M L Davis, MD FACS 12-8-12

1. M L Davis, MD FACS 12-8-12

2. November 5, 2009 2

3. 1:28 p.m. • Several rows of desks with five foot high partitions (“cubicles”) • Only one usable door in and out • More than 300 soldiers and civilians crowded into the space 3

4. On the Scene Initial shots fired at 1328 In the span of 10 minutes: 11 dead, 32 injured Soldier graduation Chaotic, unsecured scene; minimal organized triage Most of injured transported to Darnall Army Hospital 4

5. The Shooter’s Weapons The Shooter had two handguns: A FN Five-seven semi-automatic pistol (Belgium) (12-30 round magazine), Purchased at a local civilian gun store 146 spent casings in SRPC 177 unused rounds found within 10 magazines A .357 Magnum which he may not have fired.

6. Minutes Later at the Scene… 2 min and 40 seconds after the 911 call, responders arrived at the scene 1 ½ min later the gunman was incapacitated 13 people were killed, 30 others wounded Two ambulances arrived on scene about 3 min later 6

7. 2:00 p.m. Activate Full Alert Activate Full Alert “Possible Mass Casualty Shooting at Ft Hood...ICC Opening”

8. 2:00 p.m. Fearing that the surgeons that needed to respond to the ER might not all know what “activate full alert” meant, a number of general, vascular, thoracic and trauma surgeons were paged. “Go directly to ER, Mass Shooting at Fort Hood”… The OR front desk was made aware aware, and the head nurse and Anesthesia Chair were informed… 8

9. 2:05 p.m. - The Operating Room… 76 elective cases that day Elective cases most days begin to ratchet down between 2:30 and 4:00 p.m. to make room for add-ons from the night before, etc... Several patients that were about to undergo general anesthesia were moved from OR to PACU Discharges from the PACU were accelerated to the floor and ICU SHIFT CHANGE…! 9

10. 2:20 p.m. - The ER 6 Trauma Bays (new facility, 2007), fully equipped and ready to go More than 20 surgeons prior to first patient ER staff (10) Anesthesia staff (4-5) Surgery and ER residents SHIFT CHANGE… Hundreds of others, some needed, some not needed… 10

11. What we heard in the ER…ER staff, security, people on the phone… “It’s an organized, large scale, terrorist attack…” “There are four or more (groups of) shooters…” “An entire army company has begun to shoot other soldiers…” “A dirty bomb went off on base…” “There are terrorists scattered around the area, in several spots and not just Fort Hood, so they locked down all the schools…” “There are reports of other shootings around the country, like the Tet offensive!...” A lot of soldiers have been killed and there are hundreds of wounded…” 11

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13. Darnall Army Hosp. (Level III) 24 patients evaluated 5 operations on 4 pts 1 death Metroplex (Level IV) 7 pts received 1 pt DOA (GSW chest) 2 pts OR (GSW femoral artery, SB, Colon) 4 pts transferred Scott & White (Level I) 10 pts received over 2 hr period Regional Triage of Victims

14. 2:33 p.m. – First Patient 10 patients in less than two hours, first 6 in less than one hour Three air, seven ground transfer 5 immediately to OR 4 to floor 1 direct admit to ICU 14

15. Trauma Foster GSW head, arm Trauma Norton Multiple GSW abdomen and face Trauma Brad Multiple GSW abdomen Trauma Roy GSW abdomen Trauma Lance GSW right subclavian artery and brachial plexus Injured PatientsTreated at Scott & White

16. Trauma Omar GSW bilateral thighs Trauma Juan GSW humerus Trauma Tracy GSW forearm Trauma Randy GSW femur, buttock Trauma Willie Multiple GSW chest, back, arm, leg Injured PatientsTreated at Scott & White

17. CNN Bulletin, “We believe that this is a photograph of the shooter, and we have been told that it is now confirmed that he was shot, and killed at the scene…” 17

18. Despite injury severity, no patient treated at Level I Center was lost Carl R. Darnall Army Med Ctr Level III 35/14/6 Scott & White Memorial Level I Metroplex Hospital Level IV 11/10/9 7/3/3 5 direct from scene 1 from Metroplex 4 from Darnall Facility Trauma Level Designation Seen / Admitted / to OR Triage Info Both patients from Metroplex Seton Williamson County Undesignated (now L II) 2/2/2 18

19. Security Issues Were Significant First time S&W has ever been completely “locked down” Media intrusion attempts Families Other soldiers What do you do with suspected shooter? No report of his whereabouts or condition Move from ICU to corner OR in less than 12 hours Quiet transfer at the appropriate time to BAMC 19

20. Security Issues 20

21. Blood Bank Challenges Not as much of a problem as anticipated Massive transfusion protocol activated A total of 35 units of products issued (RBC’s, cryo, platelets, FFP) 891 units of blood donated over 5 days (>2.5 times average)* 21

22. What we did not plan for… System CMO Assoc System CMO Hospital CMO CNE Hospital CNO/COO SWMH CEO All out of town…

23. What we did not plan for….. Incident Command Center Immediate problems No immediate communications with Ft. Hood What happened, accident or other? Transport of casualties Are we receiving any? How many?

24. What we did not plan for….. Amazingly, CNN displays phone number direct to our ICC Media and Families begin to call ICC, overwhelming phone lines and interrupting and confusing incoming communications 12,000 calls in 4 hours

25. How we were lucky… “I think when I work 14 hours a day, 7 days a week, I get lucky…” - Armand Hammer Closed Staff Hospital Weekday OR’s starting to come down Change of shift We believe we could have handled 2X or more patients… 25

26. Computer model developed from data from 223 patients from 22 bombing incidents in Israel Analyzed two scenarios: MCI using only available in-house staff and facilities at a Level 1 trauma center MCI using resources from a fully implemented disaster plan J Trauma 2005;58:686-93

27. A level 1 trauma center under normal operations can care for 4.6 critical casualties/hour (90% optimal level of care) A Level 1 trauma center with an full activation of disaster recall plan can care for no more than > 7.1 casualties/hour. (90% optimal level of care) Full activation of a hospital disaster plan will not improve the level of trauma care for a limited incident (< 4 casualties/hr), and will not make a difference with a mass casualty loads (>14 casualties/hr)

28. What we could have done better… Communication with other hospitals, due to phone lines being tied up, in part due to CNN release of ICC number Radio system as backup now installed and checked for function daily Delineation of duties and responders to ER Plan in place Coordination of ICC and clinical mass casualty drills Plan in place System to reliably bring in resources on weekends and at night Plan being discussed Coordination with Fort Hood re: disaster planning and simulation Plan being discussed 28

29. Vast majority deals with identification and communication of internal security threats There is a chapter on Emergency and Mass Casualty Response, but it refers to the adoption of the Instillation Emergency Management Program… No mention of civilian collaboration 29

30. Long travel times = high death rates Courtesy Charles Branas, PhD Cartographic Modeling Lab Univ. of Penn. Scudder Oration, Am Coll of Surg 2009, Brent Eastman, in press

31. JOT 2006 NEJM, Jan 2006 Overall risk of death is 25% lower in Trauma Centers vs. non-Trauma Centers “Regionalized” systems do better Severely injured trauma patients have a greater inpatient survival in inclusive trauma systems Scudder Oration, Am Coll of Surg 2009, Brent Eastman, in press

32. Trauma Care The American College of Surgeons Certification and Designation program has saved tens of thousands of lives Areas of the country still bereft of Level I or II Centers need to rise up to the bar Further “regionalization” of trauma care will further improve outcomes, and applies to other types of complex care as well Coordination between the military and civilian medical and trauma corps should be encouraged 32