By Matt Martin and Elizabeth Beilman
It’s a quiet, sunny September morning in Cincinnati, Ohio. Across the city’s downtown central business district, commuters are making their way to work for the day.
Then suddenly, the stillness of the morning is violently interrupted by a loud bang near Great American Ball Park, home to the city’s professional baseball team and located just a block from the Ohio River.
The explosion is heard across the entire riverfront. Soon, emergency sirens begin to wail as Cincinnati Police Department, Cincinnati Fire Department and other first responders race to the scene of what we later learn is an ammonia gas explosion that killed 25 people and injured hundreds more in the heart of downtown Cincinnati.
Countless victims lie near the scene of the accident, dazed and frightened, pleading for help. First responders quickly triage the scene, assessing the severity of victims’ injuries while working to keep them calm.
“If you can hear my voice, step this way.”
“Tell me your name.”
“What’s bothering you the most?”
Within moments, victims are whisked away to nearby hospitals.
The most critically injured are taken to University of Cincinnati Medical Center, Greater Cincinnati’s only Level I trauma center, located just four miles north of the scene of the accident.
At the hospital’s Emergency Department, a fleet of highly trained doctors and nurses spring into action, preparing to treat an unknown number of victims with traumatic injuries.
Thankfully, this mass casualty incident was only a simulation. But emergency management officials know that it’s a matter of when—not if—the region is affected by a real-life event that threatens to overwhelm emergency medical services.
“We do this drill so we can figure out where the issues are to fix them before this happens in real life,” said Woods Curry, MD, UC Health emergency medicine physician and assistant professor of emergency medicine at the University of Cincinnati College of Medicine. “Everyone says you should train like you play, so we have to train like we have a real disaster.”
The 2019 mass casualty incident exercise was organized by several Hamilton County, Ohio agencies and the Greater Cincinnati Disaster Preparedness Coalition, specifically to test how the region’s hospitals would respond to a real-life disaster. Forty-five organizations and health systems from around Hamilton County were involved, including 395 volunteers and 170 first responders.
“Large scale exercises like this are essential to advancing regional preparedness,” said Christa Hyson, MPH, senior manager of external relations at The Health Collaborative, a local nonprofit organization that played a major role in planning the simulation.
The story that follows is a timeline of that day, beginning with the “gas explosion” at 8:29 a.m.
8:34 a.m. — UC Medical Center: The Emergency Department receives an alert via Disaster Net, a paging system that notifies local hospitals of emergency situations, that there’s been a gas explosion downtown. All doctors and nurses are told is that a large number of severely injured patients are en route via metro buses and emergency medical service transport.
Dr. Curry, one of the Emergency Department attending physicians, begins delegating predefined tasks to clinical staff and tries to prepare as many beds and operating rooms for incoming patients by transferring patients to other parts of the hospital.
8:39 a.m. — Great American Ball Park: The American Red Cross, Cincinnati Police Department and 35 fire departments from Ohio and Kentucky arrive on scene to triage patients, or determine the order that victims need care based on the severity of their conditions.
First responders escort as many victims as they can onto two metro buses. Both are going to UC Medical Center, the only Cincinnati hospital capable of treating such a large group of critically wounded patients.
8:46 a.m. — UC Medical Center: A physician and a charge nurse position themselves outside of the Emergency Department ambulance bay on the sidewalk. It’s been a quiet morning at the hospital, but that changes quickly as the victims begin to arrive via EMS, bus and car.
The physician and charge nurse wheel a cart through the crowd, triaging patients as they go.
Conal Roche, MD, a UC Health emergency medicine physician, calmly and compassionately approaches one terrified patient: “Looks like you have a pretty good gash on your head. I’m Dr. Roche. Can you tell me what happened?”
Dr. Roche and the charge nurse tie one of three colored ribbons onto each patient’s arm: green means they’re able to walk, yellow means they require immediate medical attention and red means they’re in critical condition.
Emergency Department nurses wheel patients into the Shock Resuscitation Unit—or SRU—in steady yet quick succession. The SRU receives patients who require immediate, lifesaving medical intervention. One wall of the room is covered with drawers of supplies right on hand for procedures like intubation. The SRU also contains mobile imaging equipment, including ultrasound and X-ray machines.
9:33 a.m. — Great American Ball Park: Paramedics and emergency management leaders determine the final number of casualties: 25 people were killed instantly in the explosion, while 280 surviving victims need immediate medical attention. These civilians are suffering from a number of injuries, including broken legs, large cuts and burns.
First responders place gold or silver blankets over the remaining victims. If they have a gold blanket, paramedics know to transport them to a trauma center like UC Medical Center; if silver, they will go to a community hospital.
9:46 a.m. — UC Medical Center: Matt Eilerman, RN, works alongside three or four clinicians in the SRU—emergency medicine physicians, trauma surgeons, respiratory therapists and pharmacists. His job is to stabilize the patient.
“You just have to do your best to take a deep breath, slow down and take one thing at a time,” Matt explains.
He and his team lift a newly arrived patient from a gurney and onto a bed in the SRU. The team begins volleying their observations and plan of action:
“She’s nonverbal, appears to be clutching airway.”
“Let’s move forward with intubation.”
“We have IV access.”
Just feet away, another team is “bagging” a patient—manually squeezing air into their lungs through a flexible plastic mask. The trauma surgeon at the bedside makes the decision:
“We’re taking this patient to the OR.”
10:23 a.m. — UC Medical Center Command Center: The hospital incident command team, led by Meg Lewis, MSN, RN, associate chief nursing officer at UC Medical Center, gather inside the hospital’s packed command center to prepare for a 10:30 a.m. conference call with other team leaders. The call includes leaders from operations, communications, logistics, air care/mobile care, trauma, operating room and others.
The incident command team collaborates together in a secure, private space during and after a regional emergency. Their objective is to lead the system through an emergency response and plan how each UC Health facility will handle the huge number of incoming patients.
“We have a great team. We prepare like this all the time, and practice makes us even better,” Meg said.
Members of the capacity management team monitor patient statuses and bed availability, while other site commanders are communicating traffic updates, supply availability and internal messaging for employees.
10:41 a.m. — UC Medical Center: Dr. Curry continues to oversee the flow of patients through the Emergency Department, saving precious resources for the most critical patients. A staff member alerts him of another incoming patient: “I’ve got another patient coming in with blunt chest trauma.”
Dr. Curry asks, “Is she stable?”
“She’s going to have to wait.”
After a mass casualty, space is one of those “pinch points.”
“Unfortunately, someone that might go to the operating room right now on a normal day when we have plenty of space might have to wait until the case in front of them is done,” Dr. Curry said.
11:15 a.m. — Command Center: The incident command team holds a second debrief.
Around 90–100 victims now have arrived at UC Medical Center, with 14 in the operating room. The hospital still has 11 operating rooms available. UC Health’s West Chester Hospital received 14 patients and can accept 49 more. Daniel Drake Center for Post-Acute Care is prepared to receive up to 20 victims.
Meanwhile, UC Health Public Safety officers manage foot and vehicle traffic from members of the news media around campus. Updates are given about where family members can reunite with victims.
The command center closes following the call, ending the simulation.
12:00 p.m. — UC Gardner Neuroscience Institute Building: A “hotwash,” or an evaluation after an emergency exercise or training session, takes place.
As one of the key leaders of the drill, Maria Friday, director of Emergency Management at UC Health, applauds the teamwork from everyone who participated.
“I’ve been here for about six years, and this is the most attended exercise with a lot of involvement and a lot of different departments—from physicians to environmental service staff to administrative staff,” said Maria. “The collaboration and teamwork was fantastic.”
Maria’s background prepared her to lead drills like this. She holds a master’s degree in healthcare emergency management from Boston University, one of the few colleges in the nation to have this unique program. Her goal is that UC Health keeps up the momentum going forward by continuing to work with the community to prepare for these drills.
The mass casualty exercise was a monumental achievement in planning, logistics and execution: hundreds of people were involved, whether as “victims,” first responders or healthcare providers. Dozens of local agencies mobilized resources to help ensure Cincinnati is prepared to spring into action if the worst occurs.
At UC Medical Center, nearly 300 clinical and operational employees participated in this drill, from trauma surgeons to patient care assistants. The level of commitment was so intense that one team developed a contingency plan on the fly in case the hospital’s morgue was overwhelmed in real life.
The exercise was more than a one-day event: the lessons learned during the simulation will be incorporated into the health system’s emergency management and operational plans moving forward so that the same pain points aren’t an issue in a real-world crisis.
That’s just one way that UC Health, the region’s academic healthcare system, works every day to serve the community and to lead the way, whether in clinical care or in emergency management.
“From the coordination of safe patient transfers to streamlined family reunification—our hospitals, first responders, Hazmat teams and emergency response personnel work together in a coordinated effort to keep our region safe,” Christa said. “Practicing these response skills in a ‘no fault’ learning environment is an integral part in building our region’s resiliency.”
Cincinnati is lucky to have the most committed hospital system in the country with the most experienced team of experts who know how to prepare and execute a mass casualty drill. When tragedy strikes, UC Health will swiftly work to save the most lives.
“It’s our responsibility as a community advocate to be prepared for worst-case scenarios,” Maria said. “We hope this never happens, but if it does, we will be ready.”