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Emergency room nurse Nicole Bekker is photographed in the trauma ward at St. Michael's Hospital on June 6 2012. Bekker was working in emergency when victims from the shooting spree at the Eaton Centre came.Fred Lum/The Globe and Mail

Nicole Bekker spent her lunch break a few minutes away from work on Saturday, eating a salad at Toronto's Eaton Centre on what had been a calm day in the emergency department at St. Michael's Hospital. Less than six hours later, the nurse was on the medical team working to stabilize a victim who was struck by a bullet in the same food court.

One man was shot dead and six others were struck or grazed by bullets during the hail of gunfire. Other than a 13-year-old boy who was shot in the head, the severely injured were sent to St. Michael's. It's one of two major Toronto trauma centres, where the doctors and nurses are accustomed to caring for victims of violence. Last year, staff at the hospital treated 36 gunshot wounds that were considered significant.

But this shooting was just a few minutes away, inside a mall that's visible from the emergency department's ambulance bay. "Obviously, when we heard this, it hit really close to home because it's just one of those things where you go and pick up lunch there," Ms. Bekker said. "It's around the corner."

Back at the hospital a few hours later, a voice over the emergency department's PA system alerted nurses that they were needed in the trauma room, where critical patients are stabilized before being sent to the operating room or for further testing. On her way there, a colleague said there had been a shooting at the mall.

"My initial thought was a little bit of fear and a little bit of apprehension but immediately you're like, 'OK, let's go, let's get ready for this, because that's what we do,' " Ms. Bekker said.

In the minutes that followed, Ms. Bekker and her colleagues took the familiar steps to prepare for patients with gunshot wounds. They donned green gowns to protect their scrubs from blood. Over top they wore lead aprons so x-rays could be completed quickly. Chest tubes and a resuscitation machine and the blood bank alerted.

As information trickled in to the triage nurse from EMS and police at the chaotic scene, the number of victims and extent of injuries was unclear. So the hospital began preparing for upward of 20 patients, said chief medical officer Doug Sinclair. "The principal is to over-prepare rather than under-prepare," he said.

If there had been more patients, some of the lower priority ones likely would have been sent to other hospitals, he said, adding that EMS makes those decisions.

He got a phone call about the chaos at the mall at about 6:45 p.m. As the director on call that weekend, he made high-level decisions about the hospital's response from Niagara Falls, where he was attending an emergency medicine conference.

"You don't have very much information. You don't know how many victims are coming. You don't know about safety for staff," Dr. Sinclair said, adding that the alleged gunman was yet to be found. "Obviously, because it was so close to St. Michael's, there was a concern about staff safety as well as individual patients."

For those reasons, Dr. Sinclair said, the hospital was initially placed into lockdown mode as patients began arriving. The first stage of a Code Orange, which indicates an external disaster, was declared. It reached the second stage, which allows the setup of a central command centre near the emergency department for staff.

A full external disaster wasn't declared because it soon became clear that St. Michael's could handle the number of victims. By the end of the night, four patients were brought by ambulance from the shooting scene, including one critically ill person and two other trauma patients. Only one gunshot wound victim is still at St. Mike's.

Although that number of trauma patients could come in on any night, Dr. Sinclair said the difference was the unknown and that they were all coming at once.

Emergency department doctor Martin Horak was waiting in the hospital's ambulance bay when the first patient arrived.

As he heard the sirens approaching, Dr. Horak got ready to accompany the paramedics into the trauma room where they'd give hospital staff as much information as possible about the patient. The first tasks for the team, including Dr. Horak and Ms. Bekker, are were to assess the patient's airway, breathing and circulation.

As in all cases, they checked to see if there were gunshot wounds other than the obvious. But removing bullets isn't a top priority, said Dr. Horak. "We don't go looking for bullets, we go looking for injury," he said.

Dr. Horak, who has worked as an emergency doctor at the hospital for about 13 years, said that although caring for gunshot victims is common, something was different about Saturday. "It's my job and we're prepared to deal with a lot of serious cases in the emergency department," he said. "But it's not an everyday or an every year occurrence that something would happen in that sort of a setting."

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