Imagining the unimaginable: Preparing for mass casualty

The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission require healthcare facilities to have policies and protocols in place for emergency situations and to hold regular practice drills. With natural disasters like hurricanes, floods, or fires, often there is at least some warning—some amount of time to prepare—before normal operations are disrupted. But what about a mass casualty event that demands urgent care for multiple patients all at once?

Healthcare leaders who have treated multiple victims of horrific violence shared their stories at the 2018 OR Manager Conference. In each case, hospital location and availability of OR staff tipped the scale toward more positive outcomes, but there were also many challenges. It may be hard to imagine something like this happening in your community, but the lessons learned from these three incidents are worth considering.

On April 15, 2013, Wilton Levine, MD, had just returned home from Massachusetts General Hospital (MGH) after taking call the previous night when his pager alerted him to call the OR desk. Around that same time, a Boston Emergency Medical System (EMS) radio announcement informed all area hospitals that a bomb had detonated near the finish line of the Boston Marathon.

“I went on the Internet and found a live stream of the finish line,” Dr Levine told conference attendees. “I struggled to validate if what I was looking at was real because it was so unimaginable.”

Dr Levine is medical director, perioperative services, and medical director, department of medicine procedural areas, at MGH. He returned to the hospital, where patients were admitted within minutes of the disaster. Although cell phones were down, text messages and updates via Twitter and Facebook prompted several other staff members to come to the hospital.

MGH is one of several Level 1 trauma centers close to the bombing site, and Dr Levine credits Boston EMS with distributing patients equitably to the various facilities. “Each hospital received an almost identical number of patients. That made a huge difference in the ability to provide care,” Dr Levine says.

The bombs had gone off shortly before 3 pm, which coincided with a shift change at the hospital. Three people were killed, and nearly 300 had injuries ranging from fractures, blood loss, shrapnel, and lacerations to traumatic amputations. MGH admitted 12 patients and treated 39.

Wilton Levine, MD

A timeline of the days that followed looks like this:

April 16: multiple staff debriefings and patients returning for more surgery
April 17: a visit from Massachusetts Governor Patrick
April 18: a visit from President Obama, Mrs Obama, and government officials in a 30-car motorcade
April 19: shelter in place.

Patients injured in the bombing needed multiple operations, Dr Levine says. “On Thursday, April 18, President Obama visited to meet with many of the patients, some of whom were scheduled for surgery. We altered our surgical schedule to allow patients to meet with the President.”

With the shooters still at large, on Friday morning, April 19, all residents of Boston and adjacent communities were told to shelter in place, and public transportation was shut down. MGH activated its Code Disaster.

“We had 60 first case patients and families awaiting surgery, and we had no staff,” Dr Levine says. “I drove into work and was passed by multiple SWAT vehicles going in both directions on the highway.”

Friday was the most challenging day, Dr Levine notes. “The shelter in place forced our night staff to remain at the hospital and prevented many of our regular day staff from arriving, and once at the hospital, no one was allowed to leave,” he says. “Staff from overnight needed sleep accommodations. Food service was limited, and staff were huddled in lounges not designed for the number of people present.”

Throughout much of that day, he adds, staff were online watching news, or using Twitter and other social media, which made it hard for the hospital to manage information dissemination.

The situation raised questions about where staff could sleep, how and when they would be paid or reimbursed for expenses, and when they would return to normal operations—and what “normal” now meant.

“Normal operations really didn’t resume until the following week, yet while operations were technically back to normal, our staff were certainly not back to normal, and the memory and impact will remain forever,” Dr Levine says.

Proximity to the mass shooting at the Pulse nightclub and pre-event drills were major factors in handling the influx patients who began arriving at Orlando Regional Medical Center (ORMC) at 2:10 am on June 12, 2016.

“Pulse is about three blocks from ORMC,” says Sherry Buxton, MBA, RN, NEA-BC, chief surgical services officer at ORMC. “There were about 300 people attending Latin Night. A lone gunman entered and fired about 200 rounds into the crowd.”

ORMC was notified of an active shooter situation at 2 am, and the first victim soon arrived at the hospital. Within the next 42 minutes, she says, the hospital received 38 victims. Nine victims were deceased, but everyone who arrived at the hospital alive was treated and survived.

Buxton, who was notified at home, contacted other staff while traveling to the hospital. Word spread quickly among trauma surgeons, who joined their colleagues to help. In addition, call teams from Winnie Palmer Hospital and Arnold Palmer Hospital for Children came to help. Staff normally scheduled to arrive around 6:30 am were called in early.

The first patient went to the OR around 2:30 am, and within the first 60 minutes, ORMC had four ORs running, Buxton says. Two more rooms were running within the next 60 minutes.

As operations chief of the hospital’s incident command system (HICS), Buxton turned her attention to working with law enforcement officers who were blocking roads and making it hard for staff to get to the hospital. An additional complication was that gunfire was reported in the emergency department around 3:25 am, she says. “For about half an hour, staff had to shelter in place and keep caring for the victims, not knowing if there was a shooter on site,” she says. It was a false alarm, but the presence of heavily armed police officers and the threat of danger only increased tensions.

By 7:30 am, all patients had been transferred from the emergency department (ED) to the OR, ICU, or regular floors. A total of 29 procedures were performed within 24 hours, and by 9:30 am, OR staff began working on the elective cases that had been scheduled for that day.

That sounds remarkably straightforward, but at the same time, hundreds of family members arrived in search of their loved ones, Buxton says. Some patients lacked identification, so families were asked to send pictures, which led to receipt of almost 300 emails.

About 10:30 am, Buxton says, the hospital met with city and county officials, law enforcement, and the Federal Bureau of Investigation, after which press conferences began. “The hospital was in a state of chaos with all these extra people plus the families,” she says.

Later that day, hospital leaders met with several hundred family and friends, providing a list of all identified victims.

A total of 54 procedures were performed on Pulse victims within a week after the incident, and to date more than 80 procedures have been performed on those 35 patients, she says.

“We feel very fortunate that every patient who came and survived is doing well today,” she adds.

About 3 months before the massacre of 58 people at the Route 91 Harvest Festival in Las Vegas, ORMC staff had visited the University Medical Center there to help educate them about preparing for a mass casualty event. Who knew that training would be put into practice so soon afterward?

University Medical Center (UMC) is a 541-bed academic center with about 1,100 physicians and 1,100 RNs, and it is the only Level 1 trauma center in Nevada, says Janet David Lustina, MBA, BSN, BAP, RN, director of perioperative services.

The first bullets were fired at a security guard at 9:49 pm on October 1, 2017, through the door of a guest room at the Mandalay Bay, and multiple rounds were fired from the window of that room into the festival crowd between 10:05 and 10:15 pm, she says. Minutes later, UMC was notified of the shooting, and the trauma plan was activated. The first victim arrived at the facility at 10:25 pm.

“By the time I arrived at UMC about 25 minutes later, we had three trauma ORs running,” Lustina says. “We were at the cusp of shift change, so we had additional staff.” Initially, UMC expected to receive as many as 10 patients, so night and day teams stayed, and backup surgeons and anesthesiologists were called. However, a second notification upped the number of patients expected to 50 to 100, so UMC activated its disaster plan.

Within the next 5 minutes, 40 patients arrived along with more than 20 who self-transported to the hospital.

Staff started calling each other and coming in to help, and UMC even got calls from surgeons and anesthesiologists in surrounding states to see if help was needed, Lustina says.

Of the 104 total patients who ultimately arrived, 60 were admitted, and within 24 hours, 20 surgical procedures were completed, Lustina says. Everyone who arrived at UMC alive survived.

Though the sites and number of victims in these three incidents varied, certain elements were similar. The importance of a well-oiled HICS, for example, cannot be overstated. The key roles in the HICS are incident commander, logistics, planning, finance, and operations, Dr Levine says.

At ORMC, Buxton says, the HICS was implemented within the first hour of the first victim’s arrival at the facility. “You walk into that room, you put your vest on, you each have a book, you know what your role is, and you’re connected with all the other sites within our system by screens,” she says, adding that ORMC is also connected with other hospitals in the community through the EMS.

At UMC, Lustina says, not only did they have the advantage of recent disaster management training, they also had many trauma surgeons and surgeons from other specialties who were available, as well as military members trained in the SMART (Sustained Medical and Readiness Trained) program—a partnership with UMC.

“The Joint Commission requires an ‘all hazards approach’ to incident management,” Dr Levine says. “That means working toward hazard prevention while simultaneously preparing for the unexpected emergencies.”

This three-pronged approach includes doing a risk assessment to evaluate the potential hazards, likelihood of their occurrence, and impact on the organization; scalability, ie, the ability to notify staff and determine when to notify them; and structure, which includes a predictable chain of command, clear delineation of staff roles and responsibilities, prioritized response checklists, and use of common terminology to reduce miscommunication.

“Sometimes the incident commander isn’t a hospital staff member,” Dr Levine notes. “For example, in the case of a fire, the fire chief would be the incident commander.”

Other things to anticipate in a disaster, he says, include:

There’s a short interval between notification and arrival of patients.
Early information will be inaccurate, incomplete, or both.
Patient distribution may be uneven.
Patients will arrive by mechanisms other than EMS.
The ED and hospital will likely be full.
Many response actions have to happen very quickly.
Triage must be brief.
Chaos and disorganization are inevitable, but must be managed as quickly as possible.
Practice is essential.

The large influx of friends and families at ORMC immediately after the Pulse shooting overwhelmed hospital staff, Buxton says. “People didn’t know if their child was alive or dead, or how long it would be before they had information. We didn’t bring in counselors from the outside, and we were outside our skill set.”

Hospital clergy were helpful, but Buxton says it would be good to have a way to mobilize communities and have psychological counseling readily available.

Furthermore, she notes, 30% of respondents in mass casualty incidents meet the criteria for post-traumatic stress disorder at 3 months and at 7 months after an incident, and some also develop major depression.

“Within the first 10 days after the incident, more than 1,500 team members participated in counseling. We offered counseling again at 6 months and at 1 year. If you’re involved in this kind of thing, you might need help, too,” Buxton says.

UMC also had a large influx of victims’ family members and friends, and, like ORMC, involved staff in helping to identify patients. UMC’s Social Services, Trauma Intervention Program, and chaplains played key roles in assisting and supporting visitors who lost family members, Lustina says.

Many team members voluntarily came in to help, and many served in roles outside of their traditional areas of responsibility. In addition, ORMC’s chief executive officer contacted UMC administration within hours of the shooting to provide support.

“Our chief of medical staff got down on one knee and prayed with a husband who was a newlywed. His wife was hit in the back of the head,” Lustina recalls. “We’re in such a rush to help, but it’s important to take a minute to help the family member who is just as much a victim as the family member who is lying helpless.”

Like ORMC and MGH, Lustina says her facility received plenty of media coverage and had to protect patient privacy while also keeping the public informed, with some physicians giving 4 am live interviews to provide timely updates.

In addition, UMC hosted President Trump and Mrs Trump just 3 days after the shooting, which increased the challenge of caring for patients because of the security restrictions imposed by the Secret Service.

The outpouring of community support included donations of food, water, and blood, and many events have been held to honor the victims of this tragedy.

To celebrate the team’s work, Lustina says, UMC hosted a “UMC Strong” event. In addition, UMC has trained thousands of community members to help save lives through its Stop the Bleed campaign.

“No matter how prepared you believe you are for a disaster, there will always be a situation where you realize that you are not as prepared as you thought you were,” Lustina says. “You should never be comfortable or satisfied with your disaster plan because comfort and satisfaction breed complacency.”

Lustina advises OR leaders to continuously challenge themselves and to practice their disaster plans—even by just doing a tabletop drill.

She also notes the importance of everyone involved: “What an EVS [environmental services] team member brings to the disaster plan is just as important as what the clinician brings.”

At UMC, preparation such as tabletop drills continue to take place, and they offer a class: Disaster Management & Emergency Preparedness: Understanding the Distinctive Principles of Mass Medical Care to Ensure the Success of Our Disaster Medical Response. “Moving forward, the mantra is ‘Prepare, Prepare, and Prepare,’” she says.

Dr Levine also stresses the need to prepare—before a disaster occurs. “Just like the ruptured ectopic pregnancy case, we must have a plan, know who we will call, and what levers we can pull. We must understand our backup systems for staffing, instruments, and an operating room,” he says. “We must do tabletop exercises, drills, and full-scale simulations. We must consider staffing, transport and communication. If we imagine the unthinkable, we can be prepared. We must be ready.” ✥

Reference
Buxton S, David-Lustina J, Levine W. Does your disaster recovery plan pass the test of real-life catastrophe? OR Manager Conference. 2018.