After Orlando, National Academy of Medicine offers mass shooting guidelines for healthcare providers

Following the June 12 shooting at an Orlando nightclub that left 49 people dead and 53 others wounded, the National Academy of Medicine released a paper instructing healthcare providers on how to react in a similar situation and detailing the impact of mass casualty events, such as mass shootings and terrorist attacks, on the healthcare profession.  

“Health and Medical Response to Active Shooter and Bombing Events” includes perspectives on preventing such attacks and how hospitals, emergency medical services (EMS) responders and communities can prepare and respond to them.

 “Today, active shooter events are becoming more common and, as was shown in Boston, use of improvised explosive devices is no longer simply a problem for those who are overseas," the authors wrote. "Furthermore, assailants often use military-style firearms, which have much greater lethality, firing rate, and wounding potential, than many civilian weapons. It is time to change our response paradigm.”

The paper’s first focus is on the near impossibility of predicting events in which dozens of people are injured and the difficulty of preventing them. The authors encourage law enforcement to collaborate with the healthcare community when it comes to a multi-faceted “violent extremism” prevention, since it’s causes are often multi-faceted. 

“Because the antecedents to events of terror are very often rooted in social disenfranchisement, and often exacerbated by preexisting mental health issues and in some cases socioreligious or political estrangement, preparedness focused on prevention must begin with strong links to the community,” they wrote.

They say communities must be trained to “hide, run, fight” and maybe even to administer emergency first aid on site.

The authors also acknowledge that healthcare’s main role in a situation such as the one in Orlando will be as emergency first responders. The paper offers them advice to prepare for and then respond to similar incidents.

They recommend hospital staff, EMS responders and law enforcement work together to “realistic[ally] and frequent[ly]” practice their responses to mass casualty events in order to establish communication and transportation channels and develop “muscle memory” of the plans that can be relied on in real situations when judgement could be clouded by danger or stress.

They note that many of the injuries will be the kind seen in war zones—more patients than usual, and with “gunshot wounds and shrapnel injuries, bomb and blast effects”—and so advise taking a cue from military first responders.

A recent report from the National Academies of Science, Engineering, and Medicine said applying military expertise to trauma care could prevent 30,000 trauma deaths annually, including some related to gunshot wounds. 

Health officials and others should learn to quickly differentiate living victims from safe ones, the authors say, and secure health care facilities from further attack and be ready to treat lots of people who are bleeding.

EMS should learn to protect themselves from any possible still-active attackers and be ready to send victim information on to trauma centers right away.

Hospitals should develop plans to for “callbacks of offsite personnel,” surge capacity and surge discharge practices and securing the physical safety of the facility. They should engage more experienced surgeons for patients’ first evaluations and have white boards on hand to communicate with victims who might be in shock or have impaired hearing from a bomb blast. They’ll also need to have a plan for acquiring extra supplies such as blood for transfusions, surgical tools and tourniquets.

Hospitals should also watch out for the possibility of confusing victims’ identities and develop a system for prioritizing treatment.

According to the authors, “Severe extremity injuries may be able to wait for operating room access after tourniquet use or other hemorrhage control, but truncal injuries with shock must be prioritized for immediate operative intervention.”

The paper also reminds healthcare providers that not only will they have to deal with the event’s emotional impact on the community but also their own emotional fallout from treating a large number of violent injuries.

Some of the potential problems outlined in the paper were real issues faced by doctors, police, EMS workers and others in Orlando.

The New York Times reported a hospital down the street from the scene of the attack at the Pulse night club, Orlando Regional Medical Center, was low on equipment used to treat people shot in the chest, had an emergency preparedness responder who was at home asleep and didn’t have a good way to get patient info from overwhelmed EMS workers.  They faced those issues even though they had just held a mass casualty simulation in March.