The Doctor’s Advocate | Fourth Quarter 2017
An Ounce of Prevention
Our thanks to Dr. Weintraub and to the leaders and staff of North American Partners in Anesthesia for sharing their story of extraordinary leadership and courage.
On Friday, June 30, 2017, a gunman opened fire on the 16th floor at Bronx-Lebanon Hospital Center in New York City. He killed one physician and wounded five other physicians before killing himself. In the chaotic moments that followed, two physicians from North American Partners in Anesthesia (NAPA) joined their colleagues and hospital staff to provide care for the wounded and help manage the unfolding tragedy. NAPA’s leadership team, from its base on Long Island, New York, provided support to their colleagues and friends on site and to the hospital’s leadership. How both the NAPA team and Bronx-Lebanon team pulled together—saving lives, facing danger, and providing support to all involved in the shooting—is a case study in leadership.
Dr. Dave Livingstone, NAPA site chief at Bronx-Lebanon, was writing orders on patients in the post anesthesia care unit when he heard the first code silver over the PA system. Several additional overhead codes immediately followed, then a call for all available personnel, stat.
In those initial moments, it was unclear what was unfolding, how many victims were in need, and just what dangers might be encountered. Dr. Livingstone knew he needed to respond. He recalled, “No one knew for sure what was happening, but from the moment we all felt threatened, we all pulled together.”
He grabbed the anesthesia code bag and a colleague, Dr. Eun Jung Park, and together they ran toward the location. The two entered the elevator and pushed the button to go up. Instead, the elevator took them directly to the ground floor. The doors opened and SWAT officers in full gear began yelling commands as they pointed automatic rifles inches from their faces. Drs. Livingstone and Park were escorted at gunpoint out of the elevator and out of the hospital. The SWAT officers were systematically clearing the hospital. Everyone was considered a suspect. Dr. Livingstone knew the SWAT response protocol from the training he received during an active shooter course he attended with colleagues two years prior.
“I knew that if we did not comply with all orders, we would be considered hostile and could be shot.” He continued, “Staying calm and following their direction was probably one of the most difficult parts because everyone was scared.”
Once outside, Drs. Livingstone and Park made their way to the side of the hospital, identified themselves as anesthesiologists, and were ultimately escorted—still at gunpoint—into the Emergency Department (ED). That was the first moment they encountered the victims of the shooting. Doctors, nurses, and other staff members were carrying victims down the stairwell and into the ED. Once Dr. Livingstone arrived, he met Dr. Ajay Shah, the assistant vice chair of surgery, and together they started the triage process.
The first two victims were gravely injured. One had suffered a gunshot wound to the abdomen, resulting in severe trauma to the liver; the other had suffered a gunshot wound to the head. Both were intubated immediately. Drs. Livingstone and Shah rushed the victim with the abdominal wound to the OR. Three more wounded victims were also in need of emergency surgery and were urgently transported to operating rooms. A sixth victim had died. The surgical, anesthesia, and nursing teams frantically prepared five operating rooms for five trauma surgeries simultaneously.
“From the moment we learned that these were our colleagues and one had died, we wanted to go above and beyond to take care of our own. Once we found out we were under attack—that doctors were under attack—there were no egos. It was game on.”
Dr. Dale Anderson, NAPA’s managing partner, was in his car somewhere north of the Throgs Neck Bridge when he received a text message from Sheryl Blumberg, NAPA senior director of human resources, saying that there was a shooter at Bronx-Lebanon. “I knew that Dave and his team were in trouble and needed help, so I went,” Dr. Anderson said.
After arriving at the hospital, Dr. Anderson encountered a barricade of law enforcement. “When I explained who I was and what I wanted to do, they really worked to get me inside as fast as they could. Hundreds of police officers in full assault gear were positioned at the hospital entrance all the way up to and inside the OR.”
Upon arriving in the OR, Dr. Anderson located Dr. Livingstone, gave him a hug, changed into scrubs, got a quick report about what was happening in the five rooms, and asked where he was needed the most. Dr. Livingstone directed him to the patient with the liver trauma.
“What happened at Bronx-Lebanon was beyond what any institution plans for, unless it’s a MASH unit in a forward military zone. All of us have had gunshot wounds at our hospitals. It’s very frightening, but that’s just one. Multiply that by five, and the scene goes from terrible to simply surreal,” said Dr. Anderson. “To this day, it’s hard for me to wrap my arms around what I saw. I’ll never forget it.”
Dr. Sheldon Newman, NAPA regional director, recalls receiving a text message from Dr. Livingstone before anyone saw it on the news. The message was simple: “Shooter at Bronx-Lebanon, all our people are okay.” Word spread quickly throughout the NAPA office. The NAPA leadership team was quickly mobilized. Dr. Newman worked with Barbara Cerrone, NAPA senior director of marketing, to develop a brief message to send to the entire organization.
Dr. Newman explained, “NAPA is a very large organization. It also happens to be a very close-knit organization, and our people were genuinely concerned for Dave and all our staff at Bronx-Lebanon.”
In all, 16 NAPA staff members were working at the hospital at the time of the shooting. Dr. Newman said, “Our immediate response was concern for the safety of our people there, these poor victims, and everyone at Bronx-Lebanon during this horrific tragedy. How could we support them acutely, emotionally, for that evening and over the ensuing hours and days? It was the mission of the entire leadership that our only concern was for patient safety and the emotional stability of the staff.”
Dr. Livingstone commented on the support of NAPA leadership, “The team was comforted by Dr. Anderson’s presence. We felt the entire NAPA organization was behind us.” In fact, Dr. Livingstone received dozens of supportive messages from NAPA providers across the enterprise.
As the hospital’s provider of anesthesia services, NAPA has a relationship with Bronx-Lebanon. NAPA identified the importance of communicating a consistent message of support to the Bronx-Lebanon clinical and administrative leadership. Tom Delaney, senior vice president of client services, commented, “I think it helped to convey that we were all rowing in the same direction at a very difficult time. That’s the kind of relationship we’ve been able to establish at this institution.”
Dr. Anderson noted, “The Bronx-Lebanon chief medical officer and leadership didn’t just have the OR to worry about, but also the entire institution. What we did was help them understand how to best manage the perioperative space. That’s where we live. Over the next four to five days, we helped ensure the staff had appropriate focus and that the patients were safe. They were appreciative of our insight.”
NAPA and Bronx-Lebanon leadership collaborated closely to ensure there was support for the perioperative team. Elective surgery cases were temporarily suspended to allow people to reflect and process what had happened. The NAPA and Bronx-Lebanon Human Resources Departments partnered to provide immediate and ongoing crisis management and counseling to the perioperative team. Staff was encouraged to speak about what had happened and were given the option of private counseling sessions on an as-needed basis.
Embroiled in the pandemonium, Dr. Livingstone credited the success of the response to team cohesion and working together toward a single goal. “I have read all kinds of management books and taken business courses, but living through this experience has really driven it home for me. When something like this happens, teamwork becomes a matter of life and death.”
Value of a Well-Coordinated Team
Dr. Livingstone: “I learned the value of a well-coordinated team response. We talk about teams and how they function, but in the condition of extreme stress—when everything you do counts and every minute matters—it’s the team’s cohesion and the ability to work together toward a single goal. I have read all kinds of management books and taken business courses. We talk about it, but living through this experience has really cemented this, driven this home for me.”
A United Response from All Leadership
Dr. Newman: “What I saw was the immediate and united response from all leadership. It never wavered in unanimity and commitment to supporting our staff and the patients and people at Bronx-Lebanon at all cost.”
Importance of Planning
NAPA plans to incorporate the lessons learned from this tragic situation into its leadership training programs. Barbara Cerrone, NAPA senior director of marketing, said, “We’re living in an age where, sadly, these acts are increasingly common, and we have a responsibility to educate our teams on how best to handle themselves and the situation, should it arise.”
The NAPA and Bronx-Lebanon leadership took responsibility to ensure immediate and ongoing crisis management in the perioperative team. Their actions exemplify the principles of Extreme Ownership, leadership lessons based on U.S. Navy SEAL training. The principles, embraced by The Doctors Company, have helped us build high-performance teams within our own organization.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.
Fourth Quarter 2017
Electronic Health Record Closed Claims Study
An Ounce of Prevention
Teamwork Saves Lives in Bronx-Lebanon Hospital Shooting
Government Relations Report
Social Inflation Increases Pressure on Medical Liability Limits
Foundation Gets Involved at Patient Safety Camp
The Back Page
Industry and Company News