Aurora Shooting Activates EDs; Psychiatric Questions Remain

Lori Batcheller

July 25, 2012

July 25, 2012 — Just minutes after a gunman wearing a gas mask, helmet, and full body armor opened fire in a crowded movie theater late on Thursday, local emergency departments (EDs) sprang into action. The incident, in the Denver suburb of Aurora, Colorado, took place during a midnight showing of the Batman movie The Dark Knight Rises, and ended with 12 people dead, 58 injured (some critically), and the alleged shooter in police custody.

Shortly after the first call to 911, officials at Colorado's Emergency Medical Services (EMS) Command were triaging patients and sending them to hospitals according to proximity and the availability of rooms and staff. The Swedish Medical Center, the third farthest hospital from the scene, activated their emergency crisis plan as soon as they received the page.

Robert Blache sits next to his daughter as Christina "Crispy" Blache speaks during an interview from her hospital bed at Swedish Medical Center, Monday, July 23, 2012, in Englewood, Colorado. Blache was one of the people shot in the attack early Friday at an Aurora, Colorado, theater during a showing of the Batman movie, "The Dark Knight Rises." (AP Photo/Alex Brandon)

"As a Level I Trauma Center, we have the resources set up 24/7 to respond to crises such as tornados, fires, and shootings," Kari Goerke, chief nurse officer for the critical care unit at Swedish Medical Center, said in an interview with Medscape Medical News.

"We already have doctors and staff onsite and ready to go," she explained, including a trauma surgeon, ED doctor, anesthesiologist, neurosurgeon, and orthopedic surgeon. When the EMS call came in, staff immediately identified patients in the ED who could be safely transferred to another unit, and 5 additional crews were called in. The Swedish Medical Center received 2 victims in critical condition and 2 in fair condition, but was prepared to do surgery on up to 6 victims right away. Goerke described the scene as "organized chaos."

Goerke was also at the hospital when victims of the Columbine High School shooting in 1999 came in, but explained that even without that experience, the staff would have been prepared for the movie shooting victims. "We have drills about twice a year," she said.

Goerke declined to provide specific medical details about the patients, but said the 2 in critical condition are "doing well."

The University of Colorado Hospital in Aurora admitted 23 patients immediately after the shooting. Four days later, 9 patients remain there, 5 in critical condition.

The Children's Hospital received 6 patients. Three were treated and released, and 1 person died. Four days after the incident, the hospital upgraded 1 adult from fair to good condition. Another adult remains in serious condition.

Two victims went to the Parker Adventist Hospital and 6 to the Denver Health Medical Center.

The Aurora Medical Center received 18 patients and admitted 7. One patient was discharged Sunday and another on Monday. Five days after the shooting, 5 patients remain there — 1 in critical condition and 4 in fair condition. In an interview with Medscape Medical News, Tracy Weise, hospital spokesperson, said: "We have good news. We have some who have been discharged and some whose status has been improved."

Minutes after the shooting, police took 24-year-old suspect James Eagen Holmes into custody outside the movie theater without resistance. According to information released by the police, the shooting spree appears to have been planned carefully. All the guns, including an AR-15, a Remington 870 shotgun, and two 40-caliber Glock handguns, were purchased legally in the past few months. Holmes stockpiled thousands of bullets in his apartment, which he booby-trapped.

At the time of the shooting, Holmes had dyed his hair red, and told authorities that he was "the Joker," one of Batman's archenemies. Holmes has been described as intelligent, shy, quiet, and a loner. He was raised in a suburban neighborhood in San Diego, California, played soccer at Westview High School, and ran cross-country. In the spring of 2010, Holmes graduated from the University of California, Riverside with a bachelor's degree in neuroscience. In 2011, he enrolled in the PhD neuroscience program at the University of Colorado–Denver, but was in the process of withdrawing. An unconfirmed report said that Holmes was studying the significance of tiny amounts of RNA as indicators of brain disorders and was scheduled to give a seminar on the topic.

According to Stuart Brown, MD, founding clinical director and chief of psychiatry at Mercy Hospital and Medical Center, San Diego, California, a common trait of mass murderers is a lack of empathy. Some are delusional, thinking they have to kill people, usually under the command of their delusions.

Sometimes the seeds of these delusions are planted through early childhood abuse and deprivation, but the pathology driving these delusions is often a major mental illness of biologic origin.

"There is evidence that major play deprivation is part of the profile of the majority of mass murderers and other homicidal males that I have studied, in contrast to matched comparison populations," said Dr. Brown in an interview with Medscape Medical News. Dr. Brown, who is also the founder of the National Institute for Play, learned of the importance of play by discerning its absence in a carefully studied group of homicidal young males, beginning with Charles Whitman, the 1966 University of Texas tower mass murderer.

Although the lack of play is a "valid consideration that has stood the test of time as being linked to the inability to handle aggressive impulses," Dr. Stuart noted, "in the Holmes circumstance, I have no valid information that would allow me to bring the dynamics of play deprivation and its effects on lack of empathy, diminished repertoire of choices to avert violence, etc, into perspective on this very tragic episode." He cautioned people about jumping to conclusions based on the incomplete information currently available.

Among the victims of the attack were recent college graduates, a recently accepted medical student, fathers, a young mother, and a 6-year-old girl, according to a report released by the Arapahoe County coroner. "The cause of death in all cases is related to gunshot wounds," said coroner Dr. Michael Doberson in an official statement. "The manner of death is homicide."

Most of the victims suffered gunshot wounds to the head, chest, abdomen, arms, and legs. Some victims were also being treated for chemical exposure, apparently related to canisters of an unknown substance thrown by the gunman.