Orlando Hospital Workers Can't Forget

Six months after the Pulse nightclub shooting killed 49 and injured scores, clinicians who treated the dying and the wounded describe the roles they played that night, and the rules they broke.

Mark Jones, president of Orlando Regional Medical Center, remembers arriving at the hospital the night of June 12, 2016 to find a police officer with an automatic weapon blocking a crowd at the entrance.

Surgeon Michael Cheatham, MD, remembers making the decision to stop CPR on a patient who was dying from gunshot wounds so he could save another patient more likely to survive.

Director of Services and Hospitality Holly Stewart recalls how she sent a clinician to the family waiting room because so many people were fainting.

They also needed a Spanish translator. It had been Latin night at the Pulse night club, the scene of the worst mass shooting in US history.

Hospital doctors, nurses, and administrators relived that awful night during the Institute for Healthcare Improvement (IHI) Forum in Orlando last week. It was streamed live on the IHI website.

"Drill Often"
One clear message emerged: Be prepared. Be prepared. Be prepared.

Three months before the shooting, the hospital had been part of a community-wide mass casualty drill. "There is no question that the work that was done that day saved lives," said Jones.

He urged hospitals to "Drill often. Do the table-top exercises when you can. You need to do this, in our opinion, when it is not convenient. You always think the hospital is busy. Do it when you are busy. Do it at night. Practice on the weekend."

The medical center is located just blocks from the Pulse nightclub, but the usual roads to the hospital were blocked because the shooter was still inside. So many patients were transported by pick-up trucks and police cars.

Many got no pre-hospital care, and there were no calls to the hospitals in advance. White medical examiner vans backed up to the hospital, loaded up, and pulled out. Over and over.

"You're Going to be Busy"
On the IHI webinar medical team members struggled with their emotions at times as they described the roles they played and the rules they broke to get through that night six months ago.

Emergency Department nurse Elisabeth "Libby" Brown, RN, got a call from her firefighter husband that night telling her: You're going to be busy. On her way in, she saw police cars flying down Orange Avenue. Cruisers on that street were not unusual; the number of them was.

"The first patient came in and we got to work," she said. "That's what we do. Then another patient came in and then another patient came in and they just kept coming. They had wounds like I had never seen before and I started to get really scared."

Brown focused on instructions from surgeon Chad Smith, MD. He was asking nurses to step outside their roles, but she said she trusted him.

"Save as Much Life as Possible"
Smith instructed staff to follow the rules of battlefield triage. The most gravely injured were treated first. For those "in extremis" who were unlikely to be saved, there was a different rule. "Their care must be ceased," he said.

Smith had trained to make decisions like these; actually making them was difficult. Teamwork helped him get it right, he said.

"Decisions like these have to be made. They have to be made to save as much life as possible," he said.

The only way to do it "is to have the training and team attitude to know that you are going to be supported by your team members, to have worked with people and trained with people, to know that they trust in you, that they trust in each other. "

Everyone on Smith's team was experiencing something they never had before, he said. They had to rely on their training and education and each other to get through it.

Leadership is Vital
"They are going to look for a leader," he said. "Those leaders need to be calm and composed despite what they are feeling inside and lead in a way that others can follow."

Fellow surgeon Cheatham started working on patients, but assumed a different role as other surgeons arrived. He began setting up the "incident command" center. The concept is a way of bringing order to an emergency situation by setting up a central, on-site command center with key staff from different departments.

He and others suggested all hospitals make themselves familiar with the practice and train for it.

After all the patients were treated, there was more to deal with... grieving families, John Doe patients with fake IDS, news team from across the country, traumatized clinicians, and visiting dignitaries.

And there was more pizza at the hospital than the staff could ever eat. Some of it came from Boston and San Bernardino, where hospital staff had a sense of what the Orlando team was going through.

Are You Prepared for the Worst?
After all the others spoke, Orlando Health COO Jamal Hakim, MD, delivered this message:

"Ours is a story of mission and passion, of preparedness and planning, of success and… a little bit of pride in being able to handle that which is really beyond preparation. Our question for you is: Are you prepared for the worst to show up on your doorstep unannounced?"