PITTSBURGH - The first to arrive was a SWAT officer with a hand wound. Then an older man, badly wounded, gray from loss of blood. Then another SWAT officer, arms and legs riddled with bullets. An elderly woman with a gunshot to her upper arm.
There was no shouting, no panic. Emergency doctors, nurses, surgeons and technicians poured into UPMC Presbyterian's trauma center as word of a mass-casualty event spread.
Four shooting victims were admitted, a fifth treated for abrasions and released. Two others, including the alleged gunman, Robert Bowers, were taken to other hospitals.
The hospital staff was ready. "We could have seen four times as many," said Donald Yealy, chief of emergency medicine. "This is unfortunately not our first rodeo."
As the number of multi-casualty shootings in the United States has grown, Level 1 trauma centers like this one have stepped up preparations and training for events like Saturday's rampage at Tree of Life synagogue here. They conduct tabletop exercises and walk-throughs. They practice organization and communication. They check and recheck supplies.
"We keep this place stocked to the gills," trauma nurse Chris Hughes said. "You never know what's going to come through the door."
On this ordinary Saturday morning, emergency physician Stephanie Gonzalez had just finished seeing a patient with a gastrointestinal bleed. Her colleague Alexandra Castro had just wrapped up a visit with a young girl with Crohn's disease.
The first call to 911 of a shooting at Tree of Life was made at 9:54 a.m.
Over the emergency radio, someone at UPMC thought they heard word of a mass shooting at a synagogue. Soon it became clear that the massacre was in Squirrel Hill, the neighborhood adjacent to this city's Oakland section, where UPMC Presbyterian's trauma center is located.
Keith Murray, a UPMC physician assigned to the city's SWAT team, and Lenny Weiss, assistant emergency medical services director who lives right behind the synagogue, were at the scene. Murray was with SWAT officers as they entered and cleared the building room by room. Weiss awoke to what he thought was construction noise, then heard screaming from the synagogue. He rushed to the staging area a block from Tree of Life, warning a neighbor who was walking her dog to get off the street.
In the trauma center, personnel were being organized into teams of about 10, one for each of the center's three trauma bays.
The SWAT officer arrived about 10:30. He was in a lot of pain, but his wounds were not life-threatening. He is in stable condition.
The 70-year-old man at the synagogue service had more serious injuries.
Gunshots had penetrated his abdomen. He had wounds in his front and back. There was no time to determine which were entry wounds and which were exit. His blood pressure was dangerously low. The lower abdomen is crammed with important blood vessels and organs.
"We don't know the trajectory of the bullet," Gonzalez said. "We see holes. We don't know if it's through and through." Within minutes of being assessed by the emergency crew, the man, who has not yet been identified, was hustled to the operating room. He had had three surgeries as of Sunday, Yealy said. He is in critical condition and faces a long recovery.
The second SWAT officer, apparently the first person to breach the gunman's hideout on the third floor of the synagogue, was also badly hurt. He also had lost a lot of blood, despite the efforts of Murray and others to help him. His head wound appeared to come from a bullet, possibly blunted by his helmet. He was still talking and able to follow commands, moaning in pain. He, too, was sent to the operating room.
The officer, identified only as a 40-year-old man, is in critical condition.
The 61-year-old woman with a wound to her arm, whom Murray helped from the synagogue, is in stable condition.
In the operating room, the top priority was identifying the sources of internal bleeding, an often complex task because of the extensive damage caused by high-velocity rounds from an assault-style rifle.
"A wound can be anywhere and can cause a devastating life-threatening injury," said Brian Zuckerbraun, chief of the hospital's division of general, trauma and acute-care surgery.
There would be time later to do more extensive repair. For now, the priority was stopping the loss of blood from vessels torn by gunshots. The wounded had to be kept stable. That meant transfusing blood, replacing fluids - warmed to body temperature - and monitoring vital signs, Zuckerbraun said.
In the operating room, order is also the goal. "We like to think it's calm," Zuckerbraun said. "In any one of these events where we take a sick patient and crash him to the OR, I am amazed at how much controlled chaos there is," he said.
In the trauma center, it was over in little more than an hour. The adrenaline has faded, and Gonzalez and Castro said they would process their emotions later.
"That's the hardest part, to switch on and switch off when something happens," Gonzalez said.
Castro said she regrets that so many victims died before they could be brought to the trauma center.
"If they would have come here, we feel like we could have given them a chance," she said.