Trauma surgeons share lessons learned from the Las Vegas mass shooting tragedy at American College of Surgeons conference

Opening remarks by Lenworth M. Jacobs, Jr., MD, MPH, FACS, Chair of the Hartford Consensus, emphasized the critical role of first responders at the scene of an MCI or other major bleeding event, who can be trained to provide hemorrhage control, specifically through the Stop the Bleed^® campaign. A national survey regarding bleeding control showed that 98 percent of the public would like to be able to stop bleeding in a family member if the need arose, and 92 percent would like to be able to stop bleeding if they came upon a stranger in a car crash, Dr. Jacobs said. "These are unbelievable numbers…the public wants to be part of the solution. There are 250 million people that we want to train [in bleeding control techniques], and we need your help," he told surgeons in attendance who filled the room to capacity.

"Let's not fool ourselves. We live in the most violent industrialized country in the world," said Alexander L. Eastman, MD, MPH, FACS, of the University of Texas Southwestern Medical Center, Dallas, and deputy medical director of the Dallas Police Department, who outlined strategies for meeting the challenges of an active shooter event in a health care facility. According to Dr. Eastman, these are "rare but powerful events" with 154 hospital shootings between 2000 and 2011.   Dr. Eastman said MCI events at hospitals require an institution-wide response. "Even in hospitals, we have to depend on civilian responders—you will need all hands on deck," he said, referring to Dr. Jacobs' presentation and the goal of training the lay public in bleeding control techniques.

Dr. Eastman asked the surgical and trauma community to "establish a culture where it is okay not to be okay after these events," and to offer support for medical colleagues in the months following an MCI.

Describing the trauma system's role in MCIs, nationally recognized expert Robert J. Winchell, MD, FACS, from New York-Presbyterian Weill Cornell Medical Center, noted that "A strong trauma system that functions well on a daily basis is the best preparation for mass casualty events," and these systems exist in a "constant state of operational readiness…Trauma systems should be prioritized as part of readiness, and must be tightly integrated into disaster and MCI response."  He states, "The best way to care for many injured patients is to use the same system built to care for them one at a time."  Switching to an MCI model to meet the challenges of a multi-casualty event, the trauma system must do the following, according to Dr. Winchell: Rapidly and sequentially engage additional resources, optimize communication, ensure accurate triage and control patient distribution, provide trauma centers and other facilities time to prepare, and anticipate the need for secondary transfers.

John Fildes, MD, FACS, medical director of the University Medical Center (UMC) Southern Nevada, a Level I trauma center, described the structure of the Southern Nevada Trauma System (SNTS).  It consists of 17 hospitals with emergency departments capable of treating injured patients based on the extent of their injuries, and three trauma centers: University Medical Center (Level 1, Pediatric Level 2), Sunrise Hospital Medical Center (Level 2), and St. Rose Dominican Hospital (Level 3). All SNTS hospitals and trauma centers treated the Las Vegas mass shooting victims, which resulted in 546 people wounded and 58 deaths. According to Dr. Fildes, the SNTS was able to seamlessly respond to the MCI due to the system's coordinated injury response network, daily operations that optimize patient outcome, and the ability to readily adapt to manage an influx of injured patients resulting from an event such as this. 

With 80 percent of the population in Nevada living in Clarks County, which includes the Las Vegas metro area, Dr. Fildes emphasized that two actions helped Las Vegas respond to this crisis: preparation and collaboration. He urged all surgeons to plan and practice their response to an MCI at their institutions. 

Deborah A. Kuhls, MD, FACS, FCCM, UMC's medical director, trauma intensive care unit, was at UMC the night of the event when she heard someone shout "there is an active shooter on the strip."  She reported their first notification was that there were five to 10 patients enroute to their trauma center. But a second notification indicated that there were 50 to 100 or more patients.  That's when UMC activated its disaster plan. "There were more than 20 self-transports to trauma and to the main emergency department," she added. "We triaged outside [in the parking lot] of the trauma center." And she commended trauma chief Dr. John Fildes, for finding quick ways for staff to utilize every possible area of the hospital to quickly treat patients, such as turning the ambulatory surgery unit into another emergency room.

Dr. Kuhls said there were more than a dozen trauma surgeons working that night, as well specialty surgeons, nurses, and more than 70 medical residents and fellows. UMC started with two faculty in-house that night, and within 30 minutes four faculty and two fellows arrived; within one hour, five additional faculty and four fellows arrived; and within two hours of the event, eight additional faculty plus four fellows were at UMC. The facility had eight operating rooms running concurrently.

Dr. Kuhls said that overall UMC physicians and staff treated 104 patients; no one who arrived with a survivable injury at UMC died.

"In the first 24 hours, we saw 212 patients and performed 58 surgeries," said Matthew Johnson, MD, FACS, with the Sunrise Hospital and Medical Center, Las Vegas. Sunrise staff grouped pods of operating rooms together for treating specific types of cases. "More than 100 physicians and more than 200 nurses responded to assist for a total of 83 surgeries performed. Everyone did their jobs. As for the residents—we couldn't have gotten through this [incident] without them," Dr. Johnson said.

In terms of lessons learned, Dr. Johnson said, "preparation and practice…engaging in regular drills, and strong leadership from emergency room physicians and trauma surgeons" enhanced his facility's ability to respond to the MCI.

"We took this [MCI] personally, just like everyone else in Las Vegas did," said Sean D. Dort, MD, FACS, St. Rose Dominican Hospital, Henderson, Nev.  Dr. Dort said a "very detailed assignment of roles" helped his facility quickly and efficiently treat victims of the Vegas MCI, although even the most detailed disaster plan can't anticipate every variable as witnessed by the surgeon on call the night of the event—the physician's first on-call at St. Rose. (Dr. Dort and colleagues quickly came to the surgeon's aid.)

"You can't start figuring things out when this is happening," Dr. Dort concluded. "You have to train beforehand." He also said surgeons treating victims in the chaotic aftermath of an MCI should be wary of false news. "Don't believe everything you hear. We kept hearing reports about a second shooter…but the only reality is the patient right in front of you."

"Looking at the Southern Nevada Trauma System, you can see the benefits of an organized, well-functioning trauma system that is prepared for mass casualty incidents (MCI) and disasters.  It's palpable [that trauma systems and MCI preparation make a critical difference]," concluded Ronald M. Stewart, MD, FACS, Chair of the ACS Committee on Trauma, which sponsored the session, "Your leadership is critical to moving forward with a national trauma action plan," he said.  However, implementing a great trauma system also requires great trauma research, great data, and great education and training, he explained.  To emphasize his point, he held up a bleeding control kit, and asked attendees to become teachers and advocates of the ACS Stop the Bleed Course offered at the conference, and subsequently, to teach everyone in their communities to become lifesavers rather than bystanders. He emphasized to attendees that the time is now for us to to make organized, well-functioning trauma centers a reality in every region of the United States and across the globe.

About the American College of Surgeons Committee on Trauma (ACS COT)
The ACS COT was formed in 1922 and has put forth a continuous effort to improve care of injured patients in our society. Today trauma activities are administered through an 86-member committee overseeing a field force of more than 3,500 Fellows who are working to develop and implement meaningful programs for trauma care in local, regional, national, and international arenas. With programs such as its Bleeding Control Basic Course, the COT strives to improve the care of injured patients before, during, and after hospitalization.   In October 2017, the ACS COT developed a consensus-based national strategy aimed at reducing death and disability from firearm injury, which is built on a trauma system (public health) model.  It has been published online on the Bulletin of the American College of Surgeons website.

SOURCE American College of Surgeons