At this point, there seemed to be a never-ending list of “Doe” names on the electronic medical record (EMR) tracking board. Tracking the location of patients was a dynamic process, and updating the tracking board was difficult. Patients were continually cycled in and out of the trauma bay, shuffled in and out of treatment rooms, lined up in the hallways, and transported up to the intensive care unit (ICU). Some of those “Doe” names belonged to patients who had succumbed to their injuries. Some patients had empty, bloody charts next to them on their stretcher. Every patient had a wristband. Dr Tarkowski improvised a rapid documentation system using quarter sheets of scrap paper that were taped either to the stretcher or door with a patient name, brief list of injuries, FAST examination result, pending tests, and medications given. This system was an efficient way of identifying which patients had been evaluated, what had been done, and what was pending.
While we were “rounding” on our patients, down the street, law enforcement had broken down the club’s wall, and a second wave of patients began to arrive. Two residents completed the secondary evaluations while the other three resuscitated new patients. The second wave seemed like a repeat of the first. Several extremity-only injuries were triaged directly to the hallways to be seen by the two residents outside of the trauma bay. By this time, the orthopedic surgery service had come down to the ED and was washing out wounds, splinting, and making plans for surgery. The internal medicine service and the medical critical care team were helping reassess patients as well.
There were many emotional moments. Dr Ponder remembered, “One of the first few patients I saw was pulseless, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’ That’s when I realized the gravity of our situation. For almost 2 hours, each resident cycled through patients.” Dr Stone recounted, “I just went down the line of patients, from head of the bed to head of the bed, some patients still on EMS stretchers, intubating many of them. It was surreal to see that many severely injured in one place.” Tory L. Weatherford, MD, recalled, “It was controlled chaos. My training kicked in, and it became about just trying to do anything possible to help.”
Dr Bondani, the overnight attending, said she does not remember many specifics from the event. “Faces and injuries blurred together. I remember looking in one young man’s eyes and telling him, ‘We are going to help you, just hang in there,’ and telling another panicking woman, ‘You’re talking, you can feel pain, you’re alive. Calm down.’ It was organized chaos as we swept from patient to patient moving as quickly as possible. Your training kicks in and you do what needs to be done in the moment.”
We were fortunate to have the EM team we did, and to be in the place that we were. On duty, we had five senior graduating residents, essentially with attending-level skills and training, who had been together since day one. “We gave everything we had; there was no time to stop. We went where our hands could be helpful—it didn’t matter if it was your traditional role or not,” said Dr Weatherford.
Dr Tarkowski remembered what it was like leaving the walls of the ED later that morning. “Leaving the hospital didn’t feel like a success. We knew the work we did was good, that we did everything we could, but it didn’t feel like it. It felt heavy. It felt empty.” Afterward, the emotional toll set in. We gathered up the names of the deceased and looked at a status board littered with “Doe” names, and we tried hard not to break down at the violence and the pain we witnessed.
Immediate Recovery Period (Prehospital Setting)
In the aftermath of the initial rescue operation, stabilization of injured victims, and demobilization of resources, a second “event” unfolded—hundreds of family members flooded to ORMC looking for unaccounted loved ones. At this point, there were dozens of deceased and critically injured patients who remained unidentified, and addressing the needs of both the victims and the families was becoming overwhelming. With the cooperation of federal, state, county, city, and private resources, a family reunification center (FRC; a family staging area/family reception center) was created and managed initially within the hospital. At this site, grief counselors, victim advocates, law enforcement and medical examiner’s officials, hospital chaplains, and translators gathered with the loved ones of those missing to synchronize efforts to identify and reunite them. The Emergency Operations Center quickly created a telephone hotline and Web site to guide those in need to this resource. Food and housing for those in need were provided by the generosity of our community—which cannot be overstated in the wake of this tragedy. As days passed, the FRC transitioned to a new location as the Orlando United Assistance Center, and will continue to serve as a navigation point for those who are and will be affected by the event for months to come.
Hospital Incident Command System
The HICS was activated shortly past 3:00 am, just after the initial wave of victims flooded our ED and the gravity of the situation became apparent. The ED and trauma services were already near full staff due to timing, rapid response, and communication between the traumatologists, as well as a bit of luck. Because of the time of the disaster, our normal notification process for incident command and all personnel was severely limited. In retrospect, this turned out to be a blessing. While everyone who normally would respond to HICS was not available, individuals serving in key positions were reached by personal phone calls and were on-site quickly. One of the main functions of HICS is to control the internal chaos that arises when a disaster occurs and all personnel want to assist in some manner. We have spent hours during drills crafting communications that target key personnel necessary to meet the mission, while controlling well-intentioned but unnecessary personnel. In our drills, this is not an issue because everyone knows the exercise is not reality; however, in a real disaster, everyone wants to help. This was confirmed by the guilt that so many of our team members expressed at not being involved that Sunday.
With an initial skeleton crew in incident command, it was easy to focus on the immediate needs of patient care. The strong leadership and cool heads of our incident command leadership led to rapid role definition and responsibility, and set forth an easy path for execution. Hospital command personnel adapted their usual roles and performed functions and assignments as needed. Many HICS staff had direct face-to-face contact with frontline providers in the ED and other vital areas. This was possible because of the close proximity of the hospital command headquarters to the ED. The need for additional resources was rapidly identified, and the hospital command leaders assumed direct responsibility for procuring them instead of delegating. A great example of this was when Orlando Health’s chief executive officer and chief operating officer went to our nearby hospitals to gather additional chest tubes after learning that we were running in short supply. Their main responsibilities lay ahead of them, and they were willing to help in any manner they could at the time. Some of the medical personnel were able to switch roles and pitch in to treat the second wave of victims that arrived at around 5:00 am.