Hospitals Need to Plan for Mass Casualties

Lessons From the Orlando Pulse Nightclub Shooting

Damian McNamara

January 26, 2017

HONOLULU — A disaster plan was in place at the Orlando Regional Medical Center, just two and a half blocks away from Pulse, and drills had been run 3 months before a shooter entered the nightclub and changed everything.

The first victim arrived after 2:00 AM. "At about 2:15 or 2:20, we realized we had 25 victims," said Charles Hunley, MD, medical director of the intensive care unit.

"When the director of surgical critical care called me and told me to come down to the trauma bay, at first I thought he was joking," Dr Hunley explained. "The trauma bay only fits five, and he was talking about 25 patients already."

The hospital called a mass-casualty incident, which mobilized the trauma surgery, pediatric trauma surgery, critical care teams, nurses, and other staff.

"By 2:35, we had nine patients we could not help," he told the crowd here at the Society of Critical Care Medicine 46th Critical Care Congress. Patients we usually code, we couldn't code. We already had a wave of about 28 patients."

By that time, clinicians had performed three thoracotomies and had run out of chest tubes. The CTs were backed up, so they were using ultrasonography and x-rays for imaging. "We were using tourniquets so we could temporize the patients," Dr Hunley explained.

The take-home message for physicians is "be prepared, run drills, and plan what your institution would do in the event of a mass casualty. In addition, have an understanding about triage," he told Medscape Medical News.

In the advanced trauma life support program, patients are color-coded, but when you are overwhelmed, "you have to triage," he pointed out.

The intensive care team started resuscitating patients. Surgeons and anesthesiologists stayed in the operating rooms while surgical residents rotated patients in and out. Within 120 minutes, the operative capacity jumped from two to four to six.

Lock Down

Yet things went from bad to worse. We heard that someone had run from Pulse into our building. And then someone reported hearing gunshots. At this point, the hospital went into "code silver" mode, which indicates that there could be a person with a weapon or an active shooter.

Staff sheltered in the trauma bay and anywhere they could.

"Everything came to a halt except the care of the patients. Staff sheltered in the trauma bay and anywhere they could," Dr Hunley explained.

By 4 AM, all the patients who could be saved had been triaged, resuscitated, and stabilized. Then there was a loud boom; an explosion. The first of the second wave of patients to arrive was an uninjured member of the SWAT team whose helmet had been hit by a bullet; he was followed by 11 more victims.

You need to have a systematic plan for "when your resources are overwhelmed," Dr Hunley advised. "We never expected that the resources would be insufficient."

Because we were on lockdown, when the families of the victims started to arrive, they had nowhere to go. "It's something in a mass-casualty event you don't think about," he said.

By 9 AM, hundreds of family members were gathered outside the hospital. "I apologize if I get a little teary eyed; I still get upset when I talk about this," Dr Hunley said.

He explained that an efficient notification system was not part of the preparedness plan, which meant that deceased victims were not identified for 24 hours. This was very stressful for people waiting for news. Families were given an email address to send photos and completed forms that went to our teams.

One of the lessons learned that night was that resources are a major issue. The Orlando Regional Medical Center typically keeps 300 total blood products on hand. In the first 24 hours, 28 operations were performed and 441 units of blood products were used. In the next 24 hours, another 54 operations were performed.

Fortunately, a stockpile of supplies had been set aside for disasters. "This was imperative on the night of the incident," Dr Hunley explained.

Pools of Blood

Another lesson was related to blood-borne pathogens. "The photos at Pulse showed victims lying in pools of everyone else's blood," he reported. We were concerned about victims being exposed to other people's blood, so baseline testing was done for hepatitis B and vaccinations.

We also learned that residents — internal medicine, emergency, orthopedic, surgical, and others — come together during a crisis. They "stepped up like champions," he said.

Collaboration was extremely important that night. Dr Hunley said he credits the coordinated response between the medical and surgical ICU teams to a close working relationship.

"This was a time when collaboration and teamwork among all the disciplines in the hospital was critical," he pointed out. "We had CCU nurses go to the trauma ICU. We had pulmonary critical care doctors in the recovery area resuscitating patients. We had intensivists in the trauma ICU helping with recovery."

Caring for Caregivers

Another lesson learned was that a program to care for the caregivers is needed. "We managed the victims and families, but the caregivers were another thing," he noted. "Our disaster plan did not anticipate the number of victims, the amount of time, the report of an active shooter. That turned out not to be true, but it felt very real."

More than 1500 team members participated in counseling sessions over the first 10 days, Dr Hunley reported.

"The biggest thing we haven't recognized is that with mass shootings — it doesn't have to be 38 patients, it could be 10 patients at a small hospital — it's a disaster that will overwhelm your hospital," said session moderator Mary Jane Reed, MD, from Geisinger Health System in Danville, Pennsylvania.

"If you plan, you know who's going to be in charge of your incident command system," Dr Reed told Medscape Medical News. "I think Dr Hunley said it best: it's important to have communication among all the services in the hospital. Figure out how you're going to surge your staff, your stuff, and your space."

"These events are happening everywhere. We are all at risk of having to deal with them," said Gregory Botz, MD, from the University of Texas M.D. Anderson Cancer Center in Houston. Data show that 55 hospitals had active-shooter events in 2014. "In those events, 39 people were killed and 18 were injured," he reported.

Training Nonmedical Personnel to Stop the Bleeding

Dr Botz spoke at the meeting about the Stop the Bleed initiative of the American College of Surgeons. The first step of the initiative's working committee was to develop a threat matrix for active-shooting situations, which includes threat suppression, hemorrhage control, and the rapid extrication of patients to a place where they can be assessed, helped, and transferred to a hospital.

They then recommended that law enforcement officers be trained to control bleeding, and that a task force be developed that consists of people willing to enter an active scene, under the cover of law enforcement, to stop any bleeding in victims.

They also want members of the public trained to pack wounds, apply pressure, and use tourniquets, because the first people who can help victims in a mass shooting are usually those in the same situation.

"You can never fully anticipate the impact of a disaster," Dr Hunley said. "We believe the outcome would have been different if we hadn't planned. There were some unanticipated events, where we had to improvise during that time period, but because we had a plan, we were able to improvise."

"Ultimately, it was the dedication of Orlando Health and the commitment of our team to do the right thing and make it through a very horrible situation," he said.

Dr Hunley, Dr Reed, and Dr Botz have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 46th Critical Care Congress. Presented January 25, 2017.


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