“Failing infrastructure, the increasing density of cities and the growing frequency of extreme weather events create public health risks on a massive scale. In Houston, improperly maintained Superfund sites ― that is, profoundly polluted hazardous-waste sites ― could not withstand the waters that rose as high as streetlights in some areas. Drainage systems failed. Poisonous chemicals and dangerous bacteria spread via floodwater through residential areas. In the wake of a flood, mold can bloom inside devastated structures, putting people at risk of allergies, asthma and other respiratory problems.
As with Houston, overdevelopment in Florida is making people more vulnerable to hurricanes and flooding, as precious swampland and marshland is encased in concrete and high-density residential zones are built in risky areas like barrier islands. Hurricane Irma, which made landfall in Florida on Sept. 10, knocked out power for between 60 and 80 percent of residents across the state, underlining the need for more diverse kinds of energy infrastructure.” (A)

“All hospital systems maintain emergency plans of action for a looming crisis such as Irma…
Hospitals have electrical generators in place if needed, are tied into their local government’s emergency operations response centers, and have preselected and specially trained administrators and medical staff at the ready, along with their relief teams. Non-critical surgeries and routine patient checkups are postponed, and clinics and physician practices closed…
Systems with multiple locations have specific plans for each “based on hazards,” such as proximity to the ocean or river, said Karen Ketchie, Baptist Health’s director of emergency management services. That’s how they were prepared to move patients when conditions at each site warranted it, she said…
“The hospital … was built to enable a defend-in-place strategy. This is due to the high acuity of our population of patients, and removing them from the building might be dangerous,” he said. (B)

“After an estimated 215 people died in hospitals and nursing homes in Louisiana following Hurricane Katrina in 2005, policy makers realized that the nation’s health care institutions were ill-prepared for disasters.
One of the rules they created after years of discussion looked especially prescient in light of the tragic deaths on Wednesday of eight nursing home residents in Florida’s post-hurricane heat. But the rule, regarding power supplies and temperature control, will not be enforced until November, and even then, some patient advocates are concerned that it does not go far enough…
The new federal rule will require that nursing homes have “alternate sources of energy to maintain temperatures to protect resident health and safety.” But the rule does not specifically require backup generators for air-conditioning systems — the nursing home in Florida, Rehabilitation Center at Hollywood Hills, did not have such a generator — and now some are questioning whether the rule should.” (C)

Escalating a legal and regulatory fight, Gov. Rick Scott’s administration issued an emergency suspension of the license of a Broward County nursing home Wednesday after the deaths of nine residents following Hurricane Irma.
The license suspension was another step after the state Agency for Health Care Administration last week placed a moratorium on admissions to The Rehabilitation Center at Hollywood Hills and suspended the facility from the Medicaid program. The nursing home late Tuesday filed a lawsuit challenging the admissions moratorium and the Medicaid cutoff.
Eight of the residents died Sept. 13, three days after Hurricane Irma shut down the nursing home’s air-conditioning system. The license suspension alleged that four of the residents had body temperatures of at least 107 degrees when they arrived at a nearby hospital or when they died.
“Respondent (the nursing home) failed to maintain safe conditions in its facility; failed to timely evacuate its facility once conditions were no longer safe for residents; and failed to timely contact ‘911’ during a medical emergency,” said the emergency suspension order, signed by AHCA Secretary Justin Senior. (D)

First, the nursing home, called the Rehabilitation Center at Hollywood Hills.
Yes, it experienced a partial loss of power after Irma. But the real problem appeared to be that the staff didn’t act quickly enough after the air conditioning failed and patients became overheated and dehydrated, according to police, emergency responders, and family members of patients.
By the time emergency responders got there, the facility’s second floor was “extremely hot,” some patients were already dead, and others were near death, Hollywood Police Chief Tom Sanchez told reporters.
Also, help was just a few steps away. Memorial Regional Hospital, which is right across the street, had power and a fully functioning emergency room when the deaths occurred.
When the hospital finally learned what was happening, dozens of workers rushed over to help, says Randy Katz, an Emergency Medicine specialist at Memorial. (E)

The first call from the Rehabilitation Center of Hollywood Hills to Florida Power & Light was placed about six hours after Hurricane Irma made landfall in Cudjoe Key on Sunday.
Irma had knocked out power to the center where 141 elderly and frail patients lived, and the following morning FPL said it would be there to restore electricity to the air conditioning units, according to a time line provided to the Miami Herald on Friday by officials of the nursing home who asked not to be identified.
The allegations in the time line — that the facility called both FPL and the governor’s cellphone for help that didn’t come, along with comments from the state and the governor’s office denying the nursing home’s version of events — added confusion Friday to a case that includes a criminal investigation into the deaths by Hollywood police.
According to the nursing home time line, FPL didn’t show up as promised on Monday, or on Tuesday, and by the time the utility arrived on Wednesday morning to repair a transformer that powered the nursing home’s air conditioners, all of the patients had been evacuated and eight elderly residents were dead. (F)

“The Texas Hospital Association this week estimated that as many as 75,000 hospital employees experienced losses and damage from Hurricane Harvey, both the storm and subsequent flooding. The association, which is based in Austin and represents more than 85 percent of the state’s acute-care hospitals and health care systems that combined employ some 365,000 health care professionals, announced Sept. 5 that it is contributing $1 million to a special assistance fund for the affected employees….
“Throughout the storm and the days following, we witnessed firsthand the dedication of our health care workforce,” said Ted Shaw, THA’s president and CEO. “Many of these individuals stayed committed to their work, knowing their families and property were at risk. While hospital administrative personnel, nurses, and other staff train for unspeakable disasters like Hurricane Harvey, their preparation and focus ensured the safety and continued operation of facilities even as the waters rose and the lights went out. Now, it’s time for us to take care of the caregivers.” (G)

“Patricia Ney was a nurse. The 56-year-old worked in the obstetrics department at Cape Coral Hospital for more than three years. In total, her career spanned more than three decades. Until last week…
The hospital system’s emergency preparedness plan in case of hurricanes is called “Code Brown.” During hurricanes, essential employees are grouped into two groups — A and B. Group A staffs the hospital during the storm and Group B takes over after to relieve the first staff workers.
Ney was part of Group A, but the day after Labor Day she went to Pennsylvania on a previously planned trip. At the time, Irma was forecasted to hit the east coast of Florida, but the cyclone surprised all by going west instead.
Under the previous guidelines for Code Brown situations, employees who did not go to work were placed under corrective actions and in some circumstances fired.
But because Irma was so remarkably unpredictable and affected large swaths of the state, Briggs said the guidelines will be tweaked allowing those employees to return to work. (H)

Local emergency management officials and state public health officials dodged a bullet with Hurricane Irma. They must do a better job of coordinating with local hospitals the care of hurricane evacuees who have been deemed “medically needy” because of serious health issues.
Emails obtained by this newspaper showed that as Hurricane Irma bore down on Chatham County, the three local hospitals initially flinched and backpedaled on their previous agreements to house 48 fragile members of the community, and that only Memorial University Medical Center eventually lived up to its commitments, but only after Chatham Emergency Management Agency Director Dennis Jones did some serious arm-twisting with top Memorial execs.
Candler accepted none of the evacuees it was assigned and St. Joseph’s, Candler’s sister hospital in the two-hospital system, accepted three “last minute” cases. (I)

“Furniture damaged by floodwater during Hurricane Irma that’s now sitting in front of people’s homes has started attracting people looking to salvage metal from it. But there is a hidden danger that could lead to infection if you aren’t careful.
On Jacksonville’s Northside, which saw a lot of flooding, two men were seen salvaging materials from soaked furniture…
“E.coli is the most common bacteria that can cause a variety of different problems,” Ashbaugh said. “Also, people with staph and strep — that can become a big problem with cellulitis, different abscesses and skin diseases.” (J)

“Nancy Reed, 77, died on Sept. 15 of flood-related necrotizing fasciitis, an infection that spreads quickly through muscle tissue and can cause organ failure…
According to the Centers for Disease Control and Prevention, necrotizing fasciitis is a serious bacterial skin infection that kills the body’s soft tissue, spreads quickly and can be fatal in a short time. Prompt diagnosis and treatment with antibiotics can prevent death.
The infection is not considered a reportable disease in Texas, meaning doctors or laboratories who diagnose it are not required to alert health authorities. But they are required to report many of the organisms that cause the disease — streptococcus, E. coli, vibrio vulnificus and certain types of drug-resistant staphylococcus.
Strep is the most common cause of flesh-eating bacteria. Vibrio is the most common in salt water. (K)

“The major general hospital for the Caribbean island of Dominica has already taken a major beating from Maria. It’s too early to tell just how much damage there will be to the Puerto Rican health system; but medical facilities on the island have historically been underfunded, putting even more strain on health care providers in the midst of an economic crisis in the region. And widespread power outages are expected for the foreseeable future, which will force patients to rely on backup generators and aid organizations.” (L)

“Health and safety are always concerns after such a disaster, but Puerto Rico must try to address those with the island largely devoid of electrical power and with a severely damaged communication system…
There are immediate needs of making sure hospitals can continue to run on generators, which require fuel that is in demand. It’s unknown how many people are trapped in homes that can’t get to a hospital or need some kind of health aid, such as a nebulizer, medication or assistance with getting around…
Jaime Pla, president of the Puerto Rico Hospital Association, told NBC News that hospitals have been able to operate normally for the past 48 hours because they have been on generator power.
“The issue we’re going to have is accessibility to diesel,” said Pla, adding that most generators operate on diesel tanks that last between three to five days…
All of this comes after Puerto Rico’s medical system already was strained as doctors have been leaving the island because of the economic crisis, as NBC News reported last month.” (M)

“The hospitals have been crippled by floods, damage and shortages of diesel. The governor said that 20 of the island’s hospitals are in working order. The rest are not operational, and health officials are now trying to determine whether it is because they lack generators, fuel or have suffered structural damage. All five of the hospitals in Arecibo, Puerto Rico’s largest city in terms of size, not population, are closed.
Making matters worse, 911 still does not work, officials said…
So far, seven regional hub hospitals are taking in patients. The island’s dialysis patients are also getting care. But none of it is easy. Hospitals should be required to have backup generators, diesel, a stockpile of medication and satellite phones, the doctor added. Even with those precautions, problems could arise. There is enough diesel on the island, but a shortage of gas tanker drivers — some cannot get to their jobs — and working gas stations. In Lares, the mayor, Roberto Pagan, said the municipal hospital almost had to close yesterday because it ran out of diesel fuel.
“We have been putting out fires,” Dr. Rodríguez-Mercado said. “The hospitals call you and say, ‘I have two hours of diesel left.’” (N)
.
“Coast Guard planes are flying in fuel, food and water from Miami and Jacksonville. The Navy hospital ship, U.S.N.S. Comfort, with 1,000 beds and 12 operating rooms, is also headed to the island. And the Department of Defense announced that U.S. Northern Command will have a commander on the ground in 24 hours.
“The issue in responding on an island is that you can’t drive trucks in like you can on mainland U.S.,” said Will Booher, a spokesman for FEMA…
At Centro Medico in San Juan, the main hospital on the island, power went out again Tuesday, forcing staff to switch to generators that have to be constantly refueled, said Jorge Matta González, the hospital’s executive director of medical services. (O)

“Aid is finally reaching the islands—fuel for generators, water, medical supplies, food—but disasters always breed disasters. And that might be what’s about to happen in Puerto Rico, too. “The first impact is people who were directly injured,” says Nahid Bhadelia, medical director of the special pathogens unit of the National Emerging Infectious Disease Laboratories at Boston University. “Then you have an entire group of people who are critically ill, facing health care systems that are overwhelmed.”
If things don’t get fixed quickly, the third wave comes. The islands are dealing with standing water, little clean water, and high heat. Those are perfect conditions for waterborne and mosquito-borne diseases—diarrheal diseases, and things like chikungunya, Zika, and dengue.” (P)

‘About 90 patients evacuated from Puerto Rico and the Virgin Islands are receiving kidney dialysis at Florida International University in Southwest Miami-Dade under a hurricane recovery response program coordinated by the state’s Department of Health.
Among the most urgent patients evacuated from Puerto Rico were the three infants with heart defects, who were born in August and September…
For transportation, Nicklaus Children’s turned to its LifeFlight program, an air ambulance service that flies jets packed with advanced life-support equipment for transferring critically ill newborns from the Caribbean, and Central and South America to Miami for medical care.” (Q)

“Evacuees from Puerto Rico and the U.S. Virgin Islands are being transported to mainland hospitals to receive care for critical medical conditions caused or impacted by Hurricane Maria.
In South Carolina, more than a dozen evacuees have arrived at the Columbia Metropolitan Airport by C-130 or private jet to be transported to various medical facilities around the state’s capitol…
In Puerto Rico, 59 out of 68 hospitals are open but not considered fully functional. Troy and her team from Fort Jackson are a part of the National Disaster Medical System, N.D.M.S, and Federal Coordination Center, F.C.C, which were activated in cities within the southern states of Louisiana, Mississippi, Georgia, and South Carolina in an effort to provide free medical assistance to those suffering from life threatening issues.” (R)

“Texas hospitals canceled surgeries, evacuated patients, and closed for days because of Hurricane Harvey. They sank millions of dollars into not caring for patients as a measure of precaution.
More than a month after Harvey made landfall, administrators at the roughly two dozen hospitals that evacuated in the eastern part of the state have now reopened their doors to patients. But some may feel the financial burdens of the storm for months to come — both caring for more patients who can’t afford treatment, while also seeing patients postpone the more lucrative elective surgeries that are many hospitals’ moneymakers.” (S)

“Hurricane Maria took almost everything from Rodriguez save for what he could fit into a backpack: the medical school he attended on the Caribbean island nation of Dominica and his family’s home in Puerto Rico. But he vows it won’t take his future — indeed, it has helped him find it.From his uncle’s house in Homestead, Florida, Rodriguez calls his experience surviving Maria “life-decisive.” In an interview by phone, he told CNN it has pushed him to pursue a new career path in his final semester at Ross University School of Medicine — emergency medicine.It was a decision born in the midst of a crisis.” (T)

“With Hurricane Irma menacing Florida, the leader of a state university campus decided on her course of action: Flee. As the storm approached earlier this month, Sophia Wisniewska dashed off an email to her boss. It included a description of the campus and indicated all was quiet at the University of South Florida at St. Petersburg.
It did not include any indication that Wisniewska was decamping for Atlanta…
Now, Wisniewska is out of her job as regional chancellor at USFSP, forced to negotiate her resignation. USF officials this week released a copy of the resignation agreement to The Washington Post, as well as a draft of a scathing termination letter from USF System President Judy Genshaft. (U)

(A) How Houston Can Become Stronger After Hurricane Harvey, by Anna Almendrala, http://www.huffingtonpost.com/entry/houston-hurricane-city-infrastructure_us_59c019f0e4b093cfe7761771
(B) Hurricane Irma: How Jacksonville-area hospitals responded to latest weather crisis, by Beth Reese Cravey, http://jacksonville.com/news/metro/2017-09-15/hurricane-irma-how-jacksonville-area-hospitals-responded-latest-weather-crisis
(C) Nursing Home Deaths in Florida Heighten Scrutiny of Disaster Planning, by NEIL REISNER and SHERI, https://www.nytimes.com/2017/09/14/us/nursing-home-deaths-irma.html?_r=0
(D) State suspends license of nursing home where 9 died after Hurricane Irma, by Jim Saunders, http://www.orlandosentinel.com/news/breaking-news/os-hurricane-irma-nursing-home-suspended-20170920-story.html
(E) When Irma Arrived, Most Florida Health Care Facilities Were Ready, by JON HAMILTON, http://www.npr.org/sections/health-shots/2017/09/19/551920301/when-irma-arrived-most-florida-health-care-facilities-were-ready
(F) Nursing home says calls for help went unanswered but state disputes claims, by DANIEL CHANG, http://www.miamiherald.com/news/weather/hurricane/article173630881.html
(G) Harvey Affected About 75,000 Hospital Employees in Texas, https://ohsonline.com/articles/2017/09/22/harvey-hospital-employees.aspx?admgarea=news
(H) Lee Health fires then rehires its essential employees who did not work during Irma, by MELISSA MONTOYA, http://www.news-press.com/story/news/local/2017/09/21/lee-health-fires-then-rehires-its-essential-employees-who-did-not-work-during-irma/687117001/
(I) Editorial: Come up with better plan for medically needy evacuees, http://savannahnow.com/opinion/editorial/2017-09-23/editorial-come-better-plan-medically-needy-evacuees
(J) Storm debris, floodwater-soaked furniture pose health risks, doctors warn, by Erik Avanier, https://www.news4jax.com/weather/hurricane-irma/storm-debris-floodwater-soaked-furniture-pose-health-risks-doctors-warn
(K) Kingwood woman confirmed as Harvey death from flesh-eating bacteria, by Cindy George and Todd Ackerman, http://www.chron.com/houston/article/Kingwood-woman-confirmed-as-Harvey-death-from-12230105.php
(L) Hurricane Maria Could Devastate Puerto Rico’s Underfunded Health System, by Sy Mukherjee, http://fortune.com/2017/09/20/hurricane-maria-puerto-rico-hospitals/
(M) Puerto Rico Attempts Recovery Amid Escalating Crisis and Dam Failure, by SUZANNE GAMBOA, https://www.nbcnews.com/news/latino/puerto-rico-precarious-situation-hurricane-recovery-begins-n803926
(N) The Crisis at Puerto Rico’s Hospitals, by OLGA KHAZAN, https://www.theatlantic.com/health/archive/2017/09/the-crisis-at-puerto-ricos-hospitals/541131/
(O) ‘This Is Like in War’: A Scramble to Care for Puerto Rico’s Sick and Injured, by LUIS FERRÉ-SADURNÍ, FRANCES ROBLES and LIZETTE ALVAREZ, https://www.nytimes.com/2017/09/26/us/puerto-rico-hurricane-healthcare-hospitals.html?mcubz=0
(P) https://www.nytimes.com/2017/09/28/opinion/puerto-rico-hurricane-maria.html?mcubz=0, by AM ROGERS, https://www.wired.com/story/puerto-rico-health/
(Q) Stranded in Puerto Rico after Hurricane Maria, infants flown to Miami for heart surgery, BY DANIEL CHANG, http://www.miamiherald.com/news/health-care/article176662251.html
(R) Hurricane Maria victims airlifted to mainland hospitals from US Virgin Islands and Puerto Rico, by Terace Garnier, http://www.foxnews.com/health/2017/10/04/hurricane-maria-victims-airlifted-to-mainland-hospitals-from-us-virgin-islands-and-puerto-rico.html
(S) Texas hospitals feeling the long-term financial strains of Harvey, byy MAX BLAU, https://www.statnews.com/2017/10/03/harvey-hurricane-texas-hospitals/
(T) Hurricane Maria took everything, but it gave med student a calling, by Paul P. Murphy, http://www.cnn.com/2017/10/06/us/hurricane-maria-survivors-story-future-trnd/index.html
(U) This university leader fled Florida during Hurricane Irma. Now she’s been ousted, by Sarah Larimer, https://www.washingtonpost.com/news/grade-point/wp/2017/09/20/this-university-leader-fled-florida-during-hurricane-irma-now-she-has-been-ousted/?utm_term=.88fe8b891f6d

“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)

to read about my experiences with mass casualty events, We don’t know what we don’t know”…The challenge to emergency preparedness…..highlight and click on https://doctordidyouwashyourhands.com/2017/08/we-dont-know-what-we-dont-know-1-the-challenge-to-emergency-preparedness/

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