The emergency team at the Orlando Regional Medical Center (ORMC) was well-experienced at responding quickly and calmly under pressure from what comes through the doors of a Level 1 trauma unit: people mangled by auto accidents, gunshot victims from a fight, and distraught family members in the waiting room begging for updates.
But nothing compared to the aftermath of the mass shooting at the Pulse nightclub on June 12, 2016. The victims started arriving just after 2 a.m. and “kept coming every minute or two for the next 30-something minutes,” recalls trauma surgeon Chadwick Smith, MD.
Forty-four victims arrived. The wounds, made by an AR-15 semiautomatic rifle, were larger and more severe than those made by the handguns that are typically used in firearm assaults. Dozens of family members and friends showed up asking about the fate of their loved ones. Amid all that, word went out to be on alert for a shooter in the hospital.
“That made it worse for everybody in the emergency department,” says Smith. He recalls the bravery of a doctor and nurse who wheeled a patient through hallways and onto an elevator to the operating room, thinking they might meet a gunman on the way. (There turned out to be no shooter in the hospital.)
The emergency preparedness plan for ORMC (part of Orlando Health) kicked in to bring in more medical staff, secure the building, and ramp up capacity. In the following months, the center did something that more hospitals have been doing in recent years: expanding its plans to prepare for the increasing number and severity of mass casualty incidents (MCIs), including violence (shootings, civic unrest, terrorism), severe weather (hurricanes, floods, heat waves, wildfires), and epidemics.
“There are manmade disasters and there are natural disasters, and both have been increasing,” says Deborah Kuhls, MD, chief of trauma at University Medical Center of Southern Nevada and former chair of the Injury Prevention and Control Committee of the American College of Surgeons (ACS) Committee on Trauma. “The frequency of mass casualty events makes it imperative that hospitals have the necessary infrastructure in place [to respond].”
The concerns are driven by the spread of MCIs to all types of places: mass shootings in cities and rural communities, storms laying waste to coastal and inland areas, wildfire smoke spreading hundreds of miles across state and national borders, and the COVID-19 pandemic accounting for 6.9 million hospitalizations and more than 1 million deaths across the United States.
“We are at a point where [hospital staff] understand that it’s not if but when,” says Christopher Colwell, MD, who responded to the 1999 shooting at Columbine High School in Colorado and has developed training materials about responding to MCIs.
“Mass casualty events, particularly those requiring multiple simultaneous operating rooms, are of increasing concern,” several authors wrote last year in the open access journal of the American Association for the Surgery of Trauma.
The increasing intensity and frequency of MCIs has compelled health care systems to change how disaster preparedness plans are developed and carried out, covering everything from immediate patient care and staff roles to security and coordination with community organizations.
“We have emergencies every day, but there’s a difference between an emergency and a disaster,” says Mark Dupuis, JD, chief of security and emergency preparedness at Ochsner Health in New Orleans. “In a disaster situation, the normal function of an emergency department can be overwhelmed.”
Preventing that overwhelm requires changes in thinking and planning about key aspects of disaster preparedness and emergency care. “The complexity of disasters that we need to prepare for has challenged our level of preparation,” Kuhls says.
Who’s involved
Preparedness planning today brings in staff with a wide variety of expertise, reaching beyond trauma surgeons and nurses. Years ago, Kuhls notes, “A lot of hospitals didn’t include anesthesiologists” in their plans. Yet, “I can’t do a surgery without an anesthesiologist.”
Including different specialties is essential to making sure that enough staff are on hand or on call, that extra supplies can be tapped, and that everyone knows their roles during the frantic moments of an MCI response.
Jeannette Capella, MD, MEd, associate medical director of Trauma Services at Iowa Methodist Medical Center, says the plans have to address various scenarios. “What if we need additional resources, whether it’s personnel, space, or supplies? What’s your plan A, plan B, plan C?”
Hospitals have traditionally had separate plans for various types of MCIs, such as explosions, accidents involving hazardous materials (like chemical agents), and terrorist attacks. Disaster preparedness plans today have shifted to an “all hazards” approach.
“We used to have a disaster plan for every disaster, whether it was an earthquake or flood,” says Susan Briggs, MD, MPH, director of the International Trauma and Disaster Institute at Massachusetts General Hospital (MGH) in Boston. “We had about 10 different plans. That’s not practical, because no one can remember all the details of each plan.”
The preference now is to train staff on a basic all-encompassing plan, with operational details to kick in depending on the incident and local risk factors.
“If you have a COVID epidemic, you want your subject medical expert [on the team] to be an infectious disease expert,” Briggs says. “If you have a hazardous material incident, you want it to be someone who’s knowledgeable about specific chemical, biological, or radioactive agents.”
Who’s in charge
When an MCI strikes, job titles and status take a back seat to how each person’s capabilities match the needs of the moment.
“We no longer talk about titles,” Briggs says. “It doesn’t matter whether I’m a doctor or a nurse.” Rather, she says, it’s an expert’s functional capabilities that determine their role during a particular MCI.
Staff might be needed for patient care, but also to manage patient flow, communications with families, and security at hospital entrances, Kuhls says. A hospital’s incident command structure will guide those decisions.
That structure includes an incident commander to make decisions about such things as priorities for care, staffing, supplies, security, and communications.
“I don’t care whether you’re a student, a resident, or an attending physician, you’re going to report to the incident commander,” Briggs says.
In turn, that commander might report to an incident commander for the city itself. Briggs notes that during the response to the Boston Marathon bombing of 2013, MGH reported to the head of emergency medical services for the city.
Who gets treated first
In presentations to doctors about responding to MCIs, Briggs stresses the difference between “conventional medical care” and “disaster medical care.” While conventional care focuses on the best care for each patient, disaster care prioritizes the greatest good for the greatest number of patients. The latter, Briggs says, takes into account the severity of injuries, the likelihood of survival, and the resources available to treat all patients.
“What has been hard for doctors is that our traditional teaching says that the severity of the injury determines who gets care first,” Briggs says. “In a disaster, that’s one factor. There’s also likelihood of survival and what your resources are.”
This can require uncomfortable calculations. When Colwell and other providers from Denver Health entered Columbine High School after the shooting, they found a severely wounded victim with agonal breathing and no pulse. Under different circumstances, it might have required all available resources to treat that person. “If doctors had done everything possible for that victim, it probably would not have had any impact,” Colwell recalls. “We had to move on.”
The doctors subsequently saved the life of a 17-year-old with gunshot wounds to the chest who “probably would not have survived had we stopped and focused all of our attention” on the other victim, Colwell explains. “You’ve got to think differently.”
Partner connections
Preparedness plans include partnering more closely than before with other hospitals, government agencies (such as fire, police, and emergency services), and community organizations. Kuhls says hospitals have developed detailed plans for steering incoming MCI victims toward facilities that can best care for them based on their medical needs.
“Should they be transported to a trauma center? If they have minor injuries, perhaps they should be transported to another hospital” to take the pressure off the trauma center, she says.
In New Orleans, where hurricanes and other extreme weather events often cause floods and blackouts, Ochsner Health uses its patient flow center as a sort of “traffic control” to steer patients to the most suitable facilities in the system, Dupuis says. “This helps us prevent our hospital from being overwhelmed.”
In addition, some people affected by MCIs don’t need hospital care as much as they need a safe space to recover. Community organizations can provide that.
“We’re recognizing that if we’re going to manage a disaster situation, we’ve got to sit down with our community leaders, we have to review settings like churches and schools,” says Colwell, now chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center. “Not everyone needs to go to the hospital. It might be okay to open a public recreation center that has running water and can manage hundreds of victims in a non-hospital setting.”
Managing visitors
When multiple victims arrive at a hospital from an MCI, several times that number of friends and family come to inquire about the fate of those victims. Disaster plans are getting more precise about where the families go within a facility and who communicates with them.
“You would have a lot of people come in and not know if their loved ones are involved” in the MCI, says Dupuis. “Our plan has designated rooms where the family can go and get information on the patients.” The plan defines specific staff positions to take information about who visitors are inquiring about and what their relationship is, and to communicate the patient’s condition.
Sometimes, the intentions of certain visitors are disruptive. During MCIs that involve guns, it’s not uncommon for rumors to flow about shooters in or near hospitals, as Smith experienced after the Pulse nightclub shooting. Likewise, even as medical staff cared for victims of the Las Vegas concert shooting in 2017, an ACS report noted, “there were false reports of an active shooter in more than one Las Vegas hospital.”
Updated disaster plans specify how those threats are assessed and communicated to staff, and how they are mitigated. Ochsner Health, for example, installed metal detectors at the emergency departments throughout its system, and has a small unit of police-trained dogs to help with crowd control.
“Their presence deters disruption and calms staff and visitors,” Dupuis says. “They’re also trained as comfort animals for the staff.”
Everyone on board
An important aspect of training for MCIs is acknowledging that they can happen anywhere.
“The unfortunate thing is these things have happened,” Dupuis says. “The fortunate thing is that [disaster planning] makes us better prepared. We don’t typically get a lot of pushback when we say we have to prepare for an active shooter or an epidemic. We’ve been through COVID, we’ve been through storms. It’s on the front of everybody’s mind.”
“You’ve got to realize the world is changing,” says Capella at Iowa Methodist Medical Center. “Something may happen here.”
