NESS - Besieged in the Bronx: Lessons from an In-Hospital Mass Casualty Report of a single institution's response to the largest mass casualty event in a hospital in the history of the United States.

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Besieged in the Bronx: Lessons from an In-Hospital Mass Casualty Report of a single institution's response to the largest mass casualty event in a hospital in the history of the United States.
Kristen Bridges-Tran¹, Pratibha Vemulapalli⁴, Allen Deborah², Bentley John³, Brian Gilchrist¹
¹Surgery, Richmond University Medical Center, Staten Island, New York, United States, ²Orthopedic Surgery, Bronxcare, Bronx, New York, United States, ³Surgery, Bronx Lebanon Hospital Center, Bronx, New York, United States, ⁴Surgery, Brooklyn Hospital Center, Brooklyn, New York, United States

Objective: An active shooter in a hospital is an emergency extraordinaire. We report a single institution"s response to the largest mass casualty event in a hospital in the history of the United States.
Design: Review of notification, flow, and key elements of the day"s dynamic after hospital attack by a lone gunman was conducted. The review included outcomes on seven victims and assailant.
Patients:
1. 32F- family medicine staff physician- shot in the heart- dead at scene
2. 38M- physician in training- shot in the left wrist- multiple carpal bones obliterated, median nerve singed but intact- loss of full range of motion of left wrist
3. 31M- medical student- shot in the abdomen- greater omental and gastro ligament tears, ruptured rectus sheath
4. 29F- intern- shot in the neck- L sternocleidomastoid mastoid muscle injured, obliterated distal L clavicle. No neurovascular injury
5. 29M- intern- shot in the abdomen and chest- grade IV liver laceration and right lung laceration- prolonged ICU stay, ERCP for bile leak, discharged home after 3 weeks
6. 26M- medical student- shot in the head and right knee- comminuted intraarticular fracture of right knee, subdural hematoma and intraparenchyal brain hemorrhage- extubated and following commands
Results: "Code Silver" announced: open display of a weapon. Concise, known, and published chain of command implemented. All house staff to Emergency Department (ED) via text blast. Operating room (OR) notified. Injured to ED, then triaged to OR by Surgeon-in-Chief. NYPD stationed throughout OR. Senior surgeons controlled key vantage points during attack with triage from the ED and OR control desk. Five operative incidents and one fatality ended on the shooter"s suicide.
Conclusions: Success favors the prepared. The response to attack, readiness of medical personnel, mitigation, and recovery have brought the following recommendations:
1. Single entrance access
2. Armed, professional guards at all entrances
3. Camouflage metal detectors
4 .Mandatory, recurrent hospital-wide active shooter training, mock and table top
5. Published physician chain of command
6. Intercom code system known to all hospital personnel indicating a weapon is openly displayed
7. A "no fly" list of former employees who are prohibited on premises
8. Stop the Bleed training with kits on every floor
9. One voice, one face to disseminate information

Injuries sustained by victims
Patient Age (years) Gender Occupation Injury Operative Findings Disposition
1 32 F Family Medicine Staff Physician Shot in the heart N/A Dead at scene
2 28 M Physician in Training Shot in the left wrist Multiple carpal bones obliterated. Median nerve intact, but singed Left wrist: loss of full range of motion
3 31 M Medical Student Shot in the abdomen Greater omental and gastro ligament tears. Ruptured rectus sheath Uneventful post-operative recovery
4 29 F Intern Shot in the neck Skin and left sternocleidomastoid muscle injured. Obliterated distal left clavicle. No neurovascular injury Uneventful post-operative recovery
5 29 M Intern Shot in the abdomen and chest Grade 4 liver laceration. Right lung laceration Prolonged ICU stay, ERCP performed for bile leak; discharged to home three weeks post injury
6 26 M Medical Student Shot in head and right knee Comminuted intra-articular facture of the right knee. Subdural hematoma and intra-parenchymal brain hemorrhage Extubated; able to speak and follow commands

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Patient	Age (years)	Gender	Occupation	Injury	Operative Findings	Disposition
1	32	F	Family Medicine Staff Physician	Shot in the heart	N/A	Dead at scene
2	28	M	Physician in Training	Shot in the left wrist	Multiple carpal bones obliterated. Median nerve intact, but singed	Left wrist: loss of full range of motion
3	31	M	Medical Student	Shot in the abdomen	Greater omental and gastro ligament tears. Ruptured rectus sheath	Uneventful post-operative recovery
4	29	F	Intern	Shot in the neck	Skin and left sternocleidomastoid muscle injured. Obliterated distal left clavicle. No neurovascular injury	Uneventful post-operative recovery
5	29	M	Intern	Shot in the abdomen and chest	Grade 4 liver laceration. Right lung laceration	Prolonged ICU stay, ERCP performed for bile leak; discharged to home three weeks post injury
6	26	M	Medical Student	Shot in head and right knee	Comminuted intra-articular facture of the right knee. Subdural hematoma and intra-parenchymal brain hemorrhage	Extubated; able to speak and follow commands