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.