Emergency providers generally have some warning when a hurricane or another natural disaster poses risks to the community. However, that is rarely the case with a mass shooting, as was evident in the early morning hours of June 12, when a lone gunman opened fire inside the Pulse nightclub in Orlando, FL. There was no predicting the scope of this disaster, as it produced 50 deaths, including the gunman, and dozens of injuries — more carnage than any other mass shooting in U.S. history.

The impact of the event was reduced because a Level I trauma center, Orlando Regional Medical Center (ORMC), was only three blocks away from the scene of the shooting. ORMC had experience treating trauma patients arriving in short intervals, although no events close to the scale of what happened on June 12. Further, hospital administrators note they had only recently held large-scale training exercises on how to respond to a mass shooting event. The practice, logistics, and fine-tuning that took place during this exercise could not have been better timed to prepare both hospital staff and community partners for the challenge of the actual event.

Patients Arrived in Two Waves

As is almost always the case in a mass casualty event, the emergency response was hardly glitch-free. For instance, the first email alert notifying Eric Alberts, ORMC’s manager of emergency preparedness, about the shooting incident failed to rouse him from sleep. It was shortly after 2 a.m. at that point. Alberts finally received word of the incident via text more than one hour later. As a result of this problem, Alberts observes that ORMC has already begun searching for a more robust notification system, but he emphasizes that the incident command structure was triggered regardless of the notification delay.

“It is a layered approach,” Alberts explains. “Whoever is there is responding in whatever roles are needed during the incident ... so it is a scalable response system, and because of that, the more people we have, the more people we are able to put in those positions to respond to the emergency.”

Timothy Bullard, MD, an emergency physician who is part of the incident command structure for mass casualty intake, describes another glitch that occurred shortly after he arrived at the hospital that morning around 3 a.m. At that point, the ED was briefly locked down because of false reports that a gunman was in the vicinity.

“With all these [types of events] there are a lot of rumors and questions about what is actually happening, how many shooters there are, and things like that,” he explains. “It didn’t last very long. We had a lot of police on site at that point in time and we had our own security ... so people were fearful for a short period of time, but that passed.”

The patients arrived in two waves, with the initial surge arriving right after the shooting took place around 2 a.m., and the second surge arriving about three hours later, after police blew a hole through the nightclub, killed the gunman, and found the remaining victims. ORMC received 44 victims, nine of whom died within minutes of arrival.

There Was No Time to Organize

One of the biggest challenges facing emergency providers was the speed with which the incident unfolded, Bullard recalls.

“Normally, we would have more time in a disaster to organize. There was really no time at all,” he says. “My partners who were there [at the time of the shooting] got the call that there would be a number of shooting victims, and then they showed up. Some of them weren’t even brought in by ambulance. They were brought in by pickups, so there was a very narrow window of notification.”

However, since ORMC is a Level I trauma facility, the hospital had the kind of expertise and resources that a smaller, community hospital might not have been able to marshal in such a short period of time.

“We have a lot of personnel in-house that we can mobilize,” Bullard says. “We have two surgical critical care guys and some fellows in house; we have a cadre of emergency physicians that are normally on staff to take care of patients; and then we have some medical intensive care physicians who are available at night as well.”

Also, in a fortuitous administrative quirk, all five resident physician slots on the schedule that night were filled by senior residents who were literally two weeks from finishing their training, Bullard notes.

“It was very close to the end of the year when new residents come in and the classes change,” he explains, noting that experience makes a difference at such critical times. “It would have been more difficult for us had more junior residents been available.”

Surgeons had to be called in, but most of them live close to the hospital and they were on site quickly, Bullard notes.

“With all this manpower ... we were up to speed quickly,” he says.

Further, with the incident occurring in the middle of the night, the ED was not overwhelmed with personnel flooding into the hospital to help out.

“That is one thing we always worry about. Everybody wants to participate and help, but sometimes it can create another level of chaos trying to organize people and just deal with personnel you actually need,” Bullard adds. “Because this happened at 2 a.m., there were an awful lot of people that really didn’t know about it. Most of the people who came in were called to come in.”

Administrators even called hospital personnel to let them know not to come in unless they were contacted.

“If the shooting had happened during the day or earlier in the evening, the ED might have had real issues with just trying to control our own personnel and keep things at a manageable level,” Bullard says.

Noise, Patient IDs Proved Challenging

One challenge clinicians faced was trying to identify patients who required treatment, but were not conscious. The hospital had procedures in place to manage this complication, Bullard notes.

“We registered [these patients] in a certain order, and that was an issue, but people went back and re-registered those patients [once they were identified] and made sure that everybody was appropriately matched with the appropriate labs and X-rays that had been done on them,” he explains.

Alberts explains that the hospital leveraged many different methods, including digital fingerprinting, to ensure patients were accurately identified and that their families were informed about their status.

“When you have an unidentified patient, you will go to great lengths to [identify] who they are and to reunite them to their families, because families have a lot of say on a patient’s care in the hospital, especially when the patient can’t speak for himself,” he explains. “We do our due diligence, not only for the patients’ families, but medically speaking we have to be doing the right thing for [the patients] to make sure they are getting appropriate care.”

Another challenge was the noise level, Bullard says.

“When you get in a room with six critical patients and you’ve got multiple teams, the noise level is always an issue,” he explains. “Normally, when we have one or two trauma victims, everybody is very quiet and listening to the reports that the EMS personnel give out, but with so many patients coming in simultaneously, some of that falls apart,” he says. “We were able to get our jobs done, but it was difficult at times for everyone to hear.”

Bullard adds that caring for patients in the midst of a mass casualty event requires adjustments beyond the speed with which clinicians normally operate.

“You are a little bit more aggressive with patients,” he explains. “If you think something needs to be done, you are not going to second-guess yourself and say, ‘let’s wait a while and see if the patient gets a little better.’ You are going to do everything right then, because you don’t have the luxury of watching them.”

At one point, there were more than 90 patients in the ED, more than half for reasons unrelated to the shooting event. Would the ED have been able to manage even more patients, if needed? Yes, according to Bullard.

“The incident command would have called a lot more people in,” he says. “I went down to the ED and asked my partners what they needed. They said from an emergency physician and surgeon standpoint, they were in pretty good shape, but they did ask that we get more vascular support and some more orthopedic support, so we got on the phone and got those people in.”

The system worked, but Bullard emphasizes that the ability to mobilize so quickly stems from the hospital’s diligence in regularly performing critical training exercises and drills. He advises colleagues to use the Orlando experience and similar incidents as motivation to drill frequently and take such exercises seriously.

“You just never know when a [mass casualty event] is going to hit your community, so that practice is first and foremost,” Bullard says. “At some point, everybody is going to get saturated, but we had the latitude to take in more patients, if needed — maybe not in a three-minute window, but had we known that we were going to get a huge number of secondary patients, we could have ramped up more.”

Alberts, who organized a massive training exercise for an active shooter event as recently as March, could not agree more.

“That was a big benefit to all our team members,” he says. “We had that training opportunity for them to see what a real response to an active shooter situation would look like, feel like, and sound like.”

The exercise was elaborate, including 500 volunteer victims who used fake blood and other materials to make their gunshot wounds and other injuries seem as authentic as possible.

“We had 15 hospitals and 50 agencies that participated,” Alberts explains. “Because of that realistic scenario, and the fact that everyone was taking it seriously, it was a true training and education opportunity for our team members.”

Alberts adds that some physicians and administrators have observed that the exercise was instrumental in helping ORMC and its community partners save lives the night of the Pulse shooting. Consequently, his advice to colleagues is to take full advantage of their training exercises so that they can identify areas of opportunity to improve.

“If you don’t do that, you are really failing as a healthcare provider, and you are failing as a community,” he says. “You must leverage any opportunity you have to learn and grow, because in a time of need like we had, training is what comes back to people’s minds. If it is ingrained in their minds enough, it becomes a rhythm, and they just kind of step into it.”

When designing such exercises, be sure to incorporate the wide array of community partners that a facility would rely on in a real mass casualty event such as law enforcement, fire and rescue, and even hazardous materials teams, Alberts advises.

“The collaboration and coordination that takes place when something like this happens is just astronomical,” he says. “The exercises are a great opportunity to do that because you will be able to see how each [group] reacts and responds to the incident.”

If hospitals don’t engage with such partners before a mass casualty event occurs, the critical element of trust may be missing, Alberts suggests.

“If you shake their hands ahead of time and you plan with them and work with them, you will get to know each other and get acclimated with one another,” he says. “That is going to help you to respond in a real situation. That just shined through in this whole incident.”

With the crisis over, there are more opportunities to learn from the event. Administrators are still combing through data to put together a full after-action review.

“That is going to take some time, but one of the things we identified [for improvement] already is communications,” Alberts notes. “With any real emergency or exercise you are always going to have an issue with communications, so we are looking at the efforts we have undertaken with communications and how we can do things better. That is really what our process is: We look at the things that can be tweaked and try to improve them for the entire organization and also for our community.”

Part of this review process involves a series of debriefings, Alberts explains.

“We grab the critical stakeholders together within our organization and we walk through the situation,” he says. “We try to start at a high level with sort of a snapshot of what happened, and then we start working through some of the things where we have questions regarding what worked well, what are some of the areas of opportunity, and where can we do things better.”

At press time, ORMC had already conducted three debriefing sessions about the emergency response, which then led to a number of smaller “breakout sessions,” Alberts notes.

“On top of that, our team members are going through employee assistance program [EAP] briefings to make sure everyone is properly taken care of,” he explains. “When you experience traumatic incidents like this, it is going to impact human beings, and it is going to impact them in different ways. Some people are more accustomed to it than others and more adept at being able to respond to it. Others aren’t, so we are taking this seriously.”

The hospital has been conducting many EAP group sessions, but team members also are able to arrange individual sessions.

“In addition, we have a lot of chaplains at our hospital that team members are able to talk to at any time,” Alberts says. “Our team members are encouraged to use any one of those [opportunities] in any form or fashion just to make sure they are talking through and working through this in their minds so that they are comfortable and healthy for the long haul.”