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When Dr. Avery Nathens, surgeon-in-chief at Toronto’s Sunnybrook Health Sciences Centre, raced to the hospital’s emergency department around 1:50 p.m. on Monday, he and his colleagues knew only that a van had mounted the sidewalk and mowed down pedestrians on a stretch of Yonge Street.Fred Lum/The Globe and Mail

Code Orange. Code Orange.

When the overhead speaker at Toronto’s Sunnybrook Health Sciences Centre blared the code that means mass casualties are on the way, surgeon-in-chief Avery Nathens had to pick up the phone to make sure it wasn’t another drill.

“Do you know if this is real?” he asked Rob Burgess, Sunnybrook’s director of pre-hospital medicine, emergency preparedness and patient flow.

It was. After countless mock exercises and emergency preparedness meetings – including a visit from the Orlando team that cared for the victims of the 2016 shooting rampage at the Pulse nightclub – Sunnybrook, the largest trauma centre in Canada, was about to respond to one of the deadliest attacks in the country’s history.

When Dr. Nathens raced to the emergency department around 1:50 p.m. on Monday, he and his colleagues knew only that a van had mounted the sidewalk and mowed down pedestrians on a stretch of Yonge Street near Finch Avenue, about 10 kilometres north of the hospital’s main campus at 2075 Bayview Ave.

“It could be five [victims,] it could be none, it could be 30,” Mr. Burgess said.

Their first priority was clearing space for the victims in a hospital that, like many across Ontario, is perpetually overcrowded.

Sunnybrook was at 111-per-cent capacity when the Code Orange was declared. All 84 beds in the intensive-care units were occupied; at least six more ICU patients were in the emergency department, waiting for a space.

The staff began to “decant” patients – hospital-speak for finding patients who can be discharged or moved elsewhere to make room for the victims.

They cleared out the purple zone of the emergency room, an area that is usually reserved for patients with minor injuries such as cuts, scrapes and fractures. They put operating rooms on hold, stationed security guards at the doors of the hospital and asked other hospitals in the Greater Toronto Area not to transfer any new patients to Sunnybrook.

Three trauma surgeons, an orthopedic surgeon, a neurosurgeon and dozens of other medical staff assembled in the emergency department, waiting for the ambulances to descend.

As all of this was unfolding, Andy Smith, Sunnybrook’s chief executive officer, was in a taxi on his way back to Sunnybrook from a meeting downtown with the province’s deputy health minister, Bob Bell, himself a former hospital CEO.

“I jumped in a cab immediately,” Dr. Smith said. News of the attack had begun to spread. By the time he arrived at Sunnybrook, “I had had four hospital CEOs check in with me. ‘What can we do? How can we help?’ ”

“The coming together, the connectedness, the esprit de corps,” of the health-care community inside and outside Sunnybrook blew him away, he said in an interview on Tuesday morning, alongside Mr. Burgess, Dr. Nathens and Sue Thorne, a risk manager and long-time nurse.

Two other hospitals swung into action, too. North York General Hospital, the hospital closest to the scene, called its own Code Orange and ultimately accepted four patients.

Two of those patients were well enough to be released on Tuesday morning.

“This accident happened right in our own backyard,” said Karyn Popovich, the CEO of North York General. “We really feel so connected to our community that we wanted to be able to do everything that we could.”

St. Michael’s Hospital in downtown Toronto also treated two patients from the attack.

But as the major trauma centre closest to the scene, Sunnybrook spearheaded the medical response.

Shortly after 2 p.m., ambulances began to ferry the first of 10 victims to the emergency department.

Two arrived without any vital signs and were pronounced dead at the hospital.

But it was not too late to save the others. Three were dispatched almost immediately to operating rooms, where surgeons worked to stop their bleeding. A fourth patient was sent for surgery soon afterward.

“It actually was pretty well co-ordinated,” Dr. Nathens said. “Everyone focused on the patients in front of them. No one had to worry about what was happening outside of their own little environment and that allowed them to work like they normally do.”

As of 5 p.m. Tuesday, five of the victims at Sunnybrook remained in critical condition, three in serious condition. The van attack had killed 10 people in all and a suspect was in custody.

While doctors and nurses treated the victims on Monday, Sunnybrook’s social-work team commandeered an auditorium in the basement, turning it into an information and support centre where family and friends came to find out whether their loved ones were among the dead or injured.

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The last of the families left Sunnybrook's auditorium by 2:30 a.m. on Tuesday. The auditorium's round tables were strewn with boxes of Kleenex and stacks of foam cups.Fred Lum/The Globe and Mail

The slow identification process was agonizing for some families, Ms. Thorne added, but hospital staff were determined not to make a mistake.

“Some of the detectives ended up coming down to try to help people, to sort things out, to say, ‘Call this number because we don’t think your family member is here,’ which is also devastating. … In all honesty, some people sat down there for hours because we didn’t have any information and we were trying to match people.”

The last of the families left by 2:30 a.m. On Tuesday morning, the auditorium was empty, save for round tables strewn with boxes of Kleenex and stacks of foam cups.

The work was not over for Sunnybrook. More than 30 staff members gathered on Tuesday morning in the emergency-operations centre − a boardroom with a whiteboard and a big-screen TV playing CP24 − to review the Code Orange and prepare for the day ahead.

“One of the mistakes we don’t want to make is to think that this is one day and done,” Dr. Smith told the meeting as it wrapped up.

“This is a process to [help] these people get their lives back, and to recognize that the impact goes beyond the patients and their families, it touches Torontonians even more broadly, and it certainly touches our terrific team.”

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