Police stand guard Dec. 2 outside Loma Linda University Medical Center in California on the day of the mass shooting in San Bernardino. Medical workers’ efforts were disrupted by a bomb scare. (Patrick T. Fallon/AFP/Getty Images)

On the afternoon of Dec. 2, just a few hours after terrorists killed 14 people and wounded 21 others at a California social service center, one of the hospitals where the injured were taken was further disrupted by a bomb scare. Bomb-sniffing dogs set to work under gurneys at the Loma Linda University Medical Center, where Kathleen Clem and others were working to the utmost of their abilities to save lives.

“We practice for this,” said Clem, chair of emergency medicine, explaining how staff had been trained to expect the unexpected in the volatile aftermath of attacks like the shooting in San Bernardino.

What Clem and her colleagues did not fully anticipate, however, was how onlookers would turn to social media during those hours, trying to photograph victims as they were brought into the hospital. Or how communications would be affected as staff members, patients and their families began to stream news of the shooting online.

“It overwhelmed our internal Internet,” Clem said.

The medical response to mass casualties — honed over almost two decades since Columbine and then the 9/11 attacks — has been an exercise in learning from the past and trying to anticipate new challenges. It requires cooperation among police, paramedics and private hospitals, many of which now belong to almost 500 health-care coalitions nationwide. It aspires to respond to the burgeoning threat of terrorism even as federal funding for hospital preparedness has fallen. And it relies on an evolving body of first-hand experiences in coordination and communication far more complex than the daily chaos of an urban emergency room.

“Nothing prepares you,” said Christopher Colwell, an emergency physician who went to the scene of the Columbine shootings and was working 13 years later in a local ER when a gunman opened fire in a movie theater in Aurora, Colo. What you can do, he says, is “have a plan.”

Colwell, now director of emergency medicine at Denver Health, remembers confronting questions at Columbine that had never crossed his mind. How to identify among myriad well-meaning responders from different agencies which was best equipped to help with what? And what to tell the driver of a military vehicle who wondered, “Hey, Doc, where do you want me?” Or, later, how to manage the media calling his home in the middle of the night?

“After any and every event,” said Leonard Cole, who teaches a course in terror medicine at Rutgers New Jersey Medical School, “the largest flaw is based on faulty communications.”

Challenges of a fast response

These days, all hospitals, from small, rural facilities to the 218 institutions like Loma Linda with sophisticated Level 1 trauma units, practice how to respond to disasters. They try to anticipate common features of deliberate attacks which, unlike plane crashes or earthquakes, often have ­follow-ups, sometimes targeted at health-care providers — as during the Loma Linda bomb scare.

Increasing importance is placed on taking quick action to save lives. At Columbine, rescuers waited for a SWAT team to arrive, possibly allowing one victim to bleed to death; Colwell did not enter the school until it was declared safe, more than four hours after the shootings. Today, local police teams move in swiftly to hunt down the assailants; Loma Linda received its first victim less than a half-hour after the institution was notified of the massacre.

However, that emphasis on speed risks overburdening the closest ERs. That is what happened in 2012 in Aurora, where a lack of communication among emergency services meant hospitals had little warning of what to expect from the bloodshed at the theater.

Barbara Blok, an attending on duty at the University of Colorado’s Anschutz Medical Campus, had heard over the emergency dispatch system about a shooting. But it wasn’t until one of the first patients came in by car with minor pellet wounds that Blok got a sense of the scale. “She described the gunman in the theater,” Blok said. “And I’m thinking, ‘Oh, that cannot be good.’ It was a full theater.”

Ambulances were having trouble getting past the flood of emergency responders, so police cars started picking up survivors, sometimes two or three at a time, and racing to the already-busy ER. The hospital’s disaster tree was never activated to bring staffers in from outside.

“I don’t know if it would have made a difference,” said Blok, praising the physicians and nurses who joined the response from throughout the hospital. “We had physicians that had never seen trauma,” she said. “I told them, ‘Look [the victims] over from head to toe and come back to me and tell me what you see.’ It worked, but it’s not the ideal situation.”

Of the 70 people who were wounded, 23 arrived at the ER within an hour. All but one, who was declared dead on arrival, survived.

Brainstorming those kinds of challenges is a critical part of the programs Craig DeAtley runs at MedStar Washington Hospital Center, where he is director of the Institute for Public Health Emergency Readiness.

Almost a decade ago, after 9/11 and the anthrax attacks, the Hospital Center received a $5 million federal grant to bring together regional medical facilities to function as one of the nation’s first coalitions.

It continues to operate today, on a voluntary basis.

“Normally, [hospitals] are competing financially,” DeAtley said. “All that stops when the coalition takes up the task,” he said, whether it is a case of buying protective masks in bulk or, in the event of an actual disaster, using a shared software program to monitor which facility has the capacity to accept additional patients or is running low of particular supplies.

Such level of coordination has become far more common since 2012, when the Department of Health and Human Services’ Hospital Preparedness Program, which previously provided grants to individual hospitals to increase their surge capacity, instead began to support the creation of coalitions. Almost 75 percent of hospitals nationwide now belong to coalitions, which include EMS providers and long-term care facilities, as well as behavioral health and public health agencies.

But despite the ongoing threat of terrorism, funding for these efforts has dropped. The Hospital Preparedness Program received $229 million this year, less than half of its 2003 budget.

All the drilling becomes real

“We need more,” said Colwell, meaning more coordination and collaboration. He emphasized the need for community response to a threat that is “not if but when.”

That became clear just after 11:15 a.m. on Dec. 2 at Loma Linda, when Clem received a telephone call while she was sitting in a lecture hall at a training program for residents. There had been a mass shooting in neighboring San Bernardino, she learned. She asked staff to report for duty, putting in place a well-drilled plan that involved assembling a triage team, opening operating rooms and putting nurses who were doing administrative work onto active duty.

It was “fortuitous,” Clem said, that so many staffers were already on hand for the training program. Within 15 minutes, the hospital was ready to receive 50 survivors.

Clem also made a call to her husband: Would he please bring in scrubs and a white coat? Running the response would be the responsibility of the hospital’s incident command team, which included representatives from fire and police. Clem’s job was to treat patients.

Eight hospitals, most belonging to the same coalition, took victims. Five went to Loma Linda, four of them arriving little more than a half-hour after the first call, as nurses held up white sheets so that family members would not learn from social media photos that their loved ones had been hurt.

The hospital’s proximity to the shooting meant that victims arrived quickly, but it also heightened anxieties about what further evil the terrorists might have planned.

“We all have family here,” Clem said. That sentiment was sharpened by the bomb scare.

“I think the biggest lesson learned,” she reflected, was that “we did the right thing by preparing for more than we got. You can scale down if you need to.”

The hardest lesson, Clem added, might be the emotional impact of realizing that there were many people that even a well-prepared Level 1 trauma center could not save. Despite advances in coordination since Columbine, 14 people died where they were shot.