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Chapter 5

Las Vegas Mass Casualty: How One ED Made Order Out of Chaos

Kevin Menes, MD, Rhonda Davis, RN, Allan D. MacIntyre, DO, and Rob Orman, MD
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A first hand account of the emergency department response to the 2017 Las Vegas strip shooting that left 59 dead and over 800 wounded. Discussion of preparation with 20 minutes warning, how to keep patients flowing as they enter the hospital as well as once they’re in the treatment area, effective triage, critical steps to simultaneously resuscitating large numbers of trauma patients.

Pearls:

  • With practice and planning, you and your team can manage a mass casualty.

  • In a mass casualty, you are not providing comprehensive treatment.  The goal is to keep each injured person alive so they can survive to the next step in care.

  • Keep the treatment simple. The more the treatment and triage can resemble an efficient assembly line, the better.

 

  • This is the 1 year anniversary of the Las Vegas strip shooting massacre that left 58 dead and over 800 wounded.  In addition to shock, sadness, and revulsion, this event troubles us with thoughts of what it would’ve been like to be one of the responders or treating providers.

  • Many fear the management of a mass casualty to the point of avoiding preparatory drills -- the opposite of how we should tackle a weakness or a blind spot.   

    • For some, an event like this has devastating effects and can be career ending.

    • Rob admits to having been so overwhelmed by the prospect of a mass casualty that he avoided anything where he’d be exposed to that kind of turmoil and uncertainty. He worried about showing his ignorance at something so foreign to his day-to-day work in the ED.

    • The rules of a mass casualty are different.  It’s not providing comprehensive treatment for the one person.  It’s how do you keep this person from dying right now, so they can survive to the next step in care.  

    • The management of a mass casualty can only work as a team effort.  And the team is very large.

    • Participating in a mass casualty is not easy, but it’s well within the skillset of every ED provider.

  • In this episode you will hear several voices from the Sunrise Hospital staff who were working on October 1, 2017.  This was the closest hospital to the venue, and it was quickly inundated with patients. This is just the raw “How was it done?” and, by extension, “How can it be done when it happens in your community?”

  • Kevin Menes, ED physician:  

    • The shift started off quieter than usual.  Some of the providers were even talking about going home early.  

    • A police officer was nearby, visibly concerned by what was being reported on his radio.  It was clear that this was something big.

    • Kevin sprinted to his car and grabbed his police radio.  He heard the following and knew that he would be getting at least a couple hundred patients within a matter of minutes:  

      • “We have an active shooter inside the fairgrounds.”  

      • “Shots fired from Mandalay Bay.  There are many people down. We have multiple casualties.”

      • “Be advised it is fully automatic fire from an elevated position. Take cover.”

    • He ran back to the ED and started preparing his team.  “Clear out your stations. Get IV’s on all of them. Call us when they start crashing.”  He knew they would improvise the rest of the way.

    • He asked that patients not be put into rooms that were out of view, worrying patients could easily die in there unnoticed.

    • He made an initial plan with the other 3 ED physicians, the trauma surgeon, and the in-house intensivist to put red tags on patients who needed immediate treatment for survivable injuries.  

  • Rhonda Davis, ED trauma nurse:

    • While charting at her desk, she heard an officer’s radio go off.  There was gunfire, a barrage of bullets. After being informed of the shooting at the country music festival, she went into shock for a brief moment, thinking of her friends and family in attendance.  Then she started to process the information. She felt prepared, having managed mass casualties before. Only later would she realize that she’d never experienced anything like what would be coming through their door that night.

    • She started alerting her chain of command. They cleared out rooms, discharging non-critical patients.  They called for extra staff.

    • They prepared to receive patients, en masse.  They brought every stretcher and every wheelchair out into the ambulance bay where they sat waiting for cars, trucks, ambulances and police to arrive.

  • Kevin Menes:

    • Brought stretchers into the ambulance bay and blocked off ingress and egress so that he had control over who went in and out.  The idea was to make it like a pitstop where the vehicle would arrive, patients pulled out, placed on stretchers, rapidly assessed and then removed from the bay. That vehicle would leave and then the next would come in. This method of triage gives about 10 seconds of evaluation per patient.

    • The first cars to arrive were police officers, arriving 20 minutes after the first shots were fired.  There were 4-6 injured people in each car. They were quickly pulled out, put on gurneys, and assessed for the extent of injury.  He had to guess, using applied ballistics and wound estimation: Were they dying now? Or in a couple hours? Or probably not going to die?  

    • Textbooks describe a tagging system to communicate to everyone else in the patient’s chain of command the severity of injury.  Red tags are used for patients who require immediate treatment. Yellow tags identify non life-threatening injuries. Green tags signify minor injuries.   Black tags mean death is imminent.

    • Menes realized this system would be too cumbersome and confusing given the volume of expected patients.  He decided to tag the area the patient should go to, rather than tag the person.  Patients were segregated by injury severity. Red tagged patients went straight to the resuscitation bay and were treated first.  Orange tagged patients were deemed to have 30-45 minutes before dying and they went to another treatment zone.

    • How did Menes determine the severity of each patient’s injuries in just a few seconds?  Mentation was used as a marker of perfusion. There was no time for vital signs. Patients who had a palpable carotid pulse or who were talking were given an orange tag.  Those with a thready pulse or who were agonal went into the red tag section.

  • Dave McIntyre, lead trauma surgeon:

    • McIntyre was the second step in care.  He had 20-30 seriously injured patients within minutes.  From the resuscitation bay, he determined the patient’s destination based on injury type.  He kept patients organized by putting head injured patients in one area, chest traumas in another, and abdominal shots in a third.  

    • He tried to keep his treatment simple. The more the treatment and triage could resemble an efficient assembly line, the better.

      • Injured patients who were talking were propped up on the gurney, moved to the side, and closely observed by nursing staff.  

      • Any patient who was unresponsive was immediately intubated.  There was often no suction and no light. Many were intubated by feel placement, confirmed by capnometer.

      • Those with serious head injuries were sent to the trauma ICU where they were evaluated by neurosurgeons.  The decision regarding the need for imaging was made in the ICU.

      • Patients with chest injuries immediately had a chest tube placed.  IV access not readily achieved peripherally was with an IO in the humerus or tibia.  If they weren’t talking, they were intubated. If there was hemorrhage from the chest tube, the patient went straight to the OR.  Otherwise, they were transferred to the cardiovascular thoracic unit.

      • Abdominal GSW patients who were unstable went directly to the OR.  More stable patients went to preop.

    • He deferred the decision regarding the need for blood transfusion to the surgeons and anesthesiologists managing patients who went to the operating room.  He fluid resuscitated patients with impaired mentation in the ED but restricted fluids to patients with normal mental status.

    • Residents were invaluable in the process of treating so many patients.  In the OR they helped with damage control surgery -- just trying to stabilize patients.  The routine was to stop the bleeding, prevent contamination, put in a vac dressing, and clear the OR for the next patient. There were anesthesiologists in every ED pod which helped guarantee that patients weren’t left alone.  

    • There was no time for detailed medical records.  Documentation was writing critical information (ie. type of injury, tourniquet time) directly on the patient with a permanent marker.

  • Rhonda Davis:

    • Everybody knew they had a specific task to perform.  They honed in on the ABCs. Respiratory therapists were setting up intubation supplies, nurses were placing IVs and doing CPR, fire department crew members were putting in IO lines, physicians were intubating and placing chest tubes.  It was very systematic.

    • There were several nurses that night who said, “I can’t do this anymore..”  Rhonda’s reply was, “No. You can do it. You can. You have the right training.  You have the right education. You went into this position for a reason. Just when you think you’re going to be at your breaking point, you’re not.  You will be able to continue on and do exactly what you need to do to save your patients.”

Managing a mass casualty.  You can do it. You and your team, with practice and planning, can do it.  You need a simple plan for quickly treating and distributing patients. And in the aftermath, debrief.  Do it immediately, then do it later, then do it again.  Anticipate that you’re going to be impacted by this event.  One of your most important jobs after the dust settles is to acknowledge that.  Don’t hide it. This is not an easy job on a normal day, and if you’re in the position where you are at the hospital receiving a mass casualty, remember that you’ve got this.  You can do it.

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2.25 AMA PRA Category 1 Credits™ certified by Hippo Education (2018)