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