In the emergency room of the Cité-de-la-Santé in Laval, the morning is quiet.

“The day was shaping up to be okay. We even had a surplus of staff, ”says nurse Annick Kirouac.

All 49 stretchers are occupied. However, a 100% occupancy rate, in the criteria of the busiest emergency rooms in Quebec, is a “good day”.

“The Ministry asks us to have 85% of our stretchers occupied, but when we’re at 100%, it’s fine,” explains the assistant director of the Nursing Department, operations component, Sébastien Rocheleau.

This will be crucial for the rest of the story. But let’s not go too fast.

Installed prominently at the emergency nurses station, the “code” telephone has already rung once since the beginning of the day.

The line on the plain-looking old beige phone is reserved for the 911 central, which notifies the hospital of the arrival of a potentially unstable patient by ambulance.

A little after 8 a.m., this patient who suffered a cardiac arrest occupies one of the four places in the resuscitation room. This “resuscitated code”, in ER jargon, has only just arrived. The other three stretchers are unoccupied.

A few kilometers away, on the other side of the Rivière des Prairies, the morning shift also passes normally in the emergency room of the CHU Sainte-Justine.

Remember that at the end of last fall, pediatric emergencies experienced a major crisis due to exceptional traffic.

The first information from the paramedics is fragmentary. Head of the emergency medicine department at Cité-de-la-Santé, Dr. Patrick Tardif is in a meeting in the hospital auditorium when he hears of the tragedy. He rushes to the emergency room to question the paramedics still on site.

How many injured are there? Were there passengers on the bus? How old are the victims? Nobody has an answer.

Always this short, distressing sentence: “a bus has entered a daycare”.

“We want to anticipate the extent of what will happen to us, explains Dr. Martine Montigny, assistant medical director at the Professional Services Department at Cité-de-la-Santé, who is meeting at the Cité-de-la-Santé that day. exterior of the establishment. The scale of the number of wounded that we will receive is very, very important to organize the whole hospital accordingly. »

Shortly after 8:30 a.m., the “code” telephone rang for the second time that morning at the Cité-de-la-Santé nurses’ station.

The ringing is loud enough to be heard throughout the emergency room.

“When you’re a doctor and you’re in charge of resuscitation, you learn to react to that phone,” says Dr. Anne-Marie Saey, emergency physician at Cité-de-la-Santé.

At the end of the line, this time, a pediatric “code” is announced.

The intercom spits: “Doctor Saey in the sheave, Doctor Sylvestre in the sheave, attendant in the sheave”.

“It’s far too crowded,” said the head of the Emergency sector, Josée Côté, who was then far from the action in an office with a nurse in training. There is something going on. »

That morning, Dr. Weill almost didn’t go to work for personal reasons. But there she is. “Come with me because we may need some help,” Dr. Weill tells her fellow nurse who is assisting her on her rounds. The two women run down to the emergency room.

Nobody knows yet how many small patients will be transported to the Cité-de-la-Santé.

Dr. Tardif then pulls out the “code orange” binder, a protocol to be followed when five or more injured people are rushed to hospital at the same time. “Oh my God,” nurse Josée Côté thought, looking at the schoolbag. She’s never had to use it before.

The hospital goes into Code Orange “sleep” mode.

At the CHU Sainte-Justine, emergency personnel receive media alerts on their cell phones announcing that a bus has entered a daycare center in Sainte-Rose. At the same time, the code telephone rings. “We pulled out our code orange box and started to prepare,” Dr. D’Angelo said.

Again, we are in “sleep” mode. But we are active.

According to the protocols established in pre-hospital care, we already know that patients whose state of health is very precarious will be sent to the nearest hospital. In this case: Cité-de-la-Santé. But even if it is located further from Sainte-Rose, the CHU Sainte-Justine is also likely to receive patients because of its mission as a specialized pediatric hospital.

At regular intervals, CHU Sainte-Justine teams run simulations to prepare for a possible “code orange”. Chief of intensive care, Dr. Baruch Toledano still remembers the lessons of the last simulation conducted about a year and a half ago. “It was helpful. It was reassuring,” says the intensivist.

At the CHU Sainte-Justine as at the Cité-de-la-Santé, new rumors are circulating. “The paramedics were maybe talking to us about a 2nd [pediatric] code, maybe an obvious death,” recalls nurse Annick Kirouac.

In Laval, two resuscitation teams made up of doctors, nurses, respiratory therapists and attendants are assembled. To free up all the places in the resuscitation room, the patient who has just been resuscitated is moved under the close supervision of a cardiologist.

Dr. Tardif follows the steps contained in the valuable code orange binder. Medical specialists are called in to help out in the emergency room to examine as many patients as possible. Sufficiently stable patients are “upstairs”. The goal: to make room in case many children need critical care.

The operating rooms are also reserved if children have to be operated on in a hurry.

Unofficial information speaks of about fifty children in the daycare. The figure of 80 also circulated. At this point, no one knows how many are injured.

Nurses working on the floors volunteer to lend a hand in the emergency room. Others, on leave that day, arrive at the hospital in the same spirit of mutual aid. Same momentum among doctors.

The management “blocks” the Cité-de-la-Santé to ambulances except for those transporting potential small victims from the daycare. Other urgent cases will be distributed to other hospitals in the region.

In the emergency room, everyone is warned that the deadlines could be extended.

“We think that adults who are injured or in shock could also arrive,” explains nurse Josée Côté. Our goal was to empty the waiting room as much as possible. »

More than thirty minutes elapse between the call of the “pediatric code” and the arrival of the first victim in Laval.

To produce this report, La Presse is committed to respecting the confidentiality of children. We cannot reveal identifying details, including their gender, so we use the terms ‘child’ and ‘victim’.

During this half hour, the Cité-de-la-Santé resuscitation team has time to rehearse the roles of each: a nurse takes care of the child, another takes care of the medication, a third takes medical notes, an attendant will do the cardiac massage, etc. In total, there are about ten caregivers.

Pediatrician Olivia Weill is assigned to lead the team – “the team leader” in trauma jargon. His colleague emergency physician Anne-Marie Saey will be responsible for the ultrasound.

Everyone is calm, focused.

Because in traumatology, every second counts.

The team also has time to prepare any medications the child may need as well as order O-negative blood – the “universal donor” – from the blood bank. Based on the estimated weight and height of the child, we already have the correct size chest tube and airway tube.

“It’s really valuable, in fact, every minute you have in advance makes all the difference,” adds Dr. Weill.

In the rest of the emergency room, “it feels like a frenzy,” says nurse Annick Kirouac. “You have to ask people to keep their voices down,” she continues. There were also people crying. Some have young children in day care centres. »

At the CHU Sainte-Justine, Catherine Hogue quickly noticed that the morning that the hospital was full. “But we weren’t in a surreal charge like last November,” said the assistant director of operational nursing care.

“If it had been November […], it would have been a completely different story,” notes the head of the Montreal pediatric emergency department, Dr. D’Angelo.

In intensive care, there are then 22 patients out of a total of 24 beds. And two other patients already in the operating room are expected.

Despite everything, we managed to free up some beds occupied by stable patients.

In the emergency room, asthmatic patients under observation are moved to another sector. All three trauma rooms are available. And we are preparing a fourth in an observation room.

This logistical ballet is complex. Because, as Dr. D’Angelo reminds us, “there are also still sick children who keep coming into the hospital, who need urgent surgeries.”

At 9:25 a.m., Dr. Girard and Marek Abaji, Emergency Measures Coordinator at Sainte-Justine, received the first official information from the Regional Emergency Measures Department. Two patients are on their way to the Montreal hospital and the evaluation of five other patients is ongoing. When the first victim arrives at Sainte-Justine, it is almost 10 a.m.

At Cité-de-la-Santé, the first child arrived much earlier, at 9:08 a.m., in critical condition. A second victim is brought in at 9:36 a.m. Then a third at 11:09 a.m.

In any case, the little ones are not accompanied by their parents or an educator on board the ambulance. This greatly complicates their identification for the nursing staff.

The hospital has no room for error. Let us remember the tragic accident of a team of young hockey players in Western Canada which left 16 dead and as many injured: a hospitalized player was mistaken for another, dead, wrongly suggesting to a family that her child had survived. And vice versa.

“Honestly, for me, that was very stressful,” says Dr. Weill.

The pediatrician and her nurse colleague Annick Kirouac ask to see photos of the children on the cellphones of their parents who came to the emergency room.

“We really wanted to make sure we had the right parents,” says the nurse.

An experienced beneficiary attendant, Karine Chevrier is in charge of giving cardiac massage to one of the little victims. “I’ve massaged many times in 20 years, but being a child was the first time,” she says.

The attendant has never experienced anything so dramatic.

“We enter a bubble. We massage, we massage, when the doctor tells us “stop massaging”, we stop, she describes. When he says “we start again”, we start again. »

The attendant will realize the magnitude of the tragedy later that day, once the adrenaline has subsided.

Despite the best efforts of the emergency team, one of the victims died.

After long resuscitation maneuvers, it becomes clear to the team that there is nothing more to do.

The caregivers gradually withdraw from the room, leaving the child with his parent. The latter is always supported by a nurse or a “registered” doctor to accompany him in the most difficult ordeal of his life.

That morning, nurse Annick Kirouac stayed with the parent during resuscitation. “I’m explaining what’s going on,” she said. It has been proven that it is good for the parents to see that everything is done to save the child. »

In general, “it helps the grieving process, knowing that you did everything you could,” adds Dr. Weill.

Stopping the maneuvers in the presence of the parent, “it’s the most difficult thing in the whole code,” adds nurse Annick Kirouac, who has performed this delicate task several times in recent years.

When the second victim arrived, at 9:36 a.m., the second resuscitation team took care of him.

Quite quickly, we conclude that his life is not in danger. Finally some “good news,” nurse Josée Côté thought.

It’s that “for a long time” paramedics keep telling ER staff, “we’re coming out under the bus,” says Dr. Saey, who fears other seriously injured children are coming. .

At 9:54 a.m., a second text message from emergency measures mentions that there are six injured children in total, two of whom are still being assessed at the daycare site.

Dr. Tardif then understands that “we [will] have fewer patients than apprehended”.

“That’s when we started talking about resuming operations in the rest of the hospital,” he explains.

At Sainte-Justine, we see the first patient later, just before 10 a.m. And two more soon after. A fourth will be transferred from Cité-de-la-Santé to undergo surgery much later that day. Two of them are in bad shape and must be treated in intensive care.

Code Orange will not need to be activated.

Throughout the day, however, the hospital will have to respond to hundreds of calls from relatives, including several grandparents, wanting to know if such and such a child had been sent to Sainte-Justine.

The last child to be extricated from the site of the tragedy was brought to Cité-de-la-Santé at 11:09 a.m. The paramedics had difficulty “getting him out” of there, said nurse Annick Kirouac.

The little victim isn’t broken; barely a few scratches. The staff quickly gave her the nickname “the miraculous”.

A balm for the healthcare team. Because the death of one of the children shakes everyone that morning. The team that unsuccessfully attempted to resuscitate him conducts a “hot debrief” initiated by Drs. Saey and Weill.

Everyone meets in a conference room. There is a “significant emotional charge,” Dr. Saey points out, but the team needs to focus on the “clinical” aspect first. Did we do it right? Was the sequence of maneuvers the right one?, Lists the emergency physician.

Then we get to the emotions. It was during the debriefing that many learned that the tragedy seemed to be a deliberate act.

“The news was aberrant, you know, that doesn’t happen with us,” adds his fellow nurse Josée Côté.

“It does not change the care,” says emergency physician Anne-Marie Saey. [But] maybe it adds to the emotional difficulty when the dust settles. »

Management offers employees to leave without finishing their shift.

Eventually, everyone decides to stay. Some gather in the coffee room to ventilate. Four CISSS social workers were dispatched to the site to support them.

The attendant Karine Chevrier does not see herself jumping into her car to go home immediately and follow the developments of the drama on TV.

“We don’t have to say everything, everything is understood,” agrees fellow respiratory therapist Marjolaine Gariépy.

Among the staff, there are fears that the driver will be transported to the Cité-de-la-Santé to receive treatment.

The alleged murderer will instead be transported to the Sacré-Coeur hospital. “Forget it, it would have been unmanageable,” says nurse Annick Kirouac. The parents in the same emergency as the aggressor… It would have been appalling. »

In intensive care at the CHU Sainte-Justine, one of the children treated is very distressed. The staff are “touched to see the suffering of this child”, says Dr Toledano. “Our nurses are all of childcare age; they identified a lot with that,” he says.

Teams of social workers were mobilized to support the victims, their families and the workers.

The CHU Sainte-Justine also offers its support to the Cité-de-la-Santé teams. Resuscitating a child can be difficult.

“We at Sainte-Justine are part of our reality. They are rarely part of theirs, ”adds Catherine Hogue.

Clinical coordinator of the psychosocial emergency measures team at the CISSS de Laval, Simon Aubin rushed to the Cité-de-la-Santé as soon as he was made aware of the tragedy. “At the hospital, there was a good support network that was in place,” he observes.

A member of his team will return the next day to meet the staff who would need to talk about what he experienced. Support was also offered to those in charge of the daycare, its educators and the parents.

According to several workers, the impact of the tragedy is all the greater because all the media in the province are talking about it. “When I came out, it was on wall-to-wall radio. I had decided that I was going to the gym to work out. But on the screens, it was just that,” says nurse Annick Kirouac.

Dr. Weill tries to finish her day at work with her 10 inpatient pediatrics. But in the unit, co-workers follow the tragedy on screens. “I asked them to mute the sound because otherwise I couldn’t work,” she said.

Despite these challenges, Dr. Weill never regretted coming to work that day.

Also in the afternoon, Josée Beaulieu – an executive responsible for Info-Social (811) in Laval – is at Laval police headquarters where a crisis unit is meeting, made up of representatives from the school service centre, the transport company, municipal authorities, the fire department, the CISSS and the police.

How can we support the population?, they all wonder around the table. It was there that Ms. Beaulieu decided to “overstaff” 811 to respond to distress calls.

The CISSS contacts all the families whose child attends the daycare service to assess their needs. A meeting of parents is held online to advise them on how to accompany their child in the drama. They were encouraged to meet at the park the weekend after the tragedy so that the children could reconnect with each other.

The goal: to succeed in making “a return to normality as much as possible”, illustrates Ms. Beaulieu.

Inspired by the measures taken after the Lac-Mégantic tragedy, the CISSS deployed a citizen brigade two weeks after the tragedy to go door to door in the Sainte-Rose district, where the tragedy occurred. The idea is to take news of people’s morale.

“It’s a small, tightly knit neighborhood,” describes Ms. Beaulieu. A very lively neighborhood too. For us [of psychosocial measures] the work begins. »

To deal with tragedies with a high number of patients, it is essential that hospital emergency rooms are never too crowded.

Both at the Cité-de-la-Santé in Laval and at the CHU Sainte-Justine, this is one of the main lessons we have learned from this disastrous day.

“If it had happened in the evening, at night or with more congested ERs. It forces us to question ourselves,” says Dr. Patrick Tardif, from Cité-de-la-Santé.

“One of the most important things in terms of the safety of the population […] is to have emergencies that are capable of possibly receiving multiple victims through all the other patients, explains Dr. Tardif […] is important to say. I already have my pilgrim’s staff. »

Same story on the side of the CHU Sainte-Justine. “If we were at 300% like in the fall, the situation would have been really much more difficult,” insists its head of emergency, Dr. Antonio D’Angelo.

On the evening of November 13, 2015, 130 people died in Paris and 413 were injured in a series of attacks, including one in the Bataclan performance hall. Emergency rooms in the City of Light were overwhelmed with patients. In the following months, Parisian doctors presented the lessons learned from this tragedy, in particular at the CHU Sainte-Justine. Among them: the importance of managing such a drama over the long term.

“The doctors in Paris told us: everyone is going to want to come [to work]. Tell them to stay home. Because you have to have a long-term view,” emphasizes the head of intensive care, Dr Baruch Toledano. To prevent the care teams from becoming exhausted, this requires workforce planning for the following days or even weeks.

When the first information about the Laval tragedy was published in the media, several Sainte-Justine and Cité-de-la-Santé workers immediately offered their help. “But you don’t have to have everyone come in early and be burned within eight hours,” says Catherine Hogue of the Montreal Children’s Hospital. If we have a massive influx of patients, it means they will stay for a while. »

Two children died and six others were injured. Société de transport de Laval bus driver Pierre Ny St-Amand, 51, was arrested shortly after the incident and was charged with two counts of first-degree murder along with seven other counts, including attempted murder and aggravated assault.