Crisis in the ER: What to do before, after the unthinkable

Emergency department sign

headshot of Wade Fox, MDEmergency department (ED) physicians and staff are trained to cope and manage difficult and stressful situations. The responsibility and scope is clearly outlined in the very professional designation we hold.

Yet, clearly not all emergencies are the same. Some are more complex, stressful and difficult than others. My fellow physician and team members at Mercy Medical Center in Roseberg, Oregon, faced that kind of an emergency Oct. 1, 2015, when a lone gunman went to Umpqua Community College, located just a few miles from the hospital, and began shooting students and faculty. The mass shooting became the deadliest in Oregon history.

No matter your training, no matter your experience, no one is ever fully prepared for this kind of an emergency. Yet, we all somehow rose to the challenge. We pushed aside personal feelings, put our action plans into place, did our jobs, saved lives and cared for patients and their families.

That October day was a typical one at the office when at 10:30 a.m., the EMS signal went off without the typical tones. I heard the voice of the EMS operator alerting us that there was a shooter at the local college. There were multiple dead, multiple wounded and the shooter was still active.

We immediately deferred to our training and crisis manual and reached out to colleagues to assist with additional staffing, took note of our supplies and mapped out a plan for triage and treatment. 

I then realized that my 18-year-old daughter Olyvia was at UCC. I texted and called her over and over with no answer. I feared she was dead or dying. But I had to push that aside. I also knew I had to get ready for what was going to happen. We were going to be overrun with patients.
Within a few minutes, I met the first patient at the door--mostly to see if it was my daughter; it was not. However, it wasn’t until 40 minutes later, when I had seen several patients, that I finally received a text message from an unknown number that I had been waiting for: Olyvia was shaken, but fine.

Support and teamwork

While much happened during the ensuing hours, it was remarkable to experience the support we received and to witness the teamwork from my colleagues. When the shooting occurred, myself and one other ED physician, plus a physician assistant and our nursing and administrative team were on site. Within a few hours, virtually every physician, surgeon, PA and RN affiliated with the hospital, including an orthopedic surgeon and cardiologist, had showed up to offer their assistance. 

The administrative staff was especially helpful, playing interference with the media, coordinating and communicating with the friends and family (many of whom came to the hospital), helping with the many other activities that take place during a crisis; that was a true blessing.

We cared for multiple patients that day, including nine shooting victims and one patient sadly pronounced dead on arrival. While we are not a Level 1 Trauma Center (we are Level 3), we are the only facility in our community and six of the nine patients remained under our care. Three had to be transported to another facility.  

Now that several months have passed, I’ve had time to reflect on what happened. I’m often asked by other colleagues and physicians how we coped and to share recommendations. 

Steps to take: What’s not in the manual

Of course most facilities today have detailed crisis plans in place, but the situation we faced at Mercy Roseberg shows that there are other realities that must be considered as well. With that in mind, there are several steps that hospitals, urgent care centers and other facilities can consider to ensure optimal patient care and department management during a crisis.

  1. Start with the right team. If you are an administrator or medical director, don’t just hire providers. Hire physicians and clinical staff who become partners and who you would want caring for you, your family, friends and neighbors in an emergency. This is especially true in rural communities, where many clinical staff may have a personal relationship with those injured, but it also holds true in any size setting.
  2. Discard how you think you would handle a crisis. My perception of my ability to handle such a situation on my own was absolutely false. I was shaken. What helps is a well-written and rehearsed crisis plan combined with the support of a strong team and supportive administration. You may be crumbling inside, but if the infrastructure to manage and support a crisis is in place, you will get through the initial crisis.
  3. Have a plan for handling media so that your busy and stressed ED team doesn’t have to deal with that headache. It was amazing the number of media that showed up at our facility. Our small team was too busy, tired and focused on patient care to handle that distraction. Luckily our administrators and local public safety officials stepped up; their professional interference and coordination was invaluable.
  4. Be prepared to become “home base” for families and friends of the injured. As soon as word of the shooting went out, concerned family and friends came to the hospital. Someone needs to be designated to answer their questions, plus they will require a safe, quiet place to wait.  Even something as basic as parking for these people needs to be identified. Again, in our situation, this is where hospital administration played a critical role in stepping help to provide resources and support.
  5. While of course those most affected by a crisis need help, so too does staff, from the ED physicians to the environmental services team. I was lucky enough to have just completed our company’s resiliency plan prior to the shooting. If your organization doesn’t have a similar program or other service to assist and support your hospital team, consider building one soon. Keep in mind that support is needed weeks and months after the initial crisis.
  6. Recognize that everyone deals with tragedy, trauma, and loss differently. Every reaction, even to the same event, is unique. Each reaction deserves respect. Since the shooting incident, I have a newfound appreciation for patients suffering with PTSD and the physical and mental issues that come with it.
  7. Strive to be kinder to yourself and others following a crisis. Our personal lives affect our work. Accept and acknowledge this. Offering each other support in times of need does not take much. A text, an email, a phone call (of which I received hundreds) means a lot--actually, much more than you know. A personal inquiry, a hug, an interested listener or a shoulder to cry on is even more powerful.

There are other issues that each hospital or organization must address following a crisis. Another we had to manage was that we received so much food from restaurants, businesses even individuals. It was all very much appreciated as we simply didn’t have time to think about food in the hours following the onset of the crisis. Yet, we all needed to eat at some point. We also received some beautiful and thoughtful flower arrangements. Hospitals will need to set aside a place for these gifts and develop a policy for how to keep track and thank those who took the time to send something, no matter how small.

Our hospital and community is forever changed, but slowly returning to our “new normal.” Our hope is that other communities do not have to face what we did, but that if they do, they have the same professional and community support that we did during and after the crisis we faced.

Wade C. Fox, DO, FACEP, FAAEM, is an emergency department physician at Mercy Medical Center in Roseberg, Oregon, and regional director for CEP America’s Oregon and Washington regions. He has been a board certified emergency physician since 2002, and has practiced emergency medicine under certification from the state medical boards in Ohio and Oregon for more than a decade. Dr. Fox is the immediate past president of the Oregon chapter of the American College of Emergency Physicians.