another colleague, Dr. Bondani. It wasn’t until I fully awakened a little later that I saw the multiple texts from Dr. Bondani indicating the severity of what had just transpired.

My first reaction was not relief that I had switched out, but rather disappointment that I had not been there with my residents during the initial surge of patients. This gave way to concern for the well-being of our emergency medicine trainees. This was immediately followed by the fear of knowing that the largest mass shooting to date in the United States had just occurred about a mile from my house where my family slept peacefully. I remember feeling a lump in my throat as I thought about how I would explain this to my 11- and 9-year-old children. Finally, I also wondered about the aftermath and impact this would have for our residents in training.

Synopsis

As the associate residency director for emergency medicine, it was my job to oversee the education and well-being of our residents. There is no job description and very little best-practice precedent to help guide a program director through a crisis such as Pulse. Our residents, whether they were in the Emergency Department at the time of the Pulse shooting or on off-service rotations treating the recovering victims, were intimately involved in many aspects of the response.

Preparation

We prepare for disaster response, for mass casualty and for large-scale terrorist events from a clinical standpoint. But we don’t prepare for the emotional aftermath and how to help our trainees cope with this. Nor do we prepare for the creativity and fortitude that it takes to respond to an event like this. From a clinical standpoint, I don’t question the maturity and abilities of our residents to handle trauma. For that matter, I wouldn’t even question their abilities to handle a mass casualty event. The Pulse tragedy demonstrated many things that reaffirmed my commitment to medical education. Not only did they manage and triage the critically ill patients, they demonstrated teamwork, rapid decision-making, courage, confidence, compassion and improvisation skills on the fly. In the heat of the moment, they rapidly developed a short-hand charting method to communicate bedside clinical results for the multiple Doe patients who couldn’t be registered. They utilized ultrasound to make rapid clinical decisions when radiographers could not keep up with the massive influx of patients. They made critical decisions about intubation, insertion of chest tubes and rationing of blood products. They even had to make the difficult decision of determining when further care was futile in otherwise young, healthy, but critically injured patients. 

All of this had to be done in the setting with a myriad of unknowns. Although we now know that the Pulse shooting involved a single shooter with more than 100 dead and wounded victims, this was not known at the time of the MCI. Patients arrived in large groups, many with no prehospital care or notification. Some were brought in the beds of pickup trucks without any IV access or available history. The seemingly endless influx of critically injured patients made it difficult to know how to approach the situation. Further complicating matters, there was concern that another shooter had arrived and breached the hospital premises. Residents had to continue their efforts at resuscitation with no end in sight and significant concern for their own safety. They barricaded the sickest patients in the trauma bay. They took turns being leaders and followers as the situation dictated it.

Response

As a program director, I could not be more proud of the courage displayed by the young physicians who stood at the front line and experienced this tragedy first hand. It was our role, however, as program directors to also provide an opportunity for debriefing and counseling. In the immediate days after the tragedy, we cancelled our usual conference and set aside the entire session to discuss the impact. Residents and faculty shared experiences in a safe, non-judgmental environment with other first responders. Through tears and honest conversations, trainees found the freedom to express themselves. Importantly, some residents, in the immediate aftermath experienced self-doubt as to whether they had done everything they could. They received reassurances from their more senior colleagues about their clinical decision-making. Most residents also found comfort in the ability to share the experiences.

Orlando Health provided counselors and a physician coach. These resources turned out to be more valuable than I had expected. The program director strongly encouraged residents to pursue help confidentially from this resource. Several of our residents sought out these sessions and even months and years later, found them beneficial. Some found tremendously renewed value and meaning in their professional role as a caregiver in times of crisis. Others expressed symptoms of burnout in the months after the event, a feeling they had not experienced during the prior part of their residency.

Lessons Learned

A common theme from residents has been that they each found different ways to cope. The existence of a counselor and the encouragement of program leadership to pursue this option have been very valuable. Program directors should encourage their trainees to seek help. Most physicians are taught to accept challenges as “part of the profession.” But violent mass casualty events are anything but. Debriefing sessions should be done as soon as possible for the involved residents in a non-judgmental setting. It is important NOT to turn these early debriefings into quality improvement events. These sessions should include a small session where only the providers who were present are involved, but also a larger session where the entire department is involved. Trainees have found it very therapeutic to see how their actions fit into the larger scheme of efforts to save lives. It is very important for each participant in a mass casualty event to see how their specific actions, no matter how small or seemingly insignificant, played an important role. Trainees and faculty are otherwise left with the feeling of “I could have done more.”

There should be an easy mechanism, other than Doe names, whereby trainees can follow up on the patients that they treated acutely. This follow-up is helpful to trainees.

Preparation for mass casualty events should include more than the clinical response.  It also should include training in the management of limited resources. For example, during a disaster drill, we not only should practice achieving optimal patient care results, but we should anticipate an event like this occurring simultaneous with loss of EMR or computer access. Drills should be done with unexpected absence of specific support personnel, such as EMS providers or radiographers. This will create a practice environment where healthcare providers train for and are empowered to act during the unexpected.

It is vital to prepare residents for the things that will occur after a mass casualty event.  This includes media involvement, law enforcement presence and federal government appearance. Residents should be educated on the impact of media presence and the potential for harm. It is easy for a trainee to be awestruck by the international stars who appear. But it is important for them not to be tempted to share information personally or through social media with these organizations. They also should be prepared for the onslaught of calls and emails from conspiracy theorists who will accuse them of fabricating stories. They need to be warned about the importance and consequences of their actions. Trainees should be made aware, ahead of time, of the community resources that will exist during an event, such as National Guard, Red Cross, FBI and volunteers. A coordinated response with all stakeholders will be a smooth response.

And finally, program directors should be aware and taught to recognize signs of depression and burnout that may occur in the weeks and months following a disaster.

As a program director, I hope that no other program director will have to guide their residents through a mass casualty event. But, in an evolving world, it is best to be prepared for the unexpected. Although the credit for the response goes to the residents who were involved, it was the efforts of our late program director, Dr. Sal Silvestri, who ensured that each trainee was cared for. Response and actions during times of crisis truly help shape the future of our doctors in training.

Key Takeaways

• It is critical to not only perform disaster drills, but also to practice doing so with the unexpected absence of critical resources. A true disaster is likely to coexist with not only unexpected patient volumes and critical injuries, but also without certain capabilities.
• Debriefing as soon as possible in a nonjudgmental setting for the residents involved and with the entire department is therapeutic. Do not use this time to determine opportunities for improvement, but rather a recounting of what happened. Save the quality improvement for a separate time.
• It is important to provide resources to residents to help cope with the emotional toll. Confidential one on-one-counseling is a useful method for some trainees.Be aware of the possibility and monitor for depression and burnout in the weeks and months after the event.