COMMENTARY

Triaging and Treating After the Las Vegas Shooting: A Firsthand Account

Robert Glatter, MD; Dale Carrison, DO

Disclosures

November 15, 2017

At the Hospital After the Las Vegas Shooting

Robert Glatter, MD: Hello. I am Dr Robert Glatter, assistant professor of emergency medicine at Northwell Health and attending physician at Lenox Hill Hospital in New York City. The devastating shooting on October 1 in Las Vegas killed 58 people and injured more than 500 others.[1,2] This was yet another in a relentless string of mass shootings with which we struggle to come to grips. The heroic actions of first responders that day helped to save countless lives, especially with rapid transport to Las Vegas hospitals by citizens in cars, SUVs, and pick-up trucks. The use of prehospital tourniquets, improvised in many cases, was another life-saving action described by witnesses that day.[3]

University Medical Center (UMC), Nevada's only Level 1 trauma center, received 104 patients.[4] Additional patients were later transferred to UMC as a result of complex trauma that could not be effectively handled by other area hospitals.[5] Sunrise Hospital and Medical Center, a Level 2 trauma center, treated 214 patients, with at least 30 requiring surgery.[6]

Dr Dale Carrison, chairman of the department of emergency medicine at UMC, was on the front lines when patients began arriving that day. He joins us now to talk about the critical role that he and his staff played in triaging and treating patients that day.

Welcome, Dr Carrison. I know that this has been a difficult period, including these weeks after the shootings, which we will talk about at length. But I want to begin by asking you what the scene was like as you arrived. Could you describe what you saw? How many patients arrived with tourniquets already placed? What was your triage process?

Dale Carrison, DO: I am the medical director for the [Las Vegas Metropolitan] Police Department, and my initial notification came from them. Within about 10 minutes of the notification of the shooting, I put on my scrubs and drove to the trauma center. Our chief trauma surgeon, Dr John Fildes, a former chief of trauma for the Committee on Trauma of the American College of Surgeons, and I arrived at the same time.

We have an 11-bed independent trauma unit, staffed and in use. It's not in the emergency department; it's a free-standing area. When the shooting started, nine patients were already being seen in the trauma center. By the time John and I arrived, around 50 people were in the trauma unit. They were all being cared for, some with tourniquets on, and chest tubes were being inserted into at least three people at that time. Anesthesia had arrived. The three operating rooms in the trauma center were all open and staffed. The 26 operating rooms in the main hospital were also being opened.

We refined the triage process when we arrived. I have a dual role at UMC; I am also chief of staff, and I had asked if the Incident Command Center had been set up. It had not yet been set up so I asked the on-duty administrator to have the Incident Command Center set up immediately. The CEO had been notified and was on his way in.

Then John and I went through who should go to the trauma unit next. All of the patients were being taken care of; 18 patients were sitting in chairs, all had extremity wounds, some with tourniquets on. That process of triage involves deciding who goes to CT next; who immediately goes to the operating room; who does not need to be evaluated further; and who is prioritized in that group because, for example, at least two of the patients were dead by the time they got to us.

That seemed to be similar to what happened at the other hospitals. Many of the dead patients were transported simply because they may have had some vital signs when they were picked up. The emergency medical service (EMS) technicians were doing an incredible job at the scene, trying to correctly triage everyone and figure out who was who. But it was not like a bombing, where you can sit everyone down and start your triage process with "This is a red, this is a black, this is a green, this is a yellow," and that sort of thing.

Because of our location, all of the patients who came to us were primarily brought by EMS. Other hospitals in the area did a terrific job. Many of their patients were self-triaged, just as we saw in the sarin gas attacks in Tokyo, where more than 4000 people self-triaged.

That's something that needs to be discussed, because that is the most difficult thing to plan for. People were being transported by taxis, police cars, and private cars. The one gentleman who made national news essentially stole a utility vehicle and transported people to the hospital. You cannot account for that ahead of time.

With EMS, you have radio traffic and some idea of what is coming in. The immediate flow of those patients into the hospitals, particularly into our trauma center, was just tremendous. That night, my trauma center, which usually has 11 people in it (with maybe a couple in the hallway on a busy day), had more than 50 people when we walked in.

Theoretically, those patients had been triaged before they got there, but we were still getting patients who could have been well served by just going to an emergency department, because they did not have limb-threatening or life-threatening injuries. There was a tremendous amount of shrapnel injuries from the projectiles hitting the asphalt. A lot of lower-extremity injuries were caused by shrapnel, parts of the rounds that were being fired, and also parts of the asphalt shooting up when struck by the projectiles.

Meeting the Need for Blood

Dr Glatter: This was an incredible response, and the coordination of your medical center is certainly to be lauded for making it happen on a moment's notice. How did you coordinate efforts with your blood bank, especially for massive transfusions? How was the blood bank's role in this process set up? Were they ready?

Dr Carrison: It was quite efficient. We have what is called a massive transfusion protocol. Three patients can be in the operating room and all be part of the rapid transfusion protocol. It is essentially a mass transfusion. The blood bank has policies and procedures set up for that. You can go with O-negative for females and O-positive for males as a rapid transfusion. But the blood bank is set up to get patients at least typed and cross-matched in a very efficient, rapid manner so that we do not use up the O-negative and O-positive blood. Then we have it available for the people we have to use it in.

We had no problems with blood initially. We are a Level 1 trauma center and we stock a tremendous amount of blood. We have been in a position to be able to give blood to other hospitals. We did not have a shortage at the time of the shooting. That being said, multiple hospitals in our valley were all going through the same thing with whatever protocols they had, so that by the time that initial wave of patients came through, there began to be a need for blood in the community.

As you probably saw on national television, the outpouring of this community was extraordinary. The lines of people waiting to give blood were completely around a full-sized block in two different locations. This community really came together for this tragedy.

Dr Glatter: That is what was so good to see—that the public realized the need and responded.

All Hands on Deck

Dr Glatter: In terms of your procedure, how did you clear the emergency department of existing patients? This happened on a moment’s notice, probably on a busy night at your hospital. And then I want to explore the process of damage control laparotomy and the process of how your trauma surgeons quickly looked at these patients, assessed them, and got to work.

Dr Carrison: Some of the trauma surgeons had been notified and were there by the time I got there, and I got there very rapidly after being notified. A lot of people were already on duty that night. We have a trauma fellowship and an acute care surgery fellowship. All of the trauma and acute care surgery fellows were in the hospital along with the trauma team.

The emergency medicine residents were in the emergency department. All of those residents immediately came to the trauma unit. We have no fewer than two attending physicians in the emergency department at any given time. The shift changes at 10 PM, so at that particular time of night, many emergency physicians were coming and going. Four of those physicians came to the trauma unit immediately along with the residents, and we still were able to cover the emergency department.

Other emergency physicians had heard about the shooting in various ways. A lot of our friends and neighbors were at this concert; it was that kind of concert. A lot of firefighters, EMS workers, police officers, and nurses attended the concert, so the word got out very quickly, and physicians—without even being called—immediately came in.

Now what do you do? Extremity wounds need to go to the emergency department. Our emergency department is full at all times. We are very busy and the emergency department was full that night, so then the question was, what do we do with the patients? We opened up the post-anesthesia care unit (PACU). We essentially opened up everything. The nine patients who were being treated in the trauma unit were immediately moved to the post-anesthesia area within the trauma center as the gunshot victims began to arrive. Only one of those nine patients was severely injured, with a fractured cervical spine; the others had minor bumps and bruises or forearm fracture.

Where do you put someone who has been shot in the head and who you know is going to die? We have to take that patient out of the bed because we need to have that trauma resuscitation bed available for someone who has a chance to live.

Injuries and Tourniquets

Dr Glatter: Can you give us a general breakdown of the types of injuries you saw? You are describing extremity injuries, fractures, and maybe some trampling injuries, but could you break down overall what came in and what you were able to treat?

Dr Carrison: Most of the critical injuries were either abdominal or chest injuries. As I mentioned, when I came in, three people were having chest tubes inserted. Several others already had chest tubes in place. Quite frankly, those who had a tourniquet were not going to bleed to death, so we moved to the next patient until we could determine who needed surgery.

We had a lot of abdominal injuries that were caused by direct blows or shrapnel. Dr Fildes was going through with the trauma fellows to identify who they were going to take to the operating room to open up, stop the bleeding, pack the wound, get them over to the trauma unit, and get the next patient on the table.

Dr Glatter: With respect to the tourniquets, were these improvised or military-grade tourniquets? Were they placed by EMS? How did this all break down?

Dr Carrison: We have done a really good job with our EMS and police officers in this community with respect to tourniquets. We started this some years ago. In my role as medical director of the Las Vegas Metropolitan Police Department, after a long process over a couple of years, we have arranged for every police officer to carry a tourniquet. If you have a gun, you have a tourniquet. Period.

In a number of cases, police officers have placed tourniquets in the field and it has been life- or limb-saving. One police officer was in a shootout, and immediately afterwards he went over and put a tourniquet on the person he had just had a gun battle with and essentially saved that person's life. The police officer at the scene had a tourniquet. All of the EMS workers have tourniquets in all of our transporting units.

It's been a tremendous advantage to have these in our community. If we go back to the Boston Marathon bombing and even the Pulse nightclub shooting in Orlando, that just solidified for EMS the importance of having tourniquets available. The night of the Las Vegas shooting, I would say that we had more real tourniquets, such as a combat application tourniquet (Cat 3), than we had improvised tourniquets. Were there improvised tourniquets? Yes. One person had a chain as a tourniquet. It was a small chain and it worked.

But there were police officers at the scene. There was an undercover narcotics officer. At all of our events, there is an undercover officer looking for the people selling drugs. He told me that he put on multiple tourniquets, that he was just grabbing tourniquets from the responders and from the police officers and putting them on patients because he had more of a medical background than some of the other folks. But they are all trained in how to use them.

The Psychological Toll

Practice and Preparation

Dr Glatter: You have hit upon an important point, because the basics remain the basics, and being able to do what is asked of you in such a setting is so important. What else do you want providers to take away from the events that unfolded that day? What are the key take-away points?

Dr Carrison: I've thought about this quite a lot. Self-triage is something that has to be addressed. It's extremely important. When I was chairman of Homeland Security for the State of Nevada, I was invited to travel to Israel to see how they do it. They put their most senior physician in the parking lot, and when they have a bombing, all of the patients are brought to the parking lot. That physician decides who goes in and what is done. Hospitals should be aware of the self-triage issue.

The other extremely important factor is practicing, and we practice, practice, practice. We have two major events a year.

In Las Vegas, as the casinos get old, they are torn down, blown up, and replaced. Before the casinos are demolished, the EMS and police department are allowed to go in and use those for drills. We have set up multiple scenarios over many years at different times. The Metropolitan Police Department goes in and has an exercise.

We have a thing called MACTAC (Multiple-Assault Counter-Terrorism Action Capability), which is quite important. We have firemen with tactical gear who go into the hot zone where an active shooter is. But they will also go into the warm zone. If we still have an active shooter in an area, but we know where that hot area is and there are victims in the warm zone, these folks go in and start extracting patients. We have had a lot of practice with that.

We have practiced in shopping centers and malls. I believe that that has made a huge difference. In the hospital, we have our disaster drills. You have been an emergency physician and a general surgeon, so you know what it's like: "Oh, no. Not another disaster drill. I'm trying to see patients and you're interfering with what I'm doing." Ladies and gentlemen, practice! It makes a difference. You will not get any pushback once something like this happens and everyone realizes the difference it made.

Dr Glatter: Training with simulation is such a big thing in emergency medicine now, and at a lot of conferences, teams compete against one another. This is obviously an offshoot of practicing—simulating the scenarios that we have to be prepared for. That is imperative.

Thank you for your time, Dr Carrison. It has been an honor to speak with you and to hear you describe what happened that day. I look forward to future conversations.

Dr Carrison: Thank you. I cannot tell you how much I appreciate the turnout of the emergency physicians on the frontline, along with our trauma surgeons and general surgeons who came in to all of the hospitals and provided that care. Not enough can be said about how that worked out and the participation of those folks in this tragedy.

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