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


Monday, November 28, 2016


       Earlier in 2016, COL Robert B. Lim, MD, U.S. Army, edited a landmark text Surgery during natural disasters, combat, terrorist attacks, and crisis situation. I had the opportunity to chat with Dr. Lim about his text. Having been deployed numerous times into the zone of combat, I believe he can be considered an expert in this area. Several chapters peaked my interest (especially the one on unexplored ordinances), but the chapter written by Seon Jones and Gordon Wisbach on "Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation" interested me most due to the details provided on trauma teamwork in the combat environment. Trauma teamwork is difficult enough under normal circumstances, but just imagine managing a team in remote or hostile environments.

           In their chapter Jones and Wisbach reinforce the need for strict organization and planning. There is no room for error. They reiterate that success starts with Mass Casualty Planning and Rehearsal. After arrival to the operational area the team should discuss and rehearse the casualty plan. Preparation includes memorizing the layout of the trauma area, the facility as well as the outlying areas. Defined team positions and roles are key to avoid confusion and delays. In spite of the appearance of redundancy, prior to each incoming casualty, stating names and roles avoids confusion. Continued repetition focuses the team and reminds the team about potentially forgotten measures (PPE, civil closed loop communication). Team member names should be readily visible on each member to assure communication is clear and avoid distractions. Supplies and equipment need to be in standardized placement close to the immediate resuscitation area to avoid excess noise in asking or searching for supplies.  Each team member has an assigned checklist posted at their work station (detailed summary of those checklists noted in their chapter). The trauma team leader (TTL) should stand in a routine position where they have continued observation of the team (i.e. Foot of bed). One examiner is then on one side of the patient and the other examiner or RN on the other. Anesthesia should be at the head of the bed. Prior to patient arrival, each member needs to confirm their checklist has been reviewed. Team review should remind the team that only the TTL should be providing resuscitation instructions thereby avoiding the confusion that results from too many members instructing the team. A hierarchal structure helps to maintain the TTL's situational awareness. The TTL needs to remember to take a pause for summarization prior to and after critical steps in the resuscitation process- preintubation, post-BP stabilization- to avoid missing crucial details. The authors remind us that in spite of combat casualties occurring in austere environments, following standard clinical practice guidelines (CPG's) is vital- just because you may be remote, standard evidence-based protocols avoid conflict and improve team dynamics. Several other reminders of TTL roles are highlighted in this chapter.

              Finally the authors remind us of three vital team leadership roles- 1. watch for and control team stress and conflict 2. Be cognizant of Bruce Tuckman's revised stages of group development (forming, storming, norming, performing, and adjourning) to assure your team is developing appropriately 3. Morale retention and support from "compassion fatigue" is necessary to survive the arduous often primitive conditions. 

I immediately had a few questions for the authors and when I met up with Gordon Wisbach at the Excelsior meeting in advance of the ACS Clinical congress he agreed to discuss these.

1.      I constantly hear from surgeons that checklists and teamwork principles have no place in emergency or life-threatening situations.  When we discuss following the WHO and checklist principles, frequently heard complaints are: "the patient is dying! following these recommendations simply wastes valuable time and is not necessary".  I hear the complete opposite in your assessment of how to manage a team in life-threatening poorly supplied environments. Have you had success in
promoting these principles in civilian arenas? If yes, how do you convince others that moving fast without direction and rehearsal may slow you down?

Part of the reason for the usual resistance against check lists: Long, detailed, rigid, generic, all-inclusive checklist are arduous to follow and meaningless in some locations.  Checklist for emergency/life-threatening situations/crises should be developed differently than those designed to be implemented in a controlled, mindful setting.  A good analogy is a checklist prior to take off of a plane where you should take your time and focus on not missing key safety measures versus checklist that pilots and crew take during in-flight emergencies where seconds matter.  Even in the second scenario, they run through a checklist efficiently and effectively without error even though most medical personnel would think that it would slow the pilot down and the plane would crash before he even opens up the checklist.  

The reason the emergency checklist works is because they practice and drill the list so that ALL of the important steps are taken in a specific sequence without fail.  This is the principle we are very resistant to apply for major trauma resuscitations.  What we don't realize is that, as medical professionals, we already subscribe to the checklist principle whenever we take ACLS and BLS courses or do ACLS drills.  We practice those drills with the algorithms printed out on cards as cognitive aids, but we know the important first steps of that checklist by heart: 1. Open the airway, 2. Give breaths, 3. If no pulse, start compressions, 4. When the AED or crash cart arrives, check rhythm, 5. Shock or give drugs, etc.

The emergency checklists should be designed considering the frame of mind of someone who is in the emergency situation, traumatic injuries in our case.  After developing the list, it should be drilled and tested.  The actual emergency situation should not be the first time a team or an individual goes through the checklist.  It should be deliberately practiced and drilled.  Also, in this process, you may discover that some steps in your checklist are not appropriate (not practical, not useful, counterproductive, etc.)

In regard to, in your words, convincing others that moving fast without direction and rehearsal may actually be counterproductive, those others should try to remember those times when they just jumped into doing a procedure without all the necessary equipment, supplies, and set up.  They may have been all gowned up and gloved, but the patient was not prepped, yet, the chest tube was not in the room, there were no drapes, no scalpel, no hemostats, no drugs for sedation and the patient is moving too much, etc.  The patient received paralytics, but you didn't get the laryngoscope, didn't check the light was or was not working, now you're bagging him, but the O2 tank is empty, who checked the O2 tank? Ok, now the laryngoscope is here, but you can't see cords, oops we didn't plan for a difficult airway, no fiberoptics, no bougie, no LMA, need a surgical airway, stat? where is the scalpel, where is the crich tube or the 4-0 endotracheal tube, etc.

2.      When you first went into action, what preconceived notions were instantly proven false?

The preconceived notion that only the medical providers were essential personnel is false.  In a resource and personnel scarce environment, everyone is vital to running an ongoing casualty receiving area.  For optimal throughput, all the steps from restocking supplies, preparing the room for a resuscitation, litter bearing, and cleaning to be ready for the next casualty are important steps.  Nothing conveys the importance of these details than actually carrying out these tasks yourself when you can.  It's like pre-flighting your trauma bay/ED/OR like a pilot pre-flights or looks over the aircraft he is about to fly.

3.      When you arrived at a designation, was there anything that totally caught you by surprise?

In retrospect, it is incredibly rare to see the type of multi-dimensional injuries of blast casualties in any civilian setting.  The only similar situations I can recall off the top of my head are the Boston Marathon bombing, the Oklahoma bombing, and may be 9/11.  It would be much simpler in comparison to have straight forward gunshot wounds or blunt trauma from a fall or MVC.  The war time casualties come with the myriad of unique injuries characterized by blast injuries.

4.      Describe the most remote, austere operating environment you faced? Any take homes from that experience?

One room OR with two OR tables in an old Soviet Era hardened structure.  Take home points: Forget about sterility expected in a US hospital OR, the casualties have wounds that likely more contaminated than an un-sterilized instrument in the OR.  Of course, we still followed the surgical principles and used sterile procedures and equipment.  In these austere settings, advanced, expensive, cumbersome medical technology is not as good as your/your team's knowledge and training and you/your team are the patient's best chance of survival.  The other basic necessities are lights, headlights (nothing fancy), electricity, sterilizer, basic general surgery, thoracic, vascular, and orthopedic sets, IV fluids, blood, and transfer facilities.

The overall take home point I would say is to take the time to read the lessons learned from the prior team if you are fortunate enough to have that resource.  There is no pride in delivering sub-optimal care while trying to reinvent the wheel.  Also as important, continue to learn from each experience, record it, and pass on your wisdom to the next team.  And wish them success.

5.      Was there any aspect of team leadership you predetermined you would be adept at but found needed improvement, or a total rehaul?

Coming from a busy trauma center, running a casualty resuscitation was second nature, but what I needed to do more of is team-building and preventing compassion fatigue.

6.      Any leadership aspect you had not considered or discounted that you found you had to learn on the fly?

What would have been useful is de-escalation techniques during confrontations, whether as a third party observer or directly involved.  Deployed individuals are stressed, fatigued, and prone to respond poorly to perceived slights or confrontation.  Leaders should stay vigilant of this tendency in themselves and others and respond with compassion and de-escalate the situation.

7.      When the teams form initially, do the members automatically register this concise preformed process or does the process not always work as well as you wished?

In general, when teams form, they naturally follow the model and do great without any catastrophes.  Viewing the evolution of team formation with this objectivity would help you see the bigger picture, anticipate likely scenarios, and to plan ahead.  In general, being social animals, people do well as a team.  It is only rarely that a member of the team may be maladjusted sociopaths who could sabotage your team.  These individuals should be removed from the team early if possible.  I see no other solution.

8.      How do you quiet the room when the commotion becomes distracting? Paul Lucha told me he just keeps turning his voice decibels quieter and quieter until everyone has calmed down (Paul Lucha, MD, FAC, CAPT, MC, USN, Retired; Department Head, Department  Surgery Navy Medical Center Portsmouth, VA.).

This aspect of commanding the room goes back to practicing drills and getting used to running actual resuscitations so that the team members associate the voice as the Trauma Team Leader.  Likely, there will be more than one TTL; we had several.  In this instance, a quick pre-brief that includes the team member's rolls should also clearly identify who the TTL will be and establish this hierarchy for a given casualty.  During the training, drilling, and coaching of a TTL candidate, they should be taught and reminded to assume the "command voice" which is not necessarily loud, but loud enough for most situations for all to hear and listen.  More importantly, it should be confident, precise, and succinct.  Deeper male voices seem to help, but I have seen many small female surgical residents assume this voice quite effectively, leading difficult resuscitations with authority.

One other technique is to "reboot" the room by reviewing the primary survey and current status of the patient to get everyone on the same wavelength to focus on the most important tasks at hand.

In addition, the other team members in the room should be empowered to practice crowd control - less people in the room equals less extraneous noise.  People talking about other topics besides the casualty or joking around should cease or be excused from the vicinity of the trauma bay.

9.      If a team member attempts to take control but is clearly wrong, how do you redirect them?

If the action is not life-threatening, then it can be discussed afterwards during the debrief and later during peer-review.  It may even be a learning point for all the team members and can be incorporated into didactic training.

If the wrong action will lead to harm for the patient, it must be stopped and corrected immediately.  The interaction and apologies for hurt egos can be discussed afterwards during the debrief.

10.     Any particular lesson learned about combat care you did not expect but sticks with you today? 

Having had a few sudden deaths in patients that appeared fairly stable when they were physiologically compensating, I still worry particularly about patients who on the surface seems to be doing unusually well despite severe injuries or mechanism of injury.

11.     Have you arrived at a treatment facility and just did not have time for orientation and rehearsals?

Fortunately, I have not had that experience.  Our team had time to work out the kinks with drills and had time to set up.  You would just have to trust that the training works and the team members you work with are also well trained.  If things are so rapid and chaotic, more communication among team members would be needed including their identification and role during the resuscitation.  If there are few minutes to spare prior to the arrival of the casualty, the pre-brief is useful to establish roles, ensure personal safety, review the basic steps through primary survey, secondary survey, and disposition plans.  Immediately debrief the team if time allows before the next casualty.

12.     Have you missed something that in looking back was obvious?

Allowing the team to decompress and hangout together is one major pillar that maintained a functional team.

13.     Did you ever receive a godsend help when you were praying for it that arrived from a source you least expected it?

An excellent CRNA who was able to place an IV on an infant in hemorrhagic shock when all IO's failed and I could not place a central line. 

14.     When you first started, what technique worked best for you in controlling your anxiety? What about controlling another's anxiety? Or maybe you never had a situation that did not pose a threat and therefore was not anxiety provoking?

Keeping physically fit kept me resilient to anxiety, but what exponentially helped that resilience was meditation.  It really works.  I would recommend it, just not the pseudoscience of some types of meditation trends.  As for anxiety in others, developing a strong emotional IQ to detect and ameliorate the others' anxiety would be my only advice.

15.     When you encounter a patient who has no chance for survival but clearly has their mental faculties totally intact what does one say to them?

If he has family and friends, they should be with them without me monopolizing the little time he has.  If there is no one, I would be there to listen to his requests, keep him comfortable, allay his fears, and not abandon him.

Thank you so much for your questions.  I enjoyed responding to them.  Please let us know if you have further questions.

Seon Jones, LCDR MC USNR

Kenneth A. Lipshy, MD, FACS

Gordon Wisbach, MD, CDR, MC, USN, Staff Surgeon, General Surgery Department

Lim RB. Surgery during natural disasters, combat, terrorist attacks, and crisis situations. New York. springer. 2016.

Tuesday, November 22, 2016



Washington DC March 30 1981, 2:27 pm:

       On March 30 1981, 2:27 pm, John Hinckley Jr shot President Ronald Reagan, White House Press Secretary James Brady, Secret Service agent Tim McCarthy and Washington D.C. police officer Thomas Delahanty using his Röhm RG-14 .22 cal blue steel revolver loaded with six "Devastator" brand cartridges (each with small aluminum and lead azide explosive charges designed to explode on contact). Hinckley fired six shots in 1.7 seconds, first hitting Jamey Brady in the head and then officer Delahanty in the neck. As Special Agent Jerry Parr pushed President Reagan into the limousine, a fourth shot hit Secret Service agent Tim McCarthy in the abdomen. The sixth bullet ricocheted off the armored side of the limousine and hit the president.

         It was initially assumed that The President was uninjured. Thinking he was uninjured, they initially planned to take the President to the White House. Until he coughed up blood, President Reagan assumed the pain in his left chest was due to rib fractures from being pushed into the limousine. Special Agent Parr thought otherwise and directed the motorcade to George Washington University Hospital. Upon arrival the President walked into the Emergency Department unassisted but immediately collapsed. At the insistence of The Physician to the President, Daniel Ruge, the ED team was instructed to treat the President as any other trauma victim. The President was in shock and the Trauma team quickly discovered a bullet entrance wound in his left axilla. Within 30 minutes, he was stabilized and transported to the Operating Room where, with the assistance of Joseph M. Giordano, Chief Thoracic Surgery Benjamin L. Aaron, performed a thoracotomy. Wikipedia, NY TImes

           An interview a few weeks later revealed the anxiety control methods both surgeons utilized when they realized they were operating on the President:

Giordano: ''I looked at him and I could feel myself getting tense, which has happened to me occasionally when I do surgery. When that happens, I talk myself through it. I thought, 'O.K., calm yourself. You want this to go well. Concentrate, and do everything the way you always do it, if you expect to get good results.' But I could not divorce myself from the fact that he was the President and his wound could have been lethal.''

Aaron: “He assessed the seriousness of the President's wounds, and said he too would have had ‘heightened anxiety’ if he had not judged that Mr. Reagan's bleeding could be controlled. Although Dr. Aaron described himself as someone who ''doesn't get anxious about things,'' he acknowledged that he was ''on edge at times.'' ''When I couldn't feel that bullet, and I knew it should be there, I thought it might have embolized through the pulmonary veins, into the heart and gone someplace.'' …The bullet, it turned out, was flat. ''I just couldn't feel it in that spongy lung tissue,'' Dr. Aaron said. ''The X-ray settled me down because I realized that when I was feeling for the bullet it wasn't trapped in one place. It had room to move, and it just squirted away from my fingertips.” ''Then it was just a matter of hanging in there until I could find the blooming thing by passing a catheter along the bullet track. It took about five minutes of very concentrated tactile discrimination until I suddenly pinned it down and got it out.''


After Jon White revealed the heroic aspects of the team saving the Presidents life I had questions of Dr. Aaron:
1.       What leadership or crisis management experience /techniques did you discover worked well for you?
2.       What ones did you figure out quickly you had to improve upon.
3.       What preconceptions about your skill or your medical center staffs skill proved correct?
4.       What ones proved false?
5.       What lessons did you rehash with the residents and /or hospital staff in post scenario debriefings?

Dr. Aaron was kind to discuss this with me:

“Bear in mind that all this took place 35 years ago and that it is coming from an 83 year old brain.  Also, at the time, things were moving at a fast pace during which time there was not much time for reflection or organization, or to put it another way, much of the time we were "winging it" in dealing with the complexities imposed by the unique nature of the event. “

1.  Leadership or crisis management experience/techniques applied?
    The care in the ER was flawless as regards urgent processing, mobilization of staff and systematic application of appropriate care.  This was not an accident, but came about because of aggressive and thorough preparation and training of the ER staff and residents.  In order to take care of the President, James Brady and Tim McCarthy (SS), the area had to be cleared of patients, the ensuing crowd screened and managed, and assignments quickly defined.  No one consulted any manuals on procedures on techniques.  The key was preparation and training, professionally applied.

     I recall insisting, from the get-go, that everyone on my team regard the President first and foremost as a patient in trouble and to put aside any consideration of who he was or what might be swirling around beyond our perimeter of care.  This kept us focused on the task at hand and help quell nervousness.  You might call this the principle of putting first things first.  I did not note it at the time, but have been told since that as the team leader, my calm demeanor, efficiency, decisiveness and apparent lack of nervousness did much to hold things together as this event moved along. (Jon White, MD noted that this was indeed the case- Dr. Aaron maintained a calm demeanor with no yelling and no screaming, which allowed flawless communication and the ability to resuscitate the President and rapidly transport him to the OR).

2.  Consideration of changes or alterations.
     One can be persuaded in such a situation that having additional professional experience at the table could be helpful and perhaps diffuse responsibility should things go wrong.  I had many offers of help from fellow surgeons, but quickly put this aside in favor of a three-person team composed of me, my chief Thoracic resident and a surgical intern (just as it would be if the patient came in off the street).  This seemed to me to be the simplest route to good decision making during the operation.  This might be termed good management versus too many "cooks" calling the shots.

     Because of the remote possibility that the bullet might have transited the dome of the left diaphragm, the ER General Surgeons strongly supported an abdominal paracentesis before opening the chest to rule out injury to the spleen, etc. I had seen no evidence of this and had reservations about taking the time to do the procedure (20 minutes or so), but as the President's condition was stable at the time, I agreed to move ahead on this even though had I found a hole in the diaphragm, I could easily have dealt with the problem through the chest.  This gets down to using clinical judgment (was it safe to take the additional time) to forestall a fuss with the General Surgery group.

     Putting the President, post-op, on the ICU was a management mistake, as his presence along with all of his SS entourage and visiting staff rendered the ICU unworkable.  We quickly evacuated a wing of the hospital, tailored it to all the requisites and had the patient moved in 6 hours.  My plan for post-op care was drastically and suddenly altered but I and my team quickly adapted to the new circumstances and moved on. Being flexible, prepared for contingencies, and able to move in different directions effectively is essential to completing the mission.

3.  How ready were we?
     Occasionally one hears that University medicine is "sterile", impersonal, isolates a patient from compassionate care and has poor inter-staff communication.  Some of this may be true, but what University Medical centers do provide is well credentialed and experienced staff and first rate facilities.  We were prepared for this challenge at every level of staff, management and resource availability and because of this, the event came off without a significant hitch.  It was a team effort in every regard from beginning to end and a wonderful thing to be a part of.

4.  What plans or preparations proved false?

     We were not prepared for the security requirements by the SS.  There was a SWAT team on the roof at all times during the eleven days he was present.  When he needed good quality x-rays (there was a portable machine in his suite), the halls had to be cleared and explosive sniffing dogs preceded his visit to the x-ray floor.  His food supply was carefully guarded. Bullet proof glass was installed in his room (despite the fact that he was on the 3rd floor of an interior court with a window free wall opposite).  ALL entrants to the 3rd floor had to undergo a SS check, each and every time they entered.  Medical folk, especially doctors, are not particularly patient people by nature, so with great restraint, and resolve, we managed to work it through to a successful conclusion.  The lesson here is to practice situational awareness and be willing to accept imposed restraints, always keeping the mission as our first goal.

5.  Post event debriefing.
     Post mortems are standard issue for any medical event.  We had many discussions after the fact, but almost all centered about things like conduct with the intrusive press (residents and especially interns, are full of false info and quite willing to share it).  To relive and relieve tensions. we produced a high quality 30-minute documentary utilizing all the primary participants (doctors and nurses, etc) plus actors as the presidential party.  This process brought out into the open the vital parts played by each participant and highlighted the importance of the synthesis of each performance in attaining a good outcome.  On almost every count, we were satisfied with how our medical center responded to each and every challenge and this was echoed by the AMA in their commendation of our efforts.

I hope that this insight into how our medical center and all it's integrated parts dealt with a most unusual and unexpected event will help you develop a useful syntax for your book.  If you have additional questions, fire them my way and I will field them as best as I can.

Sincere regards, Ben Aaron, MD

Special thanks to Dr. Jon White, Chief Surgery VAMC Washington DC for filling in the gaps.

Altman LK. THE DOCTORS WORLD. New York Times. April 21, 1981




Kenneth A. Lipshy, MD FACS

Friday, November 4, 2016



           On October 13 2016 Boston CBC reported "Tourniquet Credited With Saving Life Of Officer Wounded In Shootout". The night prior to that report, a Boston Police Officer was shot during an attempted arrest. In the midst of a gun battle, a tactical officer pulled him from harm’s way and applied a tourniquet, saving his life. Boston Police Commissioner William Evans reported that the officer who applied it had just had tourniquet training less than a week before. Commissioner Evans noted that, while tourniquets were credited with the survival of several victims of the Boston Bombing in 2013, the crude devices used during that situation were created and applied by citizens. Since that time Boston police have had ongoing training on the use of combat tourniquets. Earlier in the year a Boston officer saved his own life by applying a tourniquet after a potentially fatal gunshot wound.

          I found it interesting that I was reading this on October 17th, just immediately prior to our American College of Surgeons Committee on Trauma Business Meeting whereby Lenworth Jacobs, Jr MD MPH FACS presented the most recent information regarding the Hartford Consensus and American College of Surgeons ongoing efforts with the “STOP THE BLEED!” campaign {and presented the following day during the Excelsior Surgical Society/Edward D. Churchill Lecture "Strategies to Increase Survival in Active Shooter and Intentional Mass Casualty Events"}. My attention was captured as Dr. Jacobs clearly pointed out some disturbing news:

1. Major Shooting events are becoming alarmingly common.

2. Educational areas remain the second most common location for these events to occur- and these types of events are definitely increasing.

3. No environment seems immune!

4. While it is fortunate that most of these events are over within minutes, large volumes of ammunition have been expended during that short time frame injuring countless people.

5. First responders may not have access to victims for easily 30-45 minutes

6. Most life-threatening hemorrhage is terminal within 5 minutes without STOPPING THE BLEEDING!.

7. More than likely, the person next to you (your friends or strangers) will be the one who has the greatest opportunity to save your life.

8. After these events a Police officer is likely to be the person closest to the victim and capable of successfully applying a tourniquet, thereby saving a life.


         With this in mind I began to wonder

a. when did the military first implement the use of tourniquets in their Individual First Aid Kits (IFAK's),

b. Was Boston the first Police force to utilize these tourniquets.

c. are any other police forces carrying these.

d. What is the response of the folks in the field regarding their being requested to be trained in, carry and utilize these in the midst of potential dangerous situations, whereby theoretically it is diverting their focus

e. Are any communities posting these STOP THE BLEED KITS and using them yet?

Fortunately, I know some of the members of the Hartford Consensus Conference, so I contacted them for some answers.


         Frank Butler, MD (Credentials below) relayed to me that while select military units (SEALS, RANGERS, PJs..…) may have carried tourniquets and hemostatic dressings prior to 2005, widespread use in U.S. Military IFAK’s (Individual First Aid Kits) did not begin until 2006. CAPT Butler, the US Special Operations Command Surgeon at that time and COL John Holcomb, Commander of the US Army Institute of Surgical Research, spearheaded the Tactical Combat Casualty Care Transition Initiative (initiated in 2005) which was designed to ensure that all deploying Special Operations forces had the recommended TCCC equipment and were trained to use it. To quote from the 2015 Hartford Consensus Compendium:

       “The TCCC Transition Initiative was funded by the USSOCOM and conducted by the USAISR. This effort, led by Sergeant First Class Dom Greydanus, was basi­cally the medical equivalent of a rapid fielding initiative. It provided TCCC training and equipping to deploying special-operations units and incorporated methodology for determining the success or failure of the newly intro­duced TCCC measures. The TCCC Transition Initiative (and the U.S. Army) chose the C-A-T as the tourniquet to field.

        The TCCC Transition Initiative was a resounding suc­cess and documented 67 uses of tourniquets in special-operations units with good effect and with no loss of limbs to tourniquet ischemia. The first four-star en­dorsement of the TCCC and tourniquets occurred when General Doug Brown, Commander of the USSOCOM in 2005, mandated TCCC training and equipment for all deploying special-operations units. The U.S. Central Command, largely through the efforts of former Colo­nel Doug Robb, also mandated in 2005 that all indi­viduals deploying to that combat theater be equipped with tourniquets and hemostatic dressings.

       As awareness of the success of the TCCC Transition Ini­tiative and the U.S. Central Command directive spread throughout the military, conventional units began to adopt the TCCC, including tourniquets. In 2005 and 2006, tourniquet use expanded rapidly throughout the U.S. military. The beneficial impact of the battlefield use of commercially manufactured tourniquets was very well documented by an army orthopaedic surgeon, Col­onel John Kragh, during his time at a combat support hospital in Baghdad in 2006.”

          Dr. Butler explained that the first Hartford Consensus Conference in Jan 2013 concluded that “Life-threatening bleeding from extremity wounds is best controlled initially through use of tourniquets, while internal bleeding resulting from penetrating wounds to the chest and trunk is best addressed through expeditious transport to a hospital setting. Optimal response to the active shooter includes identifying and teaching skill sets appropriate to each level of responder without regard to law enforcement or fire/rescue/EMS affiliation.” By the time of the Jan 2016 Hartford Consensus IV, Dr. Eastman reported that 8 major cities had initiated Trauma Kit Preparedness protocols (NYPD, Washington, Edmonton, San Francisco, Honolulu, Vancouver, Phoenix and Raleigh). By 2015 over 400 readiness courses teaching close to 7000 LAW ENFORCEMENT students have been carried out. In Denver the Tactical Casualty Care for law enforcement first responders (TCC-LEFR) has been taught at over 125 courses and 2500 LEO’s and EMTs. Known data has revealed that five officers and r civilians have been saved thus far due to this training. Admittedly up to this point clear data has been difficult at best to collect and report, but a data base for LEO TECC use nationally is in progress. During the Hartford conference, John Holcolmb reported on data from Houston whereby 105 trauma patients were treated with a PREHOSPITAL tourniquet resulting in a 3.2% mortality rate compared to 17% treated with an ED applied tourniquet.


          In an effort to learn more regarding the use of these kits in the police and civilian arena, I contacted Alex Eastman, MD and Lenworth Jacobs, MD (Credentials below). Dr. Jacobs and Dr. Eastman relayed that efforts to initiate use in the field of personal equipment including a tourniquet began some time back in police service. Alex Eastman stated that he has been a member of the Dallas Police Department since 2004 and has served as the Medical Advisor for the Major Police Chiefs Association since 2011.  Dr. Eastman said they have had a version of the combat kits in their specialized units since 2006. In the Dallas Police service, 3700 sworn officers and 400 civilian employees have been trained.  By now Parkland Hospital has taught 1000 civilians and is currently working with businesses to move this out even further into the private sector. Dr. Jacobs relayed that in other police units implementation was likely via police staff with prior military experience (Special Forces, Medics, etc).  Use of tourniquets was likely met with some hesitancy to accept officially because the Police clearly have more pressing priorities during a Police action.  By now, there is no hesitancy to support this with policy and training.


        The Dallas Police Department Kits contain the following Equipment: Quick clot ($35roll), SOFTT-W tourniquet (25 each), Wide gauze and gloves. Their Carrying cases are typically donated.
Courtesy Alex Eastman


         I was curious how much resistance the group met when this was proposed several years ago. Dr. Jacobs explained that initially there were some challenges in asking police staff to take on the training but through a series of collaborating events the vision became reality (NOT IN DALLAS THOUGH as Dr. Eastman relayed). “You need to keep in mind that Police have the primary responsibility of ending the violence and providing a safe scene for other first responders. Having said that, the police realize that they are there on the scene and able to first respond when the paramedics are likely to be delayed.”

         Daniel Linskey, (Boston Chief of Police during the Boston Marathon Bombing) explained the tourniquet implementation process in Boston to me: “We did urban shield exercises which used amputees moulaged up as if they had just lost a limb. We identified tourniquets as a gap. Dr. Rickey Kurt took over as our assistant medical director at Boston EMS. He began to train our teams on tactical EMS getting into our stack. He taught hemorrhage control to our special ops guys and many started carry tourniquets. After the marathon we got tourniquet training and quick clot for all our officers before the July 4th event 2013.  I have been explaining the need for tourniquets around the country with law enforcement. I was at a third presentation in North Carolina when an officer approached and said he saw my earlier presentation tapped his tourniquet that he got for himself and the officers he worked with. He then went on to tell me of an officer who crashed his car and they then used a tourniquet to save his life. I've spoken to dozens of groups and hundreds of departments. Just spoke to 150 officers from 30 plus agencies today in St LOUIS every one said their guys carry tourniquets on their patrol officers’ duty belts some kept extra in their glove box.

             So if that was a challenge, I could only imagine the challenge in obtaining citizen group buy in. Dr. Jacobs explained that, “the Boy and Girl scouts already are trained on first aid so it is a natural pathway to teach.” To save live citizens simply have to be trained. Communities must have policies in place to assure citizens and first responders are trained to give permission to those who are the first responders. We need to empower the responder to help. Expectedly, the initial reaction to attempts at implementation of policy were very hesitant but the events that occurred over the years, especially in Washington, prompt a positive response. The credibility of these programs continues to grow as people realize that these “rare events that will not happen in our community” are happening at an alarming rate. Add to that the non-rarity of police and citizen events in everyday trauma where there may be one person with one chance to save a life.  People are slowly realizing that the further away from care that you reside, the more reinforcement of this training is necessary.  It has been proven that waiting to get the patient to the ED to stop the bleeding is not good practice.  “When our soldiers know better how to treat exsanguination than our doctors, we have a bad situation on hand but we need to train the medical students and residents!”  People are taking this seriously now. We need surgeons to take the leadership in their community and empower them to train the citizens.

        So what does any of this have to do with working in a small, especially rural hospital? That turns out to be similar to the questions others ask: “we never have to deal with exsanguinating hemorrhage from penetrating trauma! We are a small town, small hospital. We don’t have penetrating trauma.” At first that seems like a worthy question and conclusion. However when one listens to Dr. Jacobs and others explain the realm of this problem, it becomes clear that in some situations you may be the first with an opportunity to provide this life saving care. It is certainly not inconceivable that an injury on or adjacent to the property could result in profuse hemorrhage that could be controlled by trained personnel. It takes minutes to train, little money to support and saves lives.

Kenneth A. Lipshy, MD, FACS



CAPT Frank K. Butler, Jr., MD Member of Hartford Consensus Conference. USN Retired US Navy, diving medical Officer, Director of Biomedical Research for the Naval Special Warfare Command. Platoon commander Navy Underwater Demolition and SEAL (Sea/Air/Land commando) teams. Diving Medical Research Officer, Navy Experimental Diving Unit. Chief of Ophthalmology - Naval Hospital Pensacola. Naval Special Warfare Command. Ophthalmic consultant to the Divers Alert Network.  Chairman, Committee on Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems (Feb 2015).


Alexander L. Eastman, MD, MPH, FACS, DABEMS Member of Hartford Consensus Conference Lieutenant and Deputy Medical Director Dallas Police Department (SWAT), Interim Medical Director, The Trauma Center at Parkland (UT Southwestern Medical Center). Medical advisor to the Major Cities Chiefs Association.


Lenworth M. Jacobs, Jr., MD, FACS, Trauma Surgeon Hartford Con., American College of Surgeons (ACS) Regent and Chairman of the Hartford Consensus.


Chief Daniel Linskey, Boston Chief of Police during the Boston Marathon Bombing.


Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events

Lenworth M. Jacobs, MD, MPH, FACS Hartford Hospital, American College of Surgeons (ACS) Board of Regents

Norman McSwain, MD, FACS Medical Director, Prehospital Trauma Life Support

Michael Rotondo, MD, FACS Chair, ACS Committee on Trauma

David S. Wade, MD, FACS Chief Medical Officer, Federal Bureau of Investigation (FBI)

William P. Fabbri, MD, FACEP Medical Director, Emergency Medical Support Program, FBI

Alexander Eastman, MD, MPH, FACS Major Cities Chiefs Association (Lt. Dallas Police Department)

Frank K. Butler, MD Chairman, Committee on Tactical Combat Casualty Care

John Sinclair International Director and Immediate Past-Chair, International Association of Fire Chiefs-EMS Section (Fire Chief, Kittitas Valley Fire and Rescue)