During a Wednesday session, Mass Casualty Events: Lessons Learned from Military-Civilian Collaboration, a panel of civilian and military trauma surgeons discussed lessons learned from recent U.S. civilian major mass casualty (MASCAL) events that required active engagement between U.S. military medical resources and the civilian trauma system. 


On the night of October 1, 2017, the deadliest mass shooting in modern American history occurred when a gunman opened fire from the 32nd floor of a Las Vegas, NV, hotel, targeting a large crowd of people gathered below for an outdoor concert.


Deborah A. Kuhls, MD, FACS, professor of surgery, chief of critical care, University of Nevada-Las Vegas School of Medicine, and medical director, University Medical Center (UMC) Trauma Intensive Care Unit, was on duty at UMC, a Level 1 adult trauma center, when the first notification of the shooting came in at 10:15 pm. She discussed the events of that night and UMC’s collaboration with trauma personnel at nearby Nellis Air Force Base through the military’s Sustained Medical and Readiness Training (SMART) program.


“We performed more than 20 operations overnight and, all told, we saw 104 patients, 60 of whom were admitted to our trauma center. Throughout the region, there were approximately 250 patients who were transported by ambulances,” Dr. Kuhls said. “The military SMART personnel were particularly helpful by taking about a dozen of our ICU [intensive care unit] patients who were not critical or who did not need immediate surgery and were also extremely important in terms of our readiness for this event.”


Major Stephanie M. Streit, MD, FACS, trauma medical director, 99th Medical Group, and assistant professor of surgery, Uniformed Services University, Nellis Air Force Base, Clark County, NV, discussed how the military-civilian collaboration of the SMART program allowed her and her medical colleagues in the military to quickly respond and deploy personnel to assist the civilian trauma operations that night. “Readiness” and “currency” are military terms that are often used interchangeably, but Dr. Streit said they are slightly different concepts and are cornerstones of the SMART military-civilian partnership.


“Readiness is the knowledge, skills, and abilities [KSAs] necessary to perform one’s job in the deployed setting or in support of a humanitarian crisis, while currency is the state of being up-to-date and ready to deploy at a moment’s notice,” she explained. “From the military’s perspective, the heart of the conversation around military-civilian partnerships is motivated by the achievement of currency through readiness.


“Our relationship with UMC is really unique, mainly because of the unique geographic setup,” Dr. Streit added. “Because we at Nellis are so close to UMC, we have the opportunity for Nellis providers to be fully credentialed and able to be fully integrated into UMC on a day-to-day basis.”


At any given time, she said that means 50 to 100 military health care providers—including trauma surgeons, anesthesiologists, emergency physicians, and ICU and emergency department nurses—are on site at UMC and ready to be deployed. Although not all military and civilian medical teams share such convenient proximity, the response and collaboration on the night of the Las Vegas shooting is a testament to the value of the SMART program, she said.


“It’s very clear that our current civilian-military partnerships have provided proof of concept, not only for MASCAL events, but for expanding capacity in local and regional trauma systems in general,” Dr. Streit said. “The military is currently studying the productivity of military surgeons in the context of currency and readiness to determine how to improve and grow the SMART program and determine what target military-civilian partnerships might look like into the future.”


Retired U.S. Army Col. Matthew J. Martin, MD, FACS, FASMBS, professor of surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, and clinical professor, University of Washington School of Medicine, Seattle, WA, shared lessons learned regarding readiness and response in the aftermath of an Amtrak passenger train derailment in December 2017 near DuPont, WA. He also discussed the benefit of Madigan Army Medical Center serving as a SMART program resource in the region.


“In the Level 2 trauma center response to this accident, there were a lot of high and low points,” he said. “It’s important to have a good after-action review process and then bundle that into a way to address the problems that are identified. All in all, this event clearly demonstrated the benefit of having a military medical center integrated into the local civilian trauma system.”


Ronald M. Stewart, MD, FACS, American College of Surgeons Medical Director, Trauma Programs, and chair, department of surgery, University of Texas Health Science Center at San Antonio, concluded the session with a discussion of lessons learned in response to a November 2017 mass shooting at a church in Sutherland Springs, TX.


“This event presented some significant challenges because it happened in a rural area, a long way from the nearest trauma center. But the prehospital response was terrific,” Dr. Stewart said. “We started ‘Stop the Bleed,’ turned bystanders into immediate responders, had effective professional EMS [emergency medical services] response and trauma care center coordination, and all of that is due to our civilian-military partnership. I can’t sing the praises of that enough.”