Between travel, jet lag, networking, and conference attendance 10 hours a day, I’ve been remiss in blogging this week, but promise to make up for it. I am in Atlanta at the Public Health Preparedness Summit, and will pass on some of the things I learn – hopefully others will find them interesting as well.

Yesterday’s opening session was a panel discussion of the movie theater shooting last summer in Aurora, Colorado. Wearing my disaster medicine hat, I know a reasonable amount about hospital disaster planning. However, the concept came “alive” after hearing directly from a hospital involved in this mass-casualty incident.

Emergency Rooms and Trauma Care

Photo by Military Health

Photo by Military Health

Most hospitals are not designed to care for large numbers of victims at once (TV and movie emergency room scenes don’t reflect reality – what a surprise!). First, all hospitals are not created equal. Emergency room size varies from 3-4 beds to 50 beds or more. The number of beds, and the number of staff, reflects the “usual” number of emergency patients for that hospital.  If you’ve ever been stuck in the ER, you know it’s not a quick way to receive care – you might wait several hours to be seen, and then occupy a bed for another several hours. Some patients even spend the night in emergency rooms until an inpatient bed opens upstairs. Bottom line – emergency room beds are limited and often full.

Second, not all hospitals are “trauma” hospitals. To care for severe trauma, you need trauma trained emergency room personnel, trauma and specialty surgeons (neurosurgeons, orthopedic surgeons, etc), anesthesiologists, radiologists, operating nurses, etc., etc. – and you need them quickly. Level 1 trauma centers have trauma surgeons and anesthesiologists in the hospital around the clock, with other surgical specialties rapidly available. Level 2 trauma centers also have continuous staffing by trauma trained emergency room physicians , with fairly quick access to all surgical specialists, although they may not be in-house. Both level 1 and level 2 ERs may have specialized trauma rooms for severely injured patients. Level 3 trauma centers include many community hospitals. They can evaluate, resuscitate, and stabilize trauma patients, and a surgeon is on call for mild-moderate trauma. Surgical specialists are lacking, so once stabilized, severe trauma victims are usually transferred from level 3 hospitals to higher level trauma centers. Finally, level 4 hospitals, including many rural hospitals, have minimal resources. Some even lack 24 hour a day in-house physicians. Their role in trauma is usually just resuscitation and stabilization, then punt.

Mass Casualty Planning

Even level 1 trauma centers rarely receive large numbers of victims at once. A car crash with 5-6 victims is not rare, but 20-30 trauma patients at once will stress most systems. Imagine what several hundred victims would do! To deal with these rare situations, all hospitals, independent of level, develop “mass casualty plans” to prepare for sudden patient “surge”. Plans usually include coordination with both emergency medical responders and other hospitals to distribute patients according to trauma severity and hospital resources. Unfortunately, reality can quickly derail even the best laid plans.

The Aurora, Colorado Shooting

The suspect and theater

The suspect and theater

In Aurora, the shooting started at 12:38. The first 911 call was received within 1 minute, and the first officers were on the scene by 12:41. The suspect was arrested within 9 minutes of the first shot, yet 12 people died and 58 were injured. The speed of the police response was amazing, but unfortunately, (as stated in my earlier post on mass shooters – Scary Fact # 6: Active Shooters – What Should You Do?), these episodes evolve rapidly, with most victims killed or injured in just a few minutes – not much time to think, let alone respond. At our session yesterday, we listened to 911 communications – the dispatcher deserves a prize for the calmest head in a horrible situation!

There was a massive police response, but ambulances and emergency medical responders were not on the scene. The police chose to transport victims to hospitals in squad cars, instead of waiting for EMS support. Although transport occurred rapidly, this decision bypassed key parts of hospital mass casualty planning, which usually includes triage at the scene, ongoing communication with the hospital, initial treatment during transport, and distribution of patients over multiple hospitals, depending on trauma severity and available resources.

University of Colorado Medical Center. Photo by Jeffrey Beall

University of Colorado Medical Center. Photo by Jeffrey Beallt

University of Colorado Anschutz Medical Center – An Unexpected Patient Surge

The University of Colorado Anschutz Medical Center is a level 2 trauma center, located 3.5 miles away from the shooting. At the time of the shooting, their emergency room was on “divert”. For non-healthcare people, this means ambulances are told to take patients to other emergency rooms, because the UC emergency room was full. They had patients in 49 of their 50 emergency room beds, with another 11 in the waiting room – before the shooting started!

911 notified the hospital at 12:56 to expect 3-5 shooting victims. Luckily, one emergency room physician had a bad feeling, so the hospital chose to activate their mass casualty plan – normally not required for 3-5 patients. The first patient actually arrived by private vehicle at 1:01 AM, and within a few minutes, police cars started pulling up.  The UC Colorado emergency room ended up receiving 23 patients, almost all within the first 30 minutes (a few patients arrived after later, primarily with mental health or tear gas symptoms). Only three patients arrived by ambulance. The rest came by squad car or private vehicles. One wounded teenager even ran to the hospital from the shooting – 3.5 miles!

Mass Casualty Plans Pay Off

Luckily, the University of Colorado Anschutz Medical Center had great plans, plus a lot of experience with trauma. They quickly moved non-trauma patients out of the emergency room to places like pre-op and recovery rooms (luckily empty in the middle of the night). Safety officers and other non-healthcare personnel pitched in to move patients from squad cars to emergency room beds, so that healthcare professionals could focus on care. Each trauma room received 4 patients instead of 2. Less seriously injured patients were treated in hallways. Room was made in intensive care for the seriously injured by transferring the less sick to beds on regular medical floors.

Other important parts of the hospital plan included setting aside room for families to gather, and quickly establishing a hot line – they received 1000 calls from people trying to find loved ones or gather information! The UC Anschutz hospital identified all their patients within 30 minutes (quite a feat considering unconscious patients may not have identification). By 6 hours, a comprehensive list was available of all victims at all hospitals – a major unsung success!

Overall, the UC medical center plan worked well. One patient unfortunately was dead by hospital arrival, but they saved the other 22. It helps that UC was both an academic medical center and a trauma center. Numerous house staff are always on site. In addition, academic physicians are “owned” by the medical center, and accept the need of reporting immediately when called – something that community physicians may not agree to.

Most systems worked well, with one exception. Hospitals often have mass emergency notification systems for contacting all staff automatically by phone, text, and email. Somehow, the UC physicians were left off the notification list, so it required a fair amount of work to “hunt them down”, unlike other hospital staff.

Photo by Airman Magazine

Photo by Airman Magazine

In a community hospital, an unannounced surge of 23 patients could be overwhelming. Even finding a place to put 23 patients might be difficult, let alone having staff and physicians available to treat them.

Lessons for Others

I asked what lessons the panel would pass on to healthcare elsewhere. Their answers were quick. Most important is complete buy-in and support by leadership to the idea of disaster preparedness. Leadership support not only allocates time and resources for developing and testing plans, but their attitude also sets the tone for everyone else. The panel felt all healthcare professionals should train in advance to handle large numbers of patients – no one knows when and where they may appear. It’s a different approach to medical care – checking quickly but repeatedly on all patients, focusing on the most urgent problems, and on doing good for the greatest number – quite different from the one-on one patient attention in day-to-day American medical care. They felt healthcare professionals should understand the incident command system (where for once the doctor might not be in charge), and be ready for the stress and mental health effects of disaster care. Taped interviews by UC emergency room staff stated that the evening of July 20, 2013 was one of the most traumatic of their lives – and this from professionals who treat trauma every day!

If healthcare is your area, are you ready for a mass casualty incident?

Stay safe,

Sheila Sund, M.D.

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