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Rural ED nurses treat 14 gunshot victims in one day: Teamwork is key
Mass casualty disasters such as Blacksburg 'can happen anywhere'
A young man and woman from Virginia Polytechnic Institute arriving about 8 a.m. on April 16 with gunshot wounds came as quite a shock to ED nurses at Montgomery Regional Hospital, a 146-bed facility in rural Blacksburg, VA. The male victim was dead on arrival, while the female victim was stabilized and transferred to a nearby Level 1 trauma center.
"We thought this was an isolated event," says Mike Hill, RN, director of emergency services.
But a much bigger shock was coming. "About 9:45, we got word that more shots were fired on campus, and they were finding victims all along the classrooms and corridors. We knew then it was going to start getting deep really quick," Hill says.
The ED's "Code Green" disaster plan was implemented, which uses a call tree to alert staff. However, hospital staff already had heard the news and came straight to the ED. Meanwhile, ED staff taking a class on disaster management were pulled out to come to work. "We had a lot of people real quick," Hill recalls.
To free ED beds, patients were transferred to the hospital's ambulatory care center when possible.
Meanwhile, paramedics were radioing in and saying, "I have two," or "I have three." A total of 14 patients were brought to the ED and treated over a six-hour time span. "Within the first hour and a half was when the rubber hit the road, so to speak," says Hill.
One patient after another was brought in injured and bleeding, many with multiple bullet wounds, including one shot in his abdomen, chest, and head. In the small town, almost everyone had a friend or relative working at the campus, which was an emotional pull on nurses, says Andrew Galvin, RN, the ED's nurse practitioner. "It was very difficult because everyone was waiting to see someone that they knew," he says.
The hospital ironically was no stranger to gunshot violence, even within its own walls. A security guard was shot in the ED in August 2006 by a prison inmate who escaped from the hospital.
Aside from that incident, however, car accidents and industrial accidents are the types of trauma cases the ED usually sees, says Hill. "Usually, a kid jumping off a wall who ends up with a broken ankle is the kind of trauma we have here," he says. However, even the largest urban ED doesn't see the type of trauma that occurred in Blacksburg on that terrible day, notes Galvin. "If you go to Chicago or Miami or L.A, they get trauma, but they don't get 12 penetrating traumas within a one-hour time span," he says.
Nine of the 14 shooting victims were admitted, and seven required surgery, but all eventually were discharged home, a fact that gave Montgomery's emergency nurses heart in the aftermath of the disaster. "The role of any nurse is to save a life, period," says Hill. "The thing that tugs at my heart the most is the 32 that we couldn't do a thing about."
Disaster training helped
Four ED nurses took Advanced Disaster Life Support (ADLS) training in 2006. "When you initially took the class, you thought nothing like that was going to happen here in this small town," Hill says.
The training helped Barry Akers, RN, the charge nurse on duty that day, to integrate multiple pieces of information flowing into the ED. "It was my job to coordinate the resources we had available, the number of patients coming in, and the rooms available, with many different factors possibly changing things," he says.
At one point, three phone conversations were occurring at the ED's entrance: A police officer talking to law enforcement at the scene, a staff nurse who also is chief of the Blacksburg rescue squad speaking to his members at the scene, and the ED manager conferring with other hospital units. "I had to talk to all of those folks and take all the information they were getting into account," Akers says.
Although the disaster training had addressed the need for every individual to play a limited role during a disaster, this role was difficult for several ED nurses, particularly for those with previous EMS experience, says Galvin. "As nurses, we want to jump in and apply direct pressure to stop the bleeding, but that's somebody else's job during one of these situations," he says.
The training also reinforced the "cookbook" nature of trauma care, says Galvin, with focus on airway, breathing, and circulation. "It doesn't matter whether the patient had his leg torn off by an industrial machine or been riddled with bullets," he says. "Your role as an ED nurse is to assess and provide appropriate interventions when these patients come through the door."
Disaster training also resulted in first responders tagging every patient red, yellow, green, or black — meaning that the ED received only patients with a chance of survival. "If this had happened six years ago, we would have gotten every patient and not just the ones that were viable, because the thought back then was "grab and go," says Hill.
Teamwork saved lives
Good communication was the essential ingredient that saved the day for the small community ED facing a nightmare, says Hill.
"We had nurses from every department, lab staff, X-ray techs, an anesthesiologist, and a pharmacist in the ED," he says. "If you don't work together as a team in a situation like this, you're going to fall flat on your face."
One man came in with a gunshot wound to the femoral artery, which is generally not a survivable injury, notes Hill. "He literally arrested at the ED door, and within two minutes he was on the OR table," he says. As part of the disaster plan, the OR cleared their schedule, which meant they had five rooms open and available for the shooting victims.
If it weren't for the first responders stopping the bleeding, the paramedics getting him to the ED in minutes, and the quick action of ED nurses, the death toll would certainly have been one higher, says Hill. "We made a difference that day based on what we learned and practiced," says Hill. "A lot of people take disaster drills as a headache or joke. But if it can happen in small-town Blacksburg, it can happen anywhere."
For more information about treating multiple trauma cases in the ED, contact:
Advanced Disaster Life Support (ADLS) is a two-day course covering mass casualty decontamination, use of personal protective equipment, and other essential skills, with simulated all-hazards scenarios, interactive sessions and drills with mannequins and volunteer patients. Fees for the course are approximately $400, but cost varies depending on the training center. To view a calendar of upcoming courses with registration information and course fees, go to www.bdls.com. Under "Find Courses," click on "Course Schedule," or for a map of training centers in the United States, click on "By Location." For more information, contact the National Disaster Life Support Foundation at (866) 722-4911. E-mail: email@example.com. Web: www.bdls.com.