Introduction by Croakey: They are acts of violence that can change communities, cities, even countries forever, but when massacres and suicide bombings occur, it is emergency medical staff who are first on the scene to witness the worst – and best – of humanity.
These events are of such a magnitude, both in lethality and in terms of political ramifications, that they become synonymous with the places in which they occurred: Dunblane, Port Arthur, Sandy Hook, Columbine, Christchurch.
For those who work at the frontlines of the health system, they represent some of the sternest challenges imaginable to infrastructure, resources and personnel.
Lessons from three such mass casualty incidents – the 1996 Port Arthur massacre, this year’s Easter Bombings in Sri Lanka, and the March 15 extremist attack on two mosques in Christchurch – were the focus of a sobering, at times emotional plenary session at the recent annual scientific meeting of the Australasian College for Emergency Medicine in Hobart.
Dr Dominic Fleischer, from the emergency department at Christchurch Hospital, was on duty the day 51 people were murdered and dozens more critically injured by a gunman during Friday prayers.
Fleischer shared his story with colleagues, and has kindly provided the text of his presentation for publication by the Croakey Conference News Service. It appears in slightly abridged format below as a highly recommended #LongRead.
Dominic Fleischer writes:
Nāu mai, Haere mai, Ki a koutou katoa
Kua whakakotahi mai tātou ki te whaiwhakaaro
I ta tātou huarahi whakaaroharoha
Ka mihi au tuatahi ki ōku hoamahi mo tō kaha
Ka mihi tuarua ki a koutou te whanau
Welcome everyone. We have all come together to reflect on this emotional journey. I would like to thank my colleagues for their support, and all the families involved.
Eight months ago, a 28-year-old Australian man with a camera strapped to his forehead, walked into two mosques in central Christchurch during Friday prayers. He was allegedly armed with a military style semiautomatic rifle, large capacity magazines loaded with hollow-point bullets. Nearly 100 people were shot.
He’s currently awaiting trial having pleaded not guilty to 51 counts of murder, 40 of attempted murder as well as engaging in a Terrorist Act, the first time this charge has ever been laid in New Zealand. That trial is set to begin in mid-2020.
I am here to tell you a story, several stories; many have been stitched together from recounted fragments given to me by my colleagues.
There’s much I don’t remember and much I remember too well. I am still learning new things about the sequence of events on that day. I’ve been told during stressful events people become very task focussed, develop tunnel vision, dwell repeatedly on certain events but are unable to recall many things that happened right in front of them. That’s all very true.
I started the day, March 15th, in the more sedate, walk-in side of our emergency department (ED). It was a relaxed day and I was counting down the minutes to our 4pm handover – still some two hours away.
For context: Christchurch Hospital is a 900-plus bed hospital, serving a population of 500,000. It’s the only acute hospital in the district.
We are unique in NZ in that we have almost every specialty at hand: adult and paediatrics, every surgical specialty, spinal… everything except a dedicated admitting Trauma Service.
Christchurch Hospital has the busiest ED in the South Island, the second busiest EDs in NZ: 100,000-plus patients a year, 285 presentations on average per day — mid-300s on a busy day. We see more major trauma than any other hospital in NZ, and all but a handful of hospitals in Australia.
Christchurch Hospital typically sees one or two patients a month with firearm-related injuries; most are minor – we only see one to two per year of life-threatening firearm-related trauma.
For the whole of New Zealand there are typically about seven or eight culpable homicides (murder and manslaughter) involving a firearm every year. Only about 10 percent of culpable homicide involve a firearm – surprising for a country with 1.5 million guns.
We have more than twice the gun ownership rate compared to Australia (30/100 vs 14/100) but only 60 percent of their firearm-related homicide rate. The United States, with four times the NZ gun ownership rate, (120/100) has more than 40 times our gun-related homicide rate.
In less than two hours Christchurch Hospital saw 25 years’ worth of major gunshot trauma. And New Zealand, in 15 minutes, faced up to six years’ worth of firearm-related murders.
A gunman opened fire
Dealing well with a critically unwell patient is the ultimate demonstration of an emergency physician’s skills but dealing with 50 critically, injured patients is the ultimate demonstration of the skills of a hospital.
Very quickly the situation became overwhelming: chaotic, the sheer volume of critically injured patients, the volume of staff arriving to help, and just simply the volume – it was incredibly noisy.
An extremely high-adrenaline, high cognitive-load situation, it would mark the end of life for 51 people: 42 at Al Noor Mosque, seven at the Linwood Mosque, one in our Emergency Department and one in ICU 48 days later. That’s 43 men, four women and four children killed. Thirty-four people lost a spouse. Ninety-two children lost a parent.
The Christchurch incident occurred on a Friday afternoon.
Fortunately, Fridays are a popular time for teaching sessions and committee meetings, so there’s lots of extra staff in the hospital. Anaesthetics have their teaching sessions on Friday afternoon, which meant there were many anaesthetists available and a minimum of elective cases occurring. We had our own senior nursing and doctors’ meeting at the time. Also, fortunately, the department wasn’t particularly taxed with a heavy caseload. And many nurses were arriving for their afternoon shift.
At 13:40 a gunman opened fire at the Al Noor Mosque. Ten minutes later, at 13:50, two men ran 1000m across the flat grassy fields of Hagley Park from the Al Noor Mosque to the ED. They had lacerations to their hands from breaking out through some windows. They told us to prepare for many victims soon to arrive, and were met by the triage nurse with a degree of disbelief, and an under-appreciation of what was to follow.
Four minutes after the two men warned us to expect others, five critically-injured patients arrived, all brought in by bystanders. Almost simultaneously, several heavily armed police arrived, firearms drawn – clearly frantically looking for someone. While it’s a normal daily event to see police in the department, it is not common to see armed police in our ED, weapons drawn and pointed.
A minute later, at 13:55, we activated our Major Incident Plan – the exact minute the last bullets were fired. Four minutes later, the shooter was caught – 18 minutes after he had fired his first shot.
Three weeks of trauma in 45 minutes
The St John Ambulance Service received the first of 20 calls to the Al Noor Mosque at 13:45, five minutes after the first shots. The first call stated there was five injured, then seven, then 30, then “more than 40”. The first ambulance to reach ED made it there at 14:05, 15 minutes after the first self-presenters arrived.
The bravery of the paramedics and police cannot be understated. Typically, paramedics would remain behind police lines until an active shooter scene is cleared as safe for entry by the police. On the 15th, paramedics went straight in – believing an active shooter, and IEDs were in the mosque. This first pair, crouching and crawling, were led into the mosque surrounded by four police officers “standing proud to act as targets.”
Our senior nursing team with ferocious speed cleared out the department of its patients, opening up the entire 20 bed Resus area for what was going to arrive. This rapidly expanded the department’s capacity. I don’t remember the department being emptied out, yet a dozen beds must have been wheeled right past me with patients heading first to our workup area then onwards to the inpatient wards.
We had scanty reports from a mix of police and paramedics that there were up to four shooting sites, ED being one of them, with up to eight shooters still at large. Christchurch Hospital is the only acute hospital for the district – there is no option for diversion.
We dealt with 49 patients within 45 minutes: 41 triage Category One.
Thirty-seven had been shot. Twenty-one patients were eventually classed as major traumas. To put this in perspective, we typically see one or two major trauma cases a day. We dealt with three weeks of major trauma cases in 45 minutes.
The acute surge lasted less than an hour, and all patients were moved through the department within two hours. However, a huge amount of heavy, demanding, and complex work lay ahead for the inpatient teams.
We struggled to register the injured as they arrived. Electronic Information Systems are too slow to deal with that size of surge. Paper forms were also too slow to keep up. The very rapid movements of patients arriving, moving within the department, transferring to theatres, CT, ICU, recovery and the wards meant it took days to obtain an accurate picture of what we had dealt with.
A notable observation: with all the noise and clamour in the department, none was from the patients. No groaning, no yelling. Worryingly quiet. Most arrived conscious. Every single one was quiet, undemanding.
Major Incident Plans ideally assume a single event that has occurred some distance from a hospital – a plane crash or a stadium collapse – where Emergency Services have implemented a pre-hospital assessment, triage, treatment of patients, and a forward incident control has been set-up to communicate with the hospital prior to arrival.
Both the 2011 earthquake, and this shooting, however, have had the hospital at the epicentre of the unfolding event. The result: no pre-hospital assessment, no pre-arrival triage, no pre-arrival treatments, no communications.
So, what actually happens when a disaster occurs near a hospital?
Scoop and runs. Patients will make their own way to hospital (n=9), bystanders drive those who can’t run (n=10), and police bring people in (n=2). A Christchurch Hospital nurse who lives near the Al Noor Mosque made two trips to and from the mosque and brought four people to hospital in her own car. A local tradesman transported three victims from Deans Avenue to ED – including a four-year-old girl and her father, both with life-threatening gunshot injuries.
St John paramedics brought in 28 of the 49 patients: 25 patients from the nearby Al Noor Mosque and three from the Linwood Mosques. There was much uncertainty around those figures for a long time, months.
There was no time for written documentation. Verbal handovers were exceedingly brief, few had IV access, IV fluids, or parenteral analgesia. This was essential. The success with these patients was in no small part to the rapid transits to hospital.
A tsunami of critically injured
The Al Noor Mosque is 1.7km by road, a two-minute ambulance ride to our Emergency Department. The Linwood Mosque is 5km, a five to 10 minute drive under lights and sirens to ED.
It felt like everyone had arrived at once – a tsunami of critically-injured. Then another tsunami arrived – staff offering help.
While I thought it was the Major Incident Plan activation that brought the surge in help, I later found out that this primarily occurred through word of mouth. In this age of ubiquitous texting, social media, and emails, it’s word of mouth that works quickest.
While we all know how to deal with the shocked critically-injured patient, dealing with 50 at once involves supreme teamwork, trust, innovating, and workarounds. It became immediately clear that there was only two places patients had to get to: the operating theatre (OT) and then CT, or CT and then OT.
We dealt with all this by working closely together. The Director of Surgery, two Trauma Surgeons, Clinical Director of Anaesthetics, and the Trauma Nurse Coordinator: we just kept doing the rounds, making plans and ensuring rapid flow.
One of the earliest critical decisions made was ensuring patients did not return to ED once they progressed into the hospital for their CTs. The Clinical Director of Anaesthetics and the Chief of Surgery agreed anyone going to CT would then transfer directly to Theatre Recovery for ongoing workup. This was an essential decision to ensure patient flow.
One of the first patients to arrive was a little girl, brought to hospital in a private vehicle by a bystander, who passed her into the arms of a paramedic in the ED ambulance bay. The team commented on the look of horror on the paramedic who carried her into the resus bay. In the panic she was placed face down, upside down on the bed. She was apnoeic, blue, with no output.
It has been well-publicised that a bullet passed through her lower abdomen, shredding her aorta and IVC. It seemed to me that she was there the whole time as the incident unfolded, with a huge team of nurses and doctors working on her. CPR seemed to be in progress for a long time. I remember thinking “When are they going to stop?” My perception of events, my sense of time, was clearly skewed.
In reality, she was immediately intubated, had two IOs inserted and was transfused through these. As soon as output was captured she went to OT – the very first patient to reach theatre. In total she only spent 14 minutes in our department.
Her father was placed in the cubicle next to her – we weren’t aware they were related at the time. A large team of surgeons, anaesthetists and nurses worked to save her life.
My two colleagues, part of the large team involved in her initial care, and the whole team, should be immensely proud of what they achieved with that case.
One said she then saw a further five cases. “A blur of intubations, chest drains, TXA, antibiotics. All went directly to OT.”
Space quickly became an issue. Staff and families like to mill in corridors and had to be constantly relocated out of the way – in truth, probably my main role in this whole event.
All hands on deck
Senior people are essential. People familiar with the department and hospital.
A cardiothoracic surgeon came in dressed in a T-shirt and shorts, smiling, “Do you need a hand?” An orthopaedic surgeon, his arm deep in a patient’s pelvis trying to stem the bleeding, looked up and said “Busy day?”
Our Director of Medicine promptly asked “How may I help?” We shipped dozens of minimally or completely unassessed patients to medical wards. The physicians were an immense help.
A cardiologist, asked “Will echos help?” Yes, they did. Later he came up to me and said “I’m sorry, I didn’t find any tamponades” but it was the very lack of them that meant no chests were opened in our department that afternoon.
Respiratory physicians rocked up and stated “We can do chest drains.” And they did, very carefully, precisely, in a way emergency specialists would not place chest drains into shocked, exsanguinating patients.
Physicians are not familiar with trauma and may under-appreciate injuries. “It’s just a flesh wound”, was the comment on one patient found with a physician in a side room, but “it won’t stop bleeding.” His posterior pelvic wound was covered with a large Gamgee dressing, a wound that extended through his shattered iliac crest, across iliac vessels, rectum, and bladder, and exited removing most of his genitals. He was moved back to a resus bay and a trauma team allocated to his care, one of only two people who got past me that day.
Radiology gave us an amazing service. A large team of radiologists, sonographers and radiographers came to us in ED.
Bedside ultrasound was invaluable. Everyone had either or both a FAST scan or echo.
Our CT scanners are a floor above and 200m away from ED. Radiology performed 23 CTs in two hours on two CT scanners. Radiologists ‘hot’ reported every single scan – with a written preliminary report placed on every patient bed as they left the scanner.
The Blood Bank quickly came to ED, with a transfusion nurse specialist carrying a large chiller box of O-negative. Twenty-four of the 37 shot received blood that day, an average of four units of RBCs per patient. We had multiple massive transfusion protocols in progress at once – eight in total.
That Friday we used 179 units of RBCs, far exceeding the hospital’s supply. From the NZ Blood Service perspective, this became a national emergency. That evening 135 units of RBCs [Red Blood Cells] were flown down from Auckland, Hamilton, and Wellington. On Saturday and Sunday the hospital used nearly 300 units of blood.
Our ED pharmacist was a vital part of the team. She said “I’m glad I wore closed-toe shoes that day.” She kept every team supplied with morphine, fentanyl, ketamine, sux and roc., propofol, TXA, antibiotics, ADT and metaraminol. Main pharmacy also appeared with boxes of narcotics: morphine and fentanyl.
The orderlies formed a long queue down the main corridor leading to ED waiting to be called, like a taxi-rank with an orderly immediately available to get a patient to where they needed to be.
Cleaners worked like a Formula One pit crew. As soon as a patient left a bay, the whole bloody mess, discarded equipment and all, was immediately swooped on and cleaned, ready for the next patient.
A surgical disaster
We will never know how many chest drains were placed. It seems likely that almost every patient who arrived received one. Many had bilateral chest drains inserted.
We have five prepared chest drain sets – all used almost immediately. Hospital aides frantically worked on making new sets, and they couldn’t keep up with the demand. We didn’t run out of large-bore drains but we did run out of under-water seals. Runners were sent off to theatres, ICU, cardiothoracic and respiratory wards to get more equipment.
There was huge variation in the appearance of the gunshot wounds. The majority seemed to involve being shot in both their buttocks and chests. Many wounds just appeared to be small punctures, like something marked with a sharp finger nail. Others were gaping bloody craters of torn flesh.
Throughout this we had very little information of what was happening outside the hospital. Just at the point when I thought we were going to be overwhelmed the last critical case arrived. Only a few minutes before this we were told to prepare for another 30 or more patients. But in reality, it was over.
This was essentially a surgical disaster – every case needed theatre, most would need surgery many times, operations requiring multiple surgical specialities to be involved at the same time.
I was home later that evening, able to have dinner with my family; many of the surgeons remained operating through the evening, overnight and into the next day.
Sixteen patients went from ED directly to OT; 23 patients went from ED to CT [scans], of which 17 then went straight to OT [the operating theatre]. Within 150 minutes we had 23 patients imaged and 33 patients to OT. That’s a system that worked well. Our ED length of stay ranged from 14 to 45 minutes.
There was so much self-doubt from emergency physicians leading trauma teams. I heard “That wasn’t my best resus”, and lots of dissatisfaction expressed.
But I feel the results speak for themselves. Every team did a phenomenal job. Almost no criticism of ED care has found its way to me.
A day of contradictions
How did we manage so well?
One reason it was successful: teamwork like I’ve never seen before. The earthquake forced the hospital to work as a team, and those relationships have endured. The Trauma Service has continued that spirit of cooperation.
Imagine a day where every referral was met with immediate patient review and acceptance. Where as soon as you gestured at a surgeon to see a patient they then wheeled that patient out of your department. Orthopaedics, cardiothoracics, neurosurgery, taking referrals without question.
We lost one patient that day. A man who sustained several life-ending gunshots. He was intubated on arrival. But the team – three ED nurses, three emergency specialists, anaesthetists and a surgeon – rapidly concluded his injuries were non-survivable, a decision that tore at the hearts of everyone caring for him.
He was moved into a side room in ED. He was extubated. A senior ED nurse, the attending surgeon and emergency specialist stayed at his side to the end. One of the enduring images seared in my memory was a surgeon seated next to him until he took his last breath.
Amazingly, his nurse, with the social workers and police had located his wife and brought her to the bedside before he died. She had two teenage sons, both shot. One needed urgent surgery, the other died at the Al Noor Mosque.
So what should you do? It can happen anywhere, and something similar will occur again.
Read your Major Incident Plan.
Go through in your head what you would do if this happens when you’re leading a shift.
How would you register 50 patients who arrive at once? How would you track them? How would you document? How would you ensure rapid patient flow? The most critical part of performing well when faced with something similar is the relationships with your inpatient colleagues. These relationships matter.
You need an effective way of calling in extra help when needed.
So that ends my story. A day of contradictions. Where I saw the worst and the best that people could do, to and for each other. Where I had the busiest hour of my life, with nearly 50 critically injured patients, but also one of the quietest days, with only 146 patients presenting to our ED that day instead of our average of 285.
I called handover at 16:03, only three minutes late.
I want to pass on my gratitude and condolences, for the patients – the survivors, for their families, for those murdered. To this day I remain overwhelmed with the degree of dignity displayed.
Where I expected rage, I have seen restraint. Where I expected impatience, I have seen understanding. Where I expected anger I have only seen gratitude.
He tangata, he whanau, he whenua I te nui tapu o te ao
The person, the family, the land are the most sacred things in the world
As-Salaam-Alaikum
Peace be with you
• Read this 25-page Twitter summary from the session.
Watch our interview with new ACEM President John Bonning
Bonning is the first New Zealander to hold the role, and reflects in this interview with Amy Coopes on the impact of Christchurch and on College advocacy for stronger gun controls.
The 2019 ACEM ASM was held in Hobart from November 17-21. Amy Coopes is covering it for the Croakey Conference News Service. Read our previous ACEM ASM coverage here and here.
