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November 29, 2017

1 ED, 7 hours, 200+ patients: Inside a hospital's response to the Las Vegas shooting

Daily Briefing

    Kevin Menes, an emergency physician at Sunrise Hospital, recounted to Emergency Physician Monthly how he helmed the hospital's effort to treat patients injured when a gunman opened fire on a country music concert in Las Vegas on Oct. 1.

    Have a plan in mind

    Menes had thought about how he would respond to a potential mass casualty incident (MCI) before, so when he got word that the shooting had occurred, Menes knew he needed space and staff. He tasked clerical assistants with clearing ORs and treatment areas and calling in all medical personnel. All available personnel were then stationed in the ambulance bay, where the hospital had placed any empty beds and wheelchairs, to help process patients as they arrived.

    To handle the patient volume, Menes implemented a MCI triage plan in which:

    • Patients requiring major resuscitations (red tags) were sent to Station 1, the ED's "critical care pod";
    • Patients with threatening gunshots who had not yet crashed (orange tags) were sent to Station 2—a strategy that Menes explains "is not in the textbook," adding, "In my mind, these [patients] ... were expected to [crump, or deteriorate rapidly,] near the end of the Golden hour";
    • Patients with "torso/neck or proximal extremity shots that looked very stable and were expected to survive past the Golden Hou" (yellow tags) were sent to Station 4; and
    • Patients who would need medical care but not immediately (green tags) were sent to an area staffed by two PAs, tasked with keeping an eye on patients to ensure no one rapidly deteriorated.

    Keeping things moving

    The plan, according to Menes, was to send resuscitated patients to a trauma bay, where the surgeons could prioritize them for the OR—but getting patients into the OR was "the first major choke point." If the red tag patients were not quickly moved into an OR for surgery, "the orange tags would start to crump and become the next red tags," he explains. "The yellow tags would start becoming orange tags."

    Given the expected volume of patients, coupled with the need to keep things moving quickly, providers had to "eyebal[l] patients or fee[l] for carotid pulses," as there weren't enough monitors, Menes says. "Everything was 100% clinical judgment."

    Process in practice

    According to Menes, the first patients to arrive "had thready pulses, so they went directly to Station 1." He notes that while some of the early arrivals were considered deceased by textbook standards, he "sent them to the red tag area anyway" and "didn't black tag a single one." He wanted at least one other physician to check and confirm a patient was deceased before categorizing them as a black tag.

    As time passed, the patients arriving were in less critical condition. When a nurse told Menes that staff inside were "'getting behind,'" he handed triaging over to a nurse who had been working alongside him. He notes, "The textbook says that triage should be run by the most experienced doctor, but at that point what else could we do?"

    Other delay points

    As Menes worked inside, he immediately spotted and addressed other delay points. For instance, once he realized that the Pyxis automated system for dispensing medication was slowing down access to needed drugs, he asked the ED pharmacist "for every vial" of two key medications—Etomidate and Succinylcholine—in the hospital and had a trauma nurse get all available units of O negative blood. "In order to increase the flow through the resuscitation process, nurses had Etomidate, Succinylcholine, and units of 0 negative in their pockets or nearby," Menes says.

    Menes also realized that the number of patients with gunshot wounds (GSWs) "to the head were going to clog up the E[D]" because the neurosurgeons hadn't yet arrived at the hospital. To reduce volume pending the neurosurgeons' arrival, Menes told ED doctors to get "altered, isolated GSWs to the head" intubated, sent to CT, them then to trauma ICU to await the neurosurgeons—a strategy that helped offset some of the volume in the ED and enabled nurses to focus on "the orange tags that were becoming reds."

    Improvising necessities

    To stabilize quickly crashing patients, Menes and the other physicians "went straight to [the] chest tube" for patients who were "crumping with a GSW to the chest" instead of taking other measures, such as central lines or needle decompressions. And when the hospital began to run out of thoracostomy trays and chest tubes, he improvised with suture kits and scalpels and ET tubes.

    And when the hospital needed more ventilators, Menes turned to an idea a colleague had written about: When you have two people of similar size and tidal volume, simply double the tidal volume and use Y tubing to connect them to one ventilator.

    Menes also set up a "CT Conga Line" to help speed up the CAT scan process, which typically involved a CT tech picking up a patient, taking them to a scanner, and returning the patient. Under the improvised process, Menes told the CT tech to remain at the station, manning the scanner, and had nurses line up patients who needed CAT scans outside the room.

    Menes also cut down on X-ray wait times for green tag patients. Instead of sending an X-ray to the radiologist after the patient was scanned, Menes arranged for a radiologist to stay with the X-ray tech so that he or she could scan the images as they appeared on the screen, enabling providers to "decide on disposition right there."

    Throughout the process, Menes was also instructing incoming ED physicians on how to handle the situation, telling them to "find [the] dying patients in the sea of patients still out there." According to Menes, "within hours, we had hundreds of doctors, nurses, and midlevels arrive at the hospital to help."


    According to Menes, the work the surgery team did that night was "an unprecedented feat." Over a six-hour period, the team performed "28 damage control surgeries and 67 surgeries [with]in the first 24 hours," Menes notes. He adds that by 5 a.m., about seven hours after patients started arriving, the team had dispositioned nearly all 215 patients—about 30 GSWs each hour. Menes says, "I couldn't believe that we saved that many people in that short amount of time."

    He calls the outcome "a testament to how amazingly well the hospital team worked together that night." He concludes, "We did everything we could" (Menes et al., Emergency Physician Monthly, 11/3).

    Members ask: How can our hospital prepare for disasters?

    Hospitals must be prepared for myriad disasters that can stress health care systems to the breaking point and disrupt delivery of vital health care services.

    Advisory Board has compiled step-by-step procedures for various threats your facility may encounter—though we hope you'll never need to use them.

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