Kirsten Bunker was not at the hospital when she realised it was about to face its gravest hours.
During a doctor’s appointment on Independence Boulevard for her twin daughters, she got a phone call from their dad. He had been listening to the radio and learned a shooter was at the Municipal Center.
Bunker may have had trouble hearing him over what came next. Five or six sirens, one after the other, wailed from the road.
She didn’t waste a moment before firing off a text message to Mark Day, trauma co-ordinator at Sentara Virginia Beach General Hospital.
“Do you need extra help?” she asked.
“Yes, come.”
Bunker hurried to the parking lot, put her two 6-year-olds in the car and drove.
“Mama’s gonna go take care of some sick people,” she said in an even tone.
They were there in 15 minutes.
Bunker, 34, had been an emergency medicine and trauma nurse for several years. But the long hours, day in and day out, had worn on her. About six months ago, she moved into an office job as a quality improvement co-ordinator.
Still, she couldn’t turn her back on the emergency room and continued working a couple of shifts every six weeks. She’s the sort who braces for any alert that may sound over the speakers. A pair of flats she keeps in her office is a testament to that.
An overhead page — a couple of “alphas” — signalled two patients, the sickest of the sick, would arrive in 10 minutes.
“Mass casualty contained to the ER” broadcast across the hospital.
That was her cue. Before dashing, she said goodbye to her girls and left them with a co-worker. Their dad would soon come to get them.
About 11 miles away, a 40-year-old engineer for the city’s public utilities had entered the operations building, armed with two .45-caliber handguns and a silencer. The gunman opened fire, ultimately killing a dozen.
But following his rampage, a window — a precious few hours — left open the possibility of life for a handful of trauma victims. Five of the critically wounded, including the shooter, would go to the Virginia Beach General ER. Three victims would survive.
As Bunker arrived, Day handed her a protective gown. She threw it on over her clothes.
Virginia Beach General is considered the largest “level three” or community trauma centre in the state.
Unlike Norfolk General, which is classified as “level one,” it’s not connected to a teaching facility and its trauma surgeons aren’t on site around the clock.
But their resources are fairly comparable, and the hospital’s surgeons must be able to get there no more than 20 minutes after any “alpha” page.
The ER has seen the worst mayhem the vacation city has to offer: brutal car crashes, high-rise fires, beach weekends gone awry, gang violence and domestic abuse.
On a regular day, it’s mostly heart attacks, flu-like symptoms, bumps and scuffs. On May 31, it was the victims of the nation’s worst mass shooting of 2019.
Despite their mass casualty training, medical staff said no drill compared to the real thing — the adrenaline rush and life-and-death stakes.
That evening, the ER teemed with extra hands. Three nurses, three physicians, two trauma surgeons and two cleaning employees — the ones tasked with mopping floors slick with scarlet streaks — dropped what they were doing and showed up for duty.
Over 30 staffers filled the department, not knowing who or what they were about to encounter.
There was nothing remarkable about that day before 4 o’clock.
Prior to her shift, Dr Janelle Thomas, an ER physician, power-washed her deck. And for the first couple of hours at work, she tended to routine cases: chest and abdominal pains.
Then, a police officer on duty at the hospital heard the radio calls: an active shooter. At the time, they thought he was in the courthouse.
Thomas reached for her phone and texted two close friends who work there. They were fine, and, being in a different building from the shooting, seemed to know less than she.
But as the incident unfolded, Thomas heard differing reports. First, there was said to be an officer down. Then, as police secured the scene, the tally of potential casualties swelled.
Often in the emergency department, staff will receive an early warning that an incident is underway. The shooter at Naval Air Station Oceana in April was one such example, Thomas said. When more details emerge, the number of injured usually shrinks.
In this situation, the count only worsened.
“Your first reaction is a little disbelief,” Thomas said. “Is this real?”
Because Virginia Beach General was the closest trauma centre to the Municipal Center, Emergency Medical Services designated it the lead hospital.
Thomas turned to her colleague, Dr Kathleen Anderson, another ER doctor, to help make decisions.
Just how many injured could they take? As many as were hurt?
She told EMS they would handle four and suggested sending a couple to Norfolk General. Instead, ambulances would bring five to their door, routing one to Sentara Princess Anne Hospital for stabilisation before airlifting to Norfolk. The reasons for that change are still somewhat unclear.
From the first warning, the hospital had about an hour to brace for the crush of patients.
It was an inordinately long amount of time to prepare for a disaster, Thomas thought. Back at the operations building, police had a gun battle with the shooter and were trying to secure the scene.
Those 60-or-so minutes were invaluable for the hospital.
Staff gave a heads up to the trauma surgeons and made sure no new operations were started. As surgeries were completed, more spaces opened.
Then Thomas sent an alert to her medical group, Emergency Physicians of Tidewater, which staffs all of the Sentara ERs in South Hampton Roads. It blasted a text message:
“Mass shooter incident at the courthouse.”
Including physician assistants, 101 people responded to the message in some way, Thomas said. Some were on their way; others offered their assistance.
Eventually, she realised she had enough manpower. Another message followed:
“At present time, we have plenty of help.”
Bunker had a job to do.
She needed to set up her trauma bay for a patient but didn’t know the extent of his or her injuries yet.
She started to go through a mental checklist: If there’s an airway problem, what will I need? How about an open fracture?
She wrangled a monitor for vital signs and medications to use with a breathing tube insertion. She fetched equipment for IVs.
Bunker’s role was small but needed. If rooms weren’t ready, the scramble could cost them.
Since childhood, she considered this her calling. Her stepfather had viral congestive heart failure in his 30s, causing him to stop working. Bunker spent a lot of her early years feeling powerless. She refused to feel that way again.
“If anybody ever needed me, I wanted to know how to respond,” she said.
Amid the flurry of activity that evening, EMS set up its command post outside. For added security, the ER was put on “lockdown,” meaning people who were not part of the incident response would have to find some other way to enter the hospital.
Nurses came down to the department to take admitted patients to their beds, making room for what was to come.
In waves spanning 45 minutes, the wounded — strangers known only by their genders and estimated ages — arrived.
Among them, the injured shooter.
As the patients rolled in on gurneys, a trail of countless police officers followed.
Without names, the patients received serial numbers.
And staff used another identifier for the patients, Day said: During disaster responses, a colour-coding system helps medics know the priority of a person’s injuries. In this case, all of them came with the same severity — red — which is the most critical.
They usually put ribbons somewhere visible on the patients, he said.
There wasn’t much deliberation among the emergency physicians when deciding who would take which patient. Thomas helped direct the traffic.
“I got the next one,” she said. “You take this one.”
Thomas took charge of one of the patients. Anderson had two.
In her own room, Thomas stood at the head of the bed and orchestrated the activity around her.
Virginia Beach General hasn’t disclosed the details of the mass shooting victims’ injuries. But reports from the medical examiner’s office provide insight into the devastating types of wounds doctors likely saw that evening. Of the 12 who died, all but three suffered from bullets to the head. Others took shots to their torsos and other parts of their bodies.
By 8pm, the survivors were out of the ER. Some were headed to intensive care or the operating room.
A peaceful hush fell over the department.
Thomas was roasting from her fluid-resistant trauma gear. She took off a layer of clothing and had a moment to collect her thoughts.
“Can’t talk right now,” she said in a text to loved ones, “but I’m fine.”
Unlike younger or less-experienced staff, Day can say he has seen worse.
He spent 25 years in the Navy and was assigned to a trauma team with the Marines. He did four tours in Iraq.
Day, whose shift had ended at 4pm, had been home for a few minutes and was just about to check in on the Monarch butterflies he raises when he received a call from the charge nurse, Leslie Bell, about the shooter.
“Can you please come back?” she asked.
In the midst of overseeing the nurses and watching doctors treat the victims that evening, he received a text.
His adult daughter said her friend’s mom worked in that building — she couldn’t get a hold of her.
Day paused for a moment, then put the phone back in his pocket.
He couldn’t have that conversation.
Families of the patients told Virginia Beach General to cease releasing medical condition reports to the public. It’s unknown how they’re doing or whether they’re still in the hospital. Melanie Coffey, the patient who was taken to Norfolk General, has since been discharged.
For Day, the hard part is over. But he worries about the staff, especially those who have never witnessed such trauma.
The tendency is to personalise the tragedy.
Did I do everything I could have?
“There are going to be visions. They’re going to be able to see faces,” he said. “That doesn’t go away.”
This story is based on the accounts of three staffers who were at Sentara Virginia Beach General Hospital on May 31. Some of their quotes are based on their recollections from that day. 
—The Virginian-Pilot (Norfolk, Virginia)/TNS