Buffalo's State-of-the-Art ED Was Ready for an MCI

The Buffalo News, N.Y.

ECMC's new ER was designed with a mass casualty incident in mind.

In mid-2020, Erie County Medical Center opened its $55 million KeyBank Trauma and Emergency Department, a facility designed to handle the response to a mass casualty incident — should one hit Buffalo.

Tragedy did, indeed, hit Buffalo on May 14, when a white supremacist from the Southern Tier arrived to the Tops Markets on Jefferson Avenue and shot and killed 10 Black people and wounded three others.

The three wounded victims arrived to ECMC over a 15-minute window Saturday afternoon, all in stable condition, without life-threatening injuries. That made the Emergency Department busy, but hospital staff was able to manage the situation without having to call in additional resources. It was the type of response the region's only Level 1 adult trauma center is accustomed to providing.

But Dr. Michael Manka Jr., ECMC's chief of emergency medicine, said staff members wished they would have had the opportunity to save more of the victims.

"It was somewhat deflating to us, and to everybody, really, when we heard that there were so many people who had been pronounced deceased at the scene because of how horrific that is, number one, but secondly, that we didn't even have a chance to really help those people," he said.

The Redesigned ER

ECMC's prior emergency department was cramped and dated, having opened in 1978. And the only way for ambulances to get to the emergency room, which was one story above ground, was via a ramp that would cause backups if there were multiple vehicles arriving from a mass casualty incident.

The new ER, by comparison, is on the ground level and has a large, covered offloading area for ambulances. There is also a big size difference: The new ER, at about 54,000 square feet, is nearly double the size of the old one. There are 57 treatment stations, including four dedicated trauma rooms, two behavioral health safe rooms, two isolation rooms and four medical resuscitation rooms.

The old ER was so small, Manka said, that ECMC found itself having to use its designated trauma rooms for other patients "just because we needed to use every space we had."

In the new ER, he noted, the trauma zone is strictly for managing trauma patients, and ECMC doesn't use those rooms for treating minor complaints.

So on May 14, Manka said: "When we received notification that the event had occurred and we may be receiving multiple patients, our trauma area was clear and ready to receive critically injured patients and start resuscitation right from the get-go."

What if there had been more victims to save?

Dr. Sam Cloud, an associate medical director at ECMC and an attending physician in the emergency department, wasn't working May 14, but he was aware of what was going on through a texting app the hospital uses to be prepared in the case of disasters or mass casualty situations.

Within 15 minutes, Cloud and others realized the hospital would only be getting three wounded victims of the shooting.

But had this been a situation where victims were trickling in for hours or, in a worst case, for days from a single incident, the response would have been very different and the hospital would have activated more resources and staff to be called in.

For example, such an incident would likely mean ECMC would set up an external triage area, or an exterior tent where it could receive patients who aren't seriously injured, and then triage them to an alternate place in the hospital for care. That would avoid clogging up the trauma rooms in the main part of the Emergency Department, saving those rooms for the critically injured patients.

Further, Manka said, there's also a "clear the emergency department" plan that would kick in during a mass casualty incident with dozens of seriously injured victims. Such a plan would involve taking all the patients in the emergency department who are stable and moving them to alternate spaces, making maximum room in the ER for the influx of seriously injured patients.

Challenges Remain

Despite the major investment in the new and larger ER, however, there are still backups.

For example: Of the 68,384 visits to ECMC's emergency department in 2021, about 6,700, or 10%, resulted in patients who left without being seen.

The reason: ECMC, and many other hospitals, have struggled to discharge patients into nursing homes, rehab facilities or other health care centers, which are struggling with staffing and, as such, don't have enough available staffed beds to take many patients who are ready to leave the hospital.

"Probably the most disappointing thing for all of us is that we had really hoped that the new emergency department, the additional rooms and space would allow us to be able to care for patients quicker and see that they're not waiting in the waiting room for long hours and things like that," Manka said. "But a new design doesn't really fix the bottlenecks that occur throughout the system, and that's what we're facing now and what all hospitals really are facing."