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.