Respiratory Care

How I Heard

Sometime during the 4:00 am hour, I heard the vague buzzing of my cell phone on the bedside table. I didn’t think much of it until the haziness cleared and I realized it was a phone call, not a text or email. The buzzing stopped and I almost fell back asleep, but something urged me otherwise. I looked at my phone and saw a missed call from my administrator. I immediately called her back, whispering to not wake my family… “Hey, what’s going on?” Her response, “There has been a shooting at the Pulse nightclub. We have received 20 patients and are expecting 20 more.”  My simple four-word response was, “I’ll be right there.”

Synopsis

Our Respiratory Care department is a large department consisting of 130 respiratory therapists, all with varying skill sets. Depending on the shift and day of the week, we staff 20-25 therapists plus supervisors.  We care for 40 to 45 ventilated patients, administer about 600 therapeutic treatments and perform 40 arterial blood gases on any given day at Orlando Health Orlando Regional Medical Center (ORMC).  Along with all of the other duties we perform — including bronchoscopies, a-line insertions, hemodynamic monitoring, intra-aortic balloon pumping and airway management — this can make for an intensely busy day or night for the therapists in our department. In the early morning hours of June 12, 2016, we had one supervisor and 20 therapists with an appropriate mix of skill sets for the areas in which they were assigned. This would have been adequate for a normal weekend night, but as it would turn out, this weekend night would become far from normal.

Preparation

Each year our department trains with intensity for mass casualty incidents.  We always perform the drills on week days during the day shift. We treat these drills as if they were the “real thing” and tax our operations to identify weaknesses in our process so we can make improvements for the next drill or, god forbid, a real-life incident. During our drills, our department initiates a mini command center in our ED in which both on-duty supervisors communicate with each other the equipment, supply and work force needs for the event. One supervisor is present in the patient care area of the ED, mainly the trauma bays, and the other is off-stage coordinating the needs as the frontline supervisor dictates. This enables our department to pull resources from patient-care areas that are less critical and consolidate our staff to cross cover multiple units if needed during the event. We communicate closely with our hospital incident command medical director, logistics, planning and operations chiefs.

After the events, we participate in the post-drill debrief to communicate what went well and areas that we identified as having weaknesses or gaps that could compromise operations in the event of a real disaster. With each drill, we flush out our areas of opportunity and add more oil to our machine. We walk away after each event feeling as if our machine is better-oiled than it was during the previous event.

Response

Upon the call of the mass casualty incident, the supervisor reported to the ED to assess the event and determine what staffing resources would be needed. Luckily, the supervisor on that night had recently switched from day to night shift and had regularly participated in the mass casualty drills. He was knowledgeable in the mass casualty process and well aware of what was required from our department to ensure that proper resources were available to support the incident. Upon notification of at least 20 gunshot victims, it was evident that staff would need to be pulled from the critical care areas to provide care for the victims. Unfortunately, we did not have 2 supervisors on that night, which made coordination efforts more challenging. The supervisor immediately called all available staff to the ED and prepared them for what was incoming.

Within minutes, patients began to arrive in droves. There was no report received from EMS, so expecting the worst became the standard. Each patient was immediately assessed to determine the need for airway stabilization and ventilatory support. All hands were on deck as therapists provided CPR, intubations and transports to the OR for the most critically injured victims. Supplies were quickly depleted and additional therapists were used to retrieve more supplies to restock and prepare for the next wave of victims. This continued until the last Pulse patient came through the door.

For our department, this incident didn’t just last a few hours, but continued for days, weeks and months. Our therapists provided respiratory care and support to these patients from the moment they entered our Emergency Department until the day they left our hospital. Ventilatory and oxygenation support, hemodynamic monitoring, lung expansion therapy, chest drainage monitoring and, yes, emotional support were the services we provided to the victims of the Pulse tragedy.

Lessons Learned

The Pulse tragedy identified that no matter how much you prepare, you can never be truly prepared mentally for an incident of this magnitude. This is why it is so important that we do prepare and practice. Practicing creates muscle memory for these very moments when our brains struggle to process. I vividly remember a conversation with the supervisor who was in charge of the department that early morning. He said that he immediately went back to our drills. Assemble the team, take direction from the trauma surgeon in charge and focus on the task at hand by providing the care each patient needed at that moment in time. There was no time to think and reflect during the initial hours of the disaster. They had to rely on the muscle memory developed from preparing and practicing. We learned that while drills are disruptive to our day, and we never have enough staff to pull people out of assignments for a drill, they are vital to saving lives. We learned that we need to take them even more seriously than we had in the past. We learned that in order to mitigate the horrific results of such a tragedy, we have to drill like it is real.

We also learned that performing drills during the day are beneficial to the day-time staff, but this incident didn’t occur on a weekday during day shift. We recognized the need to provide the night shift and weekend staff with the same level of preparation as we do the day shift.

Probably more than anything, we learned the emotional toll taken on the team members who worked the incident. Symptoms of post-traumatic stress affected our team for more than a year. While they are trained professionals able to care for these types of patients every day, the sheer volume of devastating injuries is something that you cannot possibly prepare your mind for. We have found that our team members have needed emotional support and mental health resources to pave the way for their healing.

What We Changed

What we found with a mass casualty incident of this size and degree was that our supplies were not in an optimal location for the speed with which we used them. Airway supplies, chest tubes, chest drainage systems, manual resuscitator bags and ventilators were depleted within minutes, and we had to utilize therapists as supply and equipment runners to retrieve additional resources to meet the influx of patients. While we had an abundance of the items we needed, they weren’t necessarily in the right location. As a result of this experience, we relocated some of the more critical supplies closer to the ED so we could access them more efficiently in the event of another mass casualty.

Conclusion

As I reflect on the Pulse nightclub shooting, I find myself re-reading a post that I put on my Facebook page the evening after the attack. Here is what I wrote:

“I saw two faces today. The face of grief beyond what any words can describe. I struggle to process the loss of life and the suffering I witnessed. Each of these victims has a story, has a family, and has friends.  Take a minute to learn someone’s story; you never know when they will no longer be here to share it.  The other face I saw was one of complete and total dedication to serving the needs of our community when it truly does matter most. The entire ORMC family of caregivers has and continues to put their hearts and souls into saving as many lives as possible. I could not be more proud to be a part of this team…wouldn’t dream of working anywhere else.”

Respiratory therapists are a vital member to the healthcare team. Knowing that we were part of a family of caregivers that saved lives by offering expert, composed and resolute care with unwavering passion and dedication gives me and my team a sense of great purpose and pride. It was an honor to serve our community when it needed us most. 

Key Takeaways

Take Drills Seriously – Drill Like It’s Real.  Every time. Don’t take shortcuts or just go through the motions without treating the event as if it were the real thing. The more you drill with intensity and purpose, the more muscle memory you create for when a real incident occurs and your mind begins to race. If you drill like this, you will fall back on what you know.

Expect the Unexpected. We never expected to experience a horrific incident of this magnitude at our hospital, but we did. We never expected to be put on the national and world stage as the hospital caring for the victims of one of the deadliest mass shootings in America, but we were. Always expect the unexpected — and be ready for it.

Validate the Efforts of the Team. As this tragedy unfolded, there was immense focus on the lives lost and the lives that would be changed forever. While it is important to memorialize the victims who didn’t make it back home from Pulse that night, it is also important to honor the lives that were saved. Because of the collective efforts of hundreds of our team members from all disciplines of care, we saved the lives of 35 people. We know their stories and we know that in some way we made a difference in their lives. Know that the work you do is meaningful and has purpose.