Editor’s note: The following article is based on information shared during a Panel Session titled Lessons Learned from Las Vegas and Other Mass Casualty Events at the American College of Surgeons Clinical Congress 2017 in San Diego, CA.
On the evening of October 1, 2017, more than 22,000 people were enjoying a concert at the Route 91 Harvest Festival on the Las Vegas Strip, NV. A lone shooter fired more than 1,000 rounds of ammunition into the crowd from his 32nd-floor window at the Mandalay Bay Hotel and Casino (see Figure 1), killing 58 and injuring more than 500 people, marking this mass casualty shooting as the deadliest in modern U.S. history. This massive attack was followed by the shooter killing himself as law enforcement officers were attempting to enter his hotel room. The injured were transported and self-transported to Las Vegas-area trauma centers and nontrauma-center hospitals, while other victims self-transported to hospitals outside the Las Vegas area. (Figure 2 depicts the site of the mass shooting, as well as the three Las Vegas trauma centers and other area hospitals.)
This article looks at the Las Vegas trauma system response. It also describes the effects of trauma and readiness programs provided by the American College of Surgeons (ACS) and its collaborators, and explores lessons learned and opportunities for improvement in trauma system disaster plans going forward. This mass shooting event is typically referred to as “1 October,” particularly by regional media outlets, and the authors will also use this term to refer to the event.
Figure 1. Mandalay Bay Hotel and Casino and Route 91 Harvest Festival
Figure 2. Las Vegas map with trauma centers and nontrauma-center hospitals
State trauma system response
Unlike other mass casualty events—where most of the wounded have been treated at a small number of health care facilities within a trauma system—the victims of the Las Vegas shooting were treated at all trauma-center and nontrauma-center hospitals within the Southern Nevada Trauma System (SNTS). In the aftermath of this incident, the SNTS provided care to more than 500 injured patients.
The SNTS is overseen by the Regional Trauma Advisory Board and consists of prehospital provider organizations, including six public fire departments and three private emergency medical services (EMS) providers, three EMS air medical providers, three ACS-verified trauma centers, and 14 nontrauma-center hospitals with emergency department (ED) services. The SNTS facilities collaborate on a daily basis to formulate, practice, and execute the region’s disaster plan, which is credited with saving lives on 1 October.
The SNTS operates in alignment with core principles set forth by the ACS Committee on Trauma (COT) Trauma Systems Evaluation and Planning Committee, namely that a strong trauma system that functions well on a daily basis is the best preparation for mass casualty events, and that the best way to care for many injured patients is to use the same system built to care for them one at a time. The key difference in an event such as 1 October is a critical paradigm shift, one that is necessary in the event of a mass casualty situation: instead of providing maximal resources for a single injured patient, the system must work to preserve high-level resources for those who can be saved and ensure the provision of minimum essential care for others. This paradigm shift requires trauma system communication to ensure triage and control of patient distribution so that resources and time are available for necessary secondary transfers as patient conditions change.
Level I trauma center response
Deborah A. Kuhls, MD, FACS, FCCM, director of the University Medical Center (UMC) of Southern Nevada, Las Vegas, trauma intensive care unit and a co-author of this article, had finished a busy trauma day on-call but was still in-house, along with on-call trauma surgeon Syed Saquib, MD, and both their resident teams, when the report came in of an active shooter on the strip. They were informed a few minutes after 10:00 pm that more than 50–100 victims were on their way to UMC, which houses Nevada’s only ACS-verified Level I adult trauma center and Level II pediatric trauma center. UMC, approximately six miles from the scene, quickly activated its disaster plan, and the emergency physician on duty at the trauma center set up a triage area outside the trauma center.
UMC’s trauma center is a “hospital within a hospital” design, so the 11-bed trauma resuscitation area and the main emergency center with 59 beds were both prepared for a large influx of injured patients. Minutes after initial notification, more than 40 patients arrived and were triaged such that the most injured patients were assessed in the trauma resuscitation area for life-threatening injuries. UMC received several false messages that additional active shooters were on the strip, as well as that an active shooter was on hospital premises. Based, in part, on this information, which could potentially result in many more injured patients, two additional areas of the hospital (the main hospital post-anesthesia care unit and the same-day surgery area) were transformed into 46 additional in-house emergency room beds where less-injured patients were triaged. These areas were staffed with multidisciplinary teams, including surgeons, anesthesiologists, nurses, and respiratory therapists. The three trauma center operating rooms (ORs) and multiple main ORs were opened and staffed, with up to eight rooms running concurrently.
Trauma and specialty surgeons, as well as residents and acute care surgery fellows, operated throughout the night and into the next day and beyond, employing damage control techniques when appropriate. A total of 104 patients were assessed; three died, and more than a dozen were admitted to the intensive care unit (ICU). Everyone with survivable injuries lived.
UMC and Nellis Air Force Base have a cooperative Sustained Medical and Readiness Trained (SMART) program, which activated multiple surgeons, residents, nonsurgeon physicians, and other health care professionals to create additional surge capacity. At time zero, UMC had two trauma surgeons, an anesthesiologist, and a dozen residents in-house, which increased to more than a dozen civilian and military surgeons; dozens of nonsurgeon physicians, including anesthesiologists; and more than 70 residents and acute care surgery fellows.
Level II trauma center response
Sunrise Hospital and Medical Center, Las Vegas’ ACS-verified Level II trauma center and at 4.8 miles the closest trauma center to the mass casualty site, received 212 injured patients, of which 64 were admitted, including 31 to an ICU. All six trauma surgeons were mobilized immediately when the first notification of mass casualty was confirmed. A total of 50 crash carts were deployed within one hour. Initial assessment occurred in the ED, triaging patients to trauma bay areas and operating room pods based upon the type of injury and surgery required.
At Sunrise Hospital and Medical Center, a total of 16 patients died; 10 were dead on arrival, four were unsalvageable and expired in the ED, one expired intraoperatively, and one was a withdrawal of care due to brain death. A total of 58 operations were performed at this facility in the first 24 hours, more than 100 operations were performed thereafter in total, and more than 500 units of blood products were transfused. More than 100 physicians, including residents, and 200 nurses cared for the injured at Sunrise Hospital. A trauma surgeon at Sunrise Hospital and a co-author of this article, Matthew Johnson, MD, described the response at the institution as “organized chaos” and added that “everyone focused on taking care of the patients and doing their job, and the whole hospital came together to care for the patients in a calm manner.”
Level III trauma center response
St. Rose Dominican Hospital, Las Vegas’ ACS-verified Level III trauma center, has a detailed disaster plan and training in place to meet the challenges of mass casualty incidents like the 1 October shootings. Within minutes of the incident, St. Rose Dominican Hospital, located 8.2 miles from Mandalay Bay Hotel and Casino, had set up an incident command in the ED, and a SWAT (Special Weapons and Tactics) team arrived to enhance security and to place the hospital on lockdown. Surgeons and other physicians, nurses, and administrators responded to the internal alert system and cared for 37 victims with serious injuries who required operations in multiple body cavities, including chest and abdomen. No victims of the mass casualty event died at St. Rose Dominican Hospital.
The Advanced Trauma Life Support® (ATLS®) training that is mandatory for all emergency medicine and surgeon providers at St. Rose was an essential element of the hospital’s successful response to this event, leading health care professionals to assess patients in a standardized, prioritized manner to ensure appropriate triage and management.
Lessons learned and a path forward
The response to the 1 October Las Vegas shooting revealed the value of several ACS programs and pointed to new directions for these initiatives in the future. Examples are summarized as follows:
Response to active shooter in the hospital
While the Las Vegas mass shooting represented the kind of large-scale active shooter incident that law enforcement, EMS, and other responders include in their disaster plans, an active shooter within a hospital or other health care facility requires a very different response. As noted earlier, during the 1 October mass casualty event, there were false reports of an active shooter in more than one Las Vegas hospital. According to co-author Alexander Eastman, MD, MPH, FACS, Medical Director and chief, Rees-Jones Trauma Center at Parkland and a Dallas Police Department Lieutenant, more than 150 hospital shootings have occurred since 2000, and the standard advice of “run, hide, or fight” doesn’t necessarily apply when health care providers are with patients. This is a topic that requires much more research to keep both health care providers and patients safe when there is an active shooter in a hospital or other health care facility.
Stop the Bleed®
The chief tenet of the ACS-led Hartford Consensus, led by co-author and ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, is that no one should die from uncontrolled compressible bleeding. A study conducted by the Hartford Consensus and published in the Journal of the American College of Surgeons revealed that 92 percent of the respondents stated they would like to be able to assist a stranger bleeding as a result of trauma. This response led to a collaboration between the ACS and several national groups to offer Stop the Bleed training to the public in an effort to empower immediate responders to react properly to any incident involving significant blood loss. A key element of the program is the distribution of Stop the Bleed kits in public places and training members of the public in proper use of the materials in the kits, including gauze for wound packing and tourniquets.
While the final October 1, 2017, Las Vegas survivor injury data were still being compiled at press time, multiple patients arrived at the trauma centers mentioned in this article with tourniquets. Coroner data has been released, citing homicide relating to gunshot wounds as the cause of death in all 58 who died. A total of 18 victims died from at least one gunshot wound to the head, 21 from at least one gunshot wound to the chest, 15 from at least one gunshot wound to the back, three from a gunshot wound to the neck, and one from a gunshot wound to a lower extremity. Since the Las Vegas shootings, the demand for Stop the Bleed courses in Las Vegas has more than quadrupled, underscoring the public desire to help save lives.
Military-civilian trauma center integration
The ACS COT has developed a strategy to reduce death and disability from firearm injury, which is aimed at preventing firearm injury from occurring, turning bystanders into immediate responders through Stop the Bleed training, advocating for and developing excellent EMS care, continuing to improve definitive trauma center care, and advocating for trauma systems as the framework for disaster and mass casualty preparation and response. The Las Vegas mass shooting demonstrated that trauma systems and military-civilian trauma center integration, exemplified by the UMC and Nellis Air Force Base SMART program, works to save lives during mass casualty events.
Because the 1 October event is the deadliest civilian mass shooting in recent U.S. history, collaboration with our military colleagues may enhance our understanding of the SNTS response and opportunities for improvement in the future.
Disaster plan preparation
While complete after-action analysis of the SNTS continues, surgeons at all three trauma centers assert that both trauma system and hospital disaster plan preparation and practice were key in successfully responding to the Las Vegas mass casualty event. The SNTS’ early establishment of an incident command center in each hospital, as well as mobilization of human and supply resources, were crucial to being able to care for the volume of injured patients. Human resources are vital and surge capacity was enhanced by residents, fellows, active duty U.S. Air Force surgeons, nonsurgeon physicians, and other health care professionals, as well as by civilian physicians and other health care personnel from nontrauma centers. The collective experience of the trauma centers in Las Vegas underscores the value of trauma system and hospital disaster preparedness.
The value of several ACS COT programs—including ATLS, Prehospital Trauma Life Support, Disaster Management and Emergency Preparedness, and Stop the Bleed—is significant with respect to trauma system development, disaster preparedness, and treatment to decrease death and morbidity in mass casualty incidents.
It is always important to remember that the recovery phase of a mass casualty incident begins immediately and may continue for an indeterminate amount of time, requiring significant psychological and psychiatric support for those individuals who suffered physical and emotional injury as a result of the mass casualty event.
As horrific as 1 October was, the medical response to this event resulted in decreased death and suffering for its victims and is part of the reason the motto “Vegas Strong” emerged and is now part of the city’s identity.
The authors would like to thank the ACS Clinical Congress Program Committee for making the Panel Session Lessons Learned from Las Vegas and Other Mass Casualty Events at Clinical Congress 2017 in San Diego, CA, possible.
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