Mass shootings have, unfortunately, continued to be in the news this year, and local hospitals must often quickly care for large numbers of victims. You worked the emergency department in Las Vegas the night someone opened fire on a music festival in October 2017. The shooting started at 10:04 p.m., and your first patients arrived at 10:24 p.m. What was that situation like?
As emergency department doctors, we go through a cycle during a resuscitation. There’s fear, because you’re unsure if you’re going to save someone. Then, as they start to turn the corner and you save them, it turns to exhilaration. Because there were hundreds of victims that night, that cycle perpetuated itself over and over for a couple of hours. Added to that was this fear that there was not enough time to save them all.
Hospitals have plans to respond to mass casualty incidents, but what happens when a plan hits reality?
The great philosopher Mike Tyson once said that everyone has a plan until they get punched in the mouth. I learned about mass casualties when I was in Detroit as an ER resident. Over the years of managing patients and learning efficiency and flow in an emergency department, I realized those ideas don’t really handle even a busy day in a hospital.
Do you think the standard plan would have worked the night of the Las Vegas shooting?
There are a number of hospitals that have employed that plan, and it works when you talk about a mass casualty involving five or 10 people. Now change that to a couple hundred people or a couple thousand people, and the wheels start falling off. You really need a plan that can scale or handle something big. If you can handle something large, then the small stuff is easy.
How many Las Vegas shooting victims came to your hospital, how many died, and how many were saved?
The number is between 280 and 320 patients. Despite the team coming together and working to save everybody they could, 10 people were dead on arrival; four were resuscitated and handed over to trauma surgery but deemed unsalvageable; one died in the operating room; and one was found to be brain dead.
What was unique about your response to this shooting?
The triage systems that are out there for handling mass casualties are intended for the pre-hospital environment. Triage sorts the victims so you can figure out who you need to work on next. This idea of tagging red, yellow and green is what typically happens out in the field. But really, when you look at it, it’s the red victims who are going to die.
What we ended up doing with our triage is we separated it out, so the reds were graded into red, orange and yellow. By doing that, we were able to figure out who we could save in that first 10 minutes, then we could save the next group, and then move to the last group. Even with the four ER doctors we initially had, we were able to perform all those resuscitations and save all those victims. That triage is really the key, because everything else was exactly what you would normally do.
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Did you hear from counterparts after the shooting, seeking to learn about how your emergency response worked?
I heard stuff by word of mouth, but I think when you’re in a situation like this, there is a somberness to what you saw. It’s hard to discuss or think about this type of material. The only reason why I continue to do it is because I was told this material can save lives. If somebody can get saved by just the experiences that we had to deal with, then it’s worth having to rehash those memories.
Of course, several recent incidents have shown us that healthcare workers can also be victims of gun violence at the workplace. You experienced treating gunshot victims during your residency in Detroit. But that was also when you encountered your first active shooter situation in the hospital. What did that experience teach you?
In that experience, a person shot their sibling and was then shot by security. Immediately, we had two gunshot victims. I remember realizing this protective bubble that I thought I lived in inside the ER where no violence happens was a myth. The only way I could ever be safe was to figure out a way to handle an active shooter. I asked myself: Did I have an idea of where I would go and what I would do if there was an active shooter? The truth was, I had no answer. After that, I would walk the ER, figure out where all the exits are, know where the ins and outs of all the rooms are, and then know what I would potentially have to do if something like that happened.
The truth is, you also have patients who are there. As healthcare providers, we have an attachment to our patients, even though we just met them. To think about how you would maneuver some of them out too is an additional worry. “Run, hide and fight” is the typical active shooter protocol. But our patients end up adding an additional level to that.