Tuesday, November 14, 2017

These Are My People

h/t Peter @ Bayou Renaissance Man
Vegas shooting ER team
Ironman, Captain America, Superman, and Batman 

From this month's Emergency Physician's Monthly (the trade paper for ER docs):

I’m a night shift doc. My work week is Friday to Monday, 8 p.m. to 6 a.m. Most people don’t want to work those shifts. But that’s when most of the action comes in, so that’s when I work. It was a Sunday night when the EMS telemetry call came in to alert Sunrise Hospital of a mass casualty incident. All hospitals in Las Vegas are notified in a MCI to prepare for incoming patients.
As I listened to the tele, there happened to be a police officer who was there for an unrelated incident. I saw him looking at his radio. I asked him, “Hey. Is this real?” and he said, “Yeah, man.” I ran down to my car and grabbed my police radio. The first thing that I heard when I turned it on to the area command was officers yelling, “Automatic fire…country music concert.” Ten o’clock at night at an open air concert, automatic fire into 10-20 thousand people or more in an open field—that’s a lot of people who could get hurt.
At that point, I put into action a plan that I had thought of beforehand. It might sound odd, but I had thought about these problems well ahead of time because of the way I always approached resuscitations:
1. Preplan ahead
2. Ask  hard questions
3. Figure out solutions
4. Mentally rehearse plans so that when the problem arrives, you don't have to jump over a mental hurdle since the solution is already worked out 
It’s an open secret that Las Vegas is a big target because of its large crowds. For years I had been planning how I would handle a MCI, but I rarely shared it because people might think I was crazy.

It's written by the senior ER doc on duty, and so from his perspective. Taking not one thing from him, but the reality is, while his plan helped, it was a team effort.

For instance, they had 6 ER docs working that night, including a Trauma surgeon and Trauma resident.
We also initiated our hospital’s “code triage,” in which staff from upstairs would come down to help by bringing down gurneys and spare manpower. We took all of our empty ED beds and wheelchairs out into the ambulance bay. Anybody who could push a patient, from environmental services to EKG techs to CNAs, came out to the ambulance bay. I said to the staff, “I’ll call it out. I’ll tell you guys where to go, and you guys bring these people in.”
Unstated were how many RNs on hand, but in a 36-bed main ER, they had 10+, which swelled to probably 20-50.
What were they doing?

 At that point, one of the nurses came running out into the ambulance bay and just yelled, “Menes! You need to get inside! They’re getting behind!” I turned to Deb Bowerman, the RN who had been with me triaging and said, “You saw what I’ve been doing. Put these people in the right places.” She said, “I got it.”
And so I turned triage over to a nurse. The textbook says that triage should be run by the most experienced doctor, but at that point what else could we do?
Better late than never, doc. Nurses run Triage 24/7/365 everywhere. Should've seen that coming and made the call a lot faster.
We were in the hallway of Station 1 with the beds side by side. We were butt to butt intubating these three people. “I need etomidate! I need sux!”
Up until then, the nurses would go over to the Pyxis, put their finger on the scanner, and we would wait. Right then, I realized a flow issue. I needed these medications now. I turned to our ED pharmacist and asked for every vial of etomidate and succinylcholine in the hospital. I told one of the trauma nurses that we need every unit of O negative up here now. The blood bank gave us every unit they had. In order to increase the flow through the resuscitation process, nurses had Etomidate, Succinylcholine, and units of O-negative blood in their pockets or nearby.
Another good call. But "Duh".
By this time, all the patients had bilateral IVs. As the orange tags and yellow tags would become red tags, it became very apparent that those early IVs, put in while patients still had decent veins, were lifesaving. As the patients decompensated, we had adequate access to rapidly transfuse and stabilize patients. If we didn’t have that early IV access, we would have spent valuable time trying to cannulate flat veins.
Putting in IVs: nursing skill. Twenty-forty/night. That's why all those patients magically had bilateral IVs.
Cannulating flat veins: what ER docs do when patients don't have anything better.
So again, "Duh."
Throughout the night, I would look up from what I was doing and scan the room to see if anyone was crumping. I noticed a choke point forming for CT. We were now left with stable yellow tags. These patients needed CAT Scans. Typically, the CT Tech picks up the patient, transfers them onto the scanner, and then they bring the patient back. These yellow tag patients were shot in the torso, but for some reason were stable even after 2 or 3 hours. I told the CT Tech, go over to the CAT scan machine, and sit behind the controls. “I don’t want you to move. You’re just going to press buttons for the rest of the night.” Then I took every nurse that was free—at that point we had a lot of extra staff—and told them that all the people who needed CAT scans needed to be lined up in the ambulance hallway outside of CAT scan. We placed monitors on them, and nurses watched them. Then the nurses assisted getting each patient on and off the CT, and then back over to Stations 2 and 4. I called it the CT Conga Line.
And yet again: Good improvisation, excellent use of resources, poor foresight.
But how many hospitals deal with 250 GSWs in 6 hours? So far, just this one.
I identified another choke point with the green tag patients. Many were shot in the extremities. They had potential fractures or open fractures and needed X-rays. The standard way of doing things is taking the patient for an X-Ray, then sending it off to the radiologist so they can read it in their reading room. That was just going to take too long. So I told our CEO, Todd Sklamberg, “I need a radiologist here in the ER. I’m going to attach him to an X-Ray tech because our machines have little screens on them.” They X-Rayed patients, the radiologist read off the screen, and we would decide on disposition right there.
Another genius move. Put the people where the work is, and roll the patients past them.
Create flow; eliminate the bottlenecks, choke points, and single-points-of-failure.
IOW, destroy almost everything we do now, to do what you have to do then.
In the end, we officially had 215 penetrating gunshot wounds, but the actual number is much higher. As I would circle the ER “looking for blood,” I would hear the green tags say, “You know what? I’m not that bad—I’ll be fine.” Over time, they would walk out without getting registered. Our true number was well over 250.
The surgery team performed an unprecedented feat that night. The numbers speak for themselves. In six hours, they did 28 damage control surgeries and 67 surgeries in the first 24 hours. We had dispositioned almost all 215 patients by about 5 o’clock in the morning, just a little more than seven hours after the ordeal began. That’s about 30 GSWs per hour. I couldn’t believe that we saved that many people in that short amount of time. It’s a testament to how amazingly well the hospital team worked together that night. We did everything we could.

Improvisation: 10
Pre-planning: 5
Success: 9.9

Takeaway: Plans fail. So does planning. People - who can improvise on the spot - save your ass. And in this case, 200+ patients too.
Top to bottom, these folks were rockstars, when it counted.

Hopefully some of the two dozen nurses and hordes of other staff members will be telling their stories from that night, especially for lessons learned from all the other perspectives.

Superpowers, bitchez.
F**k a cape and tights; superheroes wear scrubs and stethoscopes.
And they kick Death's ass.


Anonymous said...

Read this via Peter's site. One of the things we were taught was to get a line in, even if the bag ( We had half liters on us) went dry, at least there would be a line.
Boat Guy

Gary Griffin said...

Trauma victims get 2 lines (standard of care). Dentists usually make the best triage leads with RN's a close second. Never allow a surgeon anywhere near the triage area. It sounds lime you may have danced to a waltz like this before.

froginblender said...

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

Maybe I'm reading this wrong, but why did he keep the plan to himself? I would have thought that the ER dept in his hospital practice a dry run for a mass casualty incident at least once a year, in which he would have had the opportunity to contribute his plan and have it evaluated.

I would also have thought that at least every three years, a large-scale exercise involving several hospitals, ambulance services, cops, fire dept, and whatnot is held to simulate a multi-agency exercise in the metro area, with thorough post-mortems to spot where improvements are needed.

John ShootBetter said...

A lot of the bottleneck/flow analysis is pretty old hat in the Lean/Toyota Production System/Theory of Constraints world. Is that kind of analysis typically done in ERs? I would hope it was being done on a pretty ongoing basis in ERs and not just for mass casualty incidents.

Anonymous said...


I would also have thought that at least every three years, a large-scale exercise"

Mnnnn, not as such. Can't just close the ER for the exercise. Can't divert all the staff that are barely getting the normal work done.

I did wonder what the official hospital MCI 3 ring binder had in it, and who developed that plan, but then I remembered-- NO ONE really expects the emergency plans to be implemented, so they are rarely practical, and often put off or given only a cursory effort.

Finally the MC exercises I've been part of or read the AARs usually set pretty modest goals. The organizers know that their plans won't work (see clauswitz) and they don't want to hammer the participants. You want the participants to learn SOMETHING, not just get frustrated. For example, the exercise never starts with a trainer counting off every third person and telling them to sit down because they didn't make it in to work because the bridge was out. Or telling the first 3 sets of rescuers they've died from chemical exposure and won't be participating further.

Read the AARs from Cascadia Rising (which just took place recently.) Read some of the AARs from non-official agencies, like hams or CERT teams. It was a giant cluster grope and people were lucky just to get COMMS working.

These guys in Vegas were rock stars. They saved lives, and pulled miracles out of a hat. In the end, it wasn't the plan in the 3 ring binder from the 'table top exercise' three years ago, it was down to the people on the floor making good decisions, recognizing the extraordinary nature of the incident, and responding to what was actually happening.

Now, flip the script. Think about what a coordinated series of attacks, or several in the same place in a row, would do to the local response. Think about what would have happened if the attacker(s) just kept shooting. Gut clench? Chest get tight?


Deana said...

If only the EDs across the country knew about those dentists . . .

Aesop said...

1) Boy and girls, just to be clear, three of the ER docs in that pic are D.O.s (Doctor of Osteopathy). The "dentists" line was a comment.

2)@ froginblender
Most ERs everywhere forever run on the ragged edge of disaster every fricking day, 24/7/365. The luxury of playing MCI games is reserved for fire and EMS guys off-duty, and they're mainly dog-and-pony shows to stroke someone's ego, not actual training.
If I were emperor, one day a year, rotated so only one facility at a time was closed, I'd throw the Mother Of All Disasters at every ER in the country, I'd pull the power plug out an hour into it, and somewhere during the festivities, there would be combative family members and an active shooter or IED explosion in the triage area. Two hours in, someone would either have Ebola or come in covered in anthrax or Sarin. Three patients of different ages/sexes would have the exact same name, and 20% of them wouldn't speak any English.
It would start two hours before shift change, and cross over into night, or vice versa. Ideally, both, in two exercises, run twelve hours apart.
I'd have 50+ patients from child to senior citizen-age, 50 hands-off grader/observers, and 50 video cameramen, I'd put GoPro bodycams on all the staff, and the entire thing would get an NTC brigade-level debrief afterwards, and be edited down to one helluva debrief documentary for wide dissemination on DVD and YouTube.

No one above the level of charge nurse (no suits, no managers/directors/CEOs) would be allowed within 100 yards of it while it was happening.

I'd do one a month just in my county, I'd bring in make-up, prop, and FX artists from Hollywood productions, and they'd be mother-effing EPICs.

And everyone there would go home sweaty, and needing a change of underwear, but their damned paper plans would get ass-raped, and they'd learn how to play jazz instead of opera.

And the line to play in the next year's exercise, as both participant or test-takers would be around the block.

It was how *I* was trained, before nursing school, in a course exponentially more challenging than my degree, and I'm here to tell you it works.

Anonymous said...

Would that you could do that Aesop. If you ever CAN, I'll break a rule and come back to CA to help in any way I can.
Gary Griffin
I was not referring to "standards of care"; our situation would be getting one of our guys TO someplace with at least a line in. Whether by medevac or bringin him in ourselves we only had what we had and that's one set and a 500ml bag per guy, with maybe a 1000ml bag per in the boat.
Boat Guy

Anonymous said...

1) If you do NOT know Clarence Moore out of Cleveland (OH) EMS you should. He enjoys taking over hospitals, all by his lonesome, and does it fairly regularly.

2) Guy name of Dr J. D. Polk maintains that the absolute best Triage System is an EMT fully trained in the START Quick Triage System. If someone has an MD or DO after their name he or she needs to be MILES away from Triage.

3) Friend f mine ws the MCI Disaster Team Charge Nurse for UMC that Sunday night. She is JUST getting to being ble to talk about it....STERLING CISM, guys [/SARC--muthafeckers!!!] She is a damn good Nurse and good kid. 'S'only been a muther fuckin MONTH!!!! (Wife has sat on a Regional CISD/CISM board so.....)