June 14, 2016: Doctors and medical staff that treated the victims of the Pulse nightclub shooting answer questions at a news conference at the Orlando Regional Medical Center. (AP)
Whenever horrific events occur, it is important that we not only take stock in the event itself but we must also look at the good that rises from the ashes.
The tragedy in Orlando this week is not without heroes. Volunteers, medical personnel, first responders and blood donors have worked tirelessly to help those in need. In the early hours of June 12, 2016, health care workers in Orlando received an emergency alert to attend to those affected by the worst mass shooting in U.S. history.
The quick response and expert training of those at Orlando Regional Medical Center certainly saved numerous lives. Six trauma surgeons and countless other doctors, nurses, technicians and other specialists were mobilized within minutes and were ready to receive the massive number of critically ill patients that arrived all at once.
As a physician, I can only imagine what it was like to arrive at the hospital and begin to care for the large number of wounded. In my experience in dealing with medical emergencies, instinct and training allow doctors and other health care providers to jump in and immediately deliver care. Years of training and study allow health care workers to react with professionalism, precision and compassion. While all of us are human and are emotionally impacted by such a tragic event, somehow all of those who sprung into action at Orlando Regional Medical Center were able to separate their feelings from the situation and perform their jobs at a very high level.
Many hospital workers, physicians, nurses and first responders came in to help—whether they were on call, on duty or on a day off. The selflessness of these medical heroes should not be lost in the tragedy. Many of those involved have been interviewed in the days following the night of trauma and all consistently said that they simply were doing what needed to be done.
While many hospitals have had "disaster plans" in place for years, the events of September 11 led to more widespread adoption of these plans. Since that time, hospitals all over the country have put plans in place to deal with mass casualties. Academic societies and organizations of trauma surgeons have worked to develop the best practices and have conducted large scale studies in order to determine the most effective ways to handle these types of disasters.
These plans involve extensive, centralized communication systems and a way to quickly alert all essential personnel and mobilize resources. In addition, these plans involve intensive education and training for all hospital staff. Most hospitals, once plans are in place and staff education is complete, have regular “drills”. Many institutions even have mock disasters with actors posing as critically injured casualties. These drills allow for hospital personnel—doctors, nurses, techs, first responders and communications specialists to hone their skills and find ways to improve responses in the case of a real disaster.
In my prior experience at Duke Medical Center as well as my current experience at the University of North Carolina health care system, well-thought out protocols and training programs are in place and staff are reminded of these plans frequently. As a cardiology Fellow in the late 1990s at Duke University, I experienced an emergency event first hand.
While I was in the emergency room caring for a patient with a heart condition in the early morning hours, an alert was sent out that there had been a gang-related shooting in Durham and that there was an active shooter potentially inside the ER. We were instructed to get all patients onto the ground and pull everyone into the nearest closed room. I reacted by moving several patients to the floor and pulling them into a supply closet with me. Patients were frightened and understandably anxious. During this time, the ER was locked down and police begin moving through the department in order to clear the area of any threats.
Fortunately, there was no active shooter found inside the ER and, after about 30 minutes, we were allowed to return to normal operations. After this experience, I remained visibly shaken and it took me a long while to move past the fear I felt that night. I can only imagine what it was like for those medical professionals involved in the Orlando tragedy.
While you may not think of the importance of these issues during the time that a disaster occurs, there are a few things that seem to make a difference in the way we as health care workers respond. After my experience during my cardiology Fellowship here are a few things that I believe to be essential:
1. Centralized communication: In a disaster or mass casualty event, communication is critical. Effective communication allows for patients and personnel to be where they need to be at all times in order to provide the most efficient and effective life saving care.
2. Coordinated care: Cooperation and coordination between surgeons, nurses, administrators and other personnel is key to the successful treatment of large numbers of patients.
3. Staff education: Extensive education and training must take place in order to prepare staff for mass casualty events. When called upon, staff must be able to react in an organized and calm way—all of this comes from preparation over time.
4. Drills: It is important to practice a response to a mass casualty event. Practice allows for those in charge of the disaster plan to assess response times and identify areas for improvement.
What are the biggest challenges in a mass casualty event and what are the initial steps?
The heroic efforts of those in Orlando cannot be understated. These men and women should serve as an inspiration to all of us in medicine. Each person did their job and worked through the night to help as many victims as they could. For many of us, the thought of being faced with such a large number of seriously wounded can be overwhelming.—this is the stuff of war.
However, those first responders in Orlando met the challenge head on—they worked quickly to identify and triage the most critically ill patients. Emergency personnel attempted to quickly stabilize each patient, and then decided who needed the most urgent treatment in the OR. Patients were sequentially moved from the scene, to the emergency department, and to the OR very quickly. In order to triage the large number of victims, health care professionals are trained to use the ABCDE approach:
1. Airway: Make sure that each patient has stable airway—if not, we must quickly establish an airway
2. Breathing: We must make sure that every patient is breathing on his or her own. If not, we must provide an external means of providing them with oxygen.
3. Circulation/Hemorrhage: First responders must quickly assess if the patient has a pulse and if there is major bleeding. If there is no pulse CPR is initiated. If there is an obvious hemorrhage, efforts must be made to apply pressure, field dressings and other interventions designed to stop bleeding prior to definitive treatment. In many cases, blood and fluids must be administered in order to restore blood pressure and adequate circulation.
4. Disability: First responders must assess each victim’s level of consciousness and if they have suffered any type of neurologic or brain injury. These injuries must be quickly triaged to a neurosurgeon in cases of head trauma.
5. Environment: In many disaster situations there are environmental exposures (chemicals, spills, etc.,) that may contribute to the trauma—in the case of the Orlando shooting, this was not the case.
Unfortunately, mass casualty events have become more common in the U.S. in the last decade. Medical personnel and hospital systems are learning to better care for patients in these large-scale emergency situations. Events such as the Orlando tragedy will cause all of us in medicine to review our protocols, plans and readiness procedures so that we will be more equipped to handle emergencies when they occur. Were it not for the heroic efforts of first responders, trauma teams, doctors, nurses and other hospital personnel in Orlando, the number of casualties could have been much greater.
In the coming months, those medical heroes that helped treat the massive number of wounded will need time to heal and time to process all that they have seen and experienced. Thankfully, they were prepared and ready to respond with a heroic effort on Sunday.
Kevin R. Campbell, MD, FACC is an assistant professor of medicine in the division of cardiology at the University of North Carolina.
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