Certain names-Sandy Hook, Pulse, Las Vegas, Parkland-no longer designate mere places in the nation's collective psyche. They also evoke scenes of bloodshed caused by a mass shooting. Although mass shootings make up a small percentage of annual gun violence incidents-less than 1%, according to Gun Violence Archive-they are often the most memorable because of their magnitude. In 2017, the organization tallied 346 mass shootings-which it defines as at least four people, not including the shooter, being shot or killed in a single incident-up from 270 in 2014. The FBI reports that in 2016 and 2017 there were 50 "active shooter incidents"-described as "one or more individuals actively engaged in killing or attempting to kill people in a populated area" with one or more firearms. Twenty such incidents occurred in 2016 and 30 in 2017.
FLEXIBLE RESPONSE PLANS ARE CRUCIAL
Health professionals called on to care for those injured in a mass shooting face unique challenges. Jeff Solheim, MSN, RN, CFRN, FAEN, FAAN, president of the Emergency Nurses Association (ENA), tells AJN that a "well-designed disaster plan should prepare for an influx of a large number of patients but be generic enough that it can be adjusted to the event. The plan should clearly lay out how operations need to change to ensure there are adequate resources (both human and supplies) as well as adequate room to expand services quickly."
Still, Solheim stresses the importance of considering the unique challenges of each situation. "Mass shootings, for example, are more likely to require significant surgical services. Mass shootings are also more likely to spawn secondary violence that may require additional security at the facility. Natural disasters are more likely to negatively impact both the physical plant and the ability to get additional human resources quickly. If a community is struck by an earthquake, for example, there is a chance that the hospital itself may be damaged. There is also a chance that staff may be unable to get to the hospital because of a disruption in services and roads. This is why it is integral to have regular disaster drills that utilize various types of scenarios."
One hospital where rigorous disaster planning was admirably put into practice is University Medical Center of Southern Nevada (UMC), a level 1 trauma center in Las Vegas, where 104 patients were cared for after the October 2017 shooting at the Route 91 Harvest music festival that left 59 people dead and 527 injured. The night of the shooting, the hospital admitted 60 patients; within the first 24 hours, another 44 patients were treated and released, and 20 surgeries were completed. Toni Mullan, RN, clinical nurse supervisor of the trauma resuscitation unit, explains that to accommodate the influx of patients, areas in other departments, such as the ambulatory surgery area and the postanesthesia care unit, were opened. In addition, gurneys and wheelchairs were rolled outside to free up the congested interior. Nurses from all departments were called in to help, according to plans already in place. "It couldn't have gone this well without intense planning," says Mullan. But she adds that the nature of a disaster is uncertainty, and any preparedness plan should leave room for improvisation.
In a webinar organized by the Department of Health and Human Services' Office of the Assistant Secretary for Preparedness and Response, John Fildes, MD, FACS, FCCM, medical director of UMC's trauma center and chair of the Department of Trauma and Burns, explained that to create capacity, patients had to be moved quickly. "We didn't know what was happening outside our four walls," he said. "We were preparing for an attack like Paris, where multiple cells acted in multiple locations at once. We were thinking that this might only be the first wave." To increase speed and efficiency, surgical patients were grouped based on their needs-those requiring neurosurgical care were concentrated together, for example-in preparation for the specialist teams that would tend to them. "I have no doubt," Mullan says, "that the hospital could have cared for more patients should the need have risen. I've been a nurse for 30 years, and this was my proudest moment."
But not all hospitals are equally prepared: according to the results of a poll by the American College of Emergency Physicians (ACEP), about 93% of physicians said they don't believe their hospital is fully prepared for patient surge capacity in the event of a natural or man-made disaster or mass-casualty incident. Jeff Solheim of the ENA agrees. "Some communities and hospitals have very active disaster preparedness committees that regularly plan and execute disaster drills, which involve coordinated responses from multiple agencies," he says. "Ideally these drills include a variety of scenarios, [and] staff from all shifts. Unfortunately, this level of preparedness does not occur in every community and at every hospital." Toni Mullan echoes these sentiments, stressing that nationwide preparedness for disasters involving children, in particular, remains inadequate. "Pediatric patients," she says, "require different resources than adults. And to complicate matters, children often don't know such basic information as their last names or phone numbers."
In addition to a lack of preparedness, drug shortages could also impair response. About 70% of the ACEP survey respondents said drug shortages had "increased a lot" in the past year. In fact, according to the American Society of Health-System Pharmacists, 176 drugs are currently in short supply, some as basic as sodium chloride, dextrose, and atenolol.
"These shortages can last for months, or longer, and constitute a significant risk to patients," said Paul Kivela, MD, FACEP, president of the ACEP, in a statement about his organization's survey. He noted that "our system cannot even meet daily demands, let alone during a medical surge for a natural or man-made disaster."
IMPROVING PREPAREDNESS
Efforts are under way to improve disaster preparedness. In 2016, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine published a report on integrating military and civilian trauma systems to address the shortfalls of both. The report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury, reveals that trauma is the leading cause of death among Americans younger than age 46. In 2013, trauma was associated with approximately $670 billion in medical and lost productivity costs. The report estimates that optimal trauma care could have prevented up to 20% of the 147,790 deaths-about 30,000-due to trauma that occurred in the United States in 2014. Legislation has also been proposed: in May, the Senate proposed to reauthorize the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2018. Senator Richard Burr (R-NC), who introduced the legislation, noted the need "to prepare for and respond to worst-case scenarios, like pandemic influenza or a deliberate attack."
No disaster plan would be complete without debriefing for staff members. Mullan says that nurses at UMC received debriefings from social workers, as well as long-term support after the shooting. And thanks to a grant from the nonprofit Show Me Your Stethoscope, whose goal is to engage nurses in self-advocacy, the hospital has set up tranquility rooms that provide a place to withdraw and, if desired, take advantage of provisions such as aromatherapy. As Mullan says, "Practice, practice, practice. And listen to other facilities that have gone through this. It's not a matter of if, but when."-Dalia Sofer