
Mobilizing an ER department to handle a mass casualty incident - tptacek
http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top-stories
======
tptacek
I felt like the title of this story was almost certainly going to generate
threads from people reacting to the headline without reading it, which would
suck, because this is from start to finish an amazing story about incident
response and improvisation. So I synthesized a title from the intro paragraph.

A bunch of the terms used in this piece (like "crumping", which apparently
means dying without doctor permission) are emergency medical jargon, all easy
to look up.

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karlkatzke
Wow, lots of impressive thinking ahead of time. I’m heading up our incident
management team at work and this is definitely going in my presentations.

A few things that jumped out:

\- Thinking ahead to how he was going to handle an MCA probably saved dozens
if not hundreds, even if he made some choices that he shouldn’t have if you’re
sitting in our present armchairs.

\- This is great demonstration of why the incident commander needs good
oversight of the whole situation, and why not everyone makes a good incident
commander. The three doctors in Station 1 should have felt empowered to solve
the bottlenecks, but they did not... they just kept working within established
procedure. That’s ok. You need good operators. But the good leaders in
incidents are the people who know how and when to establish and communicate
new standard procedures.

\- Getting ahead of and staying ahead of a cascade failure is a difficult
thing to manage, one that we don’t often accomplish in operations/sre
incidents. I know I’ve had one or two incidents like that, mostly DDoS or
other attack types. This story shows the value again of staying frosty and
planning to handle your next problem before it snowballs and hits you from
behind.

~~~
JshWright
> This story shows the value again of staying frosty and planning to handle
> your next problem before it snowballs and hits you from behind.

My experience in emergency services is my greatest asset in ops work. So, half
the datacenter has crashed, and the other half is about to buckle under the
load. Is anyone literally going to die in the next 5 minutes? Ok, cool, then
let's just sort this out and get on with our lives.

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gizmonty
I was pretty astonished by this article. I work in the medical field in
Australia and I can’t imagine any hospital here responding and coping in this
manner. Our trauma is generally from car crashes and only rarely from guns. I
think the victims of this incident were very lucky that this guy was running
the show that night. What I would like to know is how well they coped with
record keeping and infection control. These are the things that I find tend to
get deprioritised in a crisis.

~~~
JshWright
I work in EMS in the US (upstate New York).

Generally there is an "MCI kit", which has a form that can be attached to the
patient (an elastic band around the wrist or ankle, generally). That form will
contain whatever information we know about the patient, interventions thus
far, etc. It stays with them throughout the process (in the triage and
treatment areas, to the OR, etc). That being said, documentation is often a
tertiary concern at best in large scale events like this.

As far as infection control goes, the OR is obviously using standard sterile
procedures. In the ER, infection control is mostly "changing your gloves a
lot" (be sure to put on two pairs, any only change the top pair, as your hands
are going to get really sweating, and putting a new pair of gloves on your
bare hands is going to be impossible).

~~~
js2
> documentation is often a tertiary concern at best in large scale events like
> this...

 _People came in so grievously injured and so many at a time that Fisher, who
is the medical head of trauma services for the hospital, and his colleagues
used markers, writing directly on patients, to do triage.

When someone arrived, an emergency room physician would mark their wounds. It
was quick, simple and impersonal by necessity.

Fisher says in those first few hours, the patients were functionally anonymous
to the surgeons trying to save their lives. "There's no paper charts prepared
for all those patients," says Fisher. "No documentation, so literally they
just write on the patient. Just write where the wounds are."_

[https://www.npr.org/sections/health-
shots/2017/10/04/5555849...](https://www.npr.org/sections/health-
shots/2017/10/04/555584905/sheer-number-of-casualties-makes-las-vegas-count-
difficult)

> As far as infection control goes...

How soon do patients get antibiotics administered?

~~~
JshWright
Yeah, that's another common technique in extreme circumstances. You can
sharpie a lot of info onto someone's forehead...

------
JshWright
Let me preface this by saying I am in no way trying to "Monday morning
quarterback" this incident. This doctor's decisive actions saved dozens of
lives.

To facilitate discussion though, I'd like to highlight this section:

"By textbook standards, some of these first arrivals should have been black
tags, but I sent them to the red tag area anyway. I didn’t black tag a single
one. We took everybody that came in—I pulled at least 10 people from cars that
I knew were dead—and sent them straight back to Station 1 so that another doc
could see them."

There is a reason the "textbook" calls for a black tag. The simplest
definition of a "mass casualty incident" is when you need more resources than
you have. Sending those dead patients to the treatment area was a waste of the
most critical resource they had (the time and attention of medical providers).
It is likely some outcomes were worsened by that waste of resources.

~~~
mathgenius
It seems like he just wanted a second opinion. Maybe he was just seeing too
many people arriving to trust his own judgement about the black tag.

~~~
scoot
That sentence caught my eye too, and I would have commented on it if JshWright
hadn't. _" If the two of us ended up thinking that this person was dead, then
I knew that it was a legitimate black tag."_ Sending them _all_ back to the
red-tag area doesn't get you a _second_ opinion, it simply passes the
responsibility to someone else.

A better explanation might by that by taking this approach, he was tiering the
triage, in much the same way that the neurosurgeon in the article's comments
mentioned that they were able to "neuro triage" patients sent to them.

I can't begin to imagine handling this type of situation.

~~~
khed
There are a couple reasons why he might do this that I can think of.

1). He didn't know how many people were going to come in or how serious they
would be. Triage in MCI does depend to a certain degree on what your facility
is capable of and the expected volume and status of patients. If he
underestimated the volume or criticality of the patients about to come in he
might have put more into the red pod than he would have otherwise.
Underestimating seems plausible in this case because this was the worst mass
shooting in history in the US.

2). Medicolegally he might have a fear that he would be judged harshly if he
didn't automatically try to save everyone.

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ja27
Here in our county (that includes Tampa), we have an annual mass casualty
drill. The larger hospitals actually get mock patients (high school students,
some in makeup) transported and practice triage. Every capable facility in the
county, even little surgical centers in strip malls, practice communicating
with emergency dispatch and "tabletop" how they would handle trauma patient
overflow. Fire rescue practices coordinating patient transport to send more
minor cases to the more remote facilities. They rotate where they actually do
the drill so they get experience working in the different sports arenas,
airport, etc.

~~~
bbarn
When I was in the military, between boot camp and going to our first school,
we were en masse "volunteered" to be patients in a mass casualty drill at a
hospital in Chicago. I'm not sure if it was really worth the trouble. Most of
the triage staff rolled their eyes and looked annoyed when we showed up. It
was a lot of effort - probably 20 busses full of 19-25 year olds staged in
McCormick place all day, trained, made up to look wounded - I can't imagine
what it cost to put on, and it seemed to only piss off the staff.

~~~
arthur_pryor
could've still been helpful training, even if they didn't want to be doing it.

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forg0t_username
Reminder to donate blood, this is what allows medical professionals to save
lives, be it in dramatic incidents such as this one, or in more mundane
settings.

UK: [https://my.blood.co.uk/](https://my.blood.co.uk/)

US: [http://www.redcrossblood.org/donating-
blood](http://www.redcrossblood.org/donating-blood)

~~~
tehlike
I wanted to, but it sucks to be coming from a country which is in the
"restricted donation" list.

[http://www.militaryblood.dod.mil/Donors/can_i_donate.aspx](http://www.militaryblood.dod.mil/Donors/can_i_donate.aspx)

Good thing is i don't have a rare blood type.

~~~
jopsen
That doesn't suck.

I'm glad they don't want my blood, I really dislike vampires.

I'm guessing it makes sense as a rough way to limit infectious deceases. You
need only look to China to see how far something like AIDS can spread if you
don't do blood donations right. If I recalls correctly they infected something
like 50k people by accident.

Notice, that the next infectious decease like AIDS might not have been
discovered yet. Hence, why a lot of precautions around blood donations makes
sense.

~~~
tehlike
I believe some of this for the europe related restrictions was due to mad cow,
but i am not entirely sure. It was weird times for sure.

~~~
kaybe
Probably. In Germany you are unwanted if you were in UK in a similar
timeframe, with Mad Cow Disease given as reason.

By now we also have some Malaria risk areas in Greece and the Italian Po
valley.

~~~
jopsen
and MSR

but does this really exclude enough people to be problematic, if not... then
it better to have too many restrictions..

------
jxramos
Learned some pretty interesting concept on this one with the notion of "Golden
Hour":

In emergency medicine, the golden hour (also known as golden time) refers to a
time period lasting for one hour, or less, following traumatic injury being
sustained by a casualty or medical emergency, during which there is the
highest likelihood that prompt medical treatment will prevent death.
[https://en.wikipedia.org/wiki/Golden_hour_(medicine)](https://en.wikipedia.org/wiki/Golden_hour_\(medicine\))

~~~
martinmunk
At least here in Denmark, "Golden Hour" is no longer thought as a rule of
thumb to the new recruits in the national emergency agency "DEMA"
([https://en.wikipedia.org/wiki/Danish_Emergency_Management_Ag...](https://en.wikipedia.org/wiki/Danish_Emergency_Management_Agency))

Time is off course at a premium, but there seems to not be anything special
about the 60 minute mark.

~~~
cstejerean
Wikipedia says the same thing in the linked page so it’s not just Denmark.

> It is well established that the patient's chances of survival are greatest
> if they receive care within a short period of time after a severe injury;
> however, there is no evidence to suggest that survival rates drop off after
> 60 minutes

It’s a rule of thumb though and in this case it wasn’t so much about survival
rates specifically but rather the condition worsening for those with orange
and yellow tags during that time frame.

------
js2
I was looking for an interview I heard with someone from this hospital and
could not find it, but I did come across this piece with quotes from many of
the staff (it's complementary to the submission):

[https://hcatodayblog.com/2017/10/06/sunrise-hospital-
staff-s...](https://hcatodayblog.com/2017/10/06/sunrise-hospital-staff-share-
their-experience-after-las-vegas-shooting/)

------
x0x0
Even on this, the useful idiots are out trying to claim the vegas murders were
fake...

> _FB_

> _Dr. Anson,_

> _Did the bullet wounds you saw match the caliber of weapon used in the
> shooting? I ask because wounds would have been more severe than what is
> being reported. Thanks._

====

> _Dr Menes: There were single bullet-pass through-multiple extremity wounds,
> entrance /exit through narrow torso, and entrance only through dense torso
> consistent with 5.56 ballistics._

------
deepandmeaning
This story is incredible.

The standout's for me were:

* Plan - have a plan in place in advance * Flow - recognise and shift bottlenecks + understand the impact to the system * Prioritise - rank what is critical, urgent, or standard - and be ruthless * Process - simplify the processes to make it more effective and efficient * Shift - innovate and adapt in the face of changing circumstances.

These sound like no brainers, but reading the story you get a sense of how one
individual pushing these forward in a tough situation had an incredibly
powerful impact.

How could we apply these powerful lessons more widely?

~~~
walshemj
I am surprised from the article that all hospitals don't have plans in place
for major incidents and its only his experience with the SWAT team that led
him to devise the plan before time.

Also I know in the UK they do role-play major incidents out using the police
and emergency services to test there plans.

BTW this guy and his team deserve an honour of some sort

~~~
JshWright
Hospitals absolutely have plans like this in place. He certainly leaned on his
prior experiences to apply lessons learned previously (as we all do), but
there was absolutely a plan in place outside of his personal experiences.

The trauma center in our region holds similar "mock incidents" at least once a
year. Certainly nothing to this scale (there's just no way to practice
that...), but they routinely run drills with dozens of patients and simulate
various in-hospital system failures.

------
razakel
Wow. That guy's forward-thinking probably saved dozens of lives. Hats off to
him.

------
PuffinBlue
> For years I had been planning how I would handle a MCI, but I rarely shared
> it because people might think I was crazy.

I should state up front I'm ex-military and volunteer for a disaster response
organisation.

I find this to be incredible. Who in their right mind would ostracise a trauma
professional for conducting such planning? In fact, who who dare not _support_
such a professional to plan for such eventualities?

I actually can't quite believe the implication here, that there is a systemic
reluctance to plan for such events. Maybe things are different in my country
(UK) but this 'worry' the doctor has seems frankly absurd!

> The first thing I did was tell the secretaries I needed every operating room
> open. I needed every scrub tech, every nurse, every perfusionist, every
> anesthesiologist, every surgeon—they all need to get here right away.

I thought I'd misread the article, maybe I still have, but this sentence seems
to back up the claim no MCI plan was already in place.

It may be a product of our troubled history and extensive threat of terrorism
(including the Irish dissident threat) but here in the UK Major Incident
Response planning is practised extensively, and not just for medical
emergencies. Planning is in place at almost every level to deal with such
incidents. Almost every large institution, let alone just hospitals/emergency
services, will deliver a 'Major Incident Response plan' (just Google 'Major
Incident Response Plan UK' and you'll get many many examples), which will
almost universally include a Mass Casualty Response Plan.

Indeed, there is even an NHS Tactical Command Framework in place to deal with
Mass Casualty Incidents that will usually span several local health trusts and
setup a coordinated response framework dedicated to responding to incidents
like these.

Equally, all local governments departments have well rehearsed responses,
integrating tightly into the UK's Gold/Silver/Bronze Command response
coordination structure. Usually our emergency services, military and hospitals
will have physically practised inter-operability via joint exercise and will
utilise other joint working practices like JESIP and the METHANE reporting
system.

I know for a fact the US follows the very well planned ICS system which links
into both FEMA and local/state level emergency planning. I find it absolutely
unfathomable that no well rehearsed and fully scoped plan of similar
thoroughness to the UK was ready to go and instead this doctor simply made it
up on the hoof.

Despite my own disbelief, it seems this Dr. actually did have to make it up as
he went along - what an amazing, stunning personal achievement, and what a
devastating systemic failure.

------
rb666
Amazing read for sure. I wonder how many of these patients have to pay for
their life with bankruptcy. USA! USA! USA..., etc.

------
WillReplyfFood
Only tangential related: But the quality improvements in ER has saved
countless potential "murder" victimes over the last two decades. The problems
these victims phase, after they have been patched up are severe. Chronic pain,
disabilitys and hardships. But they are not murders, so its not so bad in the
city of <place-name-here>. We should write into the news how bad the victims
future prospects are limited. Not just a "wounded", but "wounded, with future
limitations on autarc living"

~~~
jopsen
Yeah, the news often only counts the dead, but there were over 500 people
shot.

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aerovistae
i link this, nobody upvotes. tptacek links this, front page. CONSPIRACY.

~~~
grzm
It's not uncommon for a given piece to be submitted a number of times before
it "takes" (if it does at all). Also, it looks like both times this has been
submitted the article title has been different. It might get more visibility
if it's submitted by a well-known HN member, but overall, I wouldn't read too
much into it.

~~~
aerovistae
i kid

~~~
jopsen
try using an emoji next time you sarcastically cry conspiracy.

~~~
ryanlol
How would you know if he had? Or is this some advanced sarcasm.

