Management, triage, and training: Lessons learned from the Las Vegas mass shooting

Panelists, from left to right: Drs. Eastman, Stewart, Jacobs, Winchell, Johnson, Kuhls, Dort, Fildes

[clear]The rise in mass casualty incidents (MCIs) creates increasing challenges for both surgeons and trauma systems in terms of adequately preparing for these crises. Tuesday’s Panel Session, Lessons Learned from Las Vegas and Other Mass Casualty Events, presented real-world insights from Nevada trauma surgeons who treated patients earlier this month as a result of the deadliest mass shooting in modern U.S. history.

[clear]Opening remarks by Lenworth M. Jacobs, Jr., MD, MPH, FACS, emphasized the critical role of first responders at the scene of a MCI or other major bleeding event, who can be trained to provide hemorrhage control, specifically via the Stop the Bleed® campaign. A national survey regarding bleeding control showed that 98 percent of the public would like to be able to stop bleeding in a family member if the need arose, and 92 percent would like to be able to stop bleeding if they came upon a stranger in a car crash, Dr. Jacobs said. “These are unbelievable numbers…what this says is that the public wants to be part of the solution. There are 250 million people that we want to train [in bleeding control techniques], and we need your help.”

[clear]”Let’s not fool ourselves. We live in the most violent industrialized country in the world,” said Alexander L. Eastman, MD, MPH, FACS, with the University of Texas Southwestern Medical Center, Dallas, and a member of the Dallas Police Department, who outlined strategies for meeting the challenges of an active shooter event in a health care facility. According to Dr. Eastman, these are “rare but powerful events” with 154 hospital shootings between 2000 and 2011. “The Department of Homeland Security advises the public to ‘run, hide, fight,’ but is this applicable in a hospital? What if you’re working on an active case?”

[clear]Dr. Eastman said MCI events at hospitals require an institution-wide response. “Even in hospitals, we have to depend on civilian responders—you will need all hands on deck,” he said, referring to Dr. Jacobs’ presentation and the goal of training the lay public in bleeding control techniques.

[clear]”[This issue] is not about gun control,” he added. “It’s about bullet-hole control.”

[clear]Dr. Eastman closed his presentation by asking the surgical and trauma community to “establish a culture where it is okay not to be okay after these events,” and to offer support for colleagues in the months following an MCI.

[clear]Describing the trauma system’s role in MCIs, Robert J. Winchell, MD, FACS, noted that these systems tend to “focus maximal resources on a single patient” and that they exist in a “constant state of operational readiness.” “The best way to care for many injured patients is to use the same system built to care for them one at a time,” Dr. Winchell said. He noted that the difference in scale for MCIs forces a change in paradigm, where the system “preserves high-level resources for those who can be saved and provides minimum necessary care for the rest.”

[clear]Switching to an MCI model to meet the challenges of a multi-casualty event, the trauma system must do the following, according to Dr. Winchell: Rapidly and sequentially engage additional resources, optimize communication, ensure accurate triage and control patient distribution, provide trauma centers and other facilities time to prepare, and anticipate the need for secondary transfers.

[clear]John Fildes, MD, FACS, described the structure of the Southern Nevada Trauma System (SNTS), which includes 17 hospitals with emergency departments and three trauma centers within this group that treated the victims of the mass shooting in Las Vegas, which resulted in 546 wounded and 58 people dead. According to Dr. Fildes, the SNTS was able to seamlessly respond to the MCI due to the system’s coordinated injury response network, daily operations that optimize patient outcome, and the ability to readily adapt to manage an influx of injured patients resulting from an event such as this.

[clear]”I heard someone shout ‘there is an active shooter on the strip,’” said Deborah A. Kuhls, MD FACS, FCCM, University Medical Center (UMC) of Southern Nevada, who was at UMC the night of the event. The first notification was that there were five to 10 patients, but the second notification indicated that there were 50 to 100 or more patients, she said, which is when UMC activated its disaster plan. “There were more than 20 self-transports to trauma and to the main emergency department,” she added. “We triaged outside [in the parking lot] of the trauma center.”

[clear]Dr. Kuhls said there were more than a dozen trauma surgeons working that night, as well as specialty surgeons, nurses, and more than 70 residents and fellows. UCM started with two faculty in-house that night, and within 30 minutes four faculty and two fellows arrived; within one hour, five additional faculty and four fellows arrived; and within two hours of the event, eight additional faculty plus four fellows were at UMC. The facility had eight operating rooms running concurrently.

[clear]At some point during the event, UCM staff received false news of a shooter on-site at their facility, underscoring the need for sustainable modes of communication at health care facilities treating victims of an MCI.

[clear]Dr. Kuhls said UCM was prepared the following day to transfer non-critical patients in the event of a copycat MCI in the area. In the end, UMC physicians and staff treated 104 patients; no one who arrived alive to UCM died.

[clear]”In the first 24 hours, we saw 212 patients and performed 58 surgeries,” said Matthew Johnson, MD, FACS, with the Sunrise Hospital and Medical Center, Las Vegas. Sunrise staff grouped pods of operating rooms together for treating specific types of cases. “More than 100 physicians and more than 200 nurses responded to assist for a total of 83 surgeries performed. Everyone did their jobs. As for the residents—we couldn’t have gotten through this without them,” Dr. Johnson said.

[clear]Dr. Johnson concluded his presentation by describing what went well in treating victims of the Las Vegas MCI and by outlining lessons learned. He said “preparation and practice with complex events like New Year’s Eve and Halloween night, engaging in regular drills, and strong leadership from emergency room physicians and trauma surgeons” enhanced his facility’s ability to respond to the MCI. One of the bigger lessons learned, he said, concerned the registration process, as a few patients were repeatedly assigned the same name.

[clear]”We took this [MCI] personally, just like everyone else in Las Vegas did,” said Sean D. Dort, MD, FACS, with St. Rose Dominican Hospital, Las Vegas. Dr. Dort said a “very detailed assignment of roles” helped his facility quickly and efficiently treat victims of the Vegas MCI, although even the most detailed disaster plan can’t anticipate every variable as witnessed by the surgeon on- call the night of the event—the physician’s first on-call at St. Rose. (Dr. Dort and colleagues quickly came to the surgeon’s aid.)

[clear]”You can’t start figuring things out when this is happening,” Dr. Dort said in his concluding comments. “You have to train beforehand.” He also said surgeons treating victims in the chaotic aftermath of an MCI should be wary of false news. “Don’t believe everything you hear. We kept hearing reports about a second shooter…but the only reality is [the patient] right in front of you.”

[clear]”Looking at the Southern Nevada Trauma System, you can see the benefits of [MCI] training. It’s palpable,” said Ronald M. Stewart, MD, FACS, Chair of the ACS Committee on Trauma, delivering the session’s final remarks. “Your leadership is critical to developing a national trauma action plan here and around the globe.”