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: http://bulletin.facs.org/2016/11/orlando-regional-medical-center-responds-to-pulse-nightclub-shooting/ ].
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:
LEADERSHIP ANALYSIS:
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)
TEAM RESPONSE AND PREEMPTIVE PLANNING ANALYSIS:
-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 orlandohealth.com)
