Code Orange: How hospitals respond to mass casualties like Toronto’s van attack

Toronto van attack: Doctor speaks on handling multiple casualty incidents in wake of deadly attack
Dr. Avery Nathens of Sunnybrook Hospital, which received the largest number of victims from the Toronto van attack, spoke Tuesday about how the hospital handles multiple casualty incidents and how it responded to the deadly incident.

Dr. Avery Nathens was in his office at Toronto’s Sunnybrook Hospital on Monday when he heard the words “Code Orange” called out over the loudspeakers.

As the medical director of Trauma Services, he went downstairs and got to work co-ordinating emergency response for incoming victims who were struck by a van near Yonge and Finch.

Code Orange – the code for a mass casualty event – is something that hospitals prepare for. And once they hear the words, they start making the hospital ready for patients’ arrival.

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“We created capacity in the emergency department in our trauma bay so we can have room to accept these patients,” said Nathens. “We put the operating room on hold, to make sure the operating room was available as needed, and we made sure there were sufficient numbers of doctors and nurses to meet the demands of the patients.”

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As patients arrived, they were triaged according to the severity of their injuries. “Do they need to go to the trauma bay where the sickest patients were? Can they go to a lower level of care in the ED to be sorted out slightly differently?”

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Several patients needed surgery immediately and thanks to preparation, there was room. Nathens also worked to make sure that the hospital’s doctors and nurses were able to focus on their patients.

“I wanted the docs and nurses to do what they needed to do and not worry about anything externally,” he said.

Sunnybrook took in 10 patients after the attack on Monday. Eight remain in intensive care as of Tuesday afternoon. Two could not be saved.

Marathon session

It can be a tough job. In 2013, Dr. David King had just finished running the Boston Marathon. He was in a taxi on his way home when he started getting text messages from his friends. “I got a bunch of messages from friends asking if I was OK. I didn’t understand what that meant,” he said.

He eventually got the impression that there was some kind of fire, so the trauma surgeon decided to go in to work at Massachusetts General Hospital.

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“I arrived just as the first wave of patients were arriving. Within about 30 seconds of walking in the door, I was taking one of the first patients to the operating room.”

He knew instantly that it wasn’t just a fire. His military experience had taught him to recognize injuries caused by improvised explosive devices. “It looked like a scene that I was very familiar with from my military service,” he said.

He and his team worked for days, treating 46 people from the Boston Marathon bombings, which ultimately injured more than 200 people and killed three.

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“In a mass casualty situation, you’re basically doing the same thing you do during your daily routine except with what we call degrees of abbreviation,” he said. So that means triaging differently, pursuing surgery more aggressively, and in some cases skipping some tests or steps that you might normally do with the luxury of time and resources.

If you have six patients in front of you but only have room for one in the operating room, “You’re trying to decide who’s sickest, who’s going to die first.”

Hospital staff “do what is required,” he said, and don’t have any time to think about the events that lead to all these patients in their emergency room. “I think it was probably two days before I or anybody else on the trauma team was able to sit down and watch the news and start understanding what happened.”

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Once that realization hits, he said, health-care workers might require support like psychological or religious counselling, because everyone processes these events differently.

“Just because people do this as their daily job, we see and treat trauma patients, doesn’t mean that they will necessarily respond the same way to a mass casualty incident like this.”

It can “shake people to their core,” he said.

“An incident like this creates more injuries than just the visual, physical ones.”

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Advance planning

Hospitals are constantly working on their emergency plans, said Dr. Andrew Willmore, medical director of emergency management at the Ottawa Hospital.

“We don’t have the luxury of closing our doors,” he said.

The tricky part is balancing the hospital’s normal responsibilities – taking care of ordinary patients – with creating the capacity to handle a disaster.

When his hospital is notified about a potential mass casualty situation, they sound a Code Orange, he said. Staff can then visit an “Emergency Code Station,” which are peppered throughout the hospital, to find out what they should do.

Every station contains colour-coded folders for each code, he said, that spell out the staff’s specific responsibilities in that situation so they’re reminded of what to do. Hospital management ensures that there are enough people, supplies, drugs, blood and space for doctors to do their jobs without interruption, said Willmore.

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“A disaster in a community is not necessarily a disaster in a hospital,” he said. Planning makes sure that it doesn’t become one.