Chaos In The ER: How Mass Shootings Flood Trauma Centers
The Pulse shooting highlights a flaw in the U.S. health care system: The closest hospital gets the most patients in a mass casualty incident.
It’s been documented in research looking at other disasters. And it’s something hospitals have to be prepared for.
“Well, I think you hit the nail on the head,” said Eric Alberts, the director of emergency preparedness for Orlando Health.
Hospitals, Albert said, can no longer think, I’m a general care hospital. I don’t have to worry about events like this.
“Those are excuses really, right? You can’t help where bad things are gonna happen,” Alberts said. “Bad things are happening in the community everywhere. It may be next door, like Pulse was for us, half a mile. That was just a coincidence. We were fortunate we were the Level 1 trauma and we had been trying to get prepared and were there to help care for the patients. But other hospitals are just gonna have to deal with it.”
WMFE has produced an hour-long documentary about the Pulse nightclub shooting. Pulse: Chaos in the ER brings the unvarnished story of what happened and what can be learned from one of the worst mass shootings in modern U.S. history.
Forty-four gunshot victims came to Orlando Regional Medical Center that morning. Most of them came in the first hour, and a third of the victims were brought by police, not ambulance. To be clear, other hospitals also got Pulse shooting victims. But Orlando Regional Medical Center got by far the most patients, and the most seriously wounded.
Orlando Regional Medical Center got 36 gunshot victims in 36 minutes. They came by police trucks and cruisers and brought themselves. Officer Joe Imburgio drove a black F-150, used as a makeshift ambulance. He remembers what it was like coming to the hospital.
“Cluelessness. I’m getting goosebumps talking about it.” Imburgio said. “At first, I went the wrong way in the emergency bay because I thought if I came that way it would be easier for them to unload the victims. And they’re like, ‘What are you doing, what are you doing, you’re going the wrong way.’ And I tried to tell them hey, we have a massive situation right down the road, and they couldn’t fathom it. Another couple passes, there was 15 doctors, 20 doctors out there. And they really understood what happened. … So then they started to realize what they were in for.”
With just 32 people working inside the emergency room that morning, that means there could have been more victims than staff before extra hands were called in. It was utter chaos.
Nine patients died the morning of June 12 at Orlando Regional Medical Center. The dead were lined up in the decontamination area outside the trauma bay while health care workers tried to save the ones who could be saved.
There was a moment when ER nurse Libby Brown realized how bad things were.
"We didn’t even have a sheet to cover a patient that was deceased going to be lined up with the other bodies,” Brown said. “So that was one of the times when I was like this is very, very bad."
That concentration of gunshot victims stressed the hospital to the limit. Resources became stretched.
“We’re just out of resources,” Brown said. “Just seeing nurses standing at the top of the bed squeezing blood products into people. We have level 1 pressure machines that will push blood in faster, we have pressure bags that will help push blood in faster, but obviously those were all being used up, so you just see nurses at the head of the bed just squeezing blood into people.”
During this, the concept of triage came into clear focus. For most people, triage simply means that health care isn’t on a first-come, first-served basis.
But during a situation like Pulse, triage means doing the most good for the most people. And that means you have to stop caring for those who aren’t going to make it.
One patient exemplified this. He came in with multiple gunshot wounds to the chest. They did what’s called a resuscitative thoracotomy at the bedside, an incision between the ribs to open up the patient’s chest. But the bullet had done its damage to his heart, his spine. There was nothing they could do.
“It was just a very intense scene to watch because Dr. (Josh) Corsa worked so hard to try and save him, and he just wasn’t going to live,” said ER nurse Elizabeth Burrows. “So you look over at one point and he’s just agonally breathing.”
And that’s when Dr. Chad Smith, the attending trauma surgeon that night, stepped in and stopped the resuscitation efforts.
“I cannot give them enough credit as far as having the sound mind to systematically stop and triage and assess every patient to figure out what do we do with this patient and do it quickly,” Burrows said. “Dr. Smith was amazing about how well he handled all of that.”
Smith said he’s trained for this kind of triage, but he’s never had to make those calls in real life.
“When you realize that a patient is not going to be able to saved, any care beyond that point is potentially taking resources and physician effort and supplies from another patient you can save,” Smith said. “And so you have to be able to go from doing the maximum amount of things for one person, to using limited resources to save as many people as possible.”
And then things got worse.
Code Silver In The ER
No one is exactly sure why it happened, but at 3:19 a.m., the call came out: Shots were fired at Orlando Regional Medical Center.
It was a false alarm. But police believed a second shooter had arrived in the ER as a victim.
Over at Pulse nightclub, Officer James Hyland was standing by his F-150 when the call came over the police radio: Shots fired in the vicinity of Orlando Regional Medical Center. In body cam footage, you can see officers scramble and jump into the bed of the truck. Hyland takes off, nearly leaving people behind still trying to get into the bed of the truck. And in less than 60 seconds, officers with assault weapons drawn converge on the hospital.
They chase someone who’s running from them as they arrive. Then, they begin searching the hospital, following a trail of blood. Eventually, they find one of the victims on the sixth floor, who’s been shot in the foot. They cuff him while he continues to get care.
Meanwhile, while all this is happening, police are telling the health care workers to barricade themselves. In the videos, you see health care workers crossing paths with armed police in the hall.
And they kept working on the patients.
“I mean, yeah, I was thinking I could get shot, but I’m gonna continue to care for these people, I’m gonna do what we can,” said Dr. Chad Smith, trauma surgeon. “I really had thought about it. I thought about, I want to say that happened in maybe half a second, I thought about my wife, I thought about my kids, I thought about God, I thought, well if this is it, this is it, but I’m not gonna leave these people.”
In the trauma bay, Dr. Michael Cheatham told workers to move a portable X-ray machine in front of the doors. It’s a big box weighing hundreds of pounds, with its own motor to move it around.
“And so we pushed those up against the doors to block them, and I said OK, let’s get back to the patients,” Cheatham said.
Smith remembers seeing workers texting their loved ones. He sent a text to his coworkers, telling them to stay out of the ER. He thought he was going to be responsible for them getting shot since he was the one who called them in.
“It seemed quick, and it also seemed slow,” Smith said.
Ultimately, there was no shooter.
“But that still, it doesn’t take away those feelings I think everybody has had," Smith said. "That is what has been the most difficult I think for most of the team members.”
It took nearly 45 minutes to make sure the entire hospital was clear. At this point, Omar Mateen had told police he had bombs, and that he was planning to strap them to victims. The decision was made to breach Pulse nightclub, and a second, smaller round of patients came to the hospital.
One thing the hospital wasn't ready for? Hundreds of loved ones gathering at the hospital, desperate for news.
But What About Mine?
People desperate to find their loved ones couldn’t get to Pulse nightclub because of the police roadblocks. They could get to Orlando Regional Medical Center, and hundreds gathered, desperate for news.
Holly Stuart is the director of patient experience for Orlando Health. That means it’s her job to make a stay at the hospital more pleasant – a difficult job normally, but an impossible task June 12. When she got to the hospital that morning, she saw two unusual things. A crowd of hundreds of people waiting outside the hospital. And inside?
“I walked by the front desk, where normally we would have a guest service team member managing it,” Stuart said. “And there was a law enforcement officer I didn’t recognize, and he was dressed in SWAT gear. And he had a really intimidating looking machine gun. I don’t know guns well, but it was not the typical thing you see in the hospital. And so I knew right then it was gonna be an unusual day.”
Hospital administrators decided to bring the family members into a big conference room. There were issues, though. There weren’t enough people who spoke Spanish to translate for families. People were fainting and needed medical attention. Stuart said the room was tense.
“People have been woken up in the middle of the night,” Stuart said. “Some people had been at the club, so they’re in a variety of dress. Some people had taken off their shirts to make tourniquets and things like that. So it was an unusual looking crowd.”
To help identify patients, they put Amy DeYoung’s email address up and asked families to email photos and identifying information. She began printing them out and trying to identify people who were dead or on breathing machines.
“I felt like any second that I stop and I don’t print these and take them to the cops is another minute this person is in total anguish,” DeYoung said. “I could hear the screaming, the blood-curdling screaming, every time they would pull someone into another room next to my office and tell them they were dead. You just never forget that sound, it’s horrible.”
At 11 a.m., hospital employees started telling families the identities of those inside. Dr. Joseph Ibrahim, one of the trauma surgeons, stood in front of the crowd in the room and began reading the names and conditions.
Frederick Johnson, stable. Felipe Sanchez, critical. Michael Morales, stable. As they read the names, people called out, or started crying. Phones ring nonstop.
They told the families that if a loved one is at Florida Hospital, go this corner. If a loved one is in critical condition, go to this corner. Stable, this corner. And when they finished, there was a huge group of families still standing in the middle of the room, with nowhere to go.
“And I think that’s when it hit everyone, how many people we were dealing with that were gonna be getting really, really bad news,” Stuart said. “We let them know that we still had several to identify. In the back of my mind, I knew that we only had four. But we still probably had 100 people in the room. You could see them kinda start processing the reality of it. OK, it’s been six or seven hours. They’ve read the list of who they know they have, I haven’t heard from my person. I can remember them staring back at us, like what about mine?”
From Orlando With Love
Forty-four victims came to Orlando Regional Medical Center June 12. Thirty-six came in the first 36 minutes. Nine of them died.
There were 28 surgeries done in the first 24 hours. More than 17,000 surgical supplies were used. By the time the last patient was discharged 86 days later, 550 units of blood were given. That’s the equivalent of all the blood in 45 to 55 people.
So what lessons can be learned from inside the ER during the Pulse nightclub shooting? What has it changed? How has it changed the people? And were lessons from Orlando used by health care workers in Las Vegas?
Eric Alberts, the director of emergency preparedness at Orlando Health, sometimes carries a binder with him. A thick binder, two to three inches at least.
“Well the binder is actually what we’ve learned since Pulse," Alberts said. "It includes personal notes, it includes our after action report, our corrective actions, it includes our power point we show to other hospital organizations and community partners across the world and the United States. So this is like the playbook, if you will, of what we learned from this situation.”
Alberts said Orlando Health has revamped the equipment they keep on mass casualty incident carts, and by the end of the year, they expect to have a mass communication system online to alert all the team members when something like this happens.
And it's possible that the first responder community is taking training drills more seriously after the shooting. This year's exercise, where they simulated multiple dirty bombs being set off at the same time, was the largest training drill in Florida's history. More than 1,200 people volunteered as victims.
Visitors to Orlando Regional Medical Center can see how Pulse has changed the hospital.
Since June 12, visitors must walk through security checkpoints with metal detectors to get inside. Now, at the hospital's blood bank, they know that if there's a mass casualty incident, they immediately start thawing plasma and universal donor blood.
The hospital is working on a website where people can upload photos and identifying information of people they believe are in the hospital. That way, it doesn't all come to one email address, and can be accessed by people outside the hospital.
Pulse also changed the people working at the hospital. Amy DeYoung, who worked the day of the shooting to try and identify patients, says she's more vocal now about her status in the LGBTQ community.
“I just don’t feel it’s my right anymore to stand back and not admit it if someone wants to ask,” DeYoung said. “Or is to say, 'Oh, you’re married, what’s his name?' No. Her name, it’s Carla, it’s my wife. I don’t feel like I have the right to lie anymore. That’s the biggest thing.”
Las Vegas took over Orlando's mantle as the site of the deadliest mass shooting in modern U.S. history. Workers from Orlando Health have done six talks in Las Vegas about how to prepare for mass casualty incidents.
Dr. Joseph Ibrahim, chief of trauma surgery for Orlando Health, said he hoped some of the health care workers heard the talks and that it helped. But he also stressed the need for community education of the Stop The Bleed campaign, which teaches people how to stop blood loss during a trauma situation.
The goal is that no one would die from bleeding from a gunshot wound to the arms or legs.
"I'm advocating knowledge in response, and knowing how to care for each other," Ibrahim said. "Because the true first responder is gonna be somebody at the concert or at the event standing there and their friend gets shot or their loved one gets shot. They're gonna have the best ability to provide the care in that moment. Any delay or ongoing bleeding decreases the chance that person is going to survive."
Ibrahim said the notes of encouragement they got from around the country helped him get through his experience. His message to those in Las Vegas?
"We're all thinking about you," Ibrahim. "Lean on each other. This is a long, drawn out process. It's not going to be immediate, so they have to take care of each other."
Those working during the Pulse nightclub shooting have spent the last 14 months teaching others what went right and what went wrong in the hospital. Now, as Las Vegas becomes the site of the deadliest mass shooting in modern U.S. history, it will be their turn to share lessons learned.