Journal of Medicine - More than a month has passed, but Daryl Johnson still begins his emergency room shift at the University of Colorado Hospital here with a sense of foreboding.

“I walk through that doorway every day and it hits me — oh my God, the E.R.’s full, is it going to happen again?” Mr. Johnson, a paramedic, said. “It’s always in the back of my mind.”

The events that played out in this Denver suburb on July 20 have shifted the course of many lives. The victims and their families will never be the same, of course. Nor will the University of Colorado’s Anschutz Medical Campus, where James E. Holmes, 24, who is charged with killing 12 and wounding 58 at a midnight showing of the new Batman movie, was until June a graduate student.

But for the doctors, nurses and other staff at the hospital — which received 23 of the injured, one of them dead on arrival — the shootings were not only a trauma but also a test of their skills, their stamina and their teamwork, as the simulated disaster drills they had practiced turned abruptly into reality.

Looking back, many said that having come through the experience, they now felt prepared for anything a violent and unpredictable world might throw at them.

“We went into emergency medicine because we know it’s crazy — you never know what’s going to come through the door,” said Dr. Comilla Sasson, one of two attending doctors in the emergency room that night. “But the thing none of us have gotten over is, we made it through. We really, truly shined.”

April Koehler, the emergency department’s nurse manager, said that for days after the shooting, she woke up in the middle of the night with the urgent feeling she had to go out and help someone — just as she did when her emergency pager went off at 12:56 a.m. that Friday, the message reading simply: “Mass shooting.”

Jason Kennedy, a paramedic, served in Iraq with the First Armored Division, and little fazes him. But he finds himself replaying the images of those hours in his mind: the flashing lights of police cruisers bearing the wounded, the screaming and the blood, the hallways filled with bandaged patients lying on stretchers or standing in a daze, baffled survivors of an unexpected battlefield.

“You catch yourself thinking about it for no good reason,” Mr. Kennedy said. “Just out of nowhere.”

All 22 patients who arrived at the emergency room for treatment survived — “Everyone who came in with a pulse left with a pulse,” said Becky Davis, the emergency room charge nurse. Only one, Caleb Medley, 23, who was shot in the head and lost an eye, remains in the hospital, in critical but stable condition. Three other local hospitals received smaller numbers of injured patients from the shootings.

Dr. Sasson arrived for her shift at 11 p.m. that Thursday. Filling in for another doctor at the last minute, she had skipped the two-hour nap she usually takes before a night shift. As her colleague ran through the list of patients, she thought, “I can just power through till 8 a.m.”

Avery MacKenzie, 28, remembers that she was focused “on increasing my efficiency and being able to clearly communicate my plan to the patients and the other doctors.” Fresh out of medical school, she had begun the first year of her residency only three weeks before and was still getting used to introducing herself as “Dr. MacKenzie.” In the first hour and a half of her shift, she examined a man with chest pain, a woman with pulmonary hypertension and another patient with a bloodstream infection. “It was typical emergency medicine,” she said.

But soon afterward, with the E.R. already full to capacity, news of a shooting began to filter in.

Ms. Davis, the charge nurse, thought it was probably a gang shooting — they had happened before at the theater — and she began preparing for one to three new patients, the usual number from such an event. But at 12:45 a.m., she got a call from a police officer at the scene telling her of “multiple wounded,” and that the victims were being transported by police car.

Mr. Kennedy, listening to the police scanner, could hear the terror in the voices of the police officers at the scene. “It basically sounded like absolute chaos,” he said. “It sounded just like a war zone.” First it was a few injured, “then it was 4, 5, 6 and then it was 15 and then it was unknown, and crowds of people covered in blood. We were like, ‘Oh man, what’s going on?’”

The first police cruiser screeched into the ambulance bay at 1:06 a.m., followed closely by others, each bearing two or three victims.

“It was another car, another car,” Dr. Sasson recalled. “We were standing out here literally pulling out bodies and putting them onto stretchers.”

By 1:21 a.m., 15 minutes later, nine patrol cars and an ambulance had pulled up, discharging 13 patients, many with disastrous injuries.

“I think a lot of us have seen very bad gunshot wounds before,” Dr. Sasson said. “But some of the pictures that I think many of us have stuck in our heads to this day are just some of the most horrible injuries, people with their guts hanging out, people with their brains coming out.”

A storeroom just inside the doors was quickly transformed into a treatment room. The two trauma rooms were already full, and stretchers lined the hallways. One man sat in the waiting room holding up his bleeding arm. “I’m O.K. Take care of the other patients first,” he told the doctors.

Every 15 minutes, Dr. Sasson and the other emergency room attending doctor, Barbara Blok, along with other staff made the rounds. Gunshot wounds are notoriously unpredictable and patients “can go from super stable to critical, blood pressures dropping, crashing, altered mental status, unresponsive, within a couple of minutes,” Dr. Sasson said.

Throughout the hospital, people were reacting. A command center was set up. Calls went out to neurosurgeons, chest and vascular specialists, and orthopedic surgeons, who sped in to work, as did more than 100 other staff members, from radiologists to housekeepers. Nurses came down from the intensive care unit. Residents hurried to the emergency room from other floors. Operating rooms were opened up. Nine operations were carried out over the next hours.

The hospital’s blood bank received 185 units of blood. Rapidly depleting supplies — chest tubes, Pleur-evacs and sterile operating room towels — were replenished.

At one point Dr. Sasson remembers thinking, “I wonder if the shooter is here?”

Dr. Gordon Lindberg, a surgeon and medical director of the hospital’s burn unit, who coordinated surgery through the night and operated on a patient with 18 shotgun holes in the small bowel, said that since the shooting he had often thought how lucky it was that the gunman’s semiautomatic rifle jammed. Shotgun pellets, smaller and traveling at a lower velocity, inflict less damage, he said.

“As good as we were in mobilizing everyone and getting everyone here and opening the operating rooms,” he said, “if it had been mostly an automatic rifle to people’s heads, bellies, vessels, you name it, I don’t see any hospital handling it; I really don’t. There would have been deaths.”

At 7 a.m., with 22 patients examined, triaged and treated, Dr. Sasson and her colleagues looked up to see the morning shift trickling in. Some of the arriving workers had not yet heard the news. “How was your night?” they asked.

Adrenaline, training and instinct had pulled the E.R. workers through. But by the next Tuesday, an immense sadness had set in. On the spur of the moment, a group of them went upstairs to visit a young woman who had been severely injured. They wanted to see that she was alive, to comfort her if they could.

But the tears that flowed were theirs.

“We walked into the room and all of us just started bawling,” Dr. Sasson said. “And she was the one saying, ‘It’s going to be O.K.’ ”

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