First responders use a table as a stretcher to transport a wounded soldier to an awaiting ambulance. (photo by Sgt. Jason R. Krawczyk, III Corps Public Affairs)
When the Fort Hood gunman opened fire on November 5, he killed 13, injured 30 and set in motion a mass casualty operation that ran like clockwork. Four emergency physicians on the scene that day give their first-hand account.
by Mark Plaster, MD
Drs. Tamara McReynolds, Rob Nolan, and Steve Beckwith were on duty at the Fort Hood emergency department when they heard the news. At approximately 1:30 in the afternoon Fred Reed, the chief paramedic, informed them that shots had been fired at the Soldier Readiness Processing Center less than a half mile away. After notifying them, Reed hurried to the scene and within minutes casualties began arriving at the emergency department by private vehicle. Many patients arriving had been shot multiple times, including wounds to the chest, abdomen, flank, and shoulder. Some patients arrived with makeshift tourniquets and litters made from uniform parts. Within minutes of the first alert the ED activated a computer program that sent a message to all the emergency staff to return to the ED.
“I actually got called at home by my secretary before I got the MASCAL page,” said Lt Col Melissa Givens, the emergency medicine residency director. “She just said ‘you need to be here now’.”
“The first thing I noticed when I arrived,” said Dr. Larry Masullo, Chief of ED Operations, “was a couple of guys holding each other up.” Both had been shot.
“In an hour we had more people than we knew what to do with,” said Givens.
“The staff was pretty oriented on getting (patients) into the right spots,” said Dr. Steve Beckwith, EMS director. “There was not a lot of overt chaos. In the past there has been a lot more of that, but for the first six we didn’t feel like we were totally overwhelmed. And at that point we were still writing names on the board and trying to organize who was a surgical priority. Very quickly, as more patients started to show, that went out the window. But for those first six, I felt like we had a handle on it for the most part.”
“I went to every bedside, looked at every patient and even talked to some of them,” said Masullo. “They were all calm. None of them were screaming. They were obviously pretty injured, but they seemed to be fairly calm.”
“I never would have known there was a MASCAL going on by the volume in the department,” agreed Dr. Givens. “It’s actually noisier in the department on a daily basis.”
Carl R. Darnall Army Medical Center at the Fort Hood Army post located near Killeen, Texas is unique in many ways. It services over 70,000 relatively healthy army personnel with an inpatient capacity of only 128 beds. The center includes the busiest OB department in the entire Department of Defense and its own psych ward. The ED sees over 75,000 patients annually, but admits fewer than 5%, many to the psych floor for suicide prevention. Despite this low acuity, the CRDAMC ED has one of the most trauma-experienced faculties in the country – many members have served in combat zones in Iraq and Afghanistan. Mass casualty drills are performed here twice a year. In fact, one was planned for the week following the shooting. So, while nothing can prepare you completely for casualties on the scale of those received on November 5th, one would have to say that Fort Hood was about as prepared as an ED could be.
The MASCAL Plan
Like many others, Fort Hood’s mass casualty plan called for separate areas for immediate, delayed, minimal, and expectant casualties. As soon as the mass casualty plan was initiated Dr. Beckwith ran into the first problem. The handheld VHF radios provided for communicating between the ED and other areas of the hospital could not reach chief paramedic Fred Reed at the scene. In order to stay in communication, Dr. Beckwith had to make the decision to leave the treatment area and go outside to triage cases as they came off the incoming ambulances. The second problem concerned traffic. The plan called for triage on the ambulance loading dock. But it soon became clear that Beckwith had to move triage to a new area, allowing ambulances to pull through without having to back up to the dock. From that location he was also able to talk to the scene and decide which patients needed to be flown directly to other hospitals in the immediate vicinity.
Initially there were three general surgeons available with a fourth on his way.
“We had little pow-wows periodically to discuss the patients and prioritize which ones to the OR," said Masullo. “There was no power struggle.”
“One of the nice things and something that was different from other MASCALs; this wasn’t a blast injury,” said Beckwith. “So you kinda knew where the holes where and where you were going.”
The Second Wave
Soon it was clear, however, that there were a lot more wounded coming. “We had a bit of a lull between when [the first six] came in and when we started to get the folks lifted from the scene,” said Beckwith. “It might have been just 5 or 10 minutes, but it was enough for us to get our heads together and get ready for triage.”
“That’s when Steve and I started to do some significant coordination and we realized that we needed to start clearing beds,” said Masullo. “We moved those that did not need to go to the OR to family med.”
Over the next hour and a half the staff triaged and stabilized twenty wounded soldiers. While they stuck to their standard trauma resuscitation protocols, they went directly to surgery with many, bypassing unnecessary imaging studies. “I remember at one point pulling the X-ray tech aside and saying ‘You do only chests from here on out’,” said Beckwith. “At one point I think they were doing a leg.”
Despite all the pressure and chaos, the staff never seemed to lose their cool, said Givens. “I’m going to give a lot of credit to (Masullo and Beckwith because the nursing staff and the techs and the clerks were watching these guys and gauging their response on their behavior.” One said to Dr. Givens “I think I would have freaked out, but I knew you had this under control and you knew what you’re doing.”
The hardest part for me was seeing all those innocent, unarmed soldiers coming in terribly/mortally wounded. There were so many people helping it was completely overwhelming. Our docs are trained to do this in war zones so they had everything under control but I don’t think anything could prepare the support staff for this assault in an urban, non-combat zone. My heart is broken.
After things calmed down and I heard some of the stories from the people who were at the scene I felt even worse. It was quite traumatic for me, but when I put things into perspective, the people at the site will never be the same. At this point, I am going to do whatever I can to help in the recovery process even if all I have to offer is a kind word.
Lessons Learned at Ft Hood
with Maj Steve Beckwith, Lt Col Larry Masullo & Lt Col Melissa Givens
Look at your system of internal communication.
The core areas, triage, ED, blood bank, lab, emergency operations, etc. all need to have ready and reliable communications. If you plan to use radios, they must be tested to see if they will transmit to the areas of intended use. In the Ft Hood experience, a critical doctor had to abandon direct patient care and leave the ED to communicate with the scene.
Finding supplies is a big problem.
Once the people who know where everything is located get tied up with cases it becomes the job of everyone else to find things for themselves. Having supplies grouped according to function, such as having ET tubes with spare laryngoscope blades would help. Having people dedicated to simply finding supplies would also address the issue. The CRDAMC staff ended up intubating 11 cases and performing chest tubes on a similar number of patients. The same problem applied to meds. Simply finding the meds was the first problem. Drawing up the meds in the proper concentrations was the next issue. Meds need to be stocked ready for delivery, or have someone assigned to do nothing but draw up meds in the proper format.
Identify the key players early.
Knowing who was in charge of triage and flow through the ED was a big asset to the CRDAMC response. Identifying them to non-ED personnel through some sort of vest, coat, etc would have eased some confusion. Having non-physicians handling some of the through put issues would free up an EP for direct patient care. The Ft Hood staff also noted that having a non-physician responsible for the administrative details of spinning up the MASCAL would have helped.
Prepare your civilian staff.
Prepare your civilian staff for the emotional impact of death and injury on a large scale. Post-event debriefing is good and necessary, but training ahead of time would have been much better, avoiding some of the post-event problems.
Streamline the administrative process.
The CRDAMC staff received a patient every one to two minutes for almost 30 minutes. All patients were wearing dog tags with names and blood types, yet they still couldn’t keep up with the administrative process. Administrative staff have to be ready from the first patient with quick packs and lots of extra bodies to handle the information flow.
Medical record charting will be one of the first casualties if it is not planned for realistically.
That means readily accessible packets of information and administrative personnel to write or dictate. Systems that require the doctors or nurses to record will break down rapidly. This is an ideal situation for scribes.
Blood and blood product utilization must be tracked in real time with anticipation for needs later in time.
Because CRDAMC did not have the capability for rapid thawing of fresh frozen plasma and possessed only a minimal supply of platelets, only packed red cells were available for transfusion. In high volume resuscitations this will lead to complications due to depletion coagulopathies. EDs need to consider acquiring rapid blood and blood product re-warming equipment. Moreover, blood utilization needs to be tracked, steps taken to acquire more blood, and the medical command needs ongoing real time updates as to supplies.
Use personnel to the maximum of their abilities, but not beyond.
Don’t expect that residents with very little clinical experience will suddenly be able to handle cases they have never seen before. Don’t expect personnel from outside the department to be able to find supplies, handle throughput, etc., in a department in which they have never practiced.
"The beginning of a nightmare”
We raged against the tragedy not with violence or anger but with violent passion, camaraderie, and tenacity, to hold the tide of fear and destruction at bay. Today I witnessed Americans who do not wear a uniform don the garb of battle and fight side by side with our uniformed brethren. God Bless our civilian staff.
Nov 5, In Their Own Words
-An Emergency Physician
I never thought before the possibility of such massive carnage, to the point that we would run out of supplies-BVM’s, stylets for ET tubes, saline, chest tubes-we even had to reuse thoracotomy trays. All this on Ft Hood.
-An ED Administrator
I remember standing in the trauma bay getting supplies for a central line when [someone] came in looking for a stylet for an ET tube. At that instant, I had absolutely no idea what a stylet was. They asked me where they were stored, which is something that I could tell you in my sleep. They’re in the airway cart that I check before every shift, but right then I couldn’t even picture what the word meant. I was really frustrated because I knew it was a word that I knew, but I couldn’t help them. Ridiculous.
I always learn patients’ names. That day, it was only GSW to body part and bed number. I never learned their names. I still don’t know who they were...
-An Emergency Physician
The ER is pretty quiet today. It seems that everyone is trying to just carry on. Not much talk about [November 5th]. I mean how do you really do that without replaying the day over and over in your mind(s). It still does not seem like it was real.
-An ED Administrator