The first indication that Friday would be the busiest day ever in Lewis-Gale Medical Center's emergency room came just before 8 a.m.

The Salem Fire Department contacted the emergency room and said they were bringing in seven patients with carbon monoxide exposure.

The charge nurse called Candi Carroll, director of emergency services at the hospital. She called the fire department and asked them what would be the maximum number of patients if they all came in for treatment.

After Carroll was told it could be more than 100, she called the hospital administration, who activated its disaster plan and paged key hospital personnel that there was an emergency.

"We had people from all over the hospital coming in to help," said Dr. Robert Dowling, medical director of emergency services at Lewis-Gale.

Dowling said that though the hospital regularly has mass casualty drills, Friday was the first time the emergency room has faced an actual mass casualty situation.

Dr. Tony McKinney, director of emergency services for Carilion Roanoke Community and Carilion Roanoke Memorial hospitals, said Carilion had also activated its disaster plan a little after 9 a.m. He said the 49 people treated and released from Roanoke Memorial's emergency room were the most people treated at one time in recent memory.

But McKinney also said that as the area's Level One trauma center, Roanoke Memorial has a situation about once a year when the system activates its disaster plan, for example if there is a major traffic accident with 10 people seriously hurt.

Typically, Carilion is the medical control center for the region because it is a trauma center, McKinney said. But Friday, many patients were taken to Lewis-Gale first because of its proximity to Roanoke College.

As more and more people arrived in Lewis-Gale's emergency room by ambulance and Roanoke College vans on Friday, staff at Lewis-Gale tried to assess what they needed.

They soon realized that the emergency room's 27 stretchers weren't going to be enough. They contacted other departments and got more stretchers.

Staff also realized they were almost out of oxygen and oxygen masks. The hospital's vendor came and refilled the tanks and Carilion let Lewis-Gale have 150 oxygen masks.

By mid-morning Friday, the walls of Lewis-Gale's emergency room were lined with people with oxygen masks on stretchers and chairs.

As part of the hospital's emergency plan, they also brought in more triage nurses to prioritize who was the sickest among the people coming in with carbon dioxide exposure and their normal patient traffic, Carroll said.

McKinney said Roanoke Memorial did not experience a similar space or supply crunch.

Dowling said the emergency room normally sees a minimum of 30 patients between 7 a.m. and noon. Friday morning, they had their regular patient traffic -- plus an additional 62 patients. One patient who was not involved in the carbon monoxide incident had a heart attack in the middle of it all, Carroll said. That patient is doing fine now.

By early afternoon, many of the patients were treated and released, and the emergency room had calmed down considerably.

"For a mass casualty, this really was a fortunate one," Dowling said. "It was not a bomb or a plane crash."