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.