Preparing for emergency response in mass casualty events

Pharmacy staff at Orlando Regional Medical Center share lessons learned

Health-system pharmacists regularly train for mass casualty events. But it’s difficult to be prepared for the worst shooting in U.S. history.

The medical team at Orlando Regional Medical Center (ORMC) learned many lessons during the early morning hours of June 12 when dozens of critically injured patients came through the emergency department (ED) doors after the Pulse nightclub massacre that left 49 people dead. Pharmacists and pharmacy technicians were there with doctors and nurses every step of the way.

“When you think of the Orlando crisis, the ED was overwhelmed with patients who needed to go into surgery or the ICU,” Frank Federico, BSPharm, vice president at the Institute for Healthcare Improvement (IHI), told Pharmacy Today. “In this type of situation, it’s of key importance to have pharmacists readily available not only as part of the health care team and decision making process, but also to make sure the appropriate departments are getting proper support in the distribution of medicines and I.V.s.”

Whether it’s a mass shooting or a natural disaster, pharmacists play a significant role as members of the response team. Being prepared is more critical than ever today, said Federico, and knowing the part every member of the team will play is part of preparation.

‘It happened at 3:00 am when staff was leanest’

As the first couple of shooting victims were rushed into the ED at ORMC—the only Level 1 trauma center in central Florida—staff knew it was not going to be an average night.

“We are a busy hospital and anticipate a fair amount of activity, but we didn’t anticipate this,” Bill Wilson, BSPharm, BCPS, pharmacy manager at ORMC, told Today.

Casualties rose quickly, and some of the first victims who came to the ED at ORMC arrived in truck loads, not ambulances.

“It happened at 3:00 am when staff was leanest,” Mikko Isaac, PharmD, BCPS, assistant manager of pharmacy operations at ORMC, told Today. As a result, pharmacists and technicians had to help in places they hadn’t necessarily planned for during hospital drills. The night of the attack, pharmacy technicians were moving patients or gathering information on patients in addition to their assigned tasks.

Initially, there was confusion about the number of victims, as well as conflicting information about the movement of the shooter toward the hospital. Hospital staff were managing that threat and the anxiety that came with it.

Right away, pharmacy technicians responded with a medication surge cart to the ED. They also prepared more intubation kits and restocked code carts.

Five individuals normally comprise an overnight pharmacy staff, but more pharmacists and pharmacy technicians were called in early for their shift on June 12, which was a Sunday. The pharmacy needed help making sure that the rush of medication used in the ED was replenished appropriately and promptly, according to Wilson.

More pharmacy staff started to come in around 5:00 am Sunday, around the time the second wave of patients started to arrive, which is also when the operating room (OR) pharmacy opened.

“We had six trauma ORs operating nonstop,” said Wilson.

Throughout the morning, pharmacists continued to check code carts, refill trays and kits with needed medications for rapid sequence intubation, as well as replenish other necessary medications. Pharmacists responded to drug consult requests for antibiotic dosing and monitored critical drips as the injured were moved to critical care areas.

“The medication used most was probably fentanyl; there were some really bad wounds,” said Wilson.

The ED pharmacist on staff that night was making sure patients got antibiotic prophylaxis and needed vaccines.

The pharmacy at ORMC backs up to the ED, which meant supplies didn’t have to move far, saving even more critical time for patients.

Isaac said the overnight pharmacy technician was at the entry point ready to distribute medication.

“They [pharmacy technicians] went above and beyond—some refilling code trays and kits while others were delivering medications to the ED,” Abigail Capo-Martinez, CPhT, pharmacy technician supervisor at ORMC, told Today.

Meanwhile, the rest of the patients at ORMC also needed to be taken care of, and many of the pharmacy technicians delivered medication to their floors.

The pharmacy technicians at ORMC, along with everyone else, would later find out that two of the victims were pharmacy technicians. They were Stanley Almodovar III, CPhT, and Amanda Alvear, CPhT. A third victim, Martin Benitez Torres, was studying to become a pharmacy technician. All three died in the attack.

Simple, important steps to take in preparation

ORMC normally holds mass casualty drills every 6 months. The most recent one took place 3 months before the Pulse nightclub shooting.

“There were lots of lessons from the drills we were able to implement right away, but there are elements you can’t expect. Beyond meeting drug distribution needs, there are extra patient care steps you need to take that you can’t prepare for,” said Isaac.

Knowing where supplies are and making sure guidance documents are readily available and staff contact information is up-to-date are simple and important steps in the preparation process, according to ORMC pharmacy staff.

Advice for pharmacist emergency responders

In most cases, IHI’s Federico advises pharmacists to first continue with patient care in-house and to then work with the medical team to make sure there is access to medications, especially if the crisis calls for a specific medication not readily available in large quantities.

Pharmacists in the ambulatory care setting also have a role in making sure there is continued access to medications. In natural disasters where victims’ homes might be destroyed, Federico said pharmacists need to know how to manage proper storage of medications and pass that information along to patients.

Federico said it also becomes vital that pharmacists are aware of other issues affecting patients. For instance, patients may not be properly hydrated or nourished during a natural disaster, which may affect medication absorption or effectiveness.

At the same time, pharmacists and other medical providers involved in the effort need to take care of themselves.

“Your own physical health becomes really important,” said Federico. “If you lose your ability to support the emergency response, then that’s one less person who can help.”

The emotional well-being of the response team is also something to consider.

“This is difficult for staff too, and it’s important that we also care for them,” said Isaac.

ORMC followed up with all the pharmacists and pharmacy technicians who were there during the first, second, and even third shifts after the attack. ORMC also provided counseling and other support services.

Resources for pharmacists

According to Michael Jackson, BSPharm, CPh, executive vice president and CEO of the Florida Pharmacy Association, a resource for facilities looking to build a plan for an active shooter can be found at the Department of Homeland Security.

Pharmacy directors should be aware of guidance and news from ASHP as well as the National Association of Boards of Pharmacy on what to do in an emergency.

“Absent those procedures, it is recommended that you engage your administration or management on a proactive plan to safeguard the lives of your staff and any clients that you are serving,” said Jackson.

“Hopefully, we never have to experience what happened in central Florida on June 12, 2016.”