“Code orange minor. Please work with your departments to stand by. This is not a drill.”

When the announcement came over the public address system at Sunnybrook Health Sciences Centre at 1:48 p.m. Monday, chief of surgery Dr. Avery Nathens shifted gears. He jumped up from his desk where he had been doing paperwork and changed into scrubs.

The code meant mass casualties were en route to Canada’s largest trauma centre. Knowing nothing of the incident that prompted this rare emergency alert, Nathens quickly switched on the TV in his office.

But all he learned from a 24-hour news service was that a royal baby had been born. That 25 individuals had been mowed down by a van on Yonge St. had not yet hit the news.

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As Nathens made haste down a flight of stairs to the hospital’s emergency department, he wondered how many surgeons he would need to rally for the convoy of ambulances that was soon to arrive. With scant details, it was hard to know.

“As you are walking down, you are asking yourself, ‘how is this going to play out and do we have the capacity?’ Then you just do it,” he said, describing a day later how he threw himself into the biggest trauma response the hospital has ever encountered.

Like a large number of hospitals across the country, Sunnybrook operates at full tilt most of the time. On Monday, immediately prior to the van attack, the hospital was already running at 111-per-cent capacity.

There were patients lying on gurneys in the ER hallway, waiting for in-patient beds. And there were patients occupying in-patient beds, waiting to move to long-term care and other community settings.

Despite these stresses, Sunnybrook responded to the Code Orange “superbly,” Nathens said.

“Thankfully, our senior leadership team is committed to preparedness. We drilled and we learned from those drills,” he said, referring to regular mock disasters carried out to test the hospital’s ability to respond to mass casualty events.

“We have joined the club unfortunately, but we were ready,” continued Nathens, who also serves as medical director of trauma quality programs of the American College of Surgeons. He was referring to recent mass casualty events in the United States, including last year’s shooting in Las Vegas and the 2016 shooting at the Pulse nightclub in Orlando, Fla.

In the 18 minutes between the Code Orange being called and the first patient from the Yonge St. carnage being rolled into the ER, staff and doctors sprang into action. Hospital vice-president Ru Taggar and director of emergency preparedness Rob Burgess converted a boardroom into an operations centre. They got the ball rolling to ensure the hospital would be able to attend to the 10 patients being transported from the scene.

Patients who could be discharged were sent home. Other patients were transferred to nearby hospitals. And elective surgeries were cancelled so that operating rooms would be free for the incoming.

Taggar said there was no problem getting extra hands on deck. Staff and doctors who were not working Monday offered to come in.

The chief medical executive at a Toronto hospital where many victims were taken after a van hit pedestrians is calling the situation “unprecedented.” Police say there were multiple deaths following the incident in north Toronto. (The Canadian Press)

Sunnybrook president Dr. Andy Smith said he was awestruck by the response. He received phone calls and emails from other hospital CEOs, offering the help of their facilities.

“Despite the maligning of our system — and god knows there are a lot of things we have to fix and we have a lot of work ahead of us — the reality is that when bad things happen to you in Toronto or Ontario, you are going to get world-class care, guaranteed. Toronto needs to know that,” Smith exclaimed.

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The last time there was a major Code Orange at Sunnybrook was in 2012, when six victims of the Danzig St. shooting in Scarborough were transported there.

But Monday’s Code Orange was the largest that veteran trauma surgeon Fred Brenneman has seen: “We get three (trauma patients) at a time sometimes, but this? It was pretty much unprecedented.”

All of the patients arrived in the span of 45 minutes.

Nurse Miranda Lamb, a team leader in the emergency department, served as the incident commander on Monday. She said she knew it was just a matter of time before the hospital would see an emergency of this scale.

“I have had sleepless nights, wondering what my response would be if I was the one in charge.”

Recalling the minutes leading up to 2:06 p.m., when the first patient was rolled into the ER, Lamb said: “I literally took a moment and took a deep breath. I said to myself, ‘Here we go, this is it.’”

She marvels at how the legion of workers involved in the response jumped into their various duties.

“Everybody just went into the roles that they needed to go into, from environmental services to portering, to lab technicians, to nurses and doctors, x-ray technicians, CT techs, everybody,” she said. “Everybody was on task. We were in our bubble.”

Brenneman helped triage patients, determining who needed the most urgent attention. He sent some directly to the OR, some to imaging and others to the trauma bay for immediate intervention.

Two patients arrived at the hospital vital signs absent and were pronounced dead.

The identities of most patients were unknown at first. Brenneman said one of the most difficult parts of the day was dealing with frantic loved ones.

“There was a lot of confusion and uncertainty. You see the pain and anxiousness in the faces of the families … It is extremely important to match the right patient to the right family. To get that wrong is horrible,” he said.

Indeed, there was such a mix-up following the Humboldt Broncos bus crash earlier this month.

Despite the intensity of the day, Brenneman said there was no sense of panic among the doctors and staff. Although they had never encountered that number of traumas in such a short timeframe before, they were able to focus on their individual tasks.

“When it hit the fan, this hospital stepped up amazingly well. It was incredible to watch. There were so many people involved. Everyone upped their game.”