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DECEMBER 2017 Vol. 29, No. 12; p. 133-144

Using machine learning,
investigators at Johns
Hopkins Hospital have
devised a new method
for triaging patients
that data suggest
differentiates patients
more effectively . . . . 138

See how a two-stage
sepsis alert process
has helped emergency
clinicians better identify
sepsis without increasing
the incidence of alert
fatigue . . . . . . . . . . . . 141

Enclosed in This Issue:

Accreditation Update:
Revised standards on
pain assessment and
management reflect
concerns about opioid
epidemic

HOSPITALS IN
THE REGION

HAD TO RAMP
UP EMERGENCY

OPERATIONS
QUICKLY AS

PATIENTS BEGAN
ARRIVING BY THE

TRUCKLOAD.

How Las Vegas Hospitals
Responded to Nation’s
Deadliest Mass Shooting
Patients continue to present to EDs in the region with PTSD-like
symptoms and anxiety related to the mass shooting

S
unday evenings tend to be rela-
tively quiet in the ED, but on
Sunday, Oct. 1, hospitals in Las

Vegas were tasked with responding to
the worst mass shooting in U.S. history
when a gunman using
automatic weapons
opened fire on a
large crowd attend-
ing a must festival on
the Las Vegas Strip.
Fifty-nine people were
killed and more than
500 injured, many
of them with severe
gunshot wounds.

At first unclear on
the extent of the in-
juries, hospitals in the
region had to ramp up
emergency operations quickly as patients
began arriving by the truckload, many
of them in private vehicles. Sunrise
Hospital and Medical Center, a level II
trauma center located just a few miles

from the festival, first received notice of
a mass casualty event at 10:20 p.m.

“Once our incident command was
stood up, we mobilized staff and sup-
plies within the ED, operating room,

inpatient units, and in
[our] pharmacy and
supply warehouse,”
explains Jeff Mu-
rawsky, MD, FACP,
the hospital’s chief
medical officer. “We
also used the incident
command structure
to ensure protocols
were enacted for
managing security,
visitors, and family of
those impacted by the

tragedy.”
With such close proximity to the

event, Sunrise Hospital received 180 pa-
tients, more than any other hospital in
the region, 124 of whom had sustained
gunshot wounds. Dozens of physicians,

134 | ED MANAGEMENT® / December 2017

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nurses, and support staff were called
in to manage the influx, and staff
essentially tripled the size of the ED,
explains Scott Scherr, MD, FACEP,
Sunrise’s medical director of emer-
gency medicine.

To organize care, arriving patients
were tagged to go to designated areas.
“We used the Sunrise Children’s
Hospital pediatric ED for the ‘green’-
tagged patients, the chest pain obser-
vation area for ‘green- and yellow-’
[tagged patients], and the PACU
[post-anesthesia care unit] for ‘yellow’
patients,” Scherr notes. “I was able
to assign one to two providers per
station with a scribe. We moved all
‘red’ patients to the trauma bays and
station one.”

Prepare for

Non-local Patients

When yellow-tagged patients
began to decompensate, they were
moved to the trauma bay or station
one, Scherr explains. “Since we had
four neurosurgeons in house on
Sunday night, we sent all isolated
gunshot wounds directly to the neuro
ICU. Orthopedic surgeons were fol-
lowing patients on the PACS [pic-
ture archiving and communications
system] machines and admitting
isolated surgical patients,” he says.

A radiologist followed patients
with a portable X-ray machine to
give clinicians instant “wet” reads,
Scherr observes. In addition, trans-
porters were assigned to each station
so they could help move injured
patients to radiology for CT scans,
upstairs to the ICU, or to the operat-
ing room, he says.

With so many patient arrivals, the
hospital quickly bypassed standard
registration processes, moving instead
to a system it uses in mass casualty
situations to capture an alias on every

patient treated. “After the emergent
stabilization was completed, we
were able to establish and verify the
identity of every patient who was
evaluated and treated,” Murawsky
notes. “Those who were treated and
released did not necessarily complete
the evaluation process.”

Because Las Vegas is a prominent
tourist area, it is not unusual for
the hospital to treat patients from
other regions, and this often requires
coordinating with hospitals in other
states. However, Murawsky notes
that this was an added challenge in
the wake of the mass shooting be-
cause so many patients were not lo-
cal. Nonetheless, Murawsky explains
that the hospital regularly practices
for mass casualty events that may
involve a large number of tourists.

“We do both table top prepared-
ness exercises on MCI [mass casualty
incidents], simulating a large [num-
ber of ] casualties, and also annually
plan for and execute a New Year’s Eve
emergency preparedness response to
meet the influx of emergency issues
among revelers each year,” he says.

Murawsky anticipates that there
will be many lessons to incorporate
into these exercises from the mas-
sive response to this unprecedented
event, but that will take some time.
“At present, we are focused on the
healing of our patients and staff,”
he says. “A structured review will be
completed and coordinated across
the community to ensure that others
benefit from our experience.”

Consider Geographic,

Travel Challenges

University Medical Center of
Southern Nevada (UMCSN), the
state’s only level I trauma center,
received 104 patients the night of the
shooting, creating multiple challenges

134 | ED MANAGEMENT® / December 2017 ED MANAGEMENT® / December 2017 | 135

EXECUTIVE SUMMARY

Hospitals in Las Vegas scrambled to respond to the deadliest mass shooting

in U .S . history after a gunman opened fire on a large crowd attending a music

festival on Oct . 1, which left 59 people dead and more than 500 injured .

• Sunrise Hospital and Medical Center received 180 patients, including 124

with gunshot sounds . The incident command structure was used to mobilize

staff and supplies and to ensure protocols were enacted to manage security as

well as the visitors and family affected by the tragedy .

• With so many patient arrivals, the hospital quickly bypassed standard

registration processes, moving instead to a system it uses in mass casualty

situations to capture an alias on every patient treated .

• University Medical Center of Southern Nevada (UMCSN), the state’s only

level I trauma center, received 104 patients from the shooting, creating

multiple challenges for staff . The hospital maintains a separate, freestanding

trauma center, which offers advantages in expediting care to critically injured

patients . However, patients arriving by private vehicle presented to both

the trauma center and the adult ED, necessitating triage operations in both

locations as well as continuous travel between the two buildings as patients

were transferred to the appropriate location .

• Providers rushing to work to care for victims of the shooting ran into

roadblocks set up by law enforcement, in some cases delaying their arrival to

UMCSN .

• Providers emphasize the importance of developing a versatile emergency

response process that can be deployed in any type of mass casualty event .

for staff. For instance, David Obert,
DO, the assistant medical director of
the ED, immediately headed to work
when he heard about the shooting by
phone from a colleague, but he ran
into obstacles related to law enforce-
ment’s response to the incident.

“The biggest issue was that they
were setting up roadblocks through-
out the city, so it was actually very
difficult for me to get to the hospi-
tal,” he recalls. “I had to go through
several roadblocks, show them my ID
and tell them where I was going, and
I was able to get through.” However,
traveling to the hospital took extra
time, and other staff faced similar
challenges, Obert notes.

Other difficulties stemmed from
the unique organizational layout at
UMCSN. “We have a freestanding
trauma center, which is in a com-
pletely separate building,” Obert
explains. “It has 11 trauma bays, and
then attached to that is a CT scanner,
an angio suite, three operating rooms,
and then the trauma ICU.”

Separate from the trauma center
is an adult ED with 55 beds. Three
floors up is a pediatric ED. Although
the resources are plentiful and state of
the art, the layout was confusing to
arriving patients, many of whom had
to be transferred between the trauma
center and the ED, depending on
what their needs were.

“The medics know where to go,
but it is different for people coming
in private vehicles,” Obert observes.
“They just see an ED and don’t differ-
entiate because most places don’t have
their own separate trauma center.”

Familiarize Staff

With Resources

The night of the shooting, the ini-
tial patients were triaged through the
adult ED, and then if needed, trauma

then was alerted. However, it wasn’t
long before truckloads of people be-
gan arriving at the trauma center. To
manage the influx, there needed to be
an immediate operative intervention
on both ends to ensure that patients
were directed to the right facility for
their needs, Obert explains. “Patients
were crisscrossing back and forth,
and, unfortunately, there is some
geographic distance between these
departments.”

Patients with local extremity
wounds showed up to the trauma
center, and the majority of these
patients would get transferred to the
adult ED.

“We set up a receiving area in
the PACU to do secondary triage
on people who just showed up on
the doorstep so that we could find
out who needed to go straight to

the operating room and who could
be delayed and then transferred [to
the adult ED] and get an extremity
evaluation and management,” Obert
explains.

When Obert arrived at the hos-
pital at 11:15 p.m., he went to the
trauma center.

“At that point, a car load of four or
five patients showed up. They all had
extremity wounds, so I basically fol-
lowed all of those patients, went over
to the adult ED with them, and then
assisted in the care of all of them,” he
explains. “I then found another eight
patients who had extremity wounds
that I helped to manage [in the adult
ED].”

Another challenge of operating
separate trauma and ED buildings is
that staff members tend to be familiar
with one area or another, but not

136 | ED MANAGEMENT® / December 2017

FURTHER, IN THE
MIDST OF THE
CRISIS, IT WAS
UNCLEAR HOW
MANY PATIENTS

WOULD BE
ARRIVING, WHICH
MADE DECISIONS

ON HOW TO
REGISTER
PATIENTS

DIFFICULT.

necessarily with all areas. This became
evident the night of the shooting.

“We had an onslaught of help,
but there was a lack of familiarity
with where resources were,” Obert
observes. “There is not much cross-
over between the nurses that work in
pediatrics or work in the adult ED or
work in trauma. They typically focus
on one of those three areas.”

As a result, when clinicians ran
out of chest tubes or other needed
supplies, staff didn’t necessarily know
where those resources were stored,
so it would take added time to track
them down.

“That was a bit of an issue because
we had a lot of people to help, but
they didn’t have familiarity with what
was there.”

Take Advantage

of Military Training

Another issue that arose was a lack
of some basic supplies such as tour-
niquets and chest seals, things that
typically are not used in the ED. “It
is very rare that we put a tourniquet
on in the department. We will put a
blood pressure cuff on, but when you
have 20 people with arterial extremity
wounds that are all heavily bleeding,
you don’t have 20 blood pressure
cuffs,” Obert notes.

Consequently, a lot of the equip-
ment emergency staff members were
using was coming from first respond-
ers. “Our physicians who support the
police department have actually built
kits for [first responders] to use on
scene, so we ended up using a bunch
of those kits,” Obert recalls. It is one
issue that definitely will be addressed
in the post-event analysis, he adds.

Given the fact that patients were
triaged to two separate buildings,
good communication between
the ED and the trauma unit was

important. In fact, the hospital’s
emergency planning calls for the
availability of two-way radios, but
this aspect did not go as smoothly as
intended, Obert observes.

“Once they set up the incident
command center and started going
through the equipment, they dis-
covered some technical issues,” he
explains. “The equipment is checked
every once in a while, but some of it
was not properly charged.”

Clinicians were able to work
around the problem by using tele-
phone communications, but it is an
area that clearly can be improved,
Obert adds.

While the distinct geography of
the trauma center presented some
obstacles, Obert stresses that the cen-
ter is uniquely designed to respond
quickly to patients with severe inju-
ries, which certainly proved advanta-
geous for the seriously wounded the
night of the shooting.

“You have proximity to a CT
scanner, you have proximity to an
angio suite and to the operating
rooms,” he says. “Someone can

be offloaded from a rig, get an
evaluation, and get to the operating
room within a few minutes, which is
a pretty phenomenal process.”

As is often the case, military train-
ing proved invaluable in the hospital’s
emergency response. In particular, a
physician assistant’s military instincts
kicked in and he took charge of the
triage process, labeling patients with
their injuries when they arrived. The
approach deviated a bit from the hos-
pital’s mass casualty training process,
but it worked, Obert notes.

“He actually did probably 90%
of the triage and he was phenomenal
because he was just very focused,” he
says. “He was the one directing who
was going to stay in trauma if they
were shot in the chest or the belly or
had a significant wound that required
tourniquets and things of that sort. If
not, he was directing patients to the
adult ED or the PACU.”

Consider Paper

Registration

While mass casualty practice drills
certainly make a difference when the
need arises to activate emergency
plans, the magnitude of this event was
overwhelming, Obert notes.

“You can drill for anything, but
it is not the same when it is real time
and there is real emotion and stress,”
he says. “And of course it happened
when [we were] not expecting it —
10:30 on a Sunday night, which isn’t
characteristically a big trauma night.”

Further, in the midst of the crisis,
it was unclear how many patients
would be arriving, which made
decisions on how to register patients
difficult.

In the end, staff used electronic
medical records (EMRs) to register
patients throughout the night, which
wasn’t necessarily the best option.

136 | ED MANAGEMENT® / December 2017 ED MANAGEMENT® / December 2017 | 137

“They didn’t know how many
patients to expect, so they went from
a few patients to 50 patients within
an hour,” Obert relates. “They actu-
ally pulled in registration people from
all over the place, and they were out
there meeting patients on the curb
and were doing bedside registration as
soon as the patients arrived.”

Switching to paper registration
might have been more expedient, Ob-
ert observes. The hospital maintains
preprinted packets for this purpose,
but it was not prepared to intake 50
patients at once.

“We use paper registration for peo-
ple who are suffering from a stroke or
a heart attack, so some of our post-
event [analysis] is that we need to
have at least 100 pre-printed labels,
tags, and charts,” he says. “To me
the biggest issue was the fact that we
were bouncing patients from depart-
ment to department and having them
followed. And, unfortunately, EMRs
aren’t that user friendly, so no mat-
ter how good they are, when we have
three separate locations, it becomes a
challenge of patient tracking.”

Despite all the challenges, Obert
gives the staff high marks for their
emergency response.

“They handled the incident very
well,” he says. “I felt comfortable
leaving at 3:30 a.m. because most of
[the patients] had already been there,
people were taken care of, and we
were discharging a lot of people,” he
says. “The patients that needed to
be there emergently were there, and
the rest had already been admitted or
seen by consultants.”

However, even a day or two after
the incident, patients from the inci-
dent continued to present to the ED.

“We were getting transfers later
on, and people eventually turned
up who had injuries sustained from
the stampede,” Obert notes. “People
were stomped on and people hit their

heads and had skull fractures, so there
were some secondary effects from [the
mass shooting]. And then we started
getting influxes of people with degrees
of PTSD [post-traumatic stress disor-
der] and anxiety.”

Even people who were not at the
festival where the mass shooting oc-
curred were developing symptoms,
Obert explains.

“We are still seeing people who
are extremely traumatized by some
relation to the event, the location or
something else that happened in their
life. This has reactivated something,”
he says. “We are seeing those kinds
of patients all over [Las Vegas] Valley
now.”

Develop a

Versatile Process

Some members of the hospital
staff are experiencing a degree of
emotional fallout from the event.

“We still have counselors [on site],
and there are some people where
there has been more of a delayed
impact,” Obert explains. “We see
things on the news all the time about
patients that we have taken care
of, but this has been of such great

magnitude that it is overwhelming.”
However, the gratitude shown by the
community has been a huge positive,
Obert stresses.

“We are getting deliveries of food
and gifts every single day still,” he
says. “I have been in Las Vegas for
12 years, and I have never seen an
outpouring from the community like
anything close to this, so it’s pretty
phenomenal. They have done a lot to
support the nurses and the physicians
and the first responders throughout
the city.”

While the shooting event on Oct.
1 was unprecedented in scope, mass
casualty events are not uncommon in
Las Vegas, Obert says. He recalls one
recent incident in which a woman
who apparently had some type of
psychiatric issue drove down the side
of the street, running over several
people.

There also have been several
deadly fires in recent years. Hospital
staff members know they need to be
prepared.

“Unfortunately, something like
this is going to happen again in Las
Vegas. We just don’t know to what
degree, and that is the challenge,”
Obert laments. “It is a matter of
preparing for a process that is going
to work in any circumstance, and not
just mass casualty shootings.” n

SOURCES
• David Obert, DO, Assistant Medi-

cal Director, Emergency Depart-

ment, University Medical Center of

Southern Nevada, Las Vegas . Email:

[email protected] .com .

• Scott Scherr, MD, FACEP, Medi-

cal Director, Emergency Medicine,

Sunrise Hospital and Medical Center,

Las Vegas . Phone: (702) 383-1958 .

• Jeff Murawsky, MD, FACP, Chief

Medical Officer, Sunrise Hospital and

Medical Center, Las Vegas . Phone:

(702) 881-8887 .

“IT IS A MAT TER
OF PREPARING

FOR A PROCESS
THAT IS GOING

TO WORK IN ANY
CIRCUMSTANCE,
AND NOT JUST

MASS CASUALT Y
SHOOTINGS.”

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