The call came in over the emergency department radio without warning: A nearby condominium building had collapsed.

“Unknown number of casualties,” the voice crackled.

A Code Orange. That’s the term B.C. emergency departments use for a mass-casualty incident, and it changes everything.

Immediately, doctors hustled to check on the condition of patients, seeing who might be moved to make room for a potential rush of new arrivals. They took an inventory of supplies, which were bound to go fast.

It wasn’t a real emergency—but a full-day disaster simulation for 58 UBC emergency medicine resident doctors, designed to feel as real and demanding as possible. The goal: to re-create the urgency, constraints and decision-making of a Code Orange. Emergency medicine residents get plenty of on-the-job training in hospitals all over B.C.—from urban to rural settings—but it’s hard to learn what a Code Orange is like until it happens.

“As emergency doctors, we have no control over what comes in the door. We would like to be ready for anything,” said Dr. Jeff Eisen, an emergency physician, clinical associate professor with UBC’s faculty of medicine, and director of the emergency medicine residency program on Vancouver Island.

The architects of this exercise spent 10 months planning. UBC clinical instructors Dr. Jessica Timmings and Dr. Max Moor-Smith, and senior emergency medicine resident Dr. Hilary Drake, put together the plan with Dr. Eisen, partners from the Justice Institute of British Columbia, Health Emergency Management BC and hosts Camosun College. The experiential learning opportunity aimed to build on simulation exercises that health authorities conduct with staff and residents every few years, further preparing these emergency physicians-in-training to serve B.C. communities in their most challenging moments.

Code Orange

The Code Orange was called at 12:37 p.m. A group of resident doctors and paramedic trainees pushed out the front doors of Camosun’s new Alex and Jo Campbell Centre for Health and Wellness, which served as the mock emergency department, and waded into a chorus of cries and shouts coming from all directions. They were volunteer actors, dozens of them, who had received envelopes that morning containing information about their assigned characters: name, age, physical symptoms, and instructions for what to say to doctors. Many had received prosthetics and makeup from Camosun College visual arts students and the Island Health trauma services program to bring their injuries to life. They lay on the ground, propped themselves up against concrete pillars or wandered in a daze.

During a Code Orange, caregivers triage patients using a simple algorithm, or decision-making tree. The aim is to identify in 60 seconds or less who needs immediate care. The trainees quickly assessed patients’ ability to walk, their breathing, pulse and mental state, then labeled them with coloured triage tags indicating their destination zone within the emergency department: green for the walking wounded; yellow for serious but not fatal injuries; red for lives in danger; and black for those who sadly cannot be saved. 

With tags attached to their patients, the trainees then paired up to hoist those who couldn’t walk into wheelchairs and maneuvered them between the other injured patients toward the building and their destination zones.

Inside the emergency department

The yellow zone received its first patient at 12:53 p.m., six minutes after the Code Orange was called. She was Lisa Murphy, pregnant in a wheelchair, with a penicillin allergy and a gaping wound in her thigh. Her instructions, unknown to the residents: “If no tourniquet applied, please lose consciousness and then quietly bleed to death.”

They got the tourniquet on. She lived.

Two more patients arrived by 12:58: a man with an injured ankle and another with burns to his upper body and arms. Carlos Ruiz arrived at 12:59 with severe abdominal pain and bruising across his abdomen. He would lose consciousness within 10 minutes, but not before two more patients arrived. They were coming fast.

“Situational awareness” is a term that comes up a lot in emergency medicine. A physician who is repositioning a bone or inserting a chest tube cannot monitor a patient’s vitals at the same time, so a colleague does that. During a Code Orange, the need for situational awareness broadens. Each zone needs a leader to monitor comings and goings. Then there’s incident command, which manages the big picture: Where are beds available? Is blood supply running low? How many ambulances are still on the way?

Dr. Tristan Jones, a UBC clinical assistant professor and emergency physician with Island Health, was overseeing the yellow zone, so third-year resident Dr. Hannah Minnabarriet approached him to report that Mr. Ruiz had collapsed and needed to get to the red zone. Dr. Jones radioed incident command.

Incident command was buzzing with calls from all four zones: requests to send patients to the operating room, for CT scans, and with orders for oxygen and blood units. They gave Dr. Jones the green light to send Mr. Ruiz to the red zone, but told another caller, “ICU does not have space. Continue to resuscitate for now. We are expecting ICU space in 10 to 15 minutes.” Incident command was balancing all of this against what they knew about the condo collapse, and what was happening outside in triage. Occasionally, they were interrupted by a woman who was trying to find her son.

The actors brought a level of realism that was essential to the exercise. Their pre-incident briefing included instructions to fully embrace their roles. They wanted to throw the trainees off balance. Triaging a patient is one thing. Doing it while others clamour for your attention is another. “The way everything was organized made it very high-fidelity, so it felt very real for us,” reflected Dr. Rod Vafaei, a fifth-year resident based in Victoria, after the event. “We were in the moment, and it really helped us identify things we can do better if a real event happens.”

Lessons learned

The exercise was repeated four times so each resident doctor could take a turn in each zone. In just over an hour, the disorganization and hesitation of Round 1 had settled into calmer, more assured rhythms by Round 4.

Senior residents assumed leadership roles, letting junior residents recommend how patients be treated. For example, first-year resident Dr. Alex Taylor was tending to Chris Atwell’s ankle injury when Ms. Atwell discovered she could now put weight on her still-tender ankle. Dr. Taylor approached Dr. Alex Senger, a fifth-year resident who was overseeing the green zone.

“She’s stabilized and she’s happy to go home and return tomorrow for more treatment,” advised Dr. Taylor.

Dr. Senger was all for opening up a bed. “I agree,” he nodded, and sent Dr. Taylor to give Ms. Atwell the good news.

The residents learned that disaster medicine requires a shift in thinking.

“Our general principle is we will do whatever we can think of, whatever it takes for a patient, even if it’s a bit of a long shot or seems kind of excessive, because that’s what we do,” said Dr. Eisen.

In a disaster, the responsibility expands to the entire room as patients arrive faster than beds, staff and supplies can keep up.

“It’s a shift from doing everything for each individual that comes in, to doing as much as you can for as many people as you can,” said Dr. Timmings. “It’s a big focus on resource stewardship, which is difficult.”

As the day wound down, residents were left with something you can’t get from reading a protocol: a real sense of what pressure does to communication, judgment and teamwork—and what can help them remain resilient through it. They’d practised triage tagging and asking patients the right questions, but also the harder, quieter skill of resetting quickly and staying useful when the room is loud and time is short.

“Emergency medicine is a team sport, so practicing teamwork in simulations like this is incredibly valuable,” said third-year resident Dr. Chelsey Ju. “It was powerful to see everyone so focused and aligned around a shared goal. Experiences like this make us better physicians when it matters most.”

That’s the point of building a day like this with partners across the health system. A Code Orange doesn’t announce itself politely, and no one can promise it will never happen. But what UBC and its partners can do is make sure these doctors don’t meet that moment for the first time when real people are waiting. In a province where the next emergency could come at anytime, anywhere, preparedness is pre-emptive care for communities.