Monthly Archives: June 2016

Bringing out the Best in Medicine: How the Tragedy in Orlando Provided An Opportunity for Greatness

Whenever horrific events occur, it is important that we not only take stock in the event itself but we must also look at the good that rises from the ashes. The tragedy in Orlando this week is not without heroes. Volunteers, medical personnel, first responders and blood donors have worked tirelessly to help those in need. In the wee hours of the morning on June 12, 2016 healthcare workers in Orlando received an emergency alert to attend those affected by the worst mass shooting in US history. The quick response and expert training of those at Orlando Regional Medical Center certainly saved numerous lives. Six trauma surgeons and countless other doctors, nurses, technicians and other specialists were mobilized within minutes and were ready to receive the massive number of critically ill patients that arrived all at once.

As a physician, I can only imagine what it was like to arrive at the hospital and begin to care for the large number of wounded. In my experience in dealing with medical emergencies, instinct and training allow doctors and other healthcare providers to jump in and immediately deliver care. Years of training and study allow healthcare workers to react with professionalism, precision and compassion. While all of us are human and are emotionally impacted by such a tragic event, somehow all of those who sprung into action at Orlando Regional Medical Center were able to separate their feelings from the situation and perform their jobs at a very high level. Many hospital workers, physicians, nurses and first responders came in to help—whether they were on call, on duty or on a day off. The selflessness of these medical heroes should not be lost in the tragedy. Many of those involved have been interviewed in the days following the night of trauma and all consistently said that they simply were doing what needed to be done….

While many hospitals have had “Disaster Plans” in place for years, the events of September 11th led to more widespread adoption of these plans. Since that time, hospitals all over the country have put plans in place to deal with mass casualties. Academic societies and organizations of Trauma surgeons have worked to develop best practices and have conducted large scale studies in order to determine the most effective ways to handle these types of disasters. These plans involve extensive, centralized communication systems and a way to quickly alert all essential personnel and mobilize resources.   In addition, these plans involve intensive education and training for all hospital staff. Most hospitals, once plans are in place and staff education is complete, have regular “drills”. Many institutions even have mock disasters with actors posing as critically injured casualties. These drills allow for hospital personnel—Doctors, nurses, techs, first responders and communications specialists to hone their skills and find ways to improve responses in the case of a real disaster.

In my experience at both Duke Medical Center (during my training years) as well as at the University of North Carolina Healthcare system currently, well thought out protocols and training programs are in place and staff are reminded of these plans frequently. As a Cardiology Fellow in the late 1990s at Duke University, I experienced an emergency event first hand. While I was in the Emergency Room caring for a patient with a heart condition in the early morning hours, an alert was sent out that there had been a gang related shooting in Durham and that there was an active shooter potentially inside the ER. We were instructed to get all patients onto the ground and pull everyone into the nearest closed room. I reacted by moving several patients to the floor and pulling them into a supply closet with me. Patients were frightened and understandably anxious. During this time, the ER was locked down and police begin moving through the department in order to clear the area of any threats. Fortunately, there was no active shooter found inside the ER and, after about 30minutes, we were allowed to return to normal operations. After this experience, I remained visibly shaken and it took me a long while to move past the fear I felt that night. I can only imagine what it was like for those medical professionals involved in the Orlando tragedy.

While you may not think of the importance of these issues during the time that a disaster occurs, there are a few things that seem to make a difference in the way we as healthcare workers respond. After my experience during my Cardiology Fellowship here are a few things that I believe to be essential–

  1. Centralized Communication—IN a disaster or mass casualty event, communication is critical. Effective communication allows for patients and personnel to be where they need to be at all times in order to provide the most efficient and effective life saving care.
  2. Coordinated Care—Cooperation and coordination between surgeons, nurses, administrators and other personnel is key to the successful treatment of large numbers of patients.
  3. Staff Education—Extensive education and training must take place in order to prepare staff for mass casualty events. When called upon, staff must be able to react in an organized and calm way—all of this comes from preparation over time.
  4. Drills—It is important to practice a response to a mass casualty event. Practice allows for those in charge of the disaster plan to assess response times and identify areas for improvement.

What Are Biggest Challenges in a Mass Casualty Event? What are the Initial Steps?

The heroic efforts of those in Orlando cannot be understated. These men and women should serve as an inspiration to all of us in Medicine. Each person did their job and worked through the night to help as many victims as they could. For many of us, the thought of being faced with such a large number of seriously wounded can be overwhelming.—this is the stuff of War.   However, those first responders in Orlando met the challenge head on—they worked quickly to identify and triage the most critically ill patients. Emergency personnel attempted to quickly stabilize each patient, and then decided who needed the most urgent treatment in the Operating Room. Patients were sequentially moved from the scene, to the Emergency Department, and to the OR very quickly. IN order to triage the large number of victims, , healthcare professionals are trained to use the ABCDE approach:

  1. Airway—Make sure that each patient has stable airway—if not, we must quickly establish an airway
  2. Breathing—We must make sure that every patient is breathing on his or her own. If not, we must provide an external means of providing them with oxygen.
  3. Circulation/Hemorrhage—First responders must quickly assess if the patient has a pulse and if there is major bleeding. If there is no pulse CPR is initiated. If there is an obvious hemorrhage, efforts must be made to apply pressure, field dressings and other interventions designed to stop bleeding prior to definitive treatment. In many cases, blood and fluids must be administered in order to restore blood pressure and adequate circulation.
  4. Disability—First responders must assess each victim’s level of consciousness and if they have suffered any type of neurologic or brain injury. These injuries must be quickly triaged to a neurosurgeon in cases of head trauma.
  5. Environment—In many disaster situations there are environmental exposures (chemicals, spills, etc) that may contribute to the trauma—in the case of the Orlando shooting, this was not the case.

Unfortunately, mass casualty events have become more common in the US in the last decade. Medical personnel and hospital systems are learning to better care for patients in these large-scale emergency situations. Events such as the Orlando tragedy will cause all of us in medicine to review our protocols, plans and readiness procedures so that we will be more equipped to handle emergencies when they occur. Were it not for the heroic efforts of first responders, trauma teams, doctors, nurses and other hospital personnel in Orlando, the number of casualties could have been much greater. In the coming months, those medical heroes that helped treat the massive number of wounded will need time to heal and time to process all that they have seen and experienced. Thankfully, they were prepared and ready to respond with a heroic effort on Sunday morning.

(this piece originally published on on June 14, 2016)



June 14, 2016: Doctors and medical staff that treated the victims of the Pulse nightclub shooting answer questions at a news conference at the Orlando Regional Medical Center. (AP)

The Sensationalization of Medical Errors—Breaking Down the Data In Order to Improve Patient Care

In the last month, a study conducted by researchers at Johns Hopkins and published in BMJ[1] addressed the rate of fatal medical errors in the United States. By using data from four previously published studies and using mathematical models to extrapolate data to the current year, the authors contend that medical errors are now the third leading cause of death in the US today.

The media has been very quick to pick up on this story and has already sensationalized the findings without carefully analyzing the data and how the study was conducted. While medical errors are a significant concern and result in countless cases of increased morbidity and mortality in the US today, I am not convinced as to the accuracy of the number of deaths that was determined in the study—over 200K deaths annually. Don’t get me wrong, I still believe that this is a very important study. It brings more focused attention to the issue of medical errors—specifically how we can identify them and what systems are needed to prevent them from occurring in the first place. As medical professionals, we need to more carefully exam the study and what we can learn from it rather than sensationalize the findings.

Controversial Study Methods and Design Leads to Debate

When interpreting this latest study we must carefully analyze the methodology and only then can we comment on the robustness of the data. While the media has focused on the numbers of deaths that have been noted in the study (nearly 250K deaths attributed to medical errors), much of the academic medical community has been debating the validity of the data as presented. In order to effect real change and address medical errors, we must first better understand the problem—this all begins with examining exactly how the researchers in the BMJ paper reached their shocking conclusions. For starters, the authors have used 4 separate studies to gather their data. Some of the studies that were used do not even make it clear what percentage of deaths due to errors were “preventable” and the Hopkins researchers simply assumed a rate of 100% in their analysis– which could have led to a gross overestimation of medical error related deaths. Moreover, some of the events classified as medical error related deaths are actually related more to understaffing issues and lack of resources due to actual errors in the treatment of patients. Critics of the study have recalculated the death rate from these data and have determined the numbers to be nearly 30% lower than those presented in the results of the original paper[2]. In addition, it is important to note that in each study, the diagnostic codes that are used are most often assigned by non medical personnel known as “coders”. Many coders have less than 6 months experience and do not fully understand the medical information that is documented in the chart. IN many cases where a study is based on coder-generated data, it is “garbage in, garbage out”. However, no matter how you evaluate the study and its methodology, it is clear that medical errors are a significant problem that must be addressed.

What exactly are the issues and why are the errors occurring?

The issues with medical errors are quite complex. Errors occur for several common reasons. Certainly, when poor clinical decisions are made by healthcare providers negative outcomes can occur. In addition, handoffs of patients between physicians, nurses and other hospital clinical workers can be haphazard and incomplete. Transitions of care are a major source of medical errors. When busy clinicians receive either incomplete or inaccurate “sign outs” important patient details can be lost. Labs may not be followed up, tests may not be ordered and care plans may not be followed. These types of errors can result in delays in treatment, wasted days in the hospital and incomplete follow up of results. Transitions between units can be even more problematic. When a patient is transferred between departments—such as between the Emergency Room and the Intensive Care Unit—mediations can be forgotten, and missed doses (or duplicated doses) of drugs are quite common. In addition, communication between caregivers can be rushed and important details can be left out. The advent of the electronic medical record (EMR) has given many healthcare professionals a false sense of security in that a patient’s story will be archived digitally for all to see. However, many EMRs are rather incomplete and the data required during documentation of a patient care event is inconsistent and often clinically irrelevant in the acute setting. System errors are the most common type of errors—these occur when the care systems and algorithms that are created within and between institutions are non-standardized and based on regional preferences. These inconsistencies can result in gaps in care. Safety measures and protocols are often inadequate to prevent error.

What needs to be done going forward?….

It is clear that there are far too many medical errors that occur in medicine in the US today. While I firmly believe that the current article far overestimates the total numbers of errors, the problem is still quite substantial. As physicians we must work together to create better ways to protect patients. We must do a better job communicating directly with one another about patients rather than rely too heavily on the EMR. Within hospital systems, we must put more checks and balances in place and make transitions between caregivers and units seamless. In addition, we must determine a more standardize way to define and measure medical errors—the creation of a national database may lead to important discoveries and allow us to provide safer, more efficient care for all of our patients in the future.

[1] Medical error—the third leading cause of death in the US BMJ 2016; 353 doi: (Published 03 May 2016)

Cite this as: BMJ 2016;353:i2139

[2] BMJ Rapid Response published online 21 May 2016 DanielBaldorMD/MPHStudent (MS3)Adam Kravietz MD/MPH Student (MS3)University of Miami Miller School of Medicine Miami Fl 33130