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Mobilizing an ER department to handle a mass casualty incident (epmonthly.com)
281 points by tptacek on Nov 13, 2017 | hide | past | web | favorite | 71 comments

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.

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.

> 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.

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.

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).

> 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."


> As far as infection control goes...

How soon do patients get antibiotics administered?

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

used markers, writing directly on patients

We did this in the Army.

Hell, I took an outdoor emergency course (the national ski patrols first responder course) and even we are trained on MCI's and triage.

While I doubt anywhere but the US or a military battlefield will get hundreds of bullet wound patients at once, it's quite possible to get dozens of patients in one go at any hospital. One memorable story I have been told is a tour bus that overturned on a tight hairpin mountain road. Most tour buses do not have seatbelts. The only hospital within reasonable driving distance got 40 elderly patients with head trauma, multiple broken bones, and exposure. Gunshot wounds are not the only Mass Casualty Incidents that can happen. Think about a riot at an Aussie Rules Football game, for instance...

The article doesn't go into detail about your two areas of concern but does mention two items: Infection control was mostly glove changes. Record keeping was on the triage tags from the MCI; cards are attached to patients and travel with the patient. Yes, both of these are a "bare minimum" effort and may not have been used, but when the priority becomes throughput of a system many features of a system can get dropped and picked up again after the crisis is over.

I once hung out for half a day at a hospital in Bakersfield, CA to watch a surgery and they had several gunshot victims come in. So in the US it seems they are highly experienced with this kind of injury unfortunately.

I don't know if it applies in this case, but US trauma medicine has also benefited tremendously from the experience of doctors who worked in military hospitals.

It goes the other way too, with military surgeons getting training in US cities: https://www.cbsnews.com/news/intense-training-for-military-s...

Before the War on Terror, US Military trauma surgeons got experience treating bullet wounds by working rotations at hospitals near high crime/gang areas like Compton.

This is also true of traumatic brain injuries. A number of my doctors after a fairly serious (to me alone) car accident mentioned that they have a lot more information thanks to doctors treating victims of TBIs caused by explosions.

As where doctors in northen Ireland during the troubles

I'd heard stories from those involved responding to the Port Arthur mass shooting.

It's obviously a completely different scale though, and they had some time to prepare before the patients started arriving.

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.

I think he was talking about the first few car loads, while he knew there were a bunch of doctors inside with nothing else to do, he was not doing this the whole night?

This triage system is pretty standard, you can see the same triage armbands in this RNLI medical kit in the bottom right corner[0] (I couldn't find a standard UK ambulance kit image), but I am told that it takes a huge amount of mental discipline to follow this training to the letter in real life. It probably took a few people going through the system for him to get into the swing of it.

I can't imagine having to do this, this guy will be going back over the decisions he made that night for the rest of his life. I hope that in writing this article he has felt validated in himself because it sounds like he and his colleagues did an incredible job.


It's definitely hard. That's part of the reason the criteria is so clearcut. Not breathing = black tag.

From my reading of the article, he was the triage officer during the arrival of almost all the critical patients, and it was only after the acuity level started to drop off that he delegated to a nurse.

This is not my understanding of how to triage in MCI. ATLS definitely does teach the importance of deprioritizing people that will be hard or impossible to resuscitate in favor of prioritizing people that leads to a roughly utilitarian greatest good.

That said, I have never heard "black tag = not breathing = don't try to help"[1]. I know for a fact that the boundary for who to try to save immediately and who to deprioritize is very grey in many cases (it is why you should have an experienced doctor doing it). A common example why that equivalency is not taught in ATLS is the case of a boat capsizing in frozen waters. There may be many frozen victims who are not breathing but could still be very salvageable medically. If you chose to not help those who are not breathing in that case you would plausibly be found negligent without some extraordinary situation to justify yourself with.

Another example would be mass overdose on fentanyl, many are saveable but none would be breathing when you first see them.

1. https://en.wikipedia.org/wiki/Triage#Conventional_classifica...

Yes, those are two special cases where respiratory statues would not map well to expected outcomes. As far as I know, there was no capsize or mass opioid overdose involved...

I'm not sure where your understanding of triage comes from, but you're mistaken if you think respiratory status isn't the primary determining factor in black/expectant classification (in the US, there may be differences in other international systems I'm not aware of).

The vast majority of triage in US is done using the START system (or START-derived systems, like SALT).

Here is a graphical depiction of the START classification algorithm: http://citmt.org/Start/images/flowchart2.jpg

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.

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.

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.

This is what it sounded like to me; normally patients arrive slowly enough that he would have enough time to be absolutely certain about declaring one deceased, but under the circumstances he needed to make quick judgments and move on to the next arrival.

In a sense, he was correctly applying the rule of optimizing for the most critical resource -- except that in this case, the most critical resource was his ability to triage incoming patients.

There is a difference between "black tag" and "deceased". It wasn't his job to determine if anyone was deceased. It was his job to determine if they were worth expending any more effort on (given the limited resources). To qualify as a black tag, a patient would need to have no pulse, or to not be breathing (after positioning their airway in an "open" position). Those are both objective findings, not judgement calls.

I just want to reiterate though... This facility (and this doctor specifically) did a fantastic job. I look forward to the more in-depth case studies as an opportunity to further my own skills in EMS.

"No pulse" sounds objective... but how long do you look for one? On two occasions I've had doctors fail to find my pulse even while I was been alert and talking to them -- admittedly the pulse they couldn't find was radial, but the only circulatory issue I had was moderate dehydration.

Is it implausible that under these conditions someone would be uncertain whether there was no pulse or simply a weak pulse which they missed?

So, the actual criteria is is breathing. I'm throwing "pulse" in there because there's no way an ER doc isn't going to check for one.

You're absolutely right that finding a pulse can be tricky (though a carotid or femoral is a lot easier than a radial). There are a handful of good studies that show a fairly high degree of uncertainty, even among well trained providers (ER docs, paramedics, etc). This is why breathing is the "real" criteria, and should have been the decision making criteria used in this case.

Thanks for clarifying -- that makes more sense. Is it possible that casualties were arriving too fast for him to confirm that they had good airways? I have no idea how long that takes.

The goal is to take ~20 seconds. You position the head and neck in a position where the airway would be open (if someone is unconscious, they can't maintain their own airway, even if it would otherwise be fine). After positioning, take 10-15 seconds to observe for breathing. During this time you might as well check for a carotid pulse as well.

The article says that he triaged 150 patients in 30-40 minutes, or one every 12-16 seconds(!!!), so it sounds like not spending the 20 seconds it would take to check for breathing may have been the right call?

Some of them would have been a lot quicker than that, some would have taken a bit longer. In studies the mean is generally in the 15-20 second range, but some individual data points are just a couple seconds and some are >30 seconds.

That's not how triage works. It's literally an algorithm. If the patient doesn't have a pulse, or isn't breathing, they're a black tag. There is a fair bit of wiggle room between the other triage classifications, but dead is dead in triage.

My understanding (and this is from a limited amount of Googling, so if you have domain experience I'll gladly defer to your judgement) is that black tags are applied to those who are already thought to be deceased, _or_ to those who are thought cannot be saved with the given care available:

"Black tags - are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available."


Again, if you are experienced and knowledgeable in triage please disregard my understanding.

Yeah, a black tag is someone who is going to be dead. That may be because they're already dead, or because they're beyond help (given the resources available).

The criteria used by all the major triage systems for a black tag classifications is a lack of respirations (and because he's an ER doc, he's going to reflexively check a pulse).

I don't think my experience is especially important (as you said, this is all googleable info), but I'm a paramedic with a little over a decade in EMS.

What do you mean by "this"?

'The simplest definition of a "mass casualty incident" is when you need more resources than you have.'

This definition is an example of the logical fallacy called begging the question. Nobody would deny that an incident that brings 250 gunshot victims to one center is a "mass casualty." The brilliance of Dr. Menes's approach is that he did not immediately assume insufficient resources. He didn't say this, but it appears to me that he proceeded under the thought that with careful planning and ingenuity, they might have just enough resources. This redefines triage from a rigid algorithm to something like "the optimal deployment of available resources to maximize the utility for as many as possible."

They in no way had adequate resources to handle that event. Not even close. A hundred of those patients would have qualified as a trauma code on a "normal" day, and would have had the dedicated attention of a dozen people during their initial arrival and stabilization. In this case they were lucky if they got the undivided attention of a single person.

They made do with what they had (very efficient, and very effectively), but the scope of the incident vastly outsized the scope of the available resources.

Your description of triage is great. The algorithm (based on a fair amount of research) is one part of maximizing that utility (it doesn't stand in the way of accomplishing that).

> It is likely some outcomes were worsened by that waste of resources

I think the more interesting concept is the second look. Doctors are trained to be sensitive, then specific. Perhaps it would be easier to black tag people if you knew the next thing that would happen is they would go the red tag area for a second call of "black tag".

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.

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.

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

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/

US: http://www.redcrossblood.org/donating-blood

It can be worth checking if a regional health provider has their own donation network. The Red Cross does blood drives here but there is also a location in one of the local clinics that makes appointments. Much more convenient than a blood drive.

The Red Cross has every day donation centers in larger cities, just not in as many places as health providers.

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


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

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.

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.

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.

and MSR

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

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)

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...)

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

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.

Another interesting thing is the Golden Hour suggests that nearly any patient far from help (e.g. wilderness) who is still alive by the time you get there, is probably going to make it.

Interestingly, there was a recent study that indicated for penetrating trauma the patient had a much higher survival rate if they were taken to the ER by private car compared with waiting for EMS transport. Presumably because you are less likely to waste that golden hour.

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):


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.

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?

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

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.

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

> 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.

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

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"

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

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

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.

i kid

try using an emoji next time you sarcastically cry conspiracy.

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

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