At 1:57 am on Sunday, June 12, the deadliest mass shooting in U.S. history erupted at the Pulse nightclub in Orlando, FL. It was a Latin night-themed dance party, and more than 300 people packed the club, most dancing in a large room. A lone gunman, armed with a .233 caliber Sig Sauer AR-15-style military assault rifle and a 9 mm semiautomatic Glock 17 pistol, entered the club and began firing into the crowd.* During a five-minute period, the gunman moved from room to room, repeatedly shooting victims, reloading his weapons, and ultimately firing more than 250 rounds of ammunition.
At 2:07 am, police officers entered the club and engaged the gunman, forcing him to retreat to restrooms at the rear of the club. This allowed law enforcement to evacuate victims to emergency medical services (EMS) personnel waiting outside. The incident quickly turned into a hostage situation with the gunman barricaded in the restroom area and threatening to attach bombs to the remaining hostages. As law enforcement continued to negotiate with the gunman over the ensuing two-and-a-half hours, additional victims were evacuated from the facility. After negotiation efforts broke down, SWAT teams made the decision to rescue the hostages and stormed the club at 5:02 am. They exchanged gunfire with the shooter, who died on the scene.
Orlando Regional Medical Center
The victims were taken to Orlando Regional Medical Center (ORMC)—the only Level I trauma center in central Florida. “It was the best day of my career; it was the worst day of my career,” is how one surgeon who was on call at ORMC describes that morning. As trauma surgeons, we drill and prepare to handle the worst that humanity or Mother Nature can produce, yet hope that such events will never happen. When they do, the lives of all involved—patients, family members, physicians, nurses, and other allied health care workers—are changed forever.
ORMC is an 808-bed tertiary hospital located three blocks north of the Pulse nightclub. Arnold Palmer Hospital (APH), the regional pediatric hospital and part of the Level I trauma center, and Winnie Palmer Hospital for Women and Babies (WPH) are located on the same campus. Together, ORMC and APH admit approximately 5,000 trauma patients annually. ORMC is staffed around the clock by an in-house attending trauma surgeon/surgical intensivist, as well as four general surgery residents. ORMC and APH each have one operating room (OR) open throughout the night. A busy academic teaching hospital, ORMC supports a variety of training and fellowship programs, including general surgery, orthopaedic surgery, emergency medicine, internal medicine, pediatrics, obstetrics and gynecology, surgical critical care, medical critical care, colon and rectal surgery, and acute care surgery.
For the last 20 years, ORMC has continuously developed and refined its mass casualty intake plan largely due to central Florida’s propensity for hurricanes and tornadoes, as well as the city’s status as an international tourist destination. ORMC holds monthly “trauma alert” training drills with local EMS agencies, and three months before the Pulse mass shooting, the facility participated in a tri-county active shooter scenario mass casualty intake drill. Most of the trauma patients to whom ORMC health care professionals provide care have been involved in motor vehicle crashes or falls, although it is not uncommon for the ORMC trauma team to admit anywhere from four to six gunshot victims per night. Data from our American College of Surgeons Trauma Quality Improvement Program (ACS TQIP®) registry demonstrates a penetrating trauma rate of 10 percent to 15 percent.
At approximately 2:00 am, the Orlando Fire Department notified the ORMC operator that an active shooter situation was occurring in the vicinity of the hospital. An estimated 10 minutes later, the first victim arrived in the ORMC emergency department (ED) with a gunshot wound to the abdomen, followed by three patients with gunshot wounds to the chest. Chadwick P. Smith, MD, FACS, a coauthor of this article, was the attending trauma surgeon on call. Dr. Smith rushed to the trauma bay, arriving as the second victim was rolled into the room. Dr. Smith was assisted by four on-call general surgery residents: Joshua Corsa, MD; Aura Fuentes, MD; Nicholas Sakis, MD; and Shalini Golla, MD. EMS officials notified the hospital that a mass casualty incident with up to 20 victims had occurred. The ORMC ED was immediately placed on lockdown due to the active shooter situation a few blocks away.
At around 2:20 am, while directing the ongoing resuscitation of multiple victims, Dr. Smith started to become aware of the magnitude of the mass casualty intake event, and he summoned additional trauma surgeons, Joseph A. Ibrahim, MD, FACS, and Michael L. Cheatham, MD, FACS (co-authors of this article), to the trauma bay. Patients began arriving at ORMC at a rate of approximately one per minute, initially brought in by foot, private vehicle, police car or van, and subsequently by ambulance. As the number of victims steadily increased, Dr. Smith called trauma surgeons Matthew W. Lube, MD, FACS, and William S. Havron III, MD, FACS (co-authors of this article), to the hospital and requested the assistance of additional general surgery residents. Having received the initial mass casualty intake page, article coauthor Marc S. Levy, MD, FACS, the APH pediatric trauma surgeon on call, offered his assistance. All five surgeons rapidly drove to the trauma center, although their arrival at ORMC was hampered by the police blockade of surrounding streets given the proximity of and ongoing gunfire at the nightclub.
Many of the initial victims arrived in extremis with limited or absent vital signs. Three of the initial six patients required immediate resuscitative thoracotomies to treat their traumatic injuries and hemorrhagic shock. These thoracotomies immediately revealed the devastating impact of the high-velocity rounds. Ongoing resuscitation was unsuccessful and these patients rapidly succumbed to their injuries. Four more patients arrived with absent vital signs. Patients who died from their injuries were moved to the hallway outside the trauma resuscitation room to allow additional victims to receive care. A total of nine patients succumbed to their injuries soon after arrival at the trauma center. The first wave of patients consisted of 38 victims in 42 minutes.
Patients were triaged based on their acuity and injuries. Resuscitation was implemented in accordance with Advanced Trauma Life Support® (ATLS®) principles. Physical examination, plain radiographs, and bedside ultrasound were used to assess patient injuries. Computed tomography scans were rarely used in the initial patient evaluations given the large number of victims.
As additional trauma surgeons arrived around 2:40 am, critically injured patients were taken immediately to the OR. Sandeep Mukerjee, MD, the anesthesiologist on call, rapidly expanded OR capacity by summoning the on-call team, as well as bringing APH and WPH OR staff to ORMC. As a result, four ORs were open within 60 minutes and six rooms within 120 minutes of the first patient’s arrival. The operating trauma surgeons remained in their ORs as new patients were brought in from the ED. Orthopaedic and vascular surgeons, including Joshua Langford, MD, FACS, and Shonak Patel, MD, FACS, participated in the initial operative response as necessary, based on the patients’ injuries.
The hospital’s mass casualty intake page resulted in a rapid influx of additional physicians, nurses, and allied health care personnel to help care for the large number of victims. The hospital worked with law enforcement to arrange clear avenues of entry to the campus from the north, avoiding the ongoing active shooter situation to the south.
After assisting in the initial surgical response, Dr. Cheatham joined hospital administrators to activate the hospital’s incident command system. This command post was responsible for fulfilling all logistical needs related to the mass casualty intake, as well as working to facilitate normal hospital operations. Arriving staff were staged in the hospital and deployed to the appropriate areas as the need arose. The incident command center remained continuously staffed for the first 36 hours following the mass casualty intake event.
Code silver alert
At around 3:25 am, as victims were actively evaluated and resuscitated, a report was issued indicating that gunfire had been heard in the ED lobby. The hospital’s “code silver” active shooter plan was implemented. Heavily armed police officers and sheriff’s deputies immediately began clearing the ED of any possible threats. Staff closed doors and remained in place while continuing to provide patient care. Portable X-ray machines were used to barricade the trauma resuscitation room doors and prevent entry. Initial reports were that one of the victims had been a second shooter at the club. This allegation was subsequently determined to be false. After 45 minutes, the code silver alert was lifted. Of note, many of the physicians and nurses continued to move from room to room of the ED during this time, caring for patients despite the risk of personal injury.
As additional surgical residents and fellows arrived, patients requiring hospitalization were transferred from the various intensive care units (ICUs) and step-down units to inpatient units as appropriate to increase critical care bed capacity. To accommodate arriving victims, patients requiring nonoperative intervention were rapidly moved from the ED to the ICUs and hospital floors where their evaluation and resuscitation continued. Two attending medical intensivists, Charles Hunley, MD, and Jeffrey Sadowsky, MD, and a surgical critical care fellow, Anthony Gielow, DO, supervised the ongoing management of patients in the ICUs while the trauma surgeons/surgical intensivists were in the OR.
All victims not held hostage in the nightclub had been evacuated to the trauma center by 4:00 am. The frenetic activity of the preceding 1.5 hours gave way to a period of relative calm. After the rapid influx of 38 victims, this lull allowed the ORMC trauma team to evaluate the initial wave of victims and systematically review their injuries and disposition. Patients were reevaluated and triaged to determine who would go to the OR next. This break in activity also allowed the hospital staff to restock the ED with supplies from prepared disaster supply carts, as the large number of chest gunshot wounds had exhausted the ED’s supply of chest tubes and water seal chambers.
Second wave of victims
A loud explosion was heard in the distance at approximately 5:02 am as SWAT teams breached the wall of the nightclub to rescue the remaining hostages. Soon after, a second wave of 10 victims arrived, including a SWAT team member who had been shot in the head. His Kevlar helmet was fractured on impact, but he sustained no intracranial injuries. Triage, evaluation, and resuscitation of the second wave of patients began. Police officers warned that numerous victims were still in the nightclub and that we should expect a third wave of victims. These remaining 40 victims, one-third with gunshot wounds to the head and some with up to 10 injuries, were subsequently found to have succumbed to their injuries, and the “third wave” never materialized.†
At 7:30 am the trauma surgeons who were not still operating met with the general surgery residents in the ED. Using a master list of victims that Dr. Smith had maintained throughout the morning, each patient’s injuries, laboratory data, and radiologic studies were carefully reviewed and a tertiary survey performed to ensure that all injuries had been noted and addressed.
The large number of victims brought to area hospitals and the number of deceased victims still within the club resulted in an unprecedented influx of concerned families. A family assistance area was established and staffed by hospital personnel. Regular updates were provided to families whenever possible. Families were provided with an e-mail address to send photographs and other details to assist in the identification of the victims. More than 300 e-mails were received from family and friends attempting to locate their loved ones. All but one of the victims who received care at ORMC was identified by that afternoon.
Evaluating the response
Of the 107 victims of this mass shooting, 49 were killed and 58 were wounded. ORMC received 49 victims plus the SWAT team member; nine succumbed to their injuries soon after arrival. Another 17 victims, some of whom initially fled the scene of the attack, presented to other local hospitals by EMS or private vehicle. A total of 40 victims died in the club.
The proximity of the nightclub to ORMC was certainly of benefit to the victims. While the first law enforcement officers on the scene were engaging the shooter, others extricated victims from the club to a casualty collection point across the street. Law enforcement vehicles and the initially responding ambulances began immediately transporting victims the short distance to ORMC, frequently carrying more than one patient per trip, and immediately returning to the scene after offloading. One-third of the victims were quickly transported to the trauma center by law enforcement using pickup trucks and patrol cars. This rapid transfer of patients to a Level I trauma center only three blocks away greatly facilitated early cessation of hemorrhage and rapid resuscitation. With the exception of the nine victims who arrived with either absent or limited vital signs, none of the remaining 40 victims succumbed to their injuries. Some of these victims would undoubtedly have died had it not been for their rapid transport to the trauma center.
A significant part of the challenge posed by this mass casualty intake event was timing. The event occurred in the early morning on Sunday when staffing and capacity were at lower levels. By rapidly combining the resources of ORMC, APH, and WPH, we were able to effectively meet the needs of the victims. We briefly considered distributing patients among the three facilities but were concerned that this option would divide our manpower and resources, weakening our response.
Instead, we chose to bring the care providers and supplies to the patients, preserving their “golden hour.” Transferring patients to other hospitals 15 to 30 minutes away also was an option, but the victims were already in a Level I trauma center that had the capacity to meet their health care needs. It is notable that through effective triaging of existing inpatients, we still had available critical care beds and operative capacity had the “third wave” of victims materialized. Given the multiple gunshot wounds and traumatic brain injuries they sustained, however, these potential 40 patients would most certainly have been of very high acuity. By 9:30 am, the ORMC Level I trauma center reopened.
Within the first 24 hours following the Pulse tragedy, our surgeons and OR team performed 29 operations on the victims. On the day after the event, two ORs were made available solely to facilitate the ongoing exploration and repair of these patients’ injuries. By the end of the first week subsequent to the event, 54 surgical procedures had been performed.
Because of the large number of gunshot wounds and the nature of the event, many victims reported being exposed to the blood of other victims. After consultation with the Centers for Disease Control and Prevention and the Orange County Health Department, all patients were offered baseline testing for hepatitis B, hepatitis C, and the human immunodeficiency virus (HIV).‡ Patients without a history of previous vaccination to hepatitis B were started on a vaccination program. Post-exposure prophylaxis against hepatitis C and HIV was not recommended. Local television and newspapers publicized these same recommendations to ensure that all individuals who had been inside the club during the mass casualty intake were aware of how to take care of themselves.
Disaster plan enhancements
It has long been recognized that adversity can bring out the best in people. Many of the 33 surgical residents and fellows in our program immediately responded to this tragic situation and worked tirelessly over the subsequent 36 hours to care for the victims. Our team members commonly provided care on patient units and in ORs with which they were unfamiliar, frequently crossing job descriptions in doing so. Further, we were inundated with offers of assistance from surgeons from our own facility, as well as other area hospitals and even other states. By the time these offers had been received, however, the immediate surgical needs of most victims had been addressed.
Through this mass casualty intake event, we identified two shortcomings in our disaster plan, which had been honed through years of drills as well as our response to three major hurricanes. First, our plan for family communication and support was designed to meet the needs of our own patient families. We had not planned to be the primary source of support and communication for the families of all victims in the community. Because the identities of the deceased victims were not made public for more than 24 hours, family members were frequently referred to ORMC for support and information. As a result, we had to expand our family assistance plan in real time to accommodate the hundreds of family and friends who came to ORMC and provide them with additional staff, food, water, chaplains, counselors, cellphone chargers, and conference rooms.
Second, our disaster plan did not anticipate the post-event counseling needs of hospital staff in the aftermath of an event of this magnitude. The sheer volume of victims, the catastrophic nature of their injuries, and the belief that an active shooter situation was occurring within the hospital perimeter all placed a significant psychological burden on our team members. We began both individual and group counseling sessions within hours of the event. More than 1,500 of our team members participated in these sessions over the first 10 days following the Pulse tragedy. We continue to see the impact of this event on our team members and greatly appreciate the tremendous outpouring of support that we have received from trauma centers and hospitals around the world.
It has been said that one can never fully anticipate the impact of a mass casualty intake such as the Pulse nightclub shooting. We strongly suspect that the outcome of this event would have been significantly different were it not for the countless hours of training and frequent disaster drills that our hospital has completed over the past two decades. Each of those drills helped to prepare our institution for the events of June 12. Ultimately, however, it was the dedication and hard work of each team member that allowed 40 victims to return home to their families.
*Minute by minute: How the attack in Orlando unfolded. Washington Post. Updated August 1, 2016. Available at: www.washingtonpost.com/graphics/national/orlando-shooting/. Accessed September 7, 2016.
†Schneider M. Autopsies: A third of Pulse nightclub victims shot in head. Associated Press. August 9, 2016. Available at: media.abcnews.com/m/story?id=41243474&sid=81. Accessed September 7, 2016.
‡Centers for Disease Control and Prevention. Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and similar mass-casualty events—United States, 2008. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5706a1.htm. Accessed September 7, 2016.