Ronald Roth, MD, emergency medicine physician at Pittsburgh-based UPMC and chief of the University of Pittsburgh School of Medicine, division of EMS, was among the first responders on the scene of the Oct. 27 shooting at the Tree of Life Synagogue in Squirrel Hill, Pa.
First responders found 11 people dead in the building, including Jerry Rabinowitz, MD, a 66-year-old primary care physician affiliated with UPMC. They also found at least six other people injured, including UPMC chaplain and nurse Daniel Leger, RN, and shooting suspect Robert Bowers, 46. Injured patients were treated at UPMC Presbyterian, UPMC Mercy and Allegheny General Hospital, all in Pittsburgh.
Becker's recently caught up with Dr. Roth to discuss the response efforts, the effects of the shooting on hospital staff and lessons learned.
Note: Responses have been lightly edited for length and clarity.
Question: What emergency response preparations were in place prior to the shooting?
RR: With respect to EMS, we've been ramping up our active threat training and ironically, several months ago we had an active threat training drill at the Jewish community center a couple blocks away from the synagogue that had a very similar scenario.
Within UPMC, we obviously have drills where we prepare for mass casualties and have a fairly robust system where one of my colleagues has set up the very in-depth program that sort of choreographs what we do in the emergency department. Each of the main players in the emergency department has cards and they tell you what your role is and what your duty is.We've exercised this several times, and we know how patients are going to come in, what rooms we're going to use. That was available and invoked [on Oct. 27].
We [also] work very closely with our trauma surgeons [and] with our other specialists like our orthopedic surgeons. I wasn't at the hospital. I was at the scene. But I understand communications went without a flaw. We had enough help where we could have one trauma surgeon with each of the injured victims.
Q: What has the community response been like?
RR: We've been having a series of debriefings for our emergency medicine personnel, for our law enforcement personnel within UPMC. I know the community is also doing that so we're working on healing.
I think one thing that has helped me is seeing how the city is responding. These things don't happen in Pittsburgh and as it was happening, I'm thinking in my mind, "This does not happen in Pittsburgh." Despite that, we train for it. But always in the back of my mind [is that thought].
I think initially it broke my spirit now that it's happened here. It's hard to get your head around, but I think what's been therapeutic for me is looking at the city response. There's a memorial at the synagogue. There are more flowers than I've ever seen in my life [and] candles. All along [the] Squirrel Hill [neighborhood], which is where I grew up, there are flowers and signs and memorials, and you see people comforting other people. You hear stories about how people have come from out of town, out of state and gone up and comforted people. I've heard victims' families are comforting people, and that's what Pittsburgh is all about. That's the kind of people we are.
Q: What has the staff response been like?
RR: After the shooting, I went to UPMC Presbyterian's emergency department and by then everything had cleared out. But nurses who had been there [right after the incident] were still there. You could tell this was very emotional. It was certainly an out-of-the-ordinary event, and I think it helps to have all your friends involved in the same event so you can chat with them.
Also, the UPMC system is sending out constant emails with respect to resources [for staff]. Hopefully there's something for everyone. We're trying to do the same thing for our responders. We have a stress management team in our county, and they're very active.
Q: What lessons did you learn from this tragedy? What advice would you give other hospitals?
RR: Our challenge was whether we initiate our hospital mass casualty plan. I know some [hospitals'] plans are based on numbers, so if there are not X number of victims, they don't initiate the plan. The challenge was we didn't know how many victims we were going to get. The SWAT team had just reached the synagogue. We had no idea how many … potentially injured patients we had. I think systems should look at their plan, and if it's based on the number of victims, that could be a flaw because they might get an influx of victims.
Hospitals often rely on reports from prehospital care providers with respect to the number of patients being transported to their facilities. Based on these reports, the hospitals can determine their response. Unfortunately, in scenarios such as [last year's] Las Vegas [shooting], a large number of victims arrived by private vehicles. Basing a hospital response solely on EMS transports would have significantly underestimated the number of victims.
Initiating a mass casualty alert at most hospitals initiates a series of events that includes bringing personnel and resources to the emergency department, stopping elective surgeries, moving patients out of the ICUs, etc., to prepare for incoming casualties. These events have the potential to cause significant disruption in the daily activities of the facility.
A hospital mass casualty response plan that works in stages, i.e., the emergency department and operating rooms are immediately made ready, while the ICUs and general medical wards prepare but don't actually move patients immediately, may be less disruptive. The mass casualty response plan must include criteria for moving to the next set of events, i.e., actively discharging or transferring patients from the facility.
Q: Allegheny General Hospital President Jeff Cohen, MD, a Jewish physician with ties to the synagogue and local community, spoke to the shooting suspect at the hospital while he was receiving treatment. Any thoughts on his decision to speak to him?
RR: I've met Dr. Cohen and watched his interview. I had all those same feelings in my mind. I've been doing emergency medicine over 30 years. Obviously, many of the people I've treated are wonderful. There were some who were not mass murderers but were equally not so nice. You have to treat that patient like any other patient. You don't have to like it, but you have to do the right thing for that person or patient. Nonetheless, it's still challenging.