[sidebar]First responders to the mass shooting on the Las Vegas Strip. Credit: STAR MAX/IPX[/sidebar]
On Oct. 1, 2017, attendees of the Route 91 Harvest country music festival in Las Vegas were enjoying the event’s closing performance by Jason Aldean when tragedy struck. A single gunman opened fire on the crowd from a room in the nearby Mandalay Bay Resort and Casino, injuring 851 people and killing 58. The victims were transported by private vehicle, taxi, and ambulance to nearby hospitals, including Sunrise Hospital & Medical Center, where Scott Scherr, MD, medical director of the emergency department, and his colleagues prepared to treat the injured.
ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with Dr. Scherr and Jeannine Ruggeiro, a 28-year-old social work graduate student from Sonoma County, California, who was one of the shooting victims that night, to discuss their experiences in the aftermath of the mass shooting. Here is Part 1 of their conversation. Part 2 will appear in the March issue.
KK: Scott, we’ll just touch base about this event Oct. 1 at the Harvest music festival in Las Vegas. You’re the medical director at Sunrise. How many patients did you receive that night?
SS: We saw 215 patients, and all 215 patients were seen within about 90 minutes. The first patient arrived by private vehicle 20 minutes after the incident started.
KK: Did you have the sense what the volume of patients would be or that there was even an event going on?
SS: I was at home getting ready for bed when I got the calls and the text messages, so I just hurried up and got dressed. I was listening to the radio on the way in and heard a report of an active shooter on the Strip with two known fatalities and multiple injuries. I wasn’t expecting this type of magnitude when I showed up 45 minutes after the incident started and saw the ambulance bay full of private vehicles, trucks, Ubers, and taxis.
KK: How were you able to coordinate all of that traffic in the ambulance bay?
SS: Fortunately, Dr. Kevin Menes is a SWAT medic. He was able to go to his car, get his radio, and listen to the police chatter. By the time I got there, he had all the gurneys, wheelchairs, and frontline staff actually sitting and waiting in the ambulance bay for the first patients to arrive.
KK: Did you do any initial triage outside of the emergency department, or did you bring everybody inside to do that?
SS: Everybody was brought inside. We were fortunate that this was a Sunday night in Las Vegas. The ED volume was not like it would be on a Monday or Tuesday night, so we were able to put our active patients in certain areas to make room for the patients that were coming in. Initially, the MCI [mass casualty incident] triage was done by a physician. However, we needed physicians in the back to take care of the sicker patients, so we passed that on to one of the nurses out there to coordinate the MCI triage. A lot of things that I’m going to learn, I’m going to learn from Jeannine, from the patient’s perspective.
Station 1 was the area where we took care of all our “red” patients. Those were our most unstable patients with the most life-threatening injuries. Station 2 and Station 4 were for what we call our “yellow” or our “immediate” patients to resuscitate them and stabilize them there. Then we utilized our ambulatory care areas, our pediatric emergency department, and our PAC-U [post-anesthesia care unit] space [as Station 3] for what we call our “green” patients, which is kind of our “walking wounded.” We had that pretty well dialed in when the first patients started to arrive.
KK: Can you give us a sense of the spectrum of injuries that you saw?
SS: Most severe were gunshot wounds to the chest, abdomen, and also to the head.
KK: I have to credit you and others for your disaster preparedness plan and making sure everybody was ready to go. Do you think that plan was adequate?
SS: It was from an organizational standpoint, but there were a lot of lessons learned. We’ve practiced MCIs and even had a few MCIs, but nothing to this scale, so there are certain things that we ran out of. We ran out chest tubes and laryngoscopes. We ran out of ventilators at one point. We ended up having to put two patients on the same ventilator at one point. Sunrise is part of a three-hospital system, so we were able to commandeer level 1 transfusers, chest tubes, laryngoscopes, and blood products from our area hospitals in a matter of minutes.
KK: What did you do in those cases where you realized you were ready to put the chest tube in and you didn’t have any more chest tubes? What do you do?
SS: We utilized endotracheal tubes to substitute as a chest tube until we could get more chest tubes.
KK: That’s impressive. And two patients on one ventilator?
SS: There’s data out there from case studies. If they’re like-sized, you just double the tidal volume and separate the ventilator by an H-tube or a T-tube. Luckily, we only had to do that one time, and it was only for a matter of minutes until we got another ventilator.
KK: Wow, but what a great solution. Who came up with that idea?
SS: Actually, Dr. Menez did. That was one of his patients. We’ve read about it, and the respiratory therapist knew exactly what equipment to provide.
KK: You mentioned earlier that you are really trying to get your arms around the data of this whole event. Can you tell us a little bit about what you know already from that assessment?
SS: A lot of things, very simple stuff. Registration got completely overwhelmed, and you can’t do anything treatment-wise on the patient or order any medications on the patient without proper identification of the patient. When you see 215 patients in 90 minutes, to get them into the computer in an accurate fashion, that was really difficult. We’re working on ways to have a more rapid intake model when it comes to patient identification.
Communication with incident command is really good, but the footprint of the ER grew from a 45-bed ER and multiplied by roughly four times as we took over the PAC-U space and the pediatric ER space and various other spaces on the ground floor of the hospital. It made my job difficult to communicate with the physicians in each station on what they needed and the status of the patients in those stations.
Another issue was obtaining radiology interpretations. When an X-ray is taken, it’s taken electronically and needs to be verified by the technologist before the radiologist could interpret it. We actually had the radiologist follow the portable X-ray machine around and provide preliminary reads to us verbally, or they would write them on the patient’s gurney or on the patients themselves. We had real-time reads.
KK: Did you get anything documented on these patients in a formal fashion at all?
SS: We did initially, but the documentation was sparse. We had 18 of our scribes show up that night, so we were able to do a pretty good job documenting later once the patients were verified and put in the proper treatment areas.
KK: I would think that’s one of the first things that is going to go by the wayside. Take care of the patients and document what you can, if you can. With 200-plus patients, how much time did it take to process and take care of all of them?
SS: By probably six o’clock in the morning, everybody had been seen and taken care of. By eight or nine o’clock in the morning, we had pretty much the entire emergency department cleared of anybody that was involved in the incident.
KK: That’s an impressive piece of work, Scott, and I can’t thank you enough for the service you provided to prepare your team and, most important, to care for those 215 victims. What a great demonstration of the impact that emergency physicians and emergency medicine can provide for a community.
SS: The response that we got, not only our ER team but from so many others, was amazing. We had 20 physicians and nurse practitioners show up to the emergency department that night. We had pediatric emergency department doctors and nurses taking care of adult patients on their side [of the emergency department] and then over 100 physicians, including pediatric surgeons, handling the sickest patients. Over 200 surgeons and additional staff responded as well.
KK: What your team, hospital, and community did in such short order is nothing less than heroic. As unfortunate as this was, I’m sure lessons can be learned from this horrific event. What we don’t hear much about is the patient’s perspective. From a humanistic perspective, what are their experiences like? So Jeannine is with us, and she’s been kind enough to share her thoughts with us. Scott, did you take care of Jeannine?
SS: I didn’t directly take care of her. She was in Station 2. The reason I know that is I had a call from one of my high school friends stating that the fiancée of one of the guys that he works with in the police department was shot and was injured, so I asked the age of the patient and the injuries and I said, “Well, that sounds like somebody who was in Station 2 that one of my docs, Dr. English, took care of,” and it ended up being Jeannine. About two days later, I was able to visit Jeannine in the hospital.
KK: Jeannine, could you tell us a little bit about your evening before this whole thing happened?
JR: It was the third day of the music festival and the last performer of the night, Jason Aldean. I was toward the front of the stage on the right-hand side, on the Mandalay Bay side, with two of my girlfriends. We were dancing, laughing, singing, had drinks, just like pretty much everyone else in the crowd, when the shooting started. When it first started, none of us knew what was going on. Everybody in the crowd said, “Oh, maybe it’s fireworks. Maybe it’s a blown amp.” Jason Aldean was still performing at that point, and then the shooting began again at a faster pace. Everyone dropped to the ground. Jason Aldean went off the stage. People were confused; people were screaming. I immediately just had this feeling like, “How do I get out of here?” Then there was a break in the shooting for a couple moments. We got up to run, and it was at that time I was shot in my back and collapsed to the ground.