Within minutes of Saturday's crash-landing at San Francisco International Airport of an Asiana Airlines flight carrying 307 passengers, employees at Stanford University's two hospitals prepared to execute their long-rehearsed "mass casualty plan."
When the first patients arrived by helicopter and ambulance at 1 p.m., about an hour and a half after the crash, medical teams -- including eight surgeons and dozens of other physicians -- had rallied to treat an unknown number of crash victims potentially on their way. Nobody yet knew how many would come or the extent of their injuries.
Ultimately 55 injured passengers were brought to Stanford University Hospital and Lucile Packard Children's Hospital, drawing not only on medical resources but on translators, social workers, chaplains, the Red Cross and government agencies -- and testing the hospitals' joint plans for a range of disaster scenarios.
"We have to continually be ready and prepared 24/7 for any of these types of events," said registered nurse Melva Scott Averhart, an administrative supervisor at Packard Children's Hospital, who regularly has trained for such "mass casualty" situations over her 36-year nursing career.
Some Mandarin-speaking children arrived at the hospital separated from the adults they'd been traveling with.
And since passengers had not cleared customs on the international flight from Seoul, U.S. agents came to the hospital to check on immigration issues. FBI agents and representatives of the U.S. Department of Homeland Security -- as well as officials from the Chinese Consulate and Asiana Airlines -- also showed up.
To "avoid getting caught up in the chaos, there's an organized dance that we do," said David Spain, chief of trauma and surgical critical care at Lucile Packard Children's Hospital and Stanford Hospital & Clinics.
"We have a very systematic, orchestrated way of evaluating patients, finding the most life-threatening injuries first and moving down the priority list," Spain said.
"That's basically what we do every day -- on an individual patient none of this was new or different. What was different was that instead of doing that for a few patients, we had 55 patients in six hours."
Available nurses from the floors were sent to the Emergency Department to help.
Medical receiving teams were assembled outdoors in the ambulance bay to facilitate rapid intake and return ambulances to the crash site. Patients who had been in the emergency department prior to the crash either were admitted to the hospital or sent home to make beds available.
All told, about 150 staff members mobilized for the disaster.
Stanford Hospital first learned of the crash moments after it happened, when an emergency-room nurse noticed photos on the TV screen in the waiting room.
She told attending physician Eric Weiss, who also happens to be medical director of Stanford's Office of Service Continuity and Disaster Planning.
At 12:06 p.m. Weiss issued a "code triage," paging about 900 employees that the hospitals were on preliminary alert for a full disaster response, said Brandon Bond, who directs the office of emergency management for both hospitals.
Bond had been doing housework in San Mateo when he got the first page and drove immediately to the hospital.
At 12:47 p.m. -- after learning that the San Francisco Fire Department was "triaging 290 patients" at the crash scene and that at least four were already headed to Stanford -- Weiss and Bond activated the hospital's "full mass casualty plan."
A logistical command center sprang up in a specially equipped conference room on the hospital's third floor.
"It has a tremendous amount of additional technology and communications equipment, allowing us to monitor the response and communicate with all our public-safety partners," Bond said. Both Stanford
Hospital and Packard Children's Hospital were represented in the room full of staff from various hospital departments, all on their laptops tracking bed availability and other aspects of the emergency.
Spain, the trauma chief, had just walked the dog and had lunch with his wife at their Palo Alto home when he received the initial "code triage" standby page.
Flipping on the television he saw fiery photos from the crash and guessed that "we weren't going to get many patients (because) there weren't going to be many survivors.
"Then it said the fire broke out later, that people were able to get off. I called in, and they (the hospital) said we were going to be getting a bunch of patients."
Spain was at the hospital by 12:30 p.m., ready to help ensure that enough staffing was available.
He found that a number of others were already there -- a trauma surgeon who had been on call and another surgeon who had been caring for patients in the Intensive Care Unit. A colorectal surgeon who happened to be in the hospital came downstairs to help. The head of pediatric surgery came in.
Two other surgeons who recently arrived at Stanford for extra training -- including U.S. Army Lt. Col. Jennifer Gurney, who has been on active duty in Afghanistan -- also were on hand.
An additional 10 surgery residents -- including four who arrived at Stanford as new interns two weeks ago -- also came to help.
"The biggest challenge was just making sure we kept track of which patient was which, what the results were, what was still pending and what the unresolved issues were," Spain said.
"It's rarely what you know that gets you in trouble -- it's what you don't know. So we spent a lot of time making sure we knew what we knew about people, and what we didn't know."
Professor Ann Weinacker, chief of staff at Stanford Hospitals & Clinics, described the scene after walking through the emergency department: "There was not a lot of drama. It was almost like business as usual, only there were many more people."
Of the 55 patients evaluated and treated Saturday, 18 were admitted -- 11 of them to Stanford Hospital and seven to Packard Children's Hospital.
As of Thursday morning, all had been released from the hospital except for two adults, one upgraded from critical to serious condition and the other listed in good condition.
Viviane Vanderwoud, who practiced pediatrics in Brazil and now manages interpreter services at Packard Children's Hospital, was having lunch at a restaurant in Town & Country Village Saturday when she got the "code triage" page.
Since it was a Korean airline, Vanderwoud first assumed she would most need her single Korean interpreter, who happened to be out of the country. (Most of Packard's 38 round-the-clock staff interpreters are Spanish-speaking.)
When it became clear that Mandarin was needed, she enlisted help from an outside agency as well as from the main hospital's staff of interpreters. The South Korean government said 141 passengers carried Chinese passports, 77 South Korean passports and 61 U.S. passports and that the rest of the passengers were other nationalities.
"The good part of having both hospitals so close together is we help each other mutually," Vanderwoud said. "Stanford offered to help us if needed because they have more in-house Mandarin interpreters as staff members."
At 6:30 a.m. Sunday, Packard Hospital social worker Lori Durand was paged to come in to work with the children from the crash.
"Thank God we had interpreters," said Durand, who helped coordinate needs such as clothing, lost glasses and locating responsible adults.
It was breakfast time and nurses were searching for "comforting food, like they'd have at home," Durand said.
Someone remembered that congee, a rice porridge, was available in the hospital cafeteria and brought it up for the kids.
"A couple of kids had lost their glasses. One of the nurses had a similar prescription as one of the children so she let him borrow her glasses for the day," Durand said.
"My partner social worker was in touch with the Red Cross, who gave them vouchers to take to an optometrist to get replacement glasses."
A Chinese Consulate official came to help, and an airline representative offered to try to locate the children's luggage.
Durand said she tried to caution the children against listening or watching accounts of the plane crash, which would hinder their recovery from the trauma.
"We used interpreters to call the parents back in the children's home countries," she said. "Luckily, they'd already talked to their kids and knew they were safe, and we just reassured them that the kids were doing well and being taken care of."
Durand worked with parents to locate responsible adults to whom the children could be released.
"One adult was at another hospital with a couple of other kids he was in charge of. He said, 'Can I send so-and-so,' but the parents had never heard of that person, so we said 'No, we can't just have anybody.'
"Eventually we were able to locate a teacher the father was familiar with, and he said it was OK," Durand said.
All seven children were discharged from the hospital by Sunday night.
In the end, both hospitals were prepared to handle more patients than the number who came Saturday.
"The Emergency Department remained fully open to accept trauma unrelated to the plane crash," Bond said following a debriefing session about the crash response held Tuesday.
Other points from the debriefing session, Bond said, were that "international relations with China remain strong and were further developed as a result of the response."
Medical staff "remained in constant communication with the (Chinese) Consulate," he said.
The hospital call centers fielded nearly 1,000 calls in four hours Saturday.
Bond said Saturday's alert was the largest Stanford hospitals have faced at least since the 1989 Loma Prieta earthquake, and he has been unable to find anyone who remembers what the hospital was like on that day.
"We learn from every response," he said Thursday. "We are developing a comprehensive after-action report, which will result in continuous improvement to our emergency operations plan."