Code Orange: ‘We were ready’
How The Ottawa Hospital co-ordinated trauma teams for victims of bus crash
Trauma surgeon Dr. Jacinthe Lampron was on her way to pick up her daughter from daycare Friday afternoon when she heard the news on her car radio: A bus had crashed into Westboro station; many were injured.
Lampron called the The Ottawa Hospital and was told it was about to declare Code Orange — a code reserved for disasters and other major events with a significant number of serious injuries. The last Code Orange had been declared in September 2013 when a VIA Rail train collided with an OC Transpo bus.
Lampron turned around and headed straight back to the hospital. Like dozens of other doctors, nurses, social workers, administrators and housekeeping staff, she converged on the Civic campus just after 4 p.m. to assume her role in the rapid and complex transformation of the hospital. The hospital, which moments before had been in the process of reducing staff and closing operating rooms for the weekend, suddenly had to prepare for a major influx of trauma cases.
Space had to be cleared in the emergency department and intensive care unit. Operating rooms had to be staffed and equipped. Social workers had to be brought in to help identify patients and contact family members. Trauma teams had to be assembled with emergency doctors, vascular surgeons, orthopedic surgeons, anesthetists and nurses.
It’s no exaggeration to say that lives were at stake as hospital staff carried out their rehearsed roles for a Code Orange.
Paramedics at the scene of the OC Transpo bus crash had already relayed preliminary information: Five to seven people with severe injuries would be dispatched to the Civic. Another 17 people had injuries of various kinds.
The Ottawa Hospital was about to experience the most significant test of its emergency preparedness in more than two decades.
The Ottawa Hospital serves as the regional trauma centre for Eastern Ontario, which means the Civic campus is always prepared to deal with two, even three, severely injured patients at any given moment.
But dealing with seven severely injured trauma patients at the same time represents a different challenge altogether.
“It takes a special kind of preparation,” said Dr. Guy Hébert, head of the department of emergency medicine.
Hébert was in a meeting when two emergency department staff interrupted to warn him about the possibility of a mass casualty event. Hébert stopped the meeting — he can’t remember now what it was about — and went to the emergency department to confirm details of the incident. Sometimes, initial reports overstate the scope of an event.
Hébert contacted the Ottawa Paramedic Service dispatcher, who told him that a bus loaded with passengers had crashed into Westboro station. The scene was only minutes away from the hospital.
“We knew we wouldn’t have that much time to prepare,” Hébert said. “So sometimes you have to make a decision with the information you have — and you tend to be more on the cautious side. When I was told there would be at least five severely injured patients, and there was the possibility of more, that’s when I made the decision to call the Code Orange.”
Code Orange activates a massive, multi-faceted response at the hospital — one regularly rehearsed during the past five
When I was told there would be at least five severely injured patients, and there was the possibility of more, that’s when I made the decision to call the Code Orange.
years. In fact, the most recent simulation took place in November.
But Friday afternoon was no dress rehearsal.
Based on the decision to call a Code Orange, the hospital’s communications centre issued alerts to phones and tablets held by key staff members using the Spok Mobile system. The timing of the OC Transpo crash was fortuitous.
The hospital had a large contingent of doctors, nurses and other support staff still in the building while more were about to come in for the evening shift. It meant that some staff stayed late while others came in early.
In keeping with the emergency preparedness plan, many things happened at once to prepare the hospital for mass casualties.
Doctors and nurses converged on the emergency department. Hébert and Lampron, the trauma director who was now back at the hospital, organized the arriving staff into eight trauma teams, each of which featured two or three nurses, a respiratory therapist, an anesthetist, an emergency physician, a trauma resident, an orthopedic surgeon, a vascular surgeon and a trauma team leader. (The hospital normally has one such trauma team in operation.)
Meanwhile, the emergency room began to be cleared of patients in order to make room for the incoming casualties.
It was the middle of flu season, and as is the case every January, icy sidewalks brought many to the ER with sprains and broken bones.
The waiting room was jammed: The emergency department had about 100 patients, including 24 admissions, late Friday afternoon.
Some patients were moved into the post-anesthetic care unit, others to the adjacent Ottawa Heart Institute.
Some patients were discharged, others moved to medical units. Patients in the waiting room were triaged and those who could be safely moved were advised to go to another emergency room. Four ambulances took patients to the General campus.
“The idea is to basically clear out the emergency department,” said Hébert. By 4:20 p.m., eight trauma bays in the ER department were ready for action.
Meanwhile, clinical manager Joanne Schubert was organizing the preparation of the Civic’s operating rooms. Schubert had been on her way home when she received notice that a Code Orange would be called. “There’s a bad accident. Can you go back?” her director asked. Schubert was on the roundabout near the Experimental Farm and looped back to the hospital, barely slowing down.
Schubert leads the command centre in the hospital’s operating room; she was already at her post when the Code Orange was officially declared.
Two operating rooms were up and running at the time with ongoing elective surgeries. Schubert needed to have six ORs staffed, equipped and ready by the time that the casualties started to roll in the door.
“I have some very dedicated staff members who actually called us before we even had the chance to call them so it made it easy for us to say, ‘Come on in,’” Schubert said. “We didn’t know exactly what we needed at the time, but we brought them in so that we were prepared.”
Schubert had enough staff to run as many as eight operating rooms if necessary since other trauma cases, unrelated to the bus crash, could arrive anytime.
“We had to make sure we could accommodate the people from the bus accident but also if something else happened to come through the doors,” she said. “I mean, we’re a very busy OR on a normal day.”
The hospital’s manager of psychosocial services, Geneviève Côté, was conducting a job interview when she was notified of the Code Orange. She had a team of social workers in the emergency department within 10 minutes. Their job would be to identify the patients as they arrived, ensure that family members were notified, and assist them through what promised to be a difficult experience.
Elsewhere, chief operating officer Cameron Love had launched the hospital’s emergency operations centre, which brings together representatives from across the hospital including officials from logistics, communications, operations and medical affairs.
The centre’s key job was to create the capacity in the hospital to accommodate an influx of patients with complex medical needs. Wards were canvassed for potential transfer candidates, and beds were opened by moving patients to the General campus and other local hospitals.
Transportation for those patients had to be arranged, and extra housekeeping staff brought in to clean and prepare hospital rooms. Extra surgical instruments had to brought in from the General campus and the Gatineau Hospital.
“You have to be prepared for any situation because you are not sure what you’re going to be faced with,” said Joanne Read, vice-president of planning and support services, and the person responsible for the hospital’s emergency management program.
Paramedics notified the emergency department whenever they left Westboro station with another crash victim. That gave hospital staff about five minutes to prepare to receive a casualty.
Some patients had to be extricated from the mangled bus and so their arrivals at the hospital were staggered over almost 90 minutes.
Some arrived at hospital suffering the effects of hypothermia. (They would be re-warmed with heated blankets or a forced-air patient warming machine known as a Bair Hugger.)
Each patient was met at the emergency room doors. A social worker would lean in to calm patients and explain what was happening: “OK, you’re in great hands. They’ll be working on you, providing you with medical care. Is there anyone you want me to call?”
With unconscious patients, social workers have to search for a wallet or other identification so that family can be notified.
Patients were immediately wheeled into a trauma bay to be assessed by one of the eight assembled trauma teams.
As nurses started IV lines and attached monitors, the trauma team went about methodically assessing each patient from head to toe. They evaluated each patient for potentially life-threatening situations: airway blockages, breathing problems, circulation issues, bleeding, head trauma. Ultrasounds were done immediately if serious internal bleeding was suspected. Some patients were rushed to an operating room within 10 minutes.
“Trauma care is all about addressing those life-threatening injuries first and stabilizing the patient,” Hébert said.
The hospital received seven patients with severe injuries, which included internal damage, head trauma, torn arteries and multiple fractures of the pelvis and limbs. Some limbs were mangled.
Every bedside trauma leader reported to the trauma medical director, Lampron, who ensured they received the necessary blood products, CT scans and other diagnostics they needed before assigning them to an operating room.
“Because of the type of injuries those patients suffered, it required a good amount of transfusion on most of them,” she said. The hospital would use more than 160 units of red blood and other blood products Friday night.
In the operating rooms, surgeons had to carefully co-ordinate their work.
Dr. Sudhir Nagpal, chief of vascular surgery, was confronted with a patient who had fractures to both legs and damage to the network of vessels and arteries that supply blood to those limbs. The patient needed both vascular and orthopedic reconstruction.
Nagpal worked to restore circulation to one leg while an orthopedic surgeon worked on the other. Then, after Nagpal worked alone for hours, the other surgeon again worked alongside him to repair fractures.
At one point Friday night, five vascular surgeons were operating at one time at The Ottawa Hospital. “That hasn’t happened before,” Nagpal said. “This is, hopefully, a once-in-a-lifetime event.”
Allan Liew, the hospital’s director of orthopedic trauma, mobilized nine orthopedic surgeons and 15 residents Friday night. He was at the hospital until 3:30 a.m. ensuring that treatment plans were in place for all of the injured bus passengers.
“I’ve been here for 20 years and this was the largest mass casualty I’ve been involved with,” he said.
The most critically injured patients, he said, suffered “severe, life-changing injuries” that will require more surgeries this week.
“We expect pretty much for the entire next week that each one of these patients will have to come back to the OR several times,” he said. “Because Friday night is what we call the damage-control phase. Each of them will have a few more surgeries to go. It will be a busy week.”
On Reddit, one nurse told readers that the scene she had witnessed at the hospital weighed heavily on her mind Friday night. “Normally I don’t let work affect me too much, but it was very sobering seeing the aftermath of an accident like this and what it does to a person,” she wrote. “I may end up calling the distress line tonight.”
The difficult work performed by hospital staff is the product of much planning, training and sacrifice.
Joanne Read, the woman responsible for The Ottawa Hospital’s emergency plan, said it was a relief to know the system worked under a real-life stress test.
“I was very proud: We were ready,” she said. “Ottawa’s a very small city, and I knew that some of these people coming in the door could be friends or family, someone you knew. We were ready.”
Said clinical manager Schubert: “It takes a lot of teamwork to manage that kind of thing, and it was a privilege to have been part of something like that.”
Eleven patients from the bus crash remained at The Ottawa Hospital on Sunday night, seven in serious condition and four in stable condition.