Mass shooting in Colorado: Practice drills, disaster preparations key to successful emergency response

Witnessing the impact of the tragedy first-hand takes an emotional toll on providers, staff

People understand that natural disasters like floods, hurricanes, or tornadoes are going to happen every year. That's why EDs across the country routinely conduct practice drills so that they have plans in place to deal with mass-casualty events. But when a lone gunman inexplicably opens fire in a crowded movie theater, killing 12 people and sending dozens of critically injured people to area hospitals, it takes a different type of emotional toll — not just on the community and the victims' families, but on the emergency providers as well.

"This was a horrific, sudden, unprecedented event that defies any explanation," stresses Richard Zane, MD, FAAEM, chair of emergency medicine at the University of Colorado School of Medicine. The University of Colorado's Anschutz Medical Campus in Aurora, CO, was one of six hospitals that received victims from the mass shooting that took place at an Aurora movie theater on July 20th. "The people who work here live in the community. The people who are patients here are our community. So we were in the community that was horribly assaulted and we saw first-hand what happened," says Zane.

In the space of about 30 minutes, the Anschutz Medical Campus received 23 critically ill or injured patients, and one of the victims was deceased upon arrival, explains Zane. "At the time, just after midnight, the ED was pretty full, and we activated a Code D, which is essentially a disaster response," he says. This set in motion a series of activities designed to send extra resources to the ED while also decompressing the department.

"Patients were moved to other areas of the hospital where they could be cared for. Simultaneously, the operating rooms were activated, the ICUs were activated, operating room staff and surgical staff were called in, and extra blood products were ordered," says Zane. "The first patient went to the operating room in less than five minutes, and the patients were all cared for. Of the 22 patients who arrived alive, 22 are still alive."

Incident command takes charge of response

While the University of Colorado's Anschutz Medical Campus received the most patients from the shooting that night, five other hospitals also cared for victims. One of them, the Medical Center of Aurora, was just across the highway and to the south of where the shooting occurred. "We have an Aurora police officer who is stationed in our ED 24/7, and he started reporting to our charge nurse that there had been a shooting at a movie theater because he heard the radio traffic, so our charge nurse had a bit of a heads-up about it," explains Mark Mayes, MD, the director of Emergency Services. "She called me after she received her second patient, not only because she had received two patients by police car, which is very strange, but she had also heard more radio traffic indicating that there were multiple victims on the scene and that we needed to implement our mass-casualty, external disaster program."

Mayes immediately got in the car and headed toward the hospital while also working the phone to alert his chief nursing officer, the medical director, and other key personnel to come in as well. "After arriving here fairly quickly, I got in touch with the trauma physicians who were already in the operating rooms taking patients," he says. "We had a trauma physician who was on-call and we also had a back-up trauma physician. Both of those physicians came in along with the head of trauma at the hospital."

Denver, CO-based Swedish Medical Center, which is a sister hospital to the Medical Center of Aurora, received three victims from the shooting, but it was also able to send operating room staff to the Medical Center of Aurora to help the hospital get patients into the OR quickly. While getting this type of assistance from Swedish is not a formal part of the hospital's emergency plan, it did facilitate the process. "We had an inter-hospital liaison who was assigned to our incident command team, and that person took care of these things for us," says Mayes. "We have disaster vests that everybody in incident command wears so that their roles are clearly assigned, from the incident commander all the way to the logistics chief and the ED section chief."

Established systems, structures make crisis manageable

The Medical Center of Aurora received 18 patients, 13 of whom had gunshot wounds. "That was a big stress on the ED, the operating room staff, and the surgeons," says Mayes, noting that the ED's typical daily census is about 165. "It wasn't necessarily the largest mass casualty event [we have ever dealt with], but it arose so fast that it was quite an undertaking."

Further, within two hours of the shooting, friends and family of the victims began flocking to the hospital to look for loved ones. "We set up a staging area where we could manage these individuals and give them information and updates," says Mayes. "Managing the media was another problem altogether because we had [inquiries] locally, nationally, and internationally the night of the crisis."

As part of the hospital's incident command structure, a media liaison took charge of these inquiries, and the hospital also got additional resources and personnel from HCA's Health One division office in Colorado. "They were able to come and provide leadership and strategy around how we were going to provide information while keeping the privacy of our patients a top priority," says Mayes. "We were the first hospital to put up a hotline for families to call into to try to find patients. We set it up through our incident command and got that out to the media as soon as we could."

While the Medical Center of Aurora has never experienced an incident like the mass shooting, Mayes says the hospital has a mature disaster response program in place, and that made a big difference during the crisis. "Everything was difficult, but what made it manageable were the systems we have in place, the structure we have in place, and the training we have done around crisis management and incident command," he says. "Everyone on the leadership team of the hospital carries a three-ring binder that is our disaster manual. We basically have a whole laid-out plan to follow."

As a result of all this preparation, the teamwork that occurred was seamless, says Mayes. The trauma surgeons would shout when they needed things right away, but no one got angry, he recalls. "You never think this is going to happen to your department. You never think it is going to happen to your hospital. And then when it does, you really see where all that training comes into play," adds Mayes.

Room for improvement on communications

The primary challenge in any mass-casualty event is managing the mismatch that occurs between the demand for services and the supply of available resources, explains Zane. But he adds that there is no way to know precisely how these events will unfold. "Although we prepare for disaster and mass-casualty care, you never prepare for specific events because preparedness is 80% generic ... and you have to accept that the last 20% is going to be enigmatic or variable," he says. "It requires leadership on the front lines, which in this case was in the ED."

While the specifics in this case were not what anyone could have anticipated, people recognized that that they were trained to deal with the crisis, and they did that, adds Zane. "We had people taking on roles that were similar to their normal roles, but not the same, and they did it without question and without exception," he says. "The response on that night was nothing short of heroic."

However, no plan works perfectly, and Zane observes that the way health care providers were called in to help with the crisis could have been more efficient. "We could have had a mass-casualty, team-like response so that surgeons, ED physicians, anesthesiologists, and others were all called at once in an organized fashion," he explains. "Instead, the system we had at the time was not functional, so a nurse in the OR called the OR nurses, a surgeon called all the surgeons, and so on. It worked, but it was not ideal, and that was a big lesson for us, so going forward we are going to revamp our technology for how we do team-based emergent calls."

Array of services critical for emotional support

For an event like this, the challenge doesn't end when the immediate crisis is over. Hospital administrators need to anticipate that at least some providers and staff will need help in dealing with the emotional impact, explains Zane. "What we know is that there is no standardization for the way you care for providers in the community after something so horrific happens," he says. "You simply have to make sure that you have different types of resources that are available because different people need different things."

For example, during this crisis some people were distraught and required a lot of emotional help immediately after the event, and then began to do better, observes Zane. "There are also people who have not thought about it, have not needed it, and don't think they want emotional help now, but in six months they may realize that this has really affected them and they need some help," he says.

In addition, Zane stresses that you have to have a variety of resources available because people respond differently to these types of scenarios, and they don't all need the same kind of assistance. Some may require spiritual help or peer support while others will fare better with the assistance of psychologists, psychiatrists, or grief counselors, he says. Further, some people prefer to get help privately, while others want to access help in a group setting with their colleagues, adds Zane. "The important thing is that you make these resources available, and that you publicize how to access them," he advises. "Create different types of venues and access, and be vigilant in making these resources available on an ongoing basis."

Mayes held a debriefing with all of his staff immediately after the crisis, and that seemed to help. "We went into one of our rooms and just went over what we did well, and how we were feeling," he says. "I told them how proud I was to work with such a group. Everything was done, everything was followed-up on, and we checked to make sure everyone was OK."

Mayes adds that while the ED has dealt with several mass-casualty events, it has never experienced one to this extreme, and the staff have learned some powerful lessons to use going forward. "What I would say to others is to practice often and practice like it is a real event," says Mayes, noting that it is critical to really test your systems. "When we practice and drill at our next mass-casualty event, it is going to have a new level of importance for us."

Further, Mayes plans to do more debriefings and reviews of this incident to pinpoint any processes or procedures that can be improved. "We always focus as hospital managers on good patient care, and this is one aspect of patient care that you never want to have to deal with, but when you do, you really want to be good at it."


  • Mark Mayes, MD, Director, Emergency Services, Medical Center of Aurora, Aurora, CO. Phone: 303-695-2600.
  • Richard Zane, MD, FAAEM, Chair, Emergency Medicine, University of Colorado School of Medicine, Aurora, CO. Phone: 888-448-9135.