Wednesday, November 4, 2020

INTEGRATION OF RESILIENCE / MINDFULNESS TRAINING INTO A DEPARTMENT OF SURGERY: Interview with Carter LeBares, MD Director UCSF Aging, Metabolism and Emotion research Center


INTEGRATION OF RESILIENCE / MINDFULNESS TRAINING INTO A DEPARTMENT OF SURGERY: Interview with Carter LeBares, MD Director UCSF Aging, Metabolism and Emotion research Center.

Historically, surgeons deemed themselves highly resilient and resistant to the effects of stress. Over the past decade, it has steadily been recognized that surgeons are very susceptible to the effects of fatigue including burnout. Fortunately, I have had the pleasure of discussing this concern with several surgeons who are experts in the field of burnout, resiliency and mindfulness.

Following our collaborative efforts during the 2017 ACS panel, Crisis Management in the Operating Room, Dr. Sharmila Dissanaike, MD* (Chair Dept Surgery at TTUHSC), met with me to discuss her work in mindfulness training and its importance in developing resilience to burnout. She explained to me that she had positive experiences with teaching mindfulness and helping trainees develop more secure emotional intelligence.

After a Duke University Feagin Leadership Conference, I met with LTG (Ret) Eric B. Schoomaker, MD** (Surgeon General of the US Army 2007 to 2011) to discuss his thoughts about resiliency and the benefits of mindfulness training during his tenure in his Army leadership positions. During that moment he revealed that he developed the skills of mindfulness towards the conclusion of his US Military leadership role. He said, in retrospect he felt that if he had mastered this early on, he would potentially have felt less stress during the many challenges he faced.

Previously, Deanna Chaukos (Harvard) discussed in their paper, Risk and resilience factors associated with resident burnout, that 33% of first year residents experience burnout and of that group, they exhibited lower levels of mindfulness and coping skills and higher levels of depression symptoms, fatigue, worry, and stress.***

Fortney noted that in primary care physicians even brief mindfulness training was associated with prolonged improvements in burnout, depression, anxiety, and stress in physicians.****

During the 2020 ACS Clinical congress, Dr. Carter C Lebares, MD ***** (Director Center for Aging, Metabolism and Emotion Research, Dept Surgery University of California, San Francisco, CA.) participated on a panel discussion on Surgeon Well-being. Her topic, “Mindfulness for Surgeons: promoting evidence d-based practices through culture change”, was an eye-opener for me!

Dr. LeBares previously forwarded me a paper her team wrote in 2018 (Journal American College of Surgeont). In their paper, Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience, their group assessed burnout and several psychological characteristics that can contribute to burnout vulnerability or resilience in surgical residents. They concluded that dispositional mindfulness was associated with lower risk of burnout, stress, anxiety, suicidal ideation, and depression. We both meant to get together for us to discuss her mindfulness research but unfortunately we forgot.

Since then Dr. Lebares recently shared with me several concepts her group has been working on. One interesting area is the use of Enhanced Stress-Resilience Training to reduce generalized anxiety among surgery trainees to reduce burnout, depression and potential for suicide.

Enhanced Stress-Resilience Training (ESRT), teaches surgeons mindfulness and affective regulation skills.

In another recent paper “The efficacy of mindfulness based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized trial (Labares C et al, JAMAOPEN access 2019:2(5):e194108) Dr. Labares described resilience as “a means of adaptive coping that changes perceived stress through the development of cognitive habits. Mindfulness based interventions have been shown to enhance resilience and approve affect, executive function and performance in the military, police, and athletes. Mindfulness meditation training involves the cultivation of key cognitive skills, including the moment to moment awareness of thoughts, emotions and sensations, and the conscious awareness of cognitive processes.” In this study her group has been utilizing a modified mindfulness-based stress reduction program (including classes and home practice). Their team examined the effects of mindfulness training on subject MRI’s when the subjects viewed negative images. Subjects who participated in MMBSR had a higher activation in the medial frontal gyrus, superior frontal gyrus and precuneus/posterior cingulate cortex signifying the act of emotional regulation.



Dr. LeBares:

Mindfulness is a set of cognitive skills that one has inherently or trained in to allow one to experience stressful events in a less reactive way.

Three skills come to play during mindfulness:

1.      Awareness training- this is the moment to moment clear perception of one’s thoughts and emotions.

2.      Emotional regulation- aka affective regulation- not getting psyched out- when we are upset/scared but have the ability to not immediately react.

3.      Metacognition-aka perspective taking- the consciousness of recognizing how you feel and how to not react to those emotions. Surgeons have all experienced stress events/crises- we have an inherent manner to remain calm and take control.




Dr. LeBares:

ENHANCED STRESS RESILIENCE TRAINING (ESRT) is a formal mindfulness-based stress resilience training. The theory is that this can modify the hypothalamic pituitary adrenal axis.

1.      SURGERY ORIENTED: The whole purpose of ESRT is to capitalize on excellent research on mindfulness used by high stress high performance individuals (ie Army and Marines- comprehensive soldier fitness- resilient warrior training). However, the problem with surgery residency is the minimal time to add in this training. We had to figure out how to integrate this proven training into our limited hours. We trimmed the training down to a more reasonable process that can be effective in the limited time.  Everything is geared to surgery. We use relative scenarios such as ‘Where I used this in my OR, or my personal life”. We focus on real examples and reinforcement. We really try to take advantage of mindful walking- Learning to take those minutes to take advantage of clearing your mind before you go to work. Learning how one can manage the interruptions in life more effectively and break up the stress that we face.

2.      MODULAR TRAINING: must be taught with fidelity.  We use the anatomical context ie starting with the skeleton, then muscles and then skin. You can suit this to different situations. This process allows for modification. The skin is the video, and audio references.

Each training site takes this format and then personalizes it to their institutions.

One Instructor has taught police force and military specialists.

For this to work, you need matching personalities.



Dr. LeBares:

Most of the course will be available remotely starting in April. We have trained Surgeons and ED MDs in military and academic institutions.

Institutions can use their instructors and teach their people. Its best to do this in small groups. Then we then identify someone locally as local instructor who is then observed.

We are currently working with Lorrie Langdale at the University of Washington and Pierre F. Saldinger, MD New York-Presbyterian Hospital


Dr. LeBares:

Best way would be to take the course. It takes time! And you must continue to practice and learn.


Dr. LeBares:

At first it is very effortful, but after 6 months it is commented that they are surprised about their subconscious use of these skills. The more you practice the more it is first nature.


Dr. LeBares:

·         Activation of ventrolateral prefrontal cortex (which includes the inferior frontal gyrus) is associated with reinterpretation of the affective stimuli to alter emotional impact. Our study proves that these images are provocative regardless who the person is. Provocation was seen in both intervention and control.

·         Activation of the Dorsolateral prefrontal cortex (which includes the middle and superior frontal gurus) is associated with the functioning of the executive control hub of higher order cognition. This is the area of filtering and responding to stimuli.

·         The precuneus (which is within the posterior Cingular’s cortex) is associated with mental imagery/ Interoception, Visio spatial motor skills/ bimanual skills and self-awareness/self-reference. It is the seat in the brain for our inner awareness. It allows you to comprehend “how might I solve this problem”.

Both areas are activated during mindfulness stress reduction. 

When ESRT trained residents are shown these images, they are able to recruit these areas of the brain to engage into problem solving.

Pernkopf Anatomy: Atlas of Topographic and Applied Human Anatomy : Head and Neck (Pernkopf Anatomy, Vol 1) (English and German Edition) (German) Subsequent Edition by Werner Platzer (Editor), Harry Monsen (Translator); Urban & Schwarzenberg; Subsequent edition (August 1, 1989)


Dr. LeBares:

Only looking at State Anxiety as trait anxiety would require subgroups which would take a very long period to accrue. It is likely most effective in state anxiety (as opposed to those who are under constant stress/anxiety).

In the UK, mindfulness training is the gold standard for mental illness (they call it MBCT training).


Dr. LeBares:

We have shown in the recent Annals Surgery article there is a diminished depersonalization by stress. In a single cohort study (no control) there was a reduction in alcohol intake, depression, and burnout in their first year. The stress of resident training is worse in the first 8 months. In their cohort, those with the training did better but without continued training the effects were not sustained. We learned that you need to practice continued mindfulness.

The question is how? Do you have to practice daily?

Is this feasible in isolation, or is it better with a group or with a guide or moment to moment during the day? Our advice is that participants practice daily up to 15 minutes.

Informal mediation seems to be the best connective pathway.


Dr. LeBares:

Steve Kohl, a molecular geneticist, assessed a collection of genetic measures for transcription levels of inflammatory proteins. He assessed the magnitude which these effector proteins are affected. Epigenetics is a real time activity. Regardless of origin of stress, all of these stressors activate the same pattern of gene transcriptions for fight or flight syndrome, inflammatory pathway and antiviral pathways. This is part of the hypothesis as to why people who are chronically stressed are sicker, that is they have worse medical comorbidities. This molecular genetic profile fits the effects of these disease states.

This team looked at these parameters in the control group who had gene pattern dysregulation alongside of decreases in antiviral activity. This magnitude of protein increase can be found in other types of stress groups.

We found that ESRT decreased that level by 50%. Your gene expression is not subjective- it is entirely objective.

Kenneth A. Lipshy


* Dr. Sharmila Dissanaike is the Professor and the Peter C. Canizaro Chair of Surgery at TTUHSC. She is the former Medical Director of the John A. Griswold Level 1 Trauma Center and the Assistant Director of the Timothy J. Harnar Burn Center at UMC. She is active in clinical surgery, with a focus on critical care, trauma and burns.
**LTG (Ret) Eric B. Schoomaker Surgeon General of The United States Army 2007 to 2011 (prior to that he was the Commander of the N. Atlantic Regional Medical Command and Walter Reed Army MC).
***Chaukos D, Chad-Friedman E, Mehta DH, et al. Risk and resilience factors associated with resident burnout. Acad Psy- chiatry 2017;41:189-194.
Deanna Chaukos
****Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med. 2013;11:412–420.
*****Carter Lebares- Assistant Professor of Surgery Division of General Surgery Director, UCSF Center for Mindfulness in Surgery
Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW,  Epel ES. Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience. J Am Coll Surg 2018;226:80-90.
The effect of mindfulness-based cognitive skills training on anxiety among general surgery residents during covid-19 Caitlin R Collins MD, MPH, Micaela L Rosser MD, Anya L Greenberg MBA, Carter C Lebares MD, University of California, San Francisco
A Feasibility trial of formal mindfulness based stress resilience training among surgery interns JAMA 2018/sur/08292018
Key factors for implementing mindfulness based burnout interventions in surgery Am J Surg 2019 in Press
Enhanced stress resilience training in surgeons: iterative adaptation and biopsychosocial effects in 2 small randomized trials. Annals Surgery In press 2020
Efficacy of mindfulness based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized clinical trial. JAMA 2019/05 24 2019.
Enhanced Stress Resilience Training in Surgeons: Iterative Adaptation and Biopsychosocial Effects in 2 Small Randomized Trials.
Annals of surgery
Lebares CC, Coaston TN, Delucchi KL, Guvva EV, Shen WT, Staffaroni AM, Kramer JH, Epel ES, Hecht FM, Ascher NL, Harris HW, Cole SW
Key factors for implementing mindfulness-based burnout interventions in surgery.
American journal of surgery
Lebares CC, Guvva EV, Desai A, Herschberger A, Ascher NL, Harris HW, O'Sullivan P
Efficacy of Mindfulness-Based Cognitive Training in Surgery: Additional Analysis of the Mindful Surgeon Pilot Randomized Clinical Trial.
JAMA network open
Lebares CC, Guvva EV, Olaru M, Sugrue LP, Staffaroni AM, Delucchi KL, Kramer JH, Ascher NL, Harris HW
Feasibility of Formal Mindfulness-Based Stress-Resilience Training Among Surgery Interns: A Randomized Clinical Trial.
JAMA surgery
Lebares CC, Hershberger AO, Guvva EV, Desai A, Mitchell J, Shen W, Reilly LM, Delucchi KL, O'Sullivan PS, Ascher NL, Harris HW
Mindful Surgeon: A Pilot Feasibility and Efficacy Trial of Mindfulness-Based Stress Resilience Training in Surgery.
Burnout and gender in surgical training: A call to re-evaluate coping and dysfunction.
American journal of surgery
Lebares CC, Braun HJ, Guvva EV, Epel ES, Hecht FM
Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience.
Journal of the American College of Surgeons
Lebares CC, Guvva EV, Ascher NL, O'Sullivan PS, Harris HW, Epel ES
Burnout in US Surgery Residents: Do Year of Training and Mindfulness Matter?.


Friday, September 11, 2020


I recently listened to a talk by Dana A. Telem, MD, MPH* titled FAILING FORWARD.
In her talk, Dr. Telem discussed several aspects of failure during her career that resonated with me including:
·         Over confidence compounded by internal focus (a “I can do everything” without help), and a fixed mindset.
She moved on to state that she learned some valuable lessons thru her failures including:
·         Failures will happen to everyone and these failures make you better.
·         Leave your insecurities at the door and have trust in a mentorship and be a mentor. Her mentorship with Justin Dimick (see prior interview below), was invaluable, as he  fostered her harvesting her potential, created a culture of radical candor and always “had her back”.
Her fondness for her mentor raised some questions from me. It is known that “effective mentoring is critical to the success of early-stage investigators at academic health centers (AHCs). Strong mentorship has been linked to enhanced mentee productivity, self-efficacy, and career satisfaction.” I was curious how she has grown thru a successful mentorship relationship.
Dr. Telem:
1.      You indicated that your strong personality tended to hamper your development along the way. Most of us never understand that a strong independent personality can be counterproductive, until late in life. This is a valuable lesson. When did you first realize this about yourself? How did you gain the emotional intelligence to realize that? How do you teach that to junior faculty or trainees?
I am solution oriented and felt I did not need to bother others. That may help in a crisis but it did not work when trying to work with others. Asking for help does not make you weak- it is good to acknowledge you need help. It is hard for surgeons. It may be a fear that we will look weak if we are vulnerable, its uncomfortable. You feel you need to prove yourself before you can be vulnerable.”
2.      Technical skills tend to be the main focus of young trainees and attendings. I have discussed the importance of non-technical skills several times in the past with Steve Yule and Rhona Flin. Given the clinical work (and research work) they are responsible for,  it seems like a considerable challenge to engage trainees and junior faculty who feel that their focus should be on clinical medicine. How do you engage residents / trainees / young faculty on non-technical skills?
Our newer trainees feel charged to seek help, call out, unlike those that came before. Millennials are good at this.
It’s the culture that sets up this path. A culture of psychological safety builds this ability to learn Non-technical skills and to change. It has to start at the top leadership. I took over as the General Surgery Chief, but I have a Department chair that supports people no matter what the need. That tone and culture fosters this. Then it is not difficult to solicit that skillset. It is supportive and not punitive.
Trust is the key to this foundation. If you have trust it is not difficult.”

3.      Those of us who have a “I can do it on my own” mentality do not take to mentorship too easily.  how did that relationship develop? Was this arranged or fortuitous?  How did you ease into that relationship?
in residency I felt I had to do everything on my own. As a junior faculty, for clinical help it was a standard practice. But for administrative needs I just did not know what I needed and sought further training instead of a mentor. I earned multiple degrees trying to better myself. Coming to U. Michigan revealed the obvious- that you DO need help. Research was very intimidating for me when I came to U. Michigan. I was so worried about my interpretation of my research but Justin allowed me to realize that a mistake is fine and not a big thing. His blunt critique to make you better instills trust. This was the first time I really got that.”
4.      I recently picked up on this article in non-medical literature: “A mentor isn't always someone who has been there, done that before, who draws on his or her own experience to guide the younger less experienced person, but in some cases, a professional trained in coaching, who is guiding and advising people who are pursuing a wide range of goals and careers. In recent years, especially in the management and human resources literature, there are consultants whose job is to advise members of the business community on the mysteries of mentoring.” **
a.       What is your focus when it comes to trainees or junior faculty regarding mentorship? Is waiting for the trainee to request a mentorship or is there a process to proactively establishing that relationship?
If this is a scheduled process how is that conducted?
“Michigan promise- promise that we will develop all new faculty. Each new faculty joins a LAUNCH TEAM. There is a team of mentors for all research. These include sounding boards. There are advisors to support those who feel they may be in a rut. They are now tracking people in their internship and identifying those with promise.
Forced mentorship does not work. This system allows for pairing until a successful relationship has started. This just started so data is coming in for analysis. This will help with the different types of residents but mostly those that are just not sure where they want to go or to be- help them identify where they want to be.”
b.      What is the secret of a successful mentorship?
“Mentorship and sponsorship are different things. Mentorship can be impactful and change the course of your career and others who mentor from afar. Success comes when the mentor allows you to build yourself but not recreate them. Trust is key. Success comes from who are there whether you are successful or not. The mentor should let you be who you were meant to be.”
Listen to Julie Ann Sosa, M.D., M.A., FACS  UCSF Department of Surgery- transformational growth.
c.       Have you equated successful mentorship with increased productivity? Reduced burnout/ less stress? Do the residents who have successful mentorships have a more successful process in finding an ideal job or fellowship?
“Yes and yes! I had a lack of focus on priorities. If you don’t have focus, you don’t know what you want. Hard to be intentional. Hard for you to know what to look for. I decided I needed more training, more fellowships. I wrote a lot of papers and felt satisfied. But in retrospect I was not satisfied that these had any impact. It was not until I had a mentor that I trusted that if felt I could write and make an impact. I learned that the best writers were mentored by the best writers!”.
d.      Can you teach this old dog new tricks? Is it too late (at 58 years old) for me to find a mentor?
“Its never too late! learn from your peers!! Peer mentors are the best! The young trainees are so smart and can teach. .
**Mentoring: What Is It? How Do We Do It and How Do We Get More Of It?[8/3/2020 9:14:53 AM]
Kenneth A. Lipshy
Dana A Telem MD, MPH, Department of Surgery University of Michigan, Vice Chair Quality and patient safety, division chief minimally invasive surgery.
INTERVIEW: INNOVATIVE STRATEGIES FOR IMPROVING SURGICAL PERFORMANCE Justin Dimick, MD, FACS; Chief of the Division of Minimally Invasive Surgery, and Director of the Center for Healthcare Outcomes & Policy at the University of Michigan.
Winston Churchill: “Definition of Success is the ability to move from failure to failure without losing enthusiasm”
“Relationships are as important as the task.” ANON
“in Failure cones strength and a new direction” ANON
“there’s almost nothing to learn from success. Failure’s the best teacher you will ever have” Blue Bloods.
“when something blows up in your face try again, try again, try again and eventually you will be on top” Wernher von Braun. V2 Rocket creator. NASA rocket engineer.
And the contradiction in philosophy, “The human condition actually prevents us from adopting lessons learned” Dr. Emily Mayhew, PhD, London. WWI 100th anniversary recognition Excelsior lecture 2018.

Tuesday, August 15, 2017

Resiliency: "Failure is not a destination!" Words of advice by Coach Mike Krzyzewski at the annual Feagin leadership program - Duke University.

Resiliency: "Failure is not a destination!" Words of advice by Coach Mike Krzyzewski at the annual Feagin leadership program - Duke University.


The 2016 annual Feagin leadership program focus was on Resilience. Coach K reminded us that "Failure is not a destination"! You must learn to survive a failure. These are my thoughts and reflections based on Coach K's talk which truly resonate with all surgeons.

"Why is it that professionals find it so difficult to move past a failure?" He asked. Coach K stated that "The problem with being a 'winner' is that we are always prepared to win and when we fail", we find it difficult to move past that point, recover and move on. But it does not have to be that way. We were reminded that we are leaders because over time we have learned to be resilient. It is in our nature. We need to train ourselves to remember that at our darkest hour, we need to pull through, move forwards (refer to Admiral McRavens commencement address at UT in a prior post of mine), gain knowledge from that failure and find a way to improve for the next time.  When failure occurs, you need to look to the future. It may sound simple now, but this can prove difficult for those who are accustomed to constant success. "We are winners. We are accustomed to winning." We need to think of these experiences as stops on the train route- at some point the train has to stop either as a planned or unplanned event. But it must carry on after each stop and move on.

     Unfortunately when we encounter failure, we tend to focus inwards and become silent when, (as Tom Kolditz teaches us) we need to be outwardly focused. To be resilient, you cannot survive alone. "A really good leader doesn't go it alone". To move forwards you need to work as a team. This does not begin at the moment you encounter failure but far ahead of that failure. Teamwork comes from training together to make improvements. Through this your team develops trust. When your team trusts you, you can survive anything.


     To be a good leader in basketball, you need to be willing to run a "motion" offense. In a motion offense, you are less structured but adapt to the defense. A resilient leader in any profession recognizes when the situation is declining and adjusts his offense to suit. They make changes based on their read of the situation before things collapse. You make "reads" based on your opponent and your team. You don't wait till everything "goes into the pot. A good leader rescues his team or allows his team to rescue themselves". "The best teams have leaders on the court who can make those decisions".

Coach K, explained that to become resilient you need four characteristics: an adaptive attitude, the belief you will overcome adversity, the acceptance that from that failure you can make changes, and the ability to move forwards.

1.    Attitude- we need a great attitude. After the failure and you have taken a moment to release your exasperation and frustration you need to be sure everyone has a great attitude. Without that positive attitude you will not recover.

2.    Belief-  before you encounter failure you need to establish belief amongst your team. belief in what you and your group can do. "Belief does not go out the window when things go bad. Belief has to be heightened when things go bad".

3.    Make changes- after a failure something has to change. You can't go back to the same way of doing things and then wonder why you failed again.

4.    Go forward- finally, after you have encountered a failure, you need a plan to move forwards. You can use the failure as a lesson but you cannot allow it to stop your train. The train needs to keep moving forwards.

Thanks Coach K for inspiring us today.

Kenneth Lipshy, MD, FACS

Saturday, December 3, 2016


        At the 2016 ACS Clinical Congress, the Committee on Trauma sponsored a panel discussion: “The Committee on Trauma Perspective on Firearm Injury and Prevention”. During the panel, Joseph A. Ibrahim*, MD FACS discussed “Incorporating Lessons Learned - Pulse Club Massacre”.  Immediately following the presentation, I approached Dr. Ibrahim to see if he would speak to me regarding his impression of the overall response to the situation and his personal response.

Orlando Florida, Sunday, June 12, 2016:

        At 2;15 am Joseph A Ibrahim was at home (having been on call the Friday before and schedule to be back on call that Sunday) when he received the call from his partner and Orlando Regional Medical Center (ORMC) trauma attending on call Chadwick P. Smith MD, FACS that there was a gunman downtown with approximately twenty victims and they needed him to return to the hospital. As he entered the trauma bay he knew immediately that this was “larger than our usual Friday/Saturday night penetrating trauma but the vastness of it all had not hit”

        At 1:57am a gunman entered the Pulse nightclub carrying a Sig Sauer military assault rifle and a Glock pistol, opened fire and within five minutes caused the deadliest mass shooting in US history. By the time Police arrived at 2:07, he had fired 250 rounds into the crowd ultimately killing 49 and wounding 58 victims.

       At 2:00 am ORMC was notified about a mass shooting involving at least twenty victims, three blocks from the medical center. Within 10 minutes, patients began arriving at a rate of one per minute by private vehicles, police cruisers or carried in. Dr. Smith hurried to the trauma bay, accompanied by the general surgery resident team, as the victims began arrive.

        ORMC is a very busy trauma center which cares for over 5000 trauma cases a year. Typically, these are blunt trauma cases or isolated penetrating trauma, but it is not uncommon for several gunshot wounds to be treated in an evening. ORMC was not caught off guard. For the past 20 years, the facility has participated in coordinated trauma training drills with their local EMS teams. They participate annually in their community mass casualty drills. In fact, just three months prior they were engaged with the tri-county active shooter mass casualty drill (Dr. Ibrahim showed us their comprehensive mass-casualty plan that has been refined as a result of these drills). As the morning wore on, it was clear that that preparedness paid off.

         Of the Thirty-eight patients who arrived within the first 42 minutes only nine died. All told 49 victims and one SWAT member arrived at the trauma center that morning. Typically, the facility has a single operating room staffed and ready during the evening. However, on this night, an hour after the patients began to pour in, four operating rooms were functional and an hour later two more were in operation. Twenty-nine operations were performed in the first 24 hours and a total of 54 total by the end of the week (78 total operations resulted from this disaster). All told, 441 units of blood were transfused into the Pulse nightclub victims. [for details see: ].

Dr. Ibrahim explained a few keys to success of the team:

1.    You teams must engage in Rapid PROPER triage and assessment of victims.

2.    Your team leaders must call in reinforcements within 10-20 minutes! You cannot hesitate or you will likely lose your window of opportunity.

3.    You must maintain flexibility and assume the worst while continuing to work.

a.    Due to the uncertainty of the existence of a shooter in the facility, the facility went into “Code Silver” lockdown alert but continued to appropriately care for their patients.

b.    They normally had a single OR after hours but had to quickly staff, equip and supply 5 extra rooms within two hours.

c.     The Hospital System focused on centralizing the hospital staff where the patients arrived likely avoiding failure to rescue. Initially they considered diverting the patients to other hospitals in the system but the administration quickly saw the sense in sending outlying hospital staff to the Level 1 Trauma center and keep the patients there instead. The majority of the trauma occurred within an extremely short time period as the shooting was rapidly over and the origin just a few blocks away. Having a backup system already in existence meant that the slower response from outside personnel was not a factor and this clearly contributed to the survival rate (only 9 patients died at the trauma center).

4.    Accurate charting and patient tracking is a must! If it is rehearsed and run appropriately it should not interfere with patient care and in spite of the massive volume of injuries a system should be established for charting and tracking every patient. Maintaining a master list of victims tracking each patient’s injuries, laboratory data, and radiologic studies allowing follow-up evaluations to assure no patient had missed injuries.

5.    Precise communication response is key especially between the surgeons and anesthesia providers.

He also explained a couple of unforeseen shortfalls of their system that were recognized as the scene unfolded:

1.    Insufficient Family Assistance Program: The large influx of victims accompanied by overwhelming response by family members and friends seemed effective initially as the facility responded with a family assistance center, providing regular updates. The system provided constant communication with families which resulted in identification of virtually every victim in the first twelve hours. Unfortunately, the sheer volume of food, water, clothing, support staff etc was not anticipated as the families poured in.

2.    Unrecognized victims-Counselling needs: The facility disaster plan did not anticipate the post-event counseling needs of patients, families, EMS, Police, hospital staff or the community as a whole in the aftermath of an event of this magnitude. The psychological burden placed on those involved was overwhelming. 1500 hospital staff participated in counseling over the first TEN days. No one was immune. Remember to assign partners to continually assess for late signs of PTSD.

Dr. Ibrahim agreed to talk with me regarding some questions I had following his talk:


In your talk, you described several leadership characters that are important during a crisis:

·         Experience in difficult situations,
·         Great interpersonal skills,
·         Strong when needed but lets others work,
·         Flexible/innovative
·         Decisive.

-Can you expand on these? Can you give examples of where you saw this in action?
-What aspect of your leadership training appeared to help the most?
-Anything in yourself or others surprise you? That is you did not expect you or another to perform as well in that aspect?
-Any leadership character you previously thought you would have excelled at, but believe you fell short?

1. Experience in difficult situations:  As I alluded to true mass triage is something most of us do not have experience with outside of the military.  Determining when enough has been done usually occurs long after we’ve contributed significant time and resources to salvage someone we likely believe will not have return of vitals.  In these situations, you have to have the individual that can recognize when you need to halt potentially futile efforts for the good of the other victims.  Our physician in charge did an excellent job of that on this occasion.  We still performed “heroic measures” on multiple occasions but he was incredible at recognizing when we needed to halt efforts and move on to someone who had a chance.

2. Great interpersonal skills:  This can be summed up by “Great team play”.  Again, we practice with our mock traumas on a regular basis and that fact that we have 4800 traumas a year gives us even more opportunity to work together.  This gives us the opportunity to know each other by name and ask for things specifically in the trauma bay rather than just yelling out into the air “I need a chest tube”.  As my team hears me say often, when you yell to someone to fetch something, someone becomes no one and that delays care.  So by knowing each other by name and asking someone specific for an item, it improves time, efficiency, and overall care.  

3. Strong when needed but let others work.  One of the most difficult skills for us “control freaks”.  Being able to let others do as trained and not micromanage.  There is no time for this anyway. However, the leader(s) must remain objective.  In this particular situation, we needed someone to tell us or others when to stop resuscitations so that we could go on to the next more likely salvageable patient.  Other examples include lifting others up.  Example: I remember calling the OR to say we were coming and the person on the other end asking for time to open the room.  We had to tell them we are coming and you can open the room around us to which they quickly complied.   This also demonstrated flexibility.  We were also flexible in dealing with the possible shooter in the ED by keeping surgeons in the OR and sending patients up rather than each surgeon coming down, evaluating the patient and taking them up individually.  You have to have trust in your team.

4.Our group excelled at flexibility, prompt action, teamwork and coordination.  We have gone over and over the response and honestly cannot find a weak point.  This went better than any drill we’ve performed.  I think we could have thought sooner about going to the paper h&ps and filling those out to have a more complete evaluation on the chart as opposed to what typically happened which was face to face hand off which is something we do with our ICU patients going to the OR every day between ICU and anesthesia.

The extent really didn’t hit until all the initial surgeries were done.  I stayed focused on the job at hand by gathering the troops (residents and extenders) and dividing up tasks:

1)tertiary exams on all the pulse victims to assess for more minor injuries that may have been missed.
2)divided the extenders with residents to round on the patients on the services not involved with the mci
3)discussed with partners rounding plans
4) saw two new consults (appy and incarcerated hernia)


-How was the team response? That is, was communication crisp and clear assuring as succinct a response as possible?
-The time worn adage is “no battle plan survives the first encounter with the enemy” so how extensive / realistic did your team drills appear in retrospect? How well were you prepared? Did you have to scrap anything immediately?
-What aspects do you all now realize need enhancement?
-Your personal lessons learned?
-Facility lessons learned?
-Did the residents step up to the plate?
-When was the decision made to have the trauma surgeons stay in the OR in lieu of going back to the ED to assist? What forced that decision?

     Team response was amazing.  The communication was outstanding but as you allude to this is something we drill as well.  The teams hear me say often “someone becomes no one” .  This means that yelling things out into the air when you need something often goes unheard.  “I need a chest tube!” yelled into the air often goes with no one hearing it.  However, eye contact, direct names, all things we drill much like the WHO checklist in the OR.  I have tried to implement this into the trauma setting but it is a work in progress.  That being said, the deliberate communication practiced in the mock alerts did help significantly.   Our community wide drills are extremely realistic with moulage and transport of patients to the planned areas (OR, icu, floor).  If you would have asked me prior I would have not known how prepared we were.  I knew all we had in place and the drills we do but we never live up to our own expectations in the drill.  We far surpassed how I thought we’d respond when the event occurred.  Not much was scrapped, instead we did add: surgeons stay in OR, OR open around patient, we have 26 OR’s so instead of cleaning a room and waiting, just open another room and have someone else clean the room just used so that if needed, we use all 26 rooms.  We do want to continue to enhance our drills and we have.  We use our sim man regularly and seem to have more involvement with ems.  We want to expand to have PD involvement.   The biggest learning point was delaying with family and how to obtain identification.  Several of our administrators have since developed a program for people to send in pics and or descriptions of loved ones on a list to the facility to allow for quicker identification.  The other learning point with family is having certain necessities, the biggest issue was phone chargers which our patient experience administrator quickly went out and bought a multitude of to provide for families.  You also need medical staff with the families as some experience medical issues during this time of great stress.

      With regards to the residents, they stepped up in a huge way.  We could not have had these results without them and the fellows.  Some were upset that they were either gone or slept through the mci page and came in late but it was a blessing that we didn’t anticipate.  You need enough personnel with the initial surge but you need people to then round and give those there initially a break if possible so the delayed response of some was a gift from God and moving forward, a progressive response would be favored over an all-out surge at the onset.   I think I answered this above but the decision to keep the surgeons in the OR occurred with there was concern for a gunman in the ER at which point, the second wave of surgeons had been called in but could not get into the ED.  Again, another blessing as this worked way better than we could have ever anticipated.

Sincerely, Joseph Ibrahim
I have some follow-up questions for Dr. Ibrahim regarding personal resiliency:
Any lessons on personal resiliency from this? Ie how are you doing? Did you find that specific lifestyle routines or changes allowed you to “survive” this event?

Kenneth A. Lipshy

*Joseph Ibrahim, MD (Trauma Medical Director,  Level I Trauma Center Associate Program Director  Orlando Regional Medical Center, a part of OrlandoHealth