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Inside the Las Vegas crisis: Surgeons answered the call

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A resident’s experience

 

I was at home and in bed with a book when my phone went off at 10:22 p.m. on that Sunday. It was a text message from one of my fellow residents who was on call at Sunrise: She wrote: “Mass casualty incident. Shooting on the Strip. You have to come now.”  


Dylan Davey, MD, PhD, General Surgery Resident, PGY-4, Sunrise Hospital & Medical Center.
Dr. Dylan Davey
I threw on on scrubs and drove across town as fast as I could. The back side of the hospital was a mob of ambulances, police cars, and civilian vehicles. I followed a pickup truck with numerous victims in the back seat.


There were multiple blood trails tracking from various parts of the ambulance bay into the ED. Medics were walking from bedside to bedside putting in lines. Two anesthesia attendings were frantically intubating patients. Two nurses were performing chest compressions.


I picked the nearest bed and started assessing patients. I placed 2 endotracheal tubes and black tagged 4 more patients within minutes of my arrival.


In the initial moments in the ER and in the OR, I focused on caring for the patient and blocked out any other thoughts or emotions. There was no time and no room for my horror or my tears.
As I went bedside to bedside in the ER, I was practically chanting in my head “airway, breathing, circulation, vital signs, other injuries.”


In the OR, I was working on controlling intra-abdominal bleeding from multiple sources, and again, my training became something of a mantra in my head. “Pack, control bleeding, assess injuries, repair.”


We saw well over 200 patients from the Route 91 shooting and operated on 95 of them within the first 24 hours.

 

Dylan Davey, MD, PhD, General Surgery Resident, PGY-4, Sunrise Hospital & Medical Center.


 

AT THE ACS CLINICAL CONGRESS

 

– Long before the horrific night of Oct. 1, the three trauma centers in the Las Vegas region were ready for a mass casualty event. It was understood among hospital leaders that the city could be the scene of a disaster that would demand a coordinated response from the city’s health care centers.

Then came the deadliest mass shooting in modern American history, and the extensive preparation turned out to have been well worth the time and effort, according to four trauma surgeons who spoke about the medical response to the massacre during a session at the annual clinical congress of the American College of Surgeons.

Deborah A. Kuhls, MD, FACS, FCCM, medical director of the Trauma Intensive Care Unit at University Medical Center of Southern Nevada.
Dr. Deborah A. Kuhls
The key is “training, training, training,” said Deborah A. Kuhls, MD, FACS, FCCM, medical director of the trauma intensive care unit at University Medical Center of Southern Nevada. Or as her colleague John Fildes, MD, FACS, medical director of the trauma center, put it, “You plan your response, you practice your response, and you execute your response. Collaboration is what makes these things happen.”

The killing spree was unusual in a variety of ways, including the fact that it occurred at a site “that’s almost strategically surrounded by trauma centers,” Dr. Fildes said.

UMC is Nevada’s only level I trauma center, while Sunrise is a level II. St. Rose Dominican, in the neighboring city of Henderson is a level III. Only one other Nevada hospital, in Reno, is a verified trauma center.

While the trauma centers received hundreds of patients, “every hospital in the valley saw patients from this event,” Dr. Fildes said. “There were 22,000 people on scene, and when the shooting started, they extricated themselves and went to safety by one means or another. Some drove home to their neighborhood and sought care there. Some drove until they found an acute care facility, whether it was a trauma center or not. Others were transported by Uber or taxi. The drivers knew where the trauma centers were, and decided where to go based on how the patients looked.”

John Fildes, MD, FACS, medical director of University Medical Center of Southern Nevada.
Dr. John Fildes
Wounded patients also walked until they found emergency rooms, he said, and some patients didn’t seek care until they’d driven themselves home to adjacent states like Utah and California.

According to Dr. Fildes, Las Vegas–area hospitals kept in touch with each other by phone, and UMC accepted some transfers from other hospitals. “We were ready for transfers,” he said, “and we expected more than we got.”

The trauma centers faced a variety of challenges from confusion and false reports to overcrowding and a media onslaught.

Pictured are representatives of the #TraumaStrong team at Sunrise Hospital and Medical Center who rallied in the aftermath of the unprecedented mass casualty event, answering the "Code Triage." Courtesy of MountainView
Pictured are representatives of the #TraumaStrong team at Sunrise Hospital and Medical Center who rallied in the aftermath of the unprecedented mass casualty event.
Sunrise Hospital & Medical Center turned its endoscopy suite into a temporary morgue and sent patients with minor injuries to the pediatric space. At UMC, less critical patients were hustled to the hallway, a post–anesthesia care unit, and an ambulatory surgery unit. Over at St. Rose Dominican Hospital–Siena Campus, a community hospital that sees little penetrating trauma, doctors managed to treat dozens of patients with serious gunshot wounds.

“We knew there was a strong possibility this would happen where we live, so we practiced this,” said Sean Dort, MD, medical director of the hospital’s trauma center. “We have talked and walked through it.”

Indeed, all hospitals in the Las Vegas area take part in regional disaster drills twice a year, and UMC runs other drills during the year such as an active shooter drill, Dr. Fildes said in an interview.

Together, the three hospitals treated hundreds of patients. Three weeks later, a handful were still inpatients.

In the aftermath, Las Vegas trauma surgeons are focusing on missed opportunities and lessons learned.

Dr. Fildes said more attention needs to be paid to how to handle situations when tides of patients bring themselves to the emergency department. “The issue of self-delivery has to be reconsidered, restudied,” he said, and he suggested that it may be a good idea to equip taxis with bleeding control kits.

He said his hospital heard from a doctor who’d treated patients during the Pulse nightclub massacre in Orlando last year. “One of their lessons learned was to position all gurneys and wheelchairs near the intake triage area,” he said. “We did that, and it improved the movement of patients to areas of the hospital that were matched to the intensity of care that they required.”

At Sunrise, the flood of unidentified patients overwhelmed the hospital’s trauma patient alias system, and some names were repeated. “In the future, I think a better naming system should be employed,” said trauma surgeon Matthew S. Johnson, MD.

To that end, he said, the hospital has begun examining how hurricanes are named.

Staff of University Medical Center of Southern Nevada standing outside the hospital with a Vegas Strong banner. Courtesy of UMC
In terms of lessons, St. Rose Dominican Hospital’s Dr. Dort said it’s crucial to ignore the noise amid the crisis. “Almost everything we heard ended up not being true,” he said. “The only reality is what’s in front of you.”

And when it comes to planning, he said, there’s no room for excuses or resistance. “Everyone knew their role,” he said. “You can’t start figuring this out when it happens. You have to push people through it when they don’t want to do it, and they’re busy.”

Dr. Fildes said that the UMC staff were physically and emotionally exhausted by the ordeal, but proud of what they were able to do for these patients, and that pride carried them through the experience. “We had support from all over the country; people sent banners with hundreds of signatures. Something like 1,100 pizzas were sent to the UMC staff, and dozens and dozens of surgeons from all over the country offered to come help us.”
Dr. Fildes noted that he is not easily surprised given his daily work, but he was impressed by the generosity and courage of the patients in this crisis situation.
He concluded that, “This was all made possible because of planning, training, commitment by staff and ultimately, the bravery of the patients.”


Dr. Dort, Dr. Fildes, Dr. Kuhls, and Dr. Johnson had no relevant financial disclosures.

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