At 8:30 p.m. on May 2, Abbie Saccary, MD, was three and a half hours into her shift at the emergency department at Yale New Haven Hospital when her wife sent a text from their apartment on State Street, near Interstate 91.

“Something’s going on in North Haven,” the text read. “I just saw state troopers flying by and three ambulances. You better get ready.”

The official notification came a few minutes later. Several officers from the South-Central SWAT Team were on their way to the hospital after an explosion in North Haven. The staff prepared for patients, though they did not yet know how many or how serious their injuries. All they knew was that the possibility of disaster was high.

In medical parlance, said Karen J. Jubanyik, MD ’94, FW ’97, HS ’00, associate professor of emergency medicine, and one of the attendings on duty that night, a disaster is “whenever your needs exceed your resources.” For Saccary, a West Point graduate who served as a medical services officer in Iraq, this was what the military call a “MASCAL,” or a mass casualty event.

With the increasing incidence of mass shootings like those in Las Vegas last year and in Parkland, Fla., this year, hospitals have learned to be prepared. “There are a lot of drills that occur and there is a lot of operational planning,” said Andrew Ulrich, MD, the emergency department’s vice chair of operations. “In this specific circumstance, patients arrived and there was a quick identification that they had non-life-threatening injuries and there was no need to bring in more resources. The team that was here, between the ED and trauma services, was able to care for these patients.”

At the scene of the crime

The chain of events that led to the explosion and injuries began at about 2 p.m. that Wednesday afternoon, when a woman appeared at North Haven police headquarters. She’d just escaped from her home on Quinnipiac Avenue where her husband had kept her prisoner for several days. She’d recently filed for divorce after 40 years of marriage, she told police, and her husband was still in the house and he had firearms. While two detectives interviewed the woman, two others went to Quinnipiac Avenue to investigate.

By shortly after 6 p.m., the SWAT team, which included officers from North Haven, North Branford, Branford, East Haven, and Guilford had set up a perimeter around the home.

“The suspect was in possession of firearms and was not responding to our calls to exit the house,” said Capt. Kevin Glenn of the North Haven police, the SWAT team commander. “We classified that as an armed, barricaded situation.”

Around 8:30 officers were clearing the backyard, which had a two-story garage, a shed, a carport, a large boat, and several cars. “In a situation like this,” Glenn said, “they suspect dangers everywhere.” About half a dozen officers were pressed against the back wall of the garage. Then the garage blew up.

“Everyone for miles felt and heard the explosion,” Glenn said. “The blast knocked down almost everybody that was within 50 yards.” The fire also set the house on fire. (A body, later identified as the woman’s husband, was recovered the next day.) Radios came alive with reports from officers, including some of the injured. An armored vehicle sheltered the SWAT medical team—a trauma surgeon and five paramedics—as they rescued the wounded, nine men from North Haven, East Haven, and Branford. All were wearing protective gear, including helmets and vests, and their injuries included broken legs, a broken hand, minor trauma to faces and hands, and concussions. While the rescue was underway, officers heard smaller explosions, including the sound of bullets popping off in the fire.

“It took minutes, but it seemed like hours at that point,” Glenn said of the rescue operation.

Responding with a preexisting plan

At the emergency department in New Haven, staff got ready.

Up until then, said Jubanyik, it had been a typical night in the ED.

“We’re seeing all the regular patients, then all of a sudden, we are having a lot of other patients come in who are going to need a lot of resources in a short period of time,” she said. “This qualified as a disaster.”

The first order of business, Jubanyik said, was clearing out the ED as much as possible, to free space and staff for the incoming patients. They expedited discharges of patients as well as hospital admittances of others. Three attendings were on duty as well as residents, interns, Physician Associates, nurse practitioners, and nursing staff. Also on duty were social workers, chaplains, and security guards.

“It’s hard to plan for every possible scenario, but likely scenarios are worked out ahead of time, so there’s a script that we follow,” Jubanyik said. “It was a rearranging of staff that we had and bringing in administrative staff familiar with disaster planning.”

Trauma staff were alerted, as were Ulrich and the hospital’s security chief.

Saccary, who participated in 50 mass casualty events during her 15 months at a forward operating base in Iraq, had also worked as a police officer and paramedic, and knew what to expect.

“My role is usually to do procedures and airways,” said Saccary, who is in her first year of residency. “Since I knew multiple traumas were coming in, I helped make sure that everything was ready, things that we would need for blast injuries. Given my experience in Iraq, I knew what some of those things were, like airway equipment because a lot of times these folks can have airway burns, which makes getting an airway really hard. We got everything placed and made sure that everyone had roles in each room.”

A triage nurse waited in the ambulance bay, but since the patients had already been triaged by the medical team at the scene, they moved quickly into the ED. As the patients entered, security staff and SWAT team members collected their weapons—no weapons are permitted in the ED.

“Immediately, you want to get the patient to talk,” Saccary said. “You ask, ‘What is your name?’ If he can talk and answer questions, then you know his head is fine and his airway is clear and he’s breathing. It gives you a lot of answers in about two seconds.”

Once the patient is in the trauma bay, a medical team goes to work. “If they don’t have a neck brace, we put on a neck brace, because if somebody has a broken bone in the cervical spine they can become paralyzed if moved,” Jubanyik said. “We assess airways, breathing, circulation. We might place IVs, they may get oxygen, we do a full head-to-toe exam. We order blood tests and imaging studies.”

Although none of the wounds were life-threatening, the patients were all admitted overnight for observation. Survivors of blast injuries may appear to be fine, Jubanyik said, but injuries to the lungs and gastrointestinal tract could surface up to 48 hours later.

“Psychological effects in the victims after a traumatic event can take many forms, and may develop days, weeks, or even years later,” added Jubanyik.

With nine patients arriving in two batches, the four resuscitation rooms filled quickly. “We had to be creative and use other rooms that are not our typical resuscitation rooms,” Jubanyik said.

“People were hyped before everyone arrived,” Saccary said, “but once people started arriving it was fairly organized. … When things go crazy, your training kicks in. It was clear that the people I was working with were very well trained. You stop overthinking it and do what you’re trained to do.”

Readiness is everything

Ulrich, the vice chair of operations, arrived from home not quite sure what his role would be. If needed, he’d add himself to the clinical team, but on this night, he worked with the families, fellow officers, and loved ones that began arriving in the emergency room, some even before the patients. “This turned out to be a lot less about the severity of the injuries than the turmoil this sort of event creates,” he said.

Ulrich, who oversaw the ED at Boston Medical Center during the Boston Marathon bombing in 2013, found a waiting room for visitors and provided regular updates, assuring family members that none of the injuries were life-threatening. Medical staff tried to get loved ones to see the injured officers as quickly as possible, but one obstacle remained.

“The ED becomes an extension of a crime scene, so there’s a need to collect evidence, like clothes,” Ulrich said.

“Everything on them is a piece of evidence and you need to maintain the chain of custody,” Saccary said. “Patients need to be processed for evidence, but if we let visitors in a room and they touch the patient, evidence could be lost.”

By 11 p.m., the last batch of patients had arrived. All were evaluated, treated, and admitted within two to three hours. Ironically, one of the most serious injuries occurred not in the blast, but on the way to the hospital. An EMT driving the ambulance had to brake suddenly on the interstate, throwing an EMT into a window.

Amid the turmoil, the ED staff also had to deal with patients who continued to arrive. “If it was not an emergency, they might have had to wait a little longer,” Jubanyik said.

“It is rare that we get nine patients with this kind of need for an intense response and rapid disposition,” Ulrich said. “We were very lucky. They were very lucky. All of them were able to be cared for in an appropriate way, but the urgency was less than it could have been because the injuries were not what they could have been.”

In a statement posted on their website, the North Haven police expressed their gratitude to the emergency department staff, in addition to emergency medical responders, and local, state, and federal law enforcement partners. Four officers were released the day after the blast, and within a few days all had been released. Some may still require surgery for their injuries, Glenn said.

“In the emergency room we feel like we’re part of the public safety family, so it’s hard to see some of your own come in injured,” said Saccary. “It was good in the sense that everything was flowing, everyone was doing their job, and everything was going really well. It’s good for the patients and it’s good for the providers.”