UVAHS Emergency Team Helps Victims in Charlottesville Protest Tragedy

Charlottesville, Virginia, Aug. 12—At 1:42 p.m., a speeding car slammed into a gathering of protestors, injuring many. Within three minutes, the Charlottesville Fire Department notified the University of Virginia Health System (UVAHS) command center of the event, reporting 30 to 40 injured persons with 10 to 20 priority RED (high-priority) victims. At that time, the UVAHS command center notified the emergency department of the occurrence and activated the mass casualty incident (MCI) plan. Within 30 minutes, 20 patients with varying injury severity presented to the emergency department via EMS transport and private vehicles. Additional physicians, nurses, EMTs, and other team members responded to the MCI declaration, including 20 emergency physicians (11 faculty and nine resident physicians), five trauma teams, and additional anesthesiology and critical care physicians along with multiple nurses, EMTs, and other care providers.

This was the sequence of events:

1:45 p.m.: Notification of event to ED nursing and physician leadership.
1:47 p.m.: Activation of UVAHS MCI plan.
1:47 p.m.: Activation of emergency notification systems of health care providers.
1:48 p.m.: EMS diversion from UVAHS of non-priority patients.
1:48 p.m.: ED triage moved from emergency department to hospital lobby.
1:52 p.m.: Report of “CPR in progress” on one victim.
1:58 p.m.: Arrival of first priority patients at UVAHS.
2:25 p.m.: All priority patients had arrived and received initial care.

Approximately 90 minutes later, a Virginia State Police helicopter, deployed to the event, crashed and burned several miles from the event site. Killed in this crash were two Virginia State Police officers, Lieutenant H. Jay Cullen and Trooper-Pilot Berke M.M. Bates. At the time of this writing, the exact cause of the crash was unknown.

UVAHS ambulances staged adjacent to the medical center and ready to respond to emergency calls.

One person, Heather Heyer, died in the emergency department as a result of her injuries. Ten patients were admitted (to the operating room and critical care and acute care units), and nine individuals were treated and released from the emergency department. During this time, the UVAHS emergency department continued to provide care for “typical” non-event patients, including those experiencing anaphylaxis, chest pain, dyspnea, etc. An additional 10 to 20 priority GREEN patients were transported to another hospital in Charlottesville. As a result of the Unite the Right rally and related counterprotest, more than 40 patients were treated by both institutions that day, many with complex traumatic injuries; one person died as a result of injuries sustained from a car assault. The majority of those individuals injured by the car received treatment rapidly, and the emergency department returned to normal operations within two hours of initial notification.

These events posed a significant challenge to UVAHS, not only to the emergency department but also the operating room and critical care and acute care units. Despite these challenges, the UVAHS emergency department cared for all patients that day, both related and unrelated to the event. The ability of the emergency department to meet this challenge was a direct result of planning and preparation that occurred over the preceding six weeks as well as past years.

The UVAHS Response

With the “scheduled” nature of this MCI, UVAHS and other community partners were able to prepare a coordinated response. The known time and place of this event, however, are in stark contrast to the unanticipated events managed recently by emergency responders in Orlando, Florida; Paris; and Boston.

Gurneys lined up outside of the University of Virginia Medical Center initial casualty collection point (the front entrance to the medical center), ready to receive patients.

First and foremost, situational awareness was a priority. During the planning process, UVAHS personnel were informed of the event and the potential impact on hospital operations, including casualty estimates and likely medical conditions generated, using the most likely and most dangerous scenarios. Graduated security options that included access to the facility were implemented. With these notifications, situational awareness was created weeks in advance and carried through the event.

Furthermore, health care provider emergency notification procedures were reviewed and updated when required. For the emergency department, emergency physician (both faculty and resident physician) call-activation systems were revised and tested using the GroupMe app; ED nursing, hospital-based EMTs, and clinical ancillary departments had similar plans. Trauma surgery, anesthesiology, and the various critical care physicians followed similar emergency notification simulations. In addition to emergency notification procedures, the specific medical care roles and responsibilities were evaluated and revised accordingly for the anticipated patient treatment needs. Lastly, potential longevity of the event and related needs were considered with the creation of at least two shifts of additional care providers (physicians, nurses, EMTs, etc).

UVAHS capacity issues were addressed; this portion of the response plan was also vital to operational preparedness and its eventual success. UVAHS leadership made the decision to limit nonurgent procedures and admissions 48 hours in advance of the event. Nonurgent transfers into the hospital were also limited at that time. With this approach, significant inpatient capacity was increased for acute care, including critical care units. Of course, with increased inpatient capacity, the emergency department was able to decompress, creating greater provider availability and bed space for patient management.

In another attempt to decompress the emergency department rapidly, the admissions process for event- and non-event-related patients was significantly curtailed, allowing patients to quickly move to an inpatient location, again creating ED capacity. This intervention, developed and implemented by the chief medical and nursing officers, was also very effective. With the increased ED and UVAHS capacity, the emergency department was able to accept a large number of patients over a very short period of time, with very efficient through-put to maintain readiness for additional patients.

Several additional patient care areas were created. One area, adjacent to the emergency department, was identified as an admission holding zone. This area normally functions as a preprocedure and recovery area for invasive radiology procedures; it is equipped with critical care monitoring, gas exchange, and suction capabilities. The hospital lobby, a very large open space, was identified as the triage point for the emergency department if the MCI plan was activated.

In addition, the circular vehicular entranceway into the UVAHS lobby allowed for the rapid entry of ambulances and other automobiles with patients. Patients were quickly unloaded and transferred into the triage area, where high-priority cases were immediately taken to the resuscitation areas of the emergency department. Lower-priority cases were managed in the lobby. Appropriate supplies, equipment, and electronic support for this area were identified and tested in advance. This equipment was stored in areas adjacent to the lobby for immediate use when triage operations shifted from the emergency department to the lobby.

The interface with public safety and other health care community partners, including fire-rescue and law enforcement leaders, was another very important area of planning and preparation. Regarding EMS response and care, UVAHA met with them and developed appropriate communication plans as well as a working knowledge of their ability to triage and manage patients at the event. Law enforcement interface was also vital, not only for security considerations in the emergency department and UVAHS but also for forewarning of the potential threats (eg, firearms, toxins, etc). A UVAHS emergency medicine faculty member, medical director of the Charlottesville Fire Department, was present at this forward triage area, allowing for physician-level triage in the field and direct communication to the UVAHS command center.

On Aug. 11, the UVAHS command center was opened and remained open through the late afternoon of Aug. 13. In the command center, an incident commander was identified along with various command and general staff positions (ie, clinical operations, logistics, plans, public information, and communications), each responsible for their specific area of UVAHS function. A member of the emergency medicine faculty, the medical director of UVAHS emergency management, was present and active on the incident commander’s staff. The command center was in communication using telephone, radio, and telemedicine.

The UVAHS command center closely monitored the event via several different mechanisms: real-time video monitoring, direct radio communications with unified command at the scene, on-site physician, and social media monitoring. With this multifactorial monitoring, UVAHS maintained a very high degree of situational awareness and ability to respond. For instance, within minutes of the car striking the crowd, the MCI plan was activated along with the recall of numerous health care providers and the movement of ED triage to the lobby of the hospital.

The use of the command center allowed the emergency department and greater UVAHS to adjust and respond to the changing needs of the community as the event evolved. Furthermore, the command center was able to take a range of duties and responsibilities “off the shoulders” of the emergency physician and nursing leaders, allowing the emergency department personnel to focus on patient management issues.

Looking Back

One area of planning and preparation that could have been more significantly explored was the psychological impact of the event on the health care team pre-, peri-, and postevent.

Immediately prior to the event, the team was able to focus on preparations. Members of the health care team, like many members of the greater Charlottesville community, experienced fear, anxiety, anger, and disbelief that such an event could occur in their community. Of course, the extreme beliefs, opinions, and practices expressed by some of the patients that day represented another challenge; appropriate instruction describing the care of such patients with the suggestion of appropriate strategies was available for providers. After the event, multiple debriefing sessions and after-action reviews were performed, reviewing not only the operational response and areas of potential improvement but also providing emotional support and guidance for the various members of the team.

The emotional devastation inflicted on the community caused by the injuries and loss of life will be with UVAHS for a long time. Lieutenant Cullen, Trooper-Pilot Bates, and Charlottesville-area resident Heather Heyer (the fatality from the car assault) all died that Saturday. The team learned many important lessons that day. Planning and preparation are vital not only for a planned event but also for the unplanned MCI.

The challenge for UVAHS and colleagues in emergency medicine across the nation is that we need to be prepared to react and amass the necessary resources within minutes of notification, for there is no one else who can.

Dr. Brady is professor of emergency medicine and medical director of emergency management at the University of Virginia in Charlottesville.