Tuesday, November 14, 2017

How the Las Vegas shooting victims were saved

There's a fascinating article at Emergency Physicians Monthly about the emergency medical response to the Las Vegas shooting, and how so many victims were saved.  Here's a brief excerpt.

The first thing I did was tell the secretaries I needed every operating room open. I needed every scrub tech, every nurse, every perfusionist, every anesthesiologist, every surgeon—they all need to get here right away. They immediately began making phone calls. I told the trauma nurses that I needed all the treatment areas completely clear. Nurses were instructed to keep an eye out for crashing patients and make sure that all patients had bilateral 14-18 gauge IVs ready for the moment that they would decompensate.

We also initiated our hospital’s “code triage,” in which staff from upstairs would come down to help by bringing down gurneys and spare manpower. We took all of our empty ED beds and wheelchairs out into the ambulance bay. Anybody who could push a patient, from environmental services to EKG techs to CNAs, came out to the ambulance bay. I said to the staff, “I’ll call it out. I’ll tell you guys where to go, and you guys bring these people in.”

. . .

My plan was that we were going to take care of all of our major resuscitations (red tags) in Station 1. Station 2 was going to have our orange tags, patients with threatening gunshots in critical areas, but had not crashed yet. This is not in the textbook. In my mind, these orange tags were expected to crump near the end of the Golden Hour. Station 4 was going to have the yellow tags, patients that had torso/neck or proximal extremity shots that looked very stable and were expected to survive past the Golden Hour. Rapid Track and Med room would hold the green tags, staffed by two PAs, were just going to end up sitting on the floor or stuffed into an area with people watching over and making sure that none of them crumped. The ER doctors would resuscitate and send the resuscitated patients to Trauma 3 or 4 for the trauma surgeon to prioritize to the OR.

In preplanning, I knew that as we started to get some of these red tags stabilized, the anesthesiologists and surgeons would start arriving and we could open up more ORs. That’s the first major choke point. I can resuscitate four or five people, but that operating room was going to be the key to stopping the bleeding and saving lives. In a high volume penetrating MCI like this, you really need flow. You need people to get stabilized and into the operating room, not sitting around perseverating about what test to order next. Getting those ORs staffed and opened was my biggest priority. With potentially hundreds of incoming patients, it was going to be a matter of eyeballing patients or feeling for carotid pulses because we didn’t have enough monitors. Everything was 100% clinical judgment. You’re looking at all these patients, and you’re just waiting for them to declare themselves—and then you start to work on them.

I was out in the ambulance bay when the first police cars arrived with patients. There were three to four people inside each cruiser. Two people on the floorboards and two in the back seat, and they were in bad shape. These patients were “scoop and run”—minimal to no prior medical care but brought in a timely manner. They had thready pulses, so they went directly to Station 1, our red tag area. By textbook standards, some of these first arrivals should have been black tags, but I sent them to the red tag area anyway. I didn’t black tag a single one. We took everybody that came in—I pulled at least 10 people from cars that I knew were dead—and sent them straight back to Station 1 so that another doc could see them. If the two of us ended up thinking that this person was dead, then I knew that it was a legitimate black tag.

There's much more at the link.  Highly recommended reading.

I'm very glad for the victims that such high-quality care was available within minutes of their getting shot.  It couldn't save all of them, but I daresay a number are still alive today who wouldn't be without access to that level of attention and the rapid, professional way in which the incoming patients were triaged and handled.

Kudos to all the emergency responders concerned.



Retired Spook said...

Thanks for linking this! I'm a part-time EMT, and I have a hard time black-tagging a patient. If I red-tag them, and someone else (above me on the chain of command) down-checks them, then it's out of my hands. Call me gutless, but even if they are around the bend, I'm going to give them a fighting chance.

Aesop said...

Strong work by all concerned. That's how the game is played.

Divemedic said...

Many health professionals like the author, and like the EMT above, have problems declaring those who are dead to actually be dead. In triage, the point is to do the most good for the largest number of people. Sometimes that means cutting your losses and allowing a person who could have been saved under some circumstances to die.

Why? Numbers. It has been shown time and again that using a large number of resources to save one person means that two or three others will experience a worse outcome because too many resources were tied up on the other, less viable patient.

Triage is a very difficult thing, and it requires a certain mindset. You can't save everyone, so you save as many as you can.

Suz said...

Because you can't save everyone, so you work hard to save as many as you can by having a double check to make sure someone that could be saved wasn't black tagged by error. There have been folks who were black tagged, sent to the morgue and revived down there. I have personally seen it happen twice. Both times it was during an MCI, multiple car accidents, not gun fire incidents, but still pretty freaky for everyone involved.

Thanks for the link, for those of us who could conceive of having to be part of an MCI, this is very good information. The biggest problem is to get organized and keep organized, as that way the available resources are best optimized. Training and practice drills are useful, but an after action report from a real event is the most helpful.

Anonymous said...

Perfectly illustrates the difference between a doer and a manager.
- Charlie

Quartermaster said...

There are few countries who could deal with situations such as Las Vegas. I hope some have learned from what they have seen here, but they haven't been tested to the extent we have. France is the closest in Europe. But, if Princess Diana had been injured in the US, she would probably still be alive. The French had nothing like the emergency medical system we had then, and doubt they've come close yet.

The only country I can think of that equals us is Israel.