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This article was originally published in JEN in the July/August issue of 1990;16(4):42A-48A.
On April 23, 1987, at approximately 6:20 PM in Palm Bay, Florida, a man began shooting in his neighborhood, then drove to two nearby shopping centers and opened fire again. Thirty minutes later six persons, including two police offers, were dead, and 14 persons, including a paramedic, had been shot or injured. Approximately 7 hours later, the gunman was apprehended without further injuries or loss of life.
The weapon used on all but the initial gunshot victim was a Ruger mini-14 semiautomatic carbine, with 0.223 caliber centerfire cartridge bullets. This combination delivers a bullet at speeds approaching 3000 feet/second with a range of 100 m. These high velocity bullets are likely to tumble when they enter the body, tend to drag more external contaminants, and fracture, creating multiple fragments. Resulting pressure waves injure distant organs and may create a cavity many times the actual size of the bullet. Injuries can range from a single, minor puncture wound to multiple, life-threatening wounds of the chest, abdomen, or head—all of which were seen in the victims (Table 1).
Table 1Victim profile—Palm Bay massacre
Time of arrival
Age
Sex
Class
Nature of injuries
Disposition
Time of disposition
Surgical procedure
Hospitalization (length of stay)
6:50 PM
25 yr
M
III
Glass fragments to left arm and back
Home
8:15 PM
—
—
6:54 PM
19 yr
M
II
Gunshot wound left shoulder and neck, spinal contusion
Surgery
7:30 PM
Removal C-6 and C-7 spinous process
20 days with transfer to rehabilitation facility
6:55 PM
27 yr
M
IV
Fatal gunshot wound head, gunshot wound right hand (police officer)
Medical examiner
—
—
—
6:55 PM
18 yr
M
III
Glass fragments right ear and face
Home
8:15 PM
—
—
6:55 PM
25 yr
M
IV
Fatal gunshot wound chest and abdomen
Medical examiner
—
—
—
7:05 PM
27 yr
M
II
Gunshot wound buttocks
Surgery
7:30 PM
Colon resection, colostomy, incision and drainage abdominal abscess
64 days with transfer to rehabilitation facility
7:05 PM
27 yr
F
II
Gunshot wound abdomen
Surgery
8:20 PM
Repair laceration, liver and pancreas
9 days
7:06 PM
15 mo
M
III
Superficial gunshot wound to chest
Home
8:15 PM
—
—
7:12 PM
23 yr
M
II
Gunshot wound to left mid-back
Admit to floor
7:35 PM
—
4 days
7:13 PM
16 yr
M
II
Gunshot wound right rest, fracture scapula
Surgery
8:15 PM
Right upper lobectomy, resection lower lobe, bronchoscopy
10 days
7:13 PM
14 yr
M
II
Gunshot wound back, left buttocks, and left arm
Admit to floor
7:35 PM
—
3 days
7:15 PM
58 yr
F
II
Gunshot wound right thigh into abdomen
Surgery
7:35 PM
Resection small bowel colostomy/tracheotomy sciatic nerve damage
It was an incredibly rapid series of events. The extensive danger zone included the parking lots of two mini-malls facing each other across a busy highway, a grocery store where the gunman had taken hostages, and a field in back of the grocery store where the majority of victims were shot as they tried to escape.
Reaching the victims without endangering the lives of rescue personnel became nearly impossible (Figure 1). Many acts of heroism accounted for the retrieval of victims, such as the civilian who, under fire, loaded several victims in the back of his pickup truck and sped them away to a waiting ambulance. The actual number of wounded was difficult to ascertain because people were “playing possum” between cars in the parking lots. Initial estimates ran as high as 150 to 200 victims.
Figure 1Continuing gunfire made it difficult to reach victims without endangering the lives of rescue personnel. Courtesy of Florida Today, Pat Jarrell, photographer.
At the time of the incident, a committee was developing a mass casualty incident plan (MCIP), but there was no widespread acceptance by all county, municipal, and private organizations of a standard set of written MCIP procedures. There was no mechanism for automatic activation of resources such as ambulances, rescue units, fire engines, and helicopters. As a result medical units responded on the request of earlier arriving units, and there were delays in the provision of mutual aid by other agencies who first had to obtain authorization. Multiple command posts in differing locations resulted in uncoordinated deployment of units.
The task of coordinating law enforcement and rescue operations overwhelmed the existing communication resources, which consisted of only two common radio frequencies to handle both the incident and all other operations. Radio overlap from nearby counties made communication difficult, if not impossible. The ambulance service could not communicate directly with area fire rescue units and paramedics possessed no hand-held radio capability that would have allowed them to transmit while rendering patient care.
On-scene rescue supervisors were unable to maintain direct radio communication with hospital emergency departments. In addition, telephone gridlock seized the entire area, making landline communications impossible. Hospitals were forced to rely on civilian call-ins and media reports for information about the incident.
Rescue workers faced the task of getting the victims out of the danger zone quickly and had no time for triage assessment in the field. In the absence of clear-cut directives, they transported victims to the closest facility, rendering treatment en route. As a result all patients (with the exception of three who were pronounced dead at the scene and a patient suffering chest pain) were taken to a single hospital, Holmee Regional Medical Center (HRMC), a 528-bed hospital located approximately three miles north of the incident. HRMC was a level II emergency department according to standards of the Joint Commission on Accreditation of Healthcare Organizations.
The emergency department at HRMC had 23 beds; one was designated as a trauma room. Initially there were six registered nurses and two emergency physicians on duty that day. Ms. Debbie Scholem, RN, BSN, CEN, who was at that time administrative director of the emergency department, recalls the following sequence of major events:6:20 PM: Shootings started.6:23 PM: Dispatch notified by 911 call-in.6:30 PM: Hospital notified of “shooting” by dispatch.6:32 PM: Unidentified caller reports two police offers down and undetermined number of additional victims. Hospital begins to call in emergency nurses who live closest to hospital.6:33 PM: A “real gun battle” overheard on ambulance radio. Begin to call in all ED staff and to clear emergency department of noncritical patients. Hospital disaster plan level I activated.6:43 PM: Paramedic request overheard on radio that MCIP be upgraded to level II because of ongoing gunfire suggesting as many as 25 to 50 victims.6:50 PM: First victim arrived.7:20 PM: Hospital disaster plan upgraded to level II based on anticipated numbers of patients, according to media reports. Landline communications gridlocked.7:30 PM: Thirteenth patient received.8:15 PM: All patients received so far from incident have been treated/released, admitted to surgery or the floor, or taken to morgue. Emergency department prepares for further arrivals.
Approximately 20 minutes after notification, the emergency department received the first patient. Within 40 minutes the department received a total of 13 patients, all with gunshot or gunshot-related wounds. Incredibly, in less than 1½ hours, all had been discharged from the emergency department: six went to surgery, two were admitted, two were sent to the morgue, and three were treated and released. The emergency department received a total of 17 patients before the event was over.
Many factors contributed to the rapid and successful hospital management of the victims.
At that time of day, staff physicians were closing up nearby offices, coming over to the hospital to eat dinner or make rounds; several were practicing only two blocks away for a hospital variety show. Consequently, four surgeons (vascular, thoracic, orthopedic, and neurosurgical) were present almost immediately. The operating rooms were winding down for the day, thus providing available rooms and sufficient staff for the influx of surgical cases. The chief of emergency medicine was still in the hospital, bringing the total number of ED physicians to three.
On the very afternoon of the incident, key emergency medicine supervisors, including Ms. Scholem, had met to refine the county’s proposed mass casualty plan. Several months earlier a practice drill had been conducted in the county to test the logistics of the plan. Mass casualty was fresh in their minds.
And finally, the people in the community, recognizing the severity of the event, stayed away with their minor illnesses and injuries or sought treatment elsewhere.
But the emergency department did not rest on its laurels. The following problems were identified and solutions implemented:
1.
The rapid sequence of events did not allow for full deployment of disaster triage procedures. Instead, a single nurse acted as a patient flow manager, matching each patient on arrival with a physician and primary nurse, and ensuring adequate documentation.
2.
The problems of interagency communication, previously addressed, later prompted the installation of a direct landline between area emergency departments and central dispatch, which will enable direct communications in the event that radio communications go down. New hospital radios, with a separate frequency dedicated to disaster communications and separate frequencies for each hospital, were obtained with grant monies.
3.
The need for traffic control of large numbers on nonessential personnel brought about changes in the hospital disaster plan to include a staging area for responding physicians away from the emergency department, where they would be called to the department as needed. The duties of hospital security were expanded to include controlling the presence of extraneous personnel, including hospital employees, media representatives, and police reinforcements.
4.
Changes were made in central supply procedures to include immediately restocking ED supply carts (i.e., IVs) so that backup carts are available at any time without delay.
5.
In spite of recent disaster drills, many ED staff were unsure of their specific responsibilities. A disaster card index was designed, listing very specific responsibilities and assignments for each individual.
6.
Other changes in the written policy included the unit nurses’ responsibility to come to the emergency department for report and for transporting patients being admitted. A provision was also included specifying that only minimal admitting orders should be written on patients not in critical condition during a disaster.
7.
Lengthy radio reports on patients arriving from a mass casualty incident would be eliminated. Instead, the supervisor of the Emergency Medical Service (EMS) command post will call with only numbers and classification (i.e., one class II, two class IIIs).
An extensive evaluation of prehospital activities also was completed with many specific recommendations. Through the diligent efforts of Jeff Money, Captain of Brevard County Fire Rescue, all of these recommendations have been addressed. The number of EMS radio systems has been increased from one to three; the first of equipment trailers specifically designed for a mass casualty incident has been purchased; a mobile communications vehicle is forthcoming; a countywide alerting system has been selected, which can activate individual groups or the entire system within 30 seconds; all ambulances are now equipped with hand-held radios; and questions of on-scene command of EMS operations during a mass casualty incident are resolved. On-scene medical supervisors will now have a direct radio line with hospital emergency departments and backup cellular phone access capabilities are being considered for the event of telephone gridlock.
Captain Money also suggests that hospitals revise “all or nothing” disaster plans and design multiple levels to coordinate with the size of the disaster and with the level of the EMS disaster plan of their area.
In addition, much was learned about the management of the survivors of this devastating occurrence.
Thirteen critical incident stress debriefing (CISD) sessions also became a learning experience. Debriefers directly involved in the incident were never fully debriefed themselves, perhaps making their own recoveries more painful than those they counseled. “It got to the point that we didn’t want to talk about it [the shooting] anymore,” recalls Ms. Scholem, one of the debriefers. “Even so, I am a big believer in CISD. Those who had the debriefing did better than those who did not.” Since then a statewide network of CISD teams has been established in Florida.
Another lesson learned was the importance of keeping the debriefing groups homogenous. Mixing such groups as hostages and emergency personnel demonstrated that each group had different unresolved feelings. As much as possible, debriefing sessions were individualized for police, rescue personnel, hospital staff, and policemen’s wives.
The most difficult aspect of this disaster for the ED staff, explains Ms. Scholem, was “waiting for the second wave of patients that never came.” Receiving so many patients with such severe injuries in so short a time and not knowing how many more they would receive made it difficult to relax. “We had already seen what he [the gunman] could do. What would the next patients be like?”
When asked whether there was a silver lining to this experience, Ms. Scholem replied immediately, “Those who came to us alive, stayed alive.” She added: “In spite of this heartbreaking tragedy, we learned that we could pull together, put aside any differences we might have. Other departments, the community, the police, rescue services—we worked together. Most important, we learned that we could do it.”
Fourteen mass shootings have occurred since 1949, coast to coast, in small towns and big cities. Nine of these have occurred since 1982, perhaps reflecting an increasingly violent society. Such incidents are disasters that, unfortunately, could happen anywhere.
Editor’s Note
At the time of publication Ms Curry included the following acknowledgment: Many thanks to Ms. Debbie Scholem, currently a clinical nurse III/preceptor in the emergency department at Indian River Memorial Hospital, for reawakening very painful memories to assist with this article.
Biography
Jill L. Curry had 12 years of experience in emergency nursing when this article was originally published in JEN.
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