On scene, a group of law enforcement officers were engaging the shooter while others assisted in extracting victims from the club and surrounding area. Injured victims were brought to a casualty collection point, under cover, across the street and were transported as units became available. Initially, law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload. Per previous training, minimal interventions were performed, and unlike standard procedure, EMS could offer no prearrival report to the hospital. The decision was made to triage only patients meeting Florida’s state trauma alert criteria to ORMC, and funnel other patients to nearby nontrauma centers. Dr Hunter attempted to notify the hospitals of patients as they were transported off the scene; however, the extremely short transport times made this process difficult.
Over the course of the incident, on-scene commands designated a casualty collection point, a transport unit staging area, and a hospital liaison. Emergency medical service responders cooperated with law enforcement to transport injured patients throughout the response. By the end of the event, nearly 100 EMS providers utilizing dozens of vehicles had responded to the scene.
The ED Period
The overnight shift of Saturday, June 11 was slower than usual in the ORMC ED, and triage housed the typical Saturday-night complaints. One of our mid-level providers, Brian Clayton, ARNP, worked in the fast track pod treating lower acuity illnesses, while the four senior residents discussed who might receive the honor of leaving early. Even the senior attending, Gary A. Parrish, MD, wrapped up his patients and was ready to leave right on time. The 11:00 pm to 7:00 am attending, Kathryn J. Bondani, MD, was looking forward to an easy shift with four graduating senior residents. We had just called in an order from a popular nearby sandwich shop when suddenly, a slew of police cars flew past the hospital—not unusual given our proximity to downtown. The radio squawked “Multiple gunshots wounds en route.” Someone said “a club downtown got shot up.” In anticipation of multiple patient arrivals, resident Amanda M. Stone, MD, and the attending hurried to the trauma/ressuscitation bay. Another resident, Amanda F. Tarkowski, MD, called the trauma attending to rally his team downstairs, informing him that “A club downtown has a shooter and we have multiple patients with a 2-minute ETA.” Multiple gunshot wounds (GSWs) at once is not unusual for our Level 1 trauma center.
The first patient arrived shortly after 2:00 am and had multiple GSWs to the abdomen, but was awake and talking. He was mildly tachycardic, but his blood pressure (BP) was stable. We all gaped at the fist-sized wound on his back—some of us had never seen a GSW like this before. It was apparent that he needed to go to the operating room, but before preparations could be made, three more patients rolled into the ED. Instead of our usual organized, methodical EMS report, these patients were dropped off by a police pickup truck and rolled in on our own stretchers by nurses and technicians. Soon, all six of our trauma bays were filled with critical patients. Christopher H. Ponder, MD, recalled, “I heard an overhead page for ‘all available trauma nurses to the trauma bay’ shortly followed by a more concerned-sounding ‘all available staff to the trauma bay.’” All four senior EM residents, both EM attendings, the trauma attending, four trauma residents, multiple ED nurses, technicians, and various ancillary staff quickly descended on the patients. Chest tubes were placed, and multiple patients were intubated. Several thoracotomies were performed at the initial point when the team was unaware of the exact number of patients who would ultimately follow. Blood bags were hung and tranexamic acid was administered liberally. Unfortunately, some of these initial attempts were unsuccessful, as the first wave contained the most critically injured patients.
We barely had time to reflect on the dead as more patients filled the hallways. In the midst of all of this, triage decisions came quickly—awake and talking patients with an acceptable BP were moved out of the trauma bay in favor of less stable patients. Intubation and chest-tube placement decisions were made instantly. There was no time for routine X-rays or laboratory evaluation. Nurses, technicians, and doctors crowded the trauma bay desperately trying to stabilize the critically injured. Vital signs were taken manually. Dr Ponder called his colleague Thomas N. Smith, MD, who was also a graduating senior EM resident, and who happened to be staffing the children’s ED across the street that night. “Is there any way you can make it over here right now?” he shouted into the phone. Dr Smith quickly grabbed several trauma supplies and hitched a ride with security to the ORMC ED to assist. He was confronted with the scene of the previously mentioned “first wave” and grabbed an ultrasound machine to help triage these unfortunate patients. In addition to Dr Smith, unit clerks continued making calls to additional off-duty medical, nursing, and support staff. Critical care attendings and fellows responded from upstairs to assist in the ED. The Hospital Incident Command System (HICS) was initiated to provide hospital and corporate coordination of services. Timothy B. Bullard, MD, another EM attending physician and medical staff director of HICS, was en route to the ED to assist in the response.
Amidst the overwhelming mass of mortally and critically wounded patients, we were told stories of terror from just down the road. The sense of horror was almost contagious, and we all wondered if the violence would spread to the hospital.
About an hour into the ordeal, we heard another page overhead “Code Silver, ED Triage. Code Silver, ED Triage.” Everyone in the trauma bay froze. We heard someone shout from the hallway “Shots fired in triage!” After a few seconds, those nearest the trauma bay doors pushed them shut. One of the trauma surgeons shouted, “Keep caring for your patients, push the portable X-ray machines in front of the doors.” That is exactly what happened, and we worked in the barricaded trauma room for the longest few minutes of the night. We would later learn that this report was false, but fearing for our own lives as well as the lives of our patients is an experience that few, if any, of us had previously been through. The fact that we continued to work in such a situation illustrates everyone’s dedication to their patients and mission.
After the first wave of patients, it was clear that reassessing patients was now our greatest challenge. There were multiple patients with stable vital signs but who had GSWs to the abdomen, pelvis, and thorax and required surgery. Having realized that the ultrasound machine and focused assessment with sonography for trauma (FAST) examinations were the most practical rapid imaging modality, Drs Tarkowski, Ponder, and Smith grabbed the machine and went from room to room repeating the FAST examinations, vital signs, and assessments for missed wounds. A portable computer allowed us to order X-ray orders for patients with extremity wounds. Several patients who initially had negative FASTs had a repeat examination that was positive for free fluid. The operating room triage list shuffled based on these examinations.