As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save.

“The Las Vegas University Medical Center looked like a war zone when trauma surgeon Jay Coates arrived just after 11 p.m. PT to care for the scores of wounded victims of the largest mass shooting in U.S. history.
“We started divvying them up, taking them to the operating room and doing what’s called ‘damage control surgery,’ where you’re not definitively repairing everything,” Coates, a medical profession of two decades, recalled. “You are just stopping the dying.”
That’s exactly what medical staff did. John Fildes, trauma center medical director, said UMC received more than 45 trauma patients Sunday night. Although some died before they reached the hospital, “the patients who arrived alive have all survived,” Fildes said.”
As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save….” (A)

University Medical Center is the only level-one trauma center in Nevada and one of only a few free-standing trauma units in the nation. That means it is fully staffed with surgeons and trauma nurses day and night to handle injuries and mass casualties, from vehicle crashes that bring in 10 patients at a time to a 2015 episode in which a woman drove onto the Las Vegas Strip, sending 17 patients to the medical center. Last week, there had been 15 trauma cases in one night.
But even with 11 trauma bays, three operating rooms, a CT scanner, a trauma intensive care unit and a pediatric intensive care unit all under one roof, the trauma center had never faced a torrent like this. For two or three hours, the patients came nonstop. The radio at the clerk’s desk blared with transmissions from paramedics. With the frequency overburdened, other paramedics resorted to calling in patients by phone. Many patients simply arrived in cars or, in one instance, several in the back of a truck.
To an outsider, “it would look like a disaster zone, a chaotic scene, very chaotic,” Ms. Mullan said. “If a nonmedical person were to be sitting there watching this, they would think nothing was being accomplished.”
But in fact much was being done. It had been a busy day, which meant some of the day shift was still present and stayed to work alongside the night shift. Pagers went off with a be-beep be-beep each time a severe trauma case was identified. Patients, most of them with gunshot wounds, were doubled up two stretchers to a trauma bay. At one point, beepers screeched as five trauma cases were clocked in at the same time. “We couldn’t hear each other talk, it was that crazy,” Ms. Mullan said…
“The patients who arrived alive have all survived,” Fildes said. (B)

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Dr. Jay Coates, a trauma surgeon at UNLV School of Medicine, said it was a night of non-stop surgeries.
“It was a little bit of controlled chaos. We’ve had mass casualties come through this trauma center but nothing of this magnitude,” he told Las Vegas station KTTV.
To save as many lives as possible during a tragic event like this, first responders and emergency room doctors must act quickly and make difficult decisions.
“It’s an ethical and moral dilemma that all physicians and health care providers go through because we try to save everyone, but unfortunately that’s not the case,” Dr. Robert Glatter, an emergency room doctor at Lenox Hill Hospital in New York, told CBS “This Morning.”
On the scene, he explains, there is a tagging system that prioritizes wounded patients based on who needs to be seen first.
People who have life-threatening injuries and need immediate attention, such as those with a collapsed lung, are tagged red and are brought in for treatment right away.
Those with severe, but less life-threatening injuries are ranked a tier lower with a yellow tag.
Unfortunately, doctors must also decide when a patient cannot be saved.
“Say there’s a person with a head injury who’s barely breathing. We try to open their airways but if there’s not much chance of saving them we have to move on,” Glatter said. (C)

“…. 100 extra doctors were called in to work Sunday night, along with another 100 people including nurses, technicians, and support staff.
“We have a relatively large emergency department. We were able to triage within our emergency department,” he says. “We used the hallway space to see patients, so it’s a lot fuller than it normally would be and it feels a lot more chaotic.”
At University Medical Center, patients were being triaged in the ambulance bays, Cohen told CNN. The hospital has an 11-bay trauma center, with three operating bays, as well as regular surgery suites, which they likely used in this situation.
“We can get patients from an ambulance into the OR [operating room] in one minute,” Cohen says.
As reports of the gunfire emerged shortly after 10:30 p.m. PST Sunday, the city’s trauma centers began calling in extra personnel.
People working in trauma centers train for such emergencies and would know they’re likely to have to report to work as soon as they heard about the shooting on the news or social media. But still, the scale of this incident may have been surprising. “When you think of more than one hundred shooting victims, ballistic injuries, that is an absolute giant number,” says Bruno Petinaux, the chief medical officer and co-chair of emergency management at the George Washington University Hospital in Washington, D.C.
“When you’re talking about a mass casualty incident like this, this is where you call in the backup, and you call in the backup to the backup, and you may have to message the rest of your medical staff that you may need their help,” he says. (D)

The Southern Nevada Health District, which includes Las Vegas and Clark County, has a 65-page trauma system plan that lays out how emergency responders and hospitals should communicate, work together, and divide responsibilities in a mass casualty situation.
Most major cities have such a plan, says Ian Weston, executive director of the American Trauma Society, which advocates for victims of trauma and the trauma care system.
“Hospitals are prepared to build capacity,” he says. “They’ll get the most critical patients into surgery quickly, they’ll stabilize more in the ER and some will even be treated in the lobby.”
He says hospitals determine exactly how many people they can care for in such a situation, even taking into account how many people they can fit into hallways, at least temporarily.
Hospitals across the Las Vegas area were inundated Sunday evening when hundreds of people injured in the mass shooting at a country music festival on the Strip arrived at their doors by ambulances and private car.
And hundreds of doctors, nurses, and support personnel were called into work to help handle the patients that were lined up in ambulance bays and hallways, officials say…
The Southern Nevada Health District, which includes Las Vegas and Clark County, has a 65-page trauma system plan that lays out how emergency responders and hospitals should communicate, work together, and divide responsibilities in a mass casualty situation. (E)

“All hospitals in North Carolina have a common agreement for mutual aid. We also have, through our disaster planning, some teams which are available that can be shared between areas,” she said.
Bisset said WakeMed regularly plans emergency response training and drills to practice for a major disaster of any kind, including infectious disease outbreaks, like Ebola, or a chemical attack. However, mass shootings with military-style weapons pose a special set of problems for critical care responders.
“We have the good fortune that a number of our trauma surgeons have served in the military and so they are very well trained with war wounds, because this is what we’re really talking about when you have many of these weapons,” she said.
Bisset said that, on any given day, WakeMed could already be at capacity. In such an event, plans are in place for moving non-critical care patients to other facilities. (F)

In moments like these, doctors, nurses, and technicians lean on their training for most of the required actions. But in every calamitous circumstance—and this is a calamitous medical emergency—there are intricacies that could never have been predicted. And that’s where improvisation comes in. Things that would never be done under normal circumstances can end up saving lives—police cars broke protocol after the 2013 Boston Marathon bombing and put bleeding victims into the back seats of their units and drove them to the hospital themselves, rather than waiting for ambulances. This move, which had also occurred after the Aurora, Colorado, shooting, likely lowered the death toll.
After each catastrophe, leaders such as my colleague Eric Goralnick, medical director for emergency preparedness at Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School and the T.H. Chan School of Public Health, share experiences, both domestically and internationally. Paris learns something from Boston: Tourniquets, long out of fashion, had turned out to be helpful in the field. In turn, Boston had learned something from Aurora: Mass casualty drills in Boston had never accounted for such a large number of victims until officials realized in the wake of Aurora that they needed to prepare for circumstances that had previously seemed too remote to train for.
Emergency departments like the ones that treated victims from Las Vegas are forced to develop their protocols based more on anecdote than evidence.
Man-made mass casualty incidents seem increasingly common. But are medical teams actually learning enough from them? Are we really getting any better? (G)

(A) LAS VEGAS STRIP SHOOTING, AT LEAST 50 DEAD, by Brett Kellman, https://www.usatoday.com/story/news/nation-now/2017/10/02/las-vegas-shooting-hospital-you-just-stopping-dying/725466001/
(B) Controlled Chaos at Las Vegas Hospital Trauma Center After Attack, by SHERI FINK, www.nytimes.com/2017/10/02/us/vegas-shooting-hospital.html?_r=0
(C) ‘It’s not a matter of if, it’s when’ How Las Vegas hospitals prepared for a massacre, by Dan Mangan, https://www.cnbc.com/amp/2017/10/02/las-vegas-hospitals-dealing-with-hundreds-of-mass-shooting-victims.html
(D) Las Vegas Hospitals Call For Backup To Handle Hundreds Of Shooting Victims, by Alison Kodjak, http://www.npr.org/sections/health-shots/2017/10/02/555044797/las-vegas-hospitals-call-for-back-up-to-handle-hundreds-of-shooting-victims
(E) Las Vegas Shooting Update: At Least 59 People Are Dead After Gunman Attacks Concert, by Bill Chappell and Doreen McCallister, http://www.npr.org/sections/thetwo-way/2017/10/02/554976369/section-of-las-vegas-strip-is-closed-after-music-festival-shooting
(F) Response to Las Vegas shooting offers lesson to local trauma centers, by Allen Mask, http://www.wral.com/response-to-las-vegas-shooting-offers-lesson-to-local-trauma-centers/16989905/
(G) Hospitals Aren’t Fully Prepared for Mass Shootings, and It’s the Gun Lobby’s Fault, Jeremy Samuel Faust, http://www.slate.com/authors.jeremy_samuel_faust.html

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