Surgical Residency

Synopsis

I can state with absolute certainty that without the involvement of our surgical residents, our response to the Pulse nightclub shooting would not have been as successful as it was. It is easy for those outside of training institutions to view residents simply as an immediate source of available manpower. However, their involvement in this tragedy extended far beyond their physical presence. In the immediate months after the mass-casualty shooting in Orlando, and throughout the ensuing year, we have learned a lot about the important role that surgical residents and the residency program played and can play in these events. We also have witnessed first-hand the toll these events can have on surgical trainees.

Preparation

Preparedness is an outstanding goal, but it is difficult to truly be prepared for a mass-casualty situation regardless of its nature. It is important to realize that no two training centers are the same. Residents are exposed to a large variety of surgical pathology in any surgical residency program. However, the amount of exposure they get to any specific specialty varies greatly between programs.

Our residents have the benefit of training in the setting of a busy Level One Trauma Center where they are routinely exposed to a high volume of critically injured patients. This experience teaches them the ability to triage and leads to confidence and competence in managing the acutely ill and injured patient. In addition to the hands-on direct patient care, we involve our residents in numerous simulation-based training exercises. We have weekly trauma drills with a simulated patient working with prehospital providers, the emergency department and the various support services. In addition, yearly we have a regional mass-casualty drill where we focus on preparing the trauma system for a variety of disaster situations. Our residents are directly involved in all of these training events. The residents’ involvement in simulated trauma training is essential to building teamwork, leadership, confidence and competence.   

Response

At the time we were notified about the shooting, the trauma surgeon on call started calling in additional attending surgeons to aid in the care of the victims. Concurrently, the senior resident on call began calling additional residents. Residents of all PGY levels were called and responded immediately and without question. These responding residents presented to the emergency room and immediately began to evaluate and treat victims. The senior resident on call, with guidance from the on-call attending, began to assign groups of patients to specific residents. Additional residents were sent to the operating rooms, triage areas and the ICU. Many of them were fulfilling jobs that were outside their routine responsibilities in a trauma situation.

Residents were involved in all aspects of care from triage and emergency procedures in the emergency room, working in the operating room with faculty, providing ongoing resuscitation in the ICU, even helping with patient transport. We believe that their trauma training was essential to the impact that they made as valuable members of the team.

Throughout the night and the following days, our residents worked tirelessly with the faculty to ensure that the victims of this tragedy were triaged, treated and identified. The influx of surgical trainees was essential in our early response and allowed for a broader allocation of surgical resources.  While not all residents were called in to help that night, nearly all of our residents provided care to the victims throughout their hospital stay.

The variables that affected the residents’ responses are numerous. Trauma training, disaster preparedness, prior exposure, leadership, compassion, confidence, dedication, availability of and allocation of resources, hospital support, patient ownership, the list goes on and on. Some of these variables — such as training and preparedness — can be quantified, some cannot. It is also important to recognize the effect the residents had on the outcome is one part of this discussion, recognizing the effect the mass casualty had on them is equally important. In our review of this mass shooting and the role our residents and residency program played we found that we were very prepared for some aspects of mass casualty response and were unprepared for others.  

Lessons Learned

While we believe the residents and the program were well-prepared for the patient-care aspects of this tragedy, we were not adequately prepared for the emotional toll this event would take on them. Immediately after the shooting, the hospital began extensive counseling efforts for all employees. As a program, we held a two-hour group debriefing and counseling session led by our physician coach, who is a PhD. Psychologist.

Shortly after the mass casualty, we surveyed our residents and looked at their emotional response to this event. While our sample size was too small to reach statistical significance, we found a high rate of major depression and post-traumatic stress disorder in our residents. This finding was not isolated to those residents who worked the night of the shooting. In addition, we found a high level of guilt in those residents who did not work the night of the shooting. Several of our residents sought additional counseling to help them deal with the emotional toll. The support we as a program received from the hospital and the hospital system was incredible. They continue to devote resources towards the well-being of our residents.   

As a program, we have recognized that we were not well-prepared for the media/social media response. Social media has become an outlet for decompression in recent times. Times of joy and times of peril are often posted in various social-media platforms. Social media is an excellent outlet for some individuals. After an event such as the Pulse shooting, social media posts ranged from tempered and appropriate to those that likely crossed the line of what would be viewed as acceptable. While we have a social-media policy in place, many of those individuals who posted felt they stayed within the lines of the policy. It was necessary to curtail some of the posts as they were viewed as being inappropriate. In those situations, we found the residents involved felt stifled or censored. It was essential to explain to them that this event was bigger than any one person’s involvement and that consideration on all fronts, social media included, needed to respect the victims, the community, the hospital system and the providers.

While social media presented various issues, the mainstream media posed others. At the initial onset of the media response, residents and their families were contacted directly by the national news media. This was in direct response to some of the social media posts that had been picked up by the mainstream news. The media policy for employees states that all requests for news interviews must be processed by the hospital’s media relations department. We found that early on numerous interviews were conducted outside of the hospital policy, and had to discuss its specifics with our residents. When we surveyed our residents, they tended to feel that the media response was overwhelming.

Key Takeaways

• First and foremost, support your residents. Make sure that the various resources they need for their well-being are available. We have to recognize that, like all providers, they can be secondary victims of the trauma. We have demonstrated evidence for the risk of developing Post-Traumatic Stress Disorder and major depression after an event such as this. Recognize that ongoing psychosocial support is needed.
• Second, include them. Include them in the training and planning needed to prepare your hospital for a major event. Have them involved in trauma training and disaster management. Make sure they get adequate trauma exposure if able and have them participate in drills and simulation.
• Lastly, make sure they get the credit they deserve. They work very hard for the people in their communities and events such as these can have profound effects on them. Make sure that they, the hospital and the community know they are essential members of the team.