The one thing that resonates in all the news reports about the five mass shootings that tore through the United States last year is the uncertainty: Police not knowing who the shooters were, EMTs wondering if they were about to come face-to-face with a gunman, emergency physicians unsure of what would come through the doors next.
All the events shared common threads, from the first shooting of the year in Charleston to the last one in San Bernardino: fear, grief, anger. But most significantly to emergency clinicians was how little time they had to prepare for these no-notice, high-impact events that tested their readiness and preparation.
More and more, emergency departments try to prepare with drills and protocols, but the usual disaster drills just may not cover it anymore. Or as health care professionals from the Assistance Publique-Hôpitaux de Paris wrote following the attacks there in November, “As terrorism becomes more lethal and violent, nothing will prevent the medical community from understanding, learning, and sharing knowledge to become more effective in saving lives.” (Lancet 2015;386:2535.) That was, in essence, a call to action.
Leonard Cole, PhD, the director of terror medicine and security in the department of emergency medicine at Rutgers New Jersey Medical School and a professor of the terror medicine course, agreed, noting that educating first responders and specialists is crucial with the potential for more violence looming.
Dr. Cole said it's impossible to spend every day thinking of all the worst things that could happen, so denial offers psychological opportunities to function in pretty much normal ways even though lurking in the background is the knowledge that the quiet period will be spoiled before long. “Whenever there's an uptick in the number of terrorist attacks anywhere in the world, there's more sensitivity to this issue and particularly so if the attacks occur within the United States,” he said. “But if there's a lull of several months before another major incident is reported, then all of us tend to possibly put our guard down. I think that's part of human nature.”
Rutgers' terror medicine course started in early 2014, a two-week elective available to all fourth-year medical students that incorporates lectures, guest speakers, videos, experts in various fields, and hands-on exercises. (http://bit.ly/1PAgTse.) “It opens their minds, even if they don't directly engage in emergency medical response, to the possibility that this could happen and [they could] be of direct benefit if they're in the vicinity of a terrorist attack. [T]heir view is that it ought to be taught or available for every physician and especially those involved with emergency medicine,” Dr. Cole said.
The best part of the course was the drill, according to Michael A. Hayoun, MD, now an emergency medicine resident at Einstein Medical Center in Philadelphia. “We are clinical people, so trying [out disaster medicine] in a high-fidelity simulation was very helpful. We failed miserably, but we learned so much from that failure. Physicians have egos, and in a large incident, it's likely they won't be in charge of everything, which is why it's important to learn how to be a team player early,” he said.
Regardless, other hospitals around the country, particularly those affected by attacks, have worked on revising their protocols for any sort of attack. A group of Israeli physicians spoke at Massachusetts General Hospital in 2005 about their experiences with urban bombings, and the Boston-based staff learned a lot of its planning assumptions were wrong. “We thought we'd have more time than they typically have between a bomb going off and the first patients presenting, so we thought we'd have more time to react, to assess the situation, to prepare. And they told us that wasn't the case. They talked to us about how we can better coordinate the emergency department, the surgical capabilities of the hospital, and some other key lessons from that,” said Paul Biddinger, MD, the director of the Center for Disaster Medicine and the vice chairman for emergency preparedness in the department of emergency medicine at Massachusetts General.
Following the visit, the hospital spent the next few years developing a specific mass casualty protocol. The hospital admitting office, for example, automatically starts to find beds because they assume the emergency department will be crowded. “The purpose of the protocol was to make sure that a large number of things happen very, very quickly without one commander having to issue a whole bunch of different orders. So when the [Boston Marathon] bombing happened, [our preparation] actually really paid off well for us,” Dr. Biddinger said.
Despite the number of protocols a hospital puts in place or however many drills a staff completes, the reality is still that handling the aftermath of an attack is going to take an emotional toll. “Normally in emergency medicine, you can compartmentalize your life, but when you realize it's your own family, your own kids, your own road, it made for a difficult day,” said William Begg III, MD, one of the emergency physicians on duty during the Sandy Hook massacre. “I was the lead clinical doc that day, and I didn't really discuss the degree of the tragedy right up front to the providers because I felt it may have impacted their ability to provide care in the first few minutes until I had more verifiable information,” he said, noting that he knew some staff who had lived nearby may have been personally affected.
“We had our routine emergency management plan, we had our drills, we did everything we had to do to be compliant [as] an organization, and we did have motivated EM personnel who met regularly. We all had the basic tools to be prepared. Our EMS folks had practiced how to deal with a tragedy in the field, so we did have some training, but we never could have prepared for the gravity or the emotional component,” said Dr. Begg, the vice chairman of Danbury Hospital's emergency department in Connecticut and the EMS medical director of the hospital.
Drs. Biddinger and Begg said their hospitals revised protocols and added certain measures from lessons they learned after their respective attacks, including the increased intensity and frequency of the mass casualty incident-related exercises and the emphasis of a lower threshold for emergency management activation based on limited early information. One lesson that remains universal is that attacks don't have location bias.
“As we see in rural Oregon, in Colorado, in Boston, in San Bernardino, these events can happen anywhere. They happen with absolutely no warning, and you will either be ready or you won't,” said Dr. Biddinger. “If the assumptions on which your plans are based are faulty, yes, people will respond and do well, but they'll do less well than they could if you have the right resources in place. Every emergency physician has to know how he or she would react and what their hospital's plans are for a no-notice terror event. Just because you're urban or rural doesn't mean an event can't happen to you.”
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