#OrlandoUnited: Coordinating the medical response to the Pulse nightclub shooting Christopher Hunter, M.D., Ph.D. Director, Orange County Health Services Department Associate Medical Director, Orange County EMS System Medical Director, Orlando Health Air Care team The Event The Aftershock The Recovery Lessons Learned Discussion Summary Contents The Event An active shooter followed by a hostage scenario 1
Location Location The Attack 2:00am A man armed with an assault-style rifle and semiautomatic pistol enters and starts shooting 2:05-2:08am Police engage with shooter 2:20am he takes hostages, reports he has a bomb 2
The Attack The Attack Nearly 3 hour standoff many rescued from north and east of building 5:14 SWAT breaks through western wall and engages 7:30 last patients transported from scene > 100 law enforcement officers > 80 EMS personnel 2 SWAT teams 2 Medical Directors Incident Command The Response 3
Timeline Scene Shooting begins Police engage Hostages taken SWAT engage Shooter killed ORMC MCI Alert 1 st patient Code Silver Last patient ER reopens All patients identified 38 patients 2 patients 9 patients Family Reunification Center At hospital At hotel At senior center Timeline ORMC - Patients came in two waves o 38 patients in the first 53 minutes At the apex, 26 patients arrived in 26 minutes o 2 patients over a 119 minute period o 9 patients in 22 minutes Florida Hospital patients were mostly from the second wave The Aftermath The deadliest shooting in modern United States history The worst attack on LGBT community in documented history The deadliest terror attack in the United States since September 11, 2001 First use of Facebook safety check in United States history 4
Prehospital Approach Situational Awareness o Close distance to trauma center SAVE training o Minimal interventions performed o Scoop and run Triage tags o Modified triage performed Incident command o Distribution of patients System-wide response o Closed ORMC to all but Pulse patients o No delays across the rest of system o > 600 calls to 911 Dispatch Centers Medical Control Patient Distribution Scene (41) 39 in club 2 collection point Transported (57) 46 ORMC 15 by police 11 FHO Walk-in/POV (9) 3 ORMC 2 DPH 1 WPH 3 FHE 5
Civilians and Law Enforcement Civilians stayed to assist o Similar to Boston Marathon bombing o Potential opportunity to assist response Police transported 30% of victims o Arrived en masse to scene for all call major alert o Aurora, CO Shooting 23 transports 12 LEO, 8 POV, 3 EMS o Close proximity to ORMC allowed multiple trips o Does evidence support this? Transport of Trauma Police transport vs. ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes Wandlinget al., 2016 Identified penetrating trauma patients from 2010-2012 using the National Trauma Databank and compared mortality rates and riskadjusted odds ratio for mortality for police vs. EMS transport. 88,564 total patients, (97.2%) transported by EMS and(2.8%) by police Unadjusted mortality was 17.7% for police transport and 11.6% for EMS. After risk-adjustment, patients transported by police were no more likely to die than those transported by EMS (OR=1.00, 95% CI: 0.69-1.45) Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit) o Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS o Risk-adjusted mortality was no different (OR=1.01, 95% CI: 0.68-1.50). Patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport Patient Distribution Considerations o Proximity to ORMC o LEO and unregulated transport o Distance to regional trauma centers o Type and severity of injuries Direction o Ensure patients meeting state trauma alert criteria went to the trauma center o Disperse others to surrounding facilities Back-up Plan o Florida Hospital Orlando stated they could take a small number of trauma alerts if necessary o Rendezvous with Air Care at the helipad to transport to Central Florida Regional or Osceola Regional 6
Hospital Approach Increased staff o Opened 6 Operating Rooms o Brought in all trauma surgeons o ED staffing Throughput o Cleared TICU o Utilized PACU and MICU o Internal medicine staffed non-trauma Offload o Outside ER, allowing quick turnaround Equipment o Brought from sister hospitals Triage Scope of Patient Care Surgeries o 28 trauma cases in first 24 hours o 76 total trauma cases Resources o 550 units of blood o 17,370 surgical supplies Disposition o 8 deceased o 16 to OR (1 died en route) o 3 to ICU o 3 to step down o 8 to floor beds o 11 discharged from emergency room Last patient discharged 9/6/16 Scope of Patient Care Every patient that survived to admission is still alive today No elective procedures were canceled by ORMC on June 12th 7
Communication Scene o Unified command o No EMS report Law Enforcement Medical Direction Hospital o Difficult to wake staff o Code Silver false alarm Patient tracking o Difficult to link or chart o Triage tags? Notification system o Never updated after initial MCI Alert Multi-Agency Coordination Multiple agencies with different chains of command o Control of scene, evidence, and information o OPD, OCSO, OFD, OCFR, FBI, FDLE, ATF, DEA, DHS, and Secret Service Lack of pre-existing relationships The Aftershock The approach to mass fatality situations, family reunification and media relations 8
Mass Fatality Hospital o Respectfully hold decedents while caring for other patients Scene o Access to federal crime scene o Coordination of decedent transportation Medical Examiner s Office o Storage o Equipment o Staffing Autopsy reports Mass Fatality District Nine Medical Examiner s Office o Called in all staff o Assistance from Florida Emergency Mortuary Operations Response team Autopsies o All performed within 48 hours Injury Patterns o 209 total gun shot wounds o Number of gun shot wounds per victim ranged from 1-13 o Mean 4.2 per victim o Only 6 had a single wound (4 head wounds) o No isolated extremity wounds Injury Profile The profile of wounding in civilian public mass shooting fatalities Smith et al., 2016 Retrospective study of autopsy reports from 12 civilian public mass shootings o Average 2.7 GSWs, 58% to head and chest versus 20% with extremity o Probable fatal wound was head or chest in 77% of cases Only 7% had potentially survivable wounds and no deaths reported from exsanguination from an extremity Pattern is different from combat, the solution goes beyond tourniquets 9
Family Reunification Unforeseen need o Needs to start immediately Hotline o Lines and call-takers o Script for right info Location o Identify locations prior to events Resource heavy o Transportation, Housing, Staff Coordination o Massive number of agencies Investigators, medical examiner, crisis assistance, counselors, chaplains, security Privacy laws Public record laws Points of contact Social media Elected Officials Media Relations Privacy Laws 10
Support Function Rehab HAZMAT Waste Evidence collection Post-exposure prophylaxis The Recovery Crisis assistance and community outreach Crisis Assistance Employee Assistance Programs o > 1,200 at ORMC 956 served at the Citrus Bowl Victims and Community o Distribution of donated funds 11
Vigils Community Support Community Support 12
Community Support Summary Preparedness o Drills o Long term strategies (graduate medical education, hospital and medical examiner expansions) Relationships o Existing law enforcement, hospitals, EMS, elected officials Evidence-based practice o S.A.V.E. training for EMS o Protocols for law enforcement transport o Mass fatality plans o Tactical medical training for law enforcement 13
Disaster Planning Versus Reality Dispatch units will self dispatch Rescue initial evacuation/rescue performed by survivors, not emergency personnel Field Triage casualties bypass triage and go directly to hospitals Transport casualties will be transported by non-ems vehicles (personal vehicle or law enforcement) Distribution casualties will go to nearest hospital regardless of capabilities Notification hospitals will not have advanced warning of potential influx of patients Hospital Triage the least serious injuries often arrive first Disaster Planning Versus Reality - Pulse Dispatch units will self dispatch YES Rescue initial evacuation/rescue performed by survivors, not emergency personnel YES Field Triage casualties bypass triage and go directly to hospitals SORT OF Transport casualties will be transported by non-ems vehicles (personal vehicle or law enforcement) YES Distribution casualties will go to nearest hospital regardless of capabilities YES Notification hospitals will not have advanced warning of potential influx of patients YES Hospital Triage the least serious injuries often arrive first NO Future Add Family Reunification Center/Hotline to mass casualty plans Bleeding Control for the Injured (BCON) stop the bleed training for law enforcement and community Improve patient tracking in MCI scenarios Improve patient identification in MCI scenarios Ensure real-time updates on notification system 14
#OrlandoUnited: Coordinating the medical response to the Pulse nightclub shooting Christopher Hunter, M.D., Ph.D. Director, Orange County Health Services Department Associate Medical Director, Orange County EMS System Medical Director, Orlando Health Air Care team 15