Michael Morkin, M.D., was working in the pediatrics area of Renown Regional Medical Center's emergency department on Sept. 16, when he got word that a plane had crashed into the crowd at the Reno Air Races.

Twenty minutes later, the most severely injured victims hit the door, followed by several waves of other wounded spectators. It was the first time the hospital had filled all eight of its trauma bays at once.

For the next four hours, Renown's carefully choreographed disaster response plan, honed during a drill back in April that imagined a similar scenario, brought routine to the unexpected. "After the fact, when everything calms down, you think, 'Man, that was awful,'" says Morkin, Renown's director of emergency medicine. "But at the time, I never felt that we were even close to being overwhelmed or out of control."

The hospital's emergency operations plan was up and running within minutes. An administrator headed to the ED to direct traffic, sending a good portion of the hospital staff downstairs and moving other ED patients to beds upstairs. "That really expedited the flow so we could open up more beds for the trauma patients," says Morkin.

Planning, logistics, and operations leaders assessed the situation to determine whether more staff was needed. Other section chiefs went to work setting up an emergency credentialing station for volunteer clinicians and a family assistance center staffed with the hospital's social service workers.

"Everyone knew where they needed to go because we had just practiced this event," says Michael Munda, Renown's emergency plan manager.

The April drill had prompted the hospital to set up additional phone lines, which were put to use for the family assistance center that had been established at a local hotel. In addition to the 50 to 100 family members who used its walk-in services on Sept. 16, the center took 2,000 calls in the hours immediately after the crash.

Initially, Renown anticipated as many as 100 wounded being transported to the 80-bed ED. But clinicians actually treated 37 crash victims, including 14 with life-threatening or limb-threatening injuries.

The victims showed up seven or eight at a time. "That was how many ambulance rigs were available," says Morkin. "They had to drop a patient off and drive back out and pick up the next group."

In the meantime, Morkin and his team had to keep things moving, continually asking, "OK, what are we going to do with this guy? He needs to go to the ICU. He needs to go to the OR. Get him out of here. Then the next wave would hit."

The setup of the trauma center, which was redesigned a decade ago from the ground up, helped expedite things, says Myron Gomez, M.D., chief of trauma services. Overhead digital X-ray imaging in the trauma rooms saved time because films didn't need to be developed and delivered and images were instantly available on monitors as patients moved to other parts of the hospital. High-speed elevators whisked patients from the trauma area to the operating room.

Gomez credits the field triage team from REMSA, Reno's emergency management agency, with having an especially organized first response and effectively determining "who should be transported first and to where. It improved our performance because we got to the appropriate patients initially, the sickest ones, and we could move them through our system quickly," he says.

The 20-minute trip back to the crash site worked in the ED's favor, says Morkin, breaking up the flow a bit.

"The thing that we've gone back to look at is, now what are we going to do if something like this happens where they're so close they're going to hit the hospital all at once?" he says. "That would make it more complicated. We have a large hotel casino that's a third of a mile away from our hospital. What if something bad happened there? In that case, you might be getting 20 or 30 patients at a time."

When the hospital stages its next drill in early 2012, "we're going to set up a scenario where 100 people hit the door all at once," says Morkin.

The crash also brought attention to a weakness in the hospital's patient registration system — that having to do a full intake for each patient in a situation with mass casualties could really slow things down. As a result, they've come up with some information system workarounds so staffers can assign numbers at check-in and doctors can override the medication-dispensing interface.

"Right now, if you come in with a sprained ankle, for me to dispense you a Motrin tablet, I have to go into a computer," he says. "You have to be entered in the system. I have to have a number for you. I have to punch in to get the Motrin out. There are too many steps when something bad happens.

"We just went back and looked and said, 'We can do this a little better.' If this were a problem with your car, it was not a case where we had to swap the engine out. It was a case where we thought, it's probably about time for an oil change."