After receiving an early morning call about a mass casualty incident on June 12, 2016, Dr. Joseph Ibrahim, trauma medical director for Orlando Regional Medical Center, made his way to the hospital.
At first, everything was relatively quiet and nothing seemed out of the ordinary. But he was one of many clinicians aiding the victims of a mass shooting at Pulse, a gay nightclub in Orlando, that killed 49 and injured 53.
"Once I opened the doors into the trauma bay, it was obvious that this was something on a larger scale than what I anticipated and what we had seen before," Ibrahim said.
Ibrahim said he immediately began helping triage dozens of patients, making split-second decisions to prioritize life-threatening injuries to patients' abdomens and chests rather than bullet wounds in arms. In the heat of the moment, he compartmentalized his emotions, focusing on working effectively and efficiently to keep patients alive.
"It really didn't hit me that hard until really the next day, when you go home and you start thinking about how these poor people were just out trying to have a good time, they weren't hurting anybody, and in a blink of an eye they were taken out for no good reason," Ibrahim said.
After the tragedy, the medical center became a nationwide leader in caring for the mental health of its staff surrounding traumatic events, and creating complex drills to prepare for the possibility of another mass shooting.
Mary Senne, director of physician wellness & resilience at Orlando Health, said she worked around the clock the first three days after the Pulse shooting, holding debriefings for staff and giving one-on-one support.
Orlando Health already had an employee assistance program in place, but Senne said she realized they needed to make more resources easily available and confidential for physicians to access.The medical center now has compassion rounds, mindful exercises, yoga, meditation, resting rooms and a buddy system available for healthcare providers.
"That notion of caring for each other has stuck," Senne said. "I think it has bode well for the COVID-19 epidemic this past year."
There have been more than 232 mass shootings in 2021, according to the Gun Violence Archive, and there were 600 mass shootings in 2020. Each incident killed or injured four or more people, not including the perpetrator.
The prevalence of these incidents has pushed more emergency departments to prepare for shootings, and they recognize that mental healthcare should be a part of that planning.
"There's a large stigma around mental illness in healthcare," said Megan Ranney, emergency physician at Rhode Island Hospital and associate professor at Brown University. "Many boards of licensure actually ask whether you are currently or have previously been receiving care for mental illness or substance use. So you could potentially lose your license if you seek care in some states. There's also a cultural issue of not admitting weakness."
Health system leadership needs to actively encourage clinical professionals to take part in a critical incident stress debriefing and promote a focus on mental health, said Dr. James G. Adams, senior vice president and chief medical officer of Northwestern Memorial. He said it is critical that anyone who cares for mass shooting victims is involved in a debriefing to stop, take deep breaths and process the trauma they have experienced as responders.
For some individuals, Adams said they may need ongoing supportive counseling because these events can affect people personally and professionally.
"We under-recognize the psychic toll that clinical care takes on caregivers," Adams said. "We're increasingly putting wellness programs in place, but I think we're really only at the beginning stages of what this demands."
Ibrahim said even before the Pulse shooting, the Orlando Regional Medical Center was good at planning drills for shootings and disaster management. Since then, he said the drills have become more realistic and are more outside the box, pushing scenarios to the point of failure and taking the discussion of preparedness to the next level by working with massive amounts of patients with fewer staff members.
The hospital collaborates with regional trauma centers, first responders, law enforcement agencies and other organizations to coordinate various drills as well.
"The drills don't prepare you emotionally for that moment, but they at least put you in the right position, and give you the right steps," Ibrahim said. "That repetition of those drills will help improve your chance for success and more importantly, your patients' chance for survival."
In addition to preparing healthcare professionals for shootings, Dr. Chethan Sathya, pediatric trauma surgeon and director of Northwell's Center for Gun Violence Prevention, said hospitals can help non-medical civilians prepare for and prevent gun violence through community outreach, research, advocacy, medical education on how to stop wounds from bleeding, and clinical integration, which includes screening patients for firearm injury risk and intervening as necessary.
"We believe that the healthcare industry is uniquely poised to act when it comes to prevention from an apolitical harm reduction standpoint, very much focused on injury prevention, and having nothing to do with the Second Amendment or gun ownership," Sathya said.
In many cities, shootings and mass casualty events are daily occurrences that healthcare providers have to handle, according to Ranney.
"[Don't] think that this is not going to touch your healthcare system, because inevitably, it will," Ranney said. "Whether it is a domestic violence shooting, or whether it's one of these public mass shootings. Every healthcare system needs to be prepared for these events, both in terms of the immediate response and supporting staff afterwards."