How can communities prepare for mass shootings? Orlando offers lessons

As doctors treated the horrific injuries of victims shot in the Pulse nightclub massacre here, a mistaken report of a gunman nearby forced officials to briefly lock down the emergency room; the medical staff shoved heavyX-raymachines against the doors, creating a makeshift barricade in a treatment bay.

Emergency room physicians ran low on tubes needed to reinflate the lungs of patients shot in the chest. The doctors scrambled to make sense of gunshot wounds because paramedics had rushed victims in with no time to assess their conditions. The hospital’s emergency preparedness manager, asleep at home, received an urgent email but did not respond until awakened by text.

But of the 44 patients brought to Orlando Regional Medical Center with life-threatening gunshot wounds in the early hours of June 12, 35 survived.

The Pulse nightclub massacre has put Orlando on a growing roster of places — Columbine, Virginia Tech, Aurora, Newtown, Paris, San Bernardino — forced to confront attacks with injuries comparable to those in war zones. More will become clear over time, but Orlando’s response is already beginning to provide lessons on the challenges, large and small, of dealing with mass shootings, as well as what went right and what went wrong, what can be anticipated and what cannot.

And it is raising hard questions about how to act when medical priorities and law enforcement ones can seem to be at odds.

Across the nation, and the world, the realization that mass killings are the new normal has been gradually sinking in. On Friday, the National Academy of Medicine in Washington published adiscussion paper— titled “Health and Medical Response to Active Shooter and Bombing Events” — that details best practices to help communities become better prepared. It warns that many are ill equipped for a “surge in major trauma cases.”

Orlando, a major tourist destination, had worked hard to prepare. In March, Orlando Regional Medical Center, the only major trauma center in Central Florida, staged a realistic, large-scale “active shooter scenario” simulating a school massacre that had left 500 wounded. Fifty agencies, including the F.B.I., participated in the four-hour exercise. High school students in ghastly makeup flooded 15 hospitals.

The Pulse shooting — which killed 49 and wounded 53 — turned the March drill into a middle-of-the-night reality for scores of doctors, nurses, hospital administrators, paramedics and pathologists. Wrenching questions remain: Could more lives have been saved if the police had stormed the nightclub earlier? Did terrified victims bleed to death waiting for help to arrive?

The Orlando experience validated what experts in emergency medicine had long known: The faster victims can reach the hospital, the more likely they are to survive. Of the 49 victims, just nine died in the trauma center — and they died minutes after arriving, hospital officials said, which suggests they had been mortally wounded.

The Pulse survivors owe their lives in part to agrim coincidence: The trauma center is just a few blocks from the nightclub. Given that, Orlando may not be a perfect model for what could happen elsewhere.

“Because of the proximity, we felt that more lives had been saved than if it were anywhere else,” said Eric Alberts, the hospital’s emergency preparedness manager.

Mr. Alberts, 39, who previously ran emergency operations at Disney World, said the active shooter drill in March, which he organized, had proved “very similar” to the Pulse massacre.

Even so, said Dr. William S. Havron, a trauma surgeon who spent the night operating on victims, “I don’t think anybody can ever be fully prepared for something like this.”

Dr. Chris Hunter, an emergency room physician and the director of the health services department for Orange County, Fla., which includes Orlando, was on an overnight shift at a hospital 20 miles away when he received a text that thrust him into supervising the response.

He made a fast decision: Orlando Regional Medical Center was going to Status Black.

That designation meant the trauma center’s emergency room would be closed to all but the shooting victims and others with serious injuries. People withsprains, sore throats or earaches would be sent elsewhere.

“We never do that,” Dr. Hunter said.

Outside Pulse, about 80 paramedics were furiously trying to cope with the carnage. Working with two cellphones and a two-way radio because he could not leave his nighttime post, Dr. Hunter tried to track the paramedics to let the emergency room know when the next patients would arrive. Thirty-four ambulances were making round trips.

Paramedics usually radio ahead to the emergency room with each patient’s condition so doctors can prepare. But at Pulse, there was not always time for that. And the police and bystanders were also driving victims to the hospital.

“It was great for the patients, but hard on the staff,” said Dr. Gary A. Parrish, the director of the emergency department.

Dr. Havron, the trauma surgeon, had just drifted off to sleep after feeding his 4-day-old son when he received the call. When he arrived at the emergency room, he could not enter; it was locked down with the mistaken report of a gunman. He called a colleague, who told him to go upstairs to the operating room. Dr. Havron performed six operations that night.

Vexing Challenges

Experts know that good communication is critical in managing a crisis. But as more patients arrived, many unconscious and without identification, Mr. Alberts, the emergency preparedness manager, missed his first alert about the Pulse shooting, an email at 2:21 a.m.; he was at home asleep. “That was one of the glitches we found that didn’t really work too well,” he said. It was not until 3:42 a.m. that he was awakened by a text from his boss.

On Mr. Alberts’s orders, the hospital activated an emergency plan, moving patients around to make room for victims in the intensive care unit. Supervising the response from a command center, he confronted other challenges, not life or death, but still vexing.

A well-meaning donor sent 50 pizzas; Mr. Alberts had them thrown out, fearing a terrorist’s poison. Foreign consuls showed up, demanding a list of patients’ names that could not legally be released; he politely referred the consuls to the State Department. Digital fingerprinting failed to identify an unconscious patient; an old-fashioned inkpad worked.

Casualties came to the hospital that night in two waves, the first around 2 a.m., shortly after the shooting started. The second wave, victims who had been trapped in the club with the gunman, arrived around 5 a.m., after the police had blasted through a wall in the club and killed him.

Dr. Havron and five other trauma surgeons at the hospital performed 28 operations that night. Of the 44 patients brought to the trauma center, eight died in the emergency room within minutes of their arrival, another died on the way to the operating room and 35 were admitted. As of Sunday, four remained in critical condition.

“Everybody that made it to the operating room is still alive,” Dr. Havron said.

But Dr. Jay Falk, the academic chairman of emergency medicine at the trauma center, warned that if there had been twice as many casualties, they might have overwhelmed the system.

This is a problem the hospital will have to address, he said, adding, “We have to rethink that.”

Across town, at Florida Hospital Orlando, victims with less serious injuries began arriving around 3 a.m. Eventually there would be 12 of them. Most had been shot in the arms or the legs; one had been trampled.

The patients were awake and stable, and F.B.I. agents were eager to question them. Lorinda Stahley, the nurse manager for the emergency department, approached the victims gingerly.

But, she said, “They were all ready and willing to be interviewed.”

Four needed surgery. Dr. Brian Vickaryous, an orthopedist and former Army surgeon who operated on combat injuries in Iraq, performed the operations. Each bullet he pulled out went to the F.B.I.

Angel Santiago, 32, of Philadelphia, was one of his patients. Mr. Santiago had been trapped in a bathroom in the club, lying in a pool of blood. He had been shot in the legs; he could see a bullet hole in the chest of his friend, who was sweating profusely. The two grew weaker as they waited, desperately, for the police to arrive.

“By the time I got to the hospital, they said myblood pressurewas very low,” Mr. Santiago said. “I was dizzy, cold; they gave me two units of blood to try to stabilize me.”

He later learned that his friend, sent to another hospital — presumably Orlando Regional Medical Center — was in critical condition. He survived.

Of the 50 who died, including the gunman, 39 died inside the club. Two more were found on the street outside. Those numbers, along with accounts like Mr. Santiago’s, raise agonizing questions about whether more lives could have been saved if the standoff had ended sooner, and whether some victims had bled slowly to death. Dr. Vickaryous, like many medical professionals here, did not want to second-guess law enforcement.

“We have a saying in medicine: ‘The retrospect-o-scope is 20-20.’” he said.

The dead were brought to the Orange County morgue, which upgraded its capacity in 2010 to store as many as 150 bodies, with a plane crash or a tornado in mind. Dr. Joshua D. Stephany, the county medical examiner, supervised the autopsies and performed some himself.

“I don’t think anyone had prolonged suffering,” he said in aninterview.

Evaluating the Response

Autopsy reports could help explain how victims died, by describing the wounds. But no details have been released because the investigation is in progress.

Analysis of bullets like the ones Dr. Vickaryous removed from victims may eventually answer another difficult question: whether some people were caught in the crossfire and shot by the police, said Dr. Jan Garavaglia, Dr. Stephany’s predecessor.

The response to the massacre is already generating debate in academia.

Dr. Irwin Redlener, the director of the National Center for Disaster Preparedness at Columbia University, said there was little doubt that more of the injured would have survived if they had been rescued sooner.

But he also urged against judging the police, because the gunman had boasted that he had bombs and accomplices. Both claims were lies, but no one could be sure at first.

As to whether victims had died quickly or suffered, it depends on where the bullets hit, Dr. Redlener said.

Here in Orlando, officials are just beginning to evaluate their response, even as they continue to care for patients, plan funerals and tend to their own emotional trauma. Mr. Alberts, the emergency preparedness manager, has had two debriefings with his medical team.

At the Orlando Fire Department, Chief Roderick S. Williams, who supervised many of the paramedics first on the scene, is planning to “tell others our lessons learned.” Fire chiefs from New York; Aurora, Colo.; and Boston — cities that have also confronted traumas — have already reached out to share their information.

“As the next city to experience a horrific event like this,” Chief Williams said, “we have to pay it forward.”