By John Palmer
“We are in an environment where underlying violence is considered acceptable. We are expected not only to survive, but turn right around, respond, and treat casualties.”
Once again, hospital staff in a major U.S. city has found themselves in the middle of the impossible task of keeping the facility running, maintaining safety, and saving lives in the nightmare scenario of one of the worst mass shootings in U.S. history.
Hospitals have started to grow used to waiting for the next big mass shooting, and preparing for how they will respond. Very little could have prepared them for the evening of October 1, 2017, when a hail of bullets fired by a lone gunman from the Mandalay Bay hotel into a crowd of 22,000 at a country music festival in Las Vegas killed at least 59 people and sent more than 500 to area hospitals, severely straining the city’s emergency response system and putting the hospitals into overdrive.
According to published news reports, it was all hands on deck at many hospitals. At University Medical Center of Southern Nevada, the state’s only level-one trauma center, which means it is staffed around the clock with surgeons and trauma nurses and personnel, virtually every available employee hustled back to work to be confronted with unimaginable carnage.
“It was a trauma bay full of at least 70 people and patients stacked everywhere. It was controlled chaos,” Dr. Jay Coates, a senior surgeon at the hospital told Yahoo News. “At one time we had eight operating rooms going at the same time.”
According to the report, eight or nine surgeons helped evaluate patients to determine who was most in need of surgery. The most critically wounded sometimes had up to 20 people around their bed working on them.
The trauma center reportedly had received 104 patients by early afternoon the next day, most suffering gunshot wounds. Four died, 40 were released, 12 were in critical condition and eight were in surgery, a spokeswoman for the hospital told Yahoo.
Apparently, the hospital had been training for just this sort of scenario. Last year, the trauma center had a training drill in which staff practiced receiving patients after a fictional mass shooting at a concert.
At Sunrise Hospital and Medical Center, a nurse told The Washington Post that she “followed a trail of blood indoors.” Dozens of patients were crammed into the waiting area, hallways, and rooms of the hospital’s emergency department. Some were “red-tagged,” meaning they needed attention immediately. Names were being assigned randomly because there was no time to register people or find IDs.
About 214 patients were treated in three hours at Sunrise Hospital, nearly the number typically seen in a day.
Scott Scherr, the director of emergency medicine at the hospital, told The Post he arrived at the hospital about 30 minutes after the attack began, breaking “every traffic law in Las Vegas” along the way.
The scene inside stunned him. He remembers blood pouring off gurneys.
“That moment was shocking, but as soon as that moment passed, I knew I had a job to do,” he told the paper. He would end up working 20 straight hours.
Hospital staffers gave each patient red or green triage tags identifying the degree of their injuries. When beds filled up, some of the less injured sat on the floor.
Hospitals getting a lot of practice
Any well-rehearsed plan depends on many things happening at once, and if circumstances change suddenly, the staff may need to be flexible and able to adapt to the changing plan. A well-oiled response to any disastrous and quick-changing incident depends on hospital staff getting updated information about incoming patients from outside responders such as police, fire, and EMS so that staff, equipment, and other resources can be put into place, but what happens when hundreds of patients descend on the ER staff all at once?
These scenarios are starting to become all too commonplace.
On June 12, 2016, Orlando, Florida was the scene of what up until October 1 had been considered the worst mass shooting in the country’s history. That night, Orlando Regional Medical Center (ORMC) experienced an overwhelming influx of patients injured in the worst terror attack on American soil since 9/11. The mass shooting, which occurred during a Latin Night at the Pulse nightclub only three blocks away from the hospital and unfolded within a three-hour period in the middle of the night, taxed the hospital in a way few ever get to experience or prepare for.
Over a two-hour span, 44 of the 53 wounded victims arrived at the hospital’s emergency department, whose staff scrambled to accommodate the sudden patient surge.
The medical staff at ORMC had no warning for what was coming. Reports came in of victims being transported by pickup trucks and literally dropped in the hallways of ORMC that night, leaving overwhelmed nurses and physicians on the night shift scrambling to find room for the victims.
The took existing patients out of the trauma ICU into other areas of the hospital, discharged as many patients as they could, and diverted other emergency patients to other hospitals, NPR reported.
The hospital opened six operating rooms (OR), with multiple surgeons working on one patient at a time. Doctors described walking out of one OR and into another to keep operating. In total, at least 28 lifesaving surgeries were performed the very first night, the report added.
In another incident in July 2012, the Denver suburb of Aurora, Colorado experienced a mass shooting at the Aurora Century 16 Movie Theater. That night, a gunman, James Holmes, entered a packed midnight showing of the newest Batman movie with the intent to kill as many people as possible. In the end, Holmes killed 12 people and injured 58, and tested the response of emergency services throughout the Denver area.
Police and fire services responded almost immediately after the first 911 call at 12:38 a.m. and found a nightmare scene of hundreds of wounded people running out of the theater. The combination of crowds of panicked people, a scene that was not immediately declared safe, and a parking lot full of police and fire vehicles parked in roadways was blamed for a slow response of ambulances to the scene—almost 25 minutes after the first call, ambulances still hadn’t reached the most mortally wounded of the victims, according to some reports.
Police commanders on scene who were stuck attending to patients with life-threatening gunshot wounds made a split-second decision that, while going against department protocol, was credited with saving many lives. Instead of waiting for ambulances to arrive, patients were packed into the back seats of police vehicles and rushed to area hospitals.
The problem was that the hospitals didn’t know what was about to hit them. Staff members at the University of Colorado Hospital (UCH) were attending to a full emergency room and a nearly full waiting room unaware of what had taken place. Just after 1 a.m., a request for bed counts went out over the EMSystem, an emergency notification system that automatically pages several members of the UCH staff as an all-hands warning. Minutes later, the first patients from the shooting, a mother and her four-month-old child, arrived at the hospital by private vehicle. Within about five minutes later, police officers began bringing more victims to the hospital for treatment. Within about 15 minutes, nine Aurora Police Department patrol cars transported up to 27 victims to the ER. In the end, UCH treated patients brought in by private vehicle and patrol cars, three victims by ambulance and another that ran from the theater to the hospital.
Thankfully, a mass shooting has not occurred inside the walls of a hospital, but many healthcare security experts say it’s only a matter of time, and while accreditation agencies such as The Joint Commission do require periodic drills, hospitals still aren’t prepared for dealing with an active shooter inside the facility.
Steven MacArthur, senior consultant and safety expert for The Greeley Company in Danvers, Massachusetts, says the Orlando tragedy was more than a wake-up call for hospitals: it was also a realization of the nightmare scenarios that can occur.
“You can have an MCI for a number of reasons—motor vehicle accidents, fires, weather events, etcetera,” says MacArthur. “The biggest weakness for a lot of hospitals is that exercise scenarios tend to focus on hospitals merely as a receiving station when they can actually also be ground zero for an event.”
While healthcare facilities still are relatively safe from the threat, the reality is that violent episodes involving guns and other weapons are on the rise. And guess what? You and your staff are expected to deal with it.
“Only in the last two years are hospitals talking about (active shooters),” says David Callaway, MD, FACEP, director of operational and disaster medicine at Carolinas Medical Center in Charlotte, North Carolina. Callaway’s hospital is one of many across the U.S. who are looking at ways they can decrease the threats presented by armed intruders, while keeping the overall environment of the facility calm and welcoming—and the staff unarmed. “We are in an environment where underlying violence is considered acceptable. We are expected not only to survive, but turn right around, respond, and treat casualties.”
So what do you do to prepare? Experts say the best thing to do is to have a well-written policy in place, starting with a zero-tolerance approach to violence, and make lots of signs making sure that visitors to your facility know it.
Next, make training a priority. More often than not, healthcare workers complain that they don’t feel they are well-trained to respond to a violent attack. At the very least, hospital staff need to learn how to recognize and then de-escalate a potentially violent situation, and what to do in the event of an active shooter situation.
Also, harden your facility defenses. One of the best ways to prevent weapons from getting into a hospital is to control the ways they can enter a facility. Many hospitals, however, are still reluctant to install metal detectors and to arm their security forces for fear of creating a threatening environment.
Lastly, plan to stay open. Some hospitals are working together with law enforcement to contain potential problems. One such plan, says Callaway, involves clearing and neutralizing a section of the hospital—the ER, for example—and turning it into a “command center,” where law enforcement and other agencies would operate to further isolate and stop any attack.
John Palmer is a contributing writer to Patient Safety & Quality Healthcare.