Trauma Surgeon

How I Heard

I was on trauma call the day of the Pulse incident. It had been busy, as usual for a Saturday in June, and we had seen around 20 new patients over 18 hours. I had performed several operations late into the evening. I had texted my wife a picture of me laying down to go to bed at 23:01, only to be immediately paged back to the emergency department for a trauma alert.

Finishing up with patient care in the emergency department yet again, I made one last check with my team before heading to the call room for some sleep. All of the work from the long day and night up until about 01:30 had been completed. Retiring to the call room in the older part of the hospital, I laid down to try and get some sleep around 01:45. This was finally going to be a period when I could perhaps get a little rest.

Shortly after I drifted off to sleep, my phone rang. It was the emergency department resident physician calling me directly. Even in my slumberous haze, I thought it odd that she would call me directly. Her voice was pressured, at an unusually fast tempo and laced with anxiety. “Dr. Smith, we have been notified there is a mass shooting taking place with potentially 20 or more gunshot wound patients who are going to be brought to the emergency department,” she exclaimed. “I’ll be right there,” I replied. I hurriedly dressed and left the call room.

Although my trek from the call room to the emergency department felt like thousands before, that was not the case when I walked into the trauma bay. The sense of urgency that emanated from team members there was more than usual. It was about to begin.

Synopsis

I am currently a practicing trauma, acute care and burn surgeon at Orlando Regional Medical Center (ORMC). Additionally, I am the medical director of the surgical intensive care units and the department of respiratory therapy. Since 2013, I also have been the surgical critical care fellowship director, responsible for two surgical critical care fellows annually. Other duties include daily teaching of surgical residents and medical students, and direction of the general surgery residency’s basic science education program.

Preparation

As a major tourist destination, Orlando has the unique identity of being a major target for terrorism. Due to its geographic location, it also is frequently endangered by tropical cyclones.  As such, ORMC has continually developed its disaster plan for more than 20 years. Since 2010, a community-wide disaster drill, or Full Scale Regional Exercise (FSRE), has been implemented with multiple community partners and agencies. The exercise that was performed three months prior to the Pulse nightclub incident included an active-shooter scenario. FSREs involve triage of multiple victims and are practiced by all facets of responding agencies with hundreds of volunteers. Inter-agency and inter-hospital communication also is tested during these events to develop improvement in the trauma system as a whole.

Trauma surgeons are vital to this preparatory process. It is of utmost importance that they familiarize themselves with disaster protocols and have a robust understanding of proper triage and scarce-resource utilization. Direct patient care of multiple victims is only one part of being able to mount an effective response. Trauma surgeons are ideally suited to perform the patient care, but they must also be knowledgeable and comfortable with all aspects of a multiple or mass casualty incident. The most effective means of gaining this knowledge is through repetitive practice.

A laissez-faire attitude toward mass casualty drills has the potential to inadequately prepare an organization for what it may someday face. Team members will look to the leadership of the trauma surgeon and other physicians in charge during a drill, and will likely emulate their attitude regarding the exercise. If leaders take their responsibilities seriously and practice as if it is a real situation, the team will be much more engaged. This leads to a more effective exercise from which more can be learned.

Response

Initially upon my arrival to the emergency department that night, I anticipated potentially 3 to 4 gunshot wound victims. The first patient who arrived was awake and shot in the abdomen. He was complaining of pain but his vital signs were stable. Ordinarily, he would be taken to the operating room immediately for an exploratory laparotomy. This is commonplace on a Friday or Saturday night at our institution and something the team is well-versed in dealing with.

This particular evening, as patient after patient began to roll in at a rate of about 1 per minute, the first to arrive was one of the most stable, and as such was not taken immediately to the operating room. Over the next 30 minutes, multiple patients were brought in literally at death’s door. Initial resuscitation was begun simultaneously by surgical and emergency medicine residents. As leader of the team, I was responsible for ensuring patients were cared for as quickly as possible based on their level of need.

Triaging dozens of patients over a short period of time takes focus and a true team approach. It also requires one to rely upon and truly trust every person on the team to perform to their maximum ability. This does not happen by accident. Previous disaster training and the typical amount of patient volume at our busy Level One Trauma Center enabled the team to mount an effective response.

Upon seeing the number of patients flowing into the emergency department, I called the back-up trauma surgeon, Dr. Joseph Ibrahim. He did not answer at first, but immediately called back and stated he was on his way. Next, I called Dr. Michael Cheatham, who lived close by. He also answered and stated he was en route.

Patient after patient continued to be brought to the emergency department, and it was obvious that more resources were required. I began contacting my remaining partners, two of whom were in town and responded. We also were aided by the pediatric surgeon on call that evening.

Simultaneously, I notified the operating room front desk that we would need to open up as many rooms as possible and as fast as possible. Ordinarily the OR has the capability to run two rooms in the middle of the night. Given the number of patients we were treating, that was not going to be enough. The anesthesiologist on that night assured me he was contacting other crews and would get more rooms open quickly.

Once a plan had been made with anesthesia to ready ORs for patients, I began to contact the chief residents who were not on call to come in and help as well. At some point, about an hour into the event, a Code Silver (gunman on the premises) was called overhead and the hospital went on lockdown.

I began phoning or texting those who had not arrived and instructed them to report directly to the trauma intensive care unit or the operating room. Having surgical teams ready for patients to be brought to them seemed the most efficient way to handle this volume of patients at once.

In the emergency department, the lead ED physician and I rapidly triaged patients based on their vital signs, wounding pattern and mental status. Those deemed to need emergent operative intervention were placed in the trauma resuscitation bay. Patients with less threatening injuries, stable vital signs and normal mental status were placed in less acute areas within the remainder of the emergency department.

Triaging patients in such an event requires an experienced trauma surgeon. Penetrating trauma has a much higher rate of required operative intervention, and those decisions should be made by a surgeon. This requires one trauma surgeon to remain in the triage area of the emergency department to determine which, and in what order, patients are taken to the operating room. The operating surgeons must rely on the triage surgeon’s judgment and proceed, at times, without meeting patients prior to them being placed on the OR table. 

Over the next several hours, patients were triaged repeatedly. I kept a patient label from every patient admitted to ensure no one was missed.

After the initial influx of patients was over and most of those who were critical had been taken to the operating room, there was a lull in the amount of work to be done. This lull in receiving patients was due to the hostage situation unfolding at the nightclub. Police had barricaded the assailant in a bathroom, but weren’t able to evacuate the remaining living victims until he had been neutralized. We used this time to re-evaluate what had happened and take inventory of what needed replenishing.

By this point, hospital incident command had been set up. Dr. Cheatham shifted roles to incident command medical officer and I notified him that the trauma room was out of supplies. Due to previous disaster planning, available prefabricated disaster carts were rolled to the emergency department essentially replacing all needed supplies.

The break in patient transport also allowed us a brief moment to reflect on what was occurring. I recall walking outside the emergency department to the ambulance bay and the decontamination area. Lined up under sheets in the “decon” area were the bodies of the nine individuals who did not survive upon arrival to the trauma center. This surreal moment will be etched onto my persona forever. The needless loss of life was overwhelming. Many team members were also present, taking in the solemnity of the moment. All of us began to comprehend the power of this event that has changed our organization, our community and our lives forever.

Once law enforcement was able to kill the terrorist, the influx of patients resumed. The brief respite of reflection was gone and the team went back to work. This second wave of patients was smaller. Eleven people were brought in at that point. The first patient was a SWAT team member who was shot in the helmet. It was a relief to all of the team members to see him awake and talking with only a large bruise on his forehead. He was discharged home a few hours later.

After those last 11 patients were treated, no more Pulse victims would be brought to ORMC. The remaining victims were deceased.

Upon completion of patient intake, the next task at hand was to account for all those brought into the hospital. Our team met briefly to determine a plan of action on how to proceed. We divided our resources, sending two trauma surgeons and a cadre of residents to the intensive care units to provide ongoing care and resuscitation of the most critically ill. Another team went to the hospital floors and step-down units to re-evaluate patients who had been admitted to the hospital without the immediate need of operative intervention. Lastly, I returned to the emergency department with yet another team of residents to account for all of those remaining there and determine their need for admission and treatment or discharge.

Lessons Learned

It is natural to reflect on one’s actions in an event such as this. Many of those who were involved have openly shared their stories of what happened. It is imperative that these recollections are documented and told so others can learn from them.

A response required for events such as the Pulse nightclub shootings is not something that can be done without prior preparation. Teams need a working basis of structure, familiarity, group cohesion and robust procedural exercise to be effective. When patient intake volumes stress teams and processes potentially to the point of failure, prior knowledge and training are the tools available to prevent it. Improvisation and the expectation that team members rise to the occasion should be the norm. A work environment that values each individual’s opinion and fosters growth is imperative.

Logistically, the response should be led by an experienced trauma surgeon, in concert with other experienced personnel at the institution. It requires a surgeon to make surgical decisions. The surgical leader is therefore unable to aid in the operating room or elsewhere. That leader must delegate and direct patient flow to other surgeons and physicians strategically placed in the operating theater, intensive care unit and other treatment areas.

What We Changed

Preparation for mass casualty incidents has been practiced at ORMC for more than two decades and enabled a successful response. However, the importance and intensity of such training has increased since the Pulse event. Team members take drills much more seriously now. Their importance is recognized and influences a larger group, including other disciplines, administration, emergency medical services, law enforcement agencies and the community at large. Support and even excitement for training are greater than ever. This is represented by a cultural shift in increased awareness and acceptance of the importance of practice.

Conclusion

It is paramount that all of those potentially involved in a mass casualty incident have a vested interest in practicing for the worst. Stressing teams to the point of failure during exercises will locate holes in the system that were previously undetectable. Inter-organizational relationships between hospitals as well as local, state and federal agencies should be continually developed to facilitate improved communication and prevent needless delays.

Societal changes now dictate that all healthcare facilities must be ready to deal with tragic events such as the Pulse nightclub shootings. They can and do happen anywhere. Hospitals, unfortunately, are also potential targets and must prepare for those type of situations, too. Engaging leadership on the medical staff, within the hospital, across the community and with all agencies involved will place organizations in the best possible position to deal with such tragedies.

Key Takeaways

1. Practice, practice, practice.
2. Know and engage your community partners.
3. Develop a culture of individual empowerment and psychological safety.
4. Support your team following any event.