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Thursday, March 28, 2024 – St. Michael’s Hospital

9:36 a.m. – Ambulance Bay

A chorus of pagers go off in the St. Michael’s Hospital Emergency Department, loud enough to be heard just outside on the stretch of pavement where ambulances park to drop off patients.

Phones are pulled out of pockets, fingers flick across screens. It’s a Code Orange – a mass casualty event. Not exactly a typical Thursday.

Information seeps in – patients are on the way to the hospital with injuries from an explosion and ensuing shootout between the perpetrator and police. It’s going to be all-hands on deck. Staff begin to prepare, huddling together to make plans and stockpile equipment and supplies.

The atmosphere is surprisingly calm given the circumstances. And then the first ambulance arrives.

10:01 a.m. – Trauma bay 2

A 17-year old patient with chest injuries is hypotensive and tachycardic: dropping blood pressure, racing heart.

Dr. Garrick Mok, Deputy Chief of the Emergency Department and a Trauma Team Leader, orders blood, x-rays and transport to the operating room.

He’s calm, unruffled by the inundation of patients and complicated choreography of the doctors, nurses and technologists around him. When the battery in his walkie-talkie – which he’s been using to communicate with other leaders responding to the code – suddenly dies, he politely asks if someone can find a new one. It’s handled within moments.

Mok runs through what they know: the patient was found with heavy debris on top of him and needs a chest tube on the right side.

“We’re going to intubate,” he tells the medical staff around him. 

10:03 a.m. – Trauma bay 1

Information comes in about the next patient, a man with multiple gunshot wounds to the abdomen. The team calls a Code Crimson – the most serious level of trauma that requires almost immediate surgery – and makes arrangements to have an operating room and trauma surgeon ready.

In the trauma bay they do what they can – cutting off clothes, assessing injuries and vital signs – and then rush to the elevators.

The police officers and paramedics who arrived with the patient linger outside the bay, talking into cell phones and relaying information to the medical team, their florescent yellow jackets reflecting the artificial hospital lights.

“Does he still have a pulse?” someone calls as the patient is wheeled towards the elevators.

“Yes,” another staff member replies. “There’s a pulse.”

10:45 a.m. – Acute Care zone

The rooms that make up the acute care hallway are almost full. Voices volley between rooms as nurses and physicians hand off ultrasound machines and bags of blood.

Dr. Emily Austin, a physician and the Incident Manager for the code, walks down the hall wearing a yellow reflective vest. She’s air traffic control for the staff and physicians around her, letting teams know which rooms are ready and what equipment is free for use.

Registered Nurse Danniella Battagin uses a red marker to fill  in a large chart with information about the cases quickly filling the acute care rooms, helping the team to keep track of who is where and what space is available. Patients are listed as stable or unstable, their injuries written out in medical shorthand.

Staff have also started writing information on the glass sliding doors of the rooms. It helps them to keep track of who is where and what their immediate needs are in the midst of the chaos.

30 y/o M. Confused. Normotensive.

A patient is moved from the acute area to the surgical unit and a team of environmental services staff rush in to clean. They’re so fast and thorough that it would be impossible to tell that the room had even been used.

11:25 – Acute Care zone, room A5

Emergency physician Dr. James Maskalyk walks towards Acute Care room 5. The patient inside, a woman in her 30s with a gunshot wound to her arm, is coherent and sitting upright on her own. Blood stains her clothes and the coverings on the bed beneath her.

“I need a nurse in five!” Maskalyk calls into the hall.

Maskalyk pulls on gloves and orders x-rays of her humerus – the long bone in her upper arm. The patient will need surgery, but since all of the ORs are in use will have to wait.

Down the hall, Battagin now checks a patients’ vitals, having replaced the marker from earlier with a handheld light. She carefully examines both eyes with careful hands. The patients’ neck is immobilized by a cervical collar – a brace that prevents further trauma to the spine. 

11:35 a.m. – Acute Care zone nursing station

Dr. Rachel Poley, an emergency physician at St. Michael’s, strides towards the acute care nursing station.

She looks around the space and projects her voice. “And I think we’re going to end there!”

Everyone freezes for a moment, turning to look at Poley and then at the people around them. They burst into applause. The same patients who had critical injuries only moments ago are now spontaneously sitting up and smiling. The soot and blood on their bodies is simulated there are simulated patients who’ve volunteered and been trained by the simulation program to play the part of victims of a catastrophe.

As a Level 1 trauma centre, St. Michael’s Hospital runs simulation codes to prepare for the possibility of real catastrophic events. These are large-scale, hours long scenarios that have been meticulously plotted out by the network’s trauma and emergency medicine teams and simulation program.

While the patients are characters – represented either by simulated patients or manikins – the symptoms and injuries they represent are very realistic and possible.

Between Poley, Verity Tulloch, Quality Improvement Specialist, Amanda McFarlan, Manager, Trauma Program Registry and Quality Assurance Specialist, and the simulation program, hundreds of hours went into planning the Code Orange simulation. They engaged various departments and teams, including imaging, respiratory therapy, intensive care, anaesthesia and more, to participate in the simulation, and worked closely with police and paramedics to demonstrate what would happen as victims of a crime or disaster are brought into the hospital.

Mark Joithe, a Simulation Educator, says that authenticity is important when running simulations.

“It allows staff to safely experience the chaos, stress and resource constraints they would face during a mass casualty event. It’s like a dress rehearsal that allows for deep learning.”

The simulation program, which supports the entire network, worked to ensure that every detail of the experience was realistic for staff and physicians. From erratic heartrates on manikins to accurate portrayals of medical conditions by simulated patients, the scenarios were designed to mimic the many issues that could arise in a real disaster.

When the exercise ends, the actors head off in search of their normal clothes and a place to wash soot off of their faces. Poley, who took the lead on planning and executing the simulation, gathers the group in the trauma bay to debrief and discuss learnings.

Even in a training exercise, it’s easy to see why the St. Michael’s team is so well known for its response to crises. It’s in the smallest moments – a nurse gently reassuring her patient, a doctor thanking his team for their effort, an x-ray technologist running down the hall to make every second count – that something becomes clear: when the worst case scenario happens, these are the people you want around.

By Olivia Lavery. Photos by Eduardo Lima.


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