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Rapid response: Triage mass shooter patients as treatable by lay people or medical professionals

Protection from above and layperson bleeding control are among the immediate takeaways from Las Vegas mass shooting for EMS personnel and paramedic chiefs


Police officers and medical personnel stand at the scene of a shooting near the Mandalay Bay resort and casino in Las Vegas.

AP Photo/John Locher

What happened: A single gunman shot into a crowded, outdoor Las Vegas concert from the 32nd floor of the Mandalay Bay hotel and casino. More than 50 people were killed and at least 400 people were injured. It’s unknown at this time if all of the deaths and injuries were from gunshots or if other causes, such as blunt trauma from trampling, may have added to the casualty count.

On- and off-duty public safety personnel, including four police officers, were among those killed or injured in the crowd of 22,000 concert attendees. The suspected gunman, Stephen Paddock, 64, allegedly died by suicide before police entered his hotel room.

Why it’s significant: The known death toll reported by Las Vegas officials already makes this the deadliest mass shooting in U.S. history, surpassing the 2016 Pulse Orlando night club and the 2007 Virginia Tech University mass shootings.

Mass gatherings, a daily occurrence in nearly every U.S. city, continue to be especially vulnerable to a lone wolf attacker with a gun, explosive device or vehicle. Police are investigating the shooter’s motive and why he selected this event versus other events.

Top takeaways: After the May 22, 2017 Manchester, England bombing, I wrote about the importance of mass gathering venue threat assessment and encouraged EMS providers and leaders to answer these questions:

  • What are the upcoming concerts, sporting events, festivals and rallies in your response area?
  • How has your EMS agency partnered with law enforcement to pre-plan and practice MCI response?

With those questions in mind, as well as the still rapidly developing news from Las Vegas, here are my top early takeaways.

1. Run! or Escape! to concealment and cover

Evacuation of attendees from a mass gathering venue is a top concern of event planners, fire code enforcement officials and medical personnel. Much of that pre-planning is likely focused on a threat that is inside the venue and on the same elevation as the venue.

The current active shooter survival mantras of Run! Hide! Fight! – or the variation Move! Escape! or Attack! – were conceived primarily for contained venues like schools, churches or office buildings. The Las Vegas shooter was 300-feet above, across Las Vegas Boulevard from the Route 91 Harvest Music Festival, and apparently shooting rapidly and indiscriminately into the crowd.

It’s lifesaving for potential victims to Run! or Move! toward concealment and cover which offers protection from a threat that has the advantage of height.

2. Lay people control severe bleeding

I anticipate two major causes of death – severe hemorrhage from penetrating trauma and blunt trauma secondary to trampling – will be reported. Control of bleeding is a layperson skill and in an incident with hundreds of victims, every able-bodied person needs to be able to apply direct pressure, improvise a tourniquet and apply a tourniquet.

3. EMS assesses, treats blunt trauma

Blunt trauma, especially injuries to the head, neck, chest and abdomen, need assessment and treatment from medical first responders, EMTs and paramedics. MCI plans and drills need to prioritize the triage of patients by injury severity, transport priority and the type of treatment – layperson or medical professional – that is required.

4. Impossibility of defending the indefensible

Hotels are inside, adjacent to or overlook major airports, stadiums, race tracks and arenas throughout the U.S. Hotels also overlook temporary mass gathering events like marathon starts or finishes, craft festivals or farmer’s markets. Is it conceivable or feasible to prevent a potential shooter from accessing those venues, potentially screen every entrant into the lobby or parking garage, or permanently close every window?

5. Multiple attackers will be exponentially more deadly

The only limit on the casualty count from a mass shooter seems to be the inability of lone wolf attackers to enlist co-conspirators. Additional shooters in multiple locations – like the 2015 hybrid targeted violence attacks in Paris – will result in exponentially more deadly mass shootings.

What’s next: We will learn more about the heroic actions of concert goers, other lay persons, paramedics and hospital personnel to save lives. Their reports will inform our preparedness for the next lone wolf attacker. Threat assessment and MCI planning for other mass gathering venues from an attacker above the crowd must begin today and not wait for the completion of the Las Vegas investigation.

Learn more about MCI preparedness and response

Here are some other articles from EMS1 on mass gathering readiness, mass casualty incidents and terrorist attacks.

Greg Friese, MS, NRP, is the Lexipol Editorial Director, leading the efforts of the editorial team on Police1, FireRescue1, Corrections1 and EMS1. Greg served as the EMS1 editor-in-chief for five years. He has a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005, and a long-distance runner. Greg was a 2010 recipient of the EMS 10 Award for innovation. He is also a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and the 2018 and 2020 Eddie Award winner for best Column/Blog. Connect with Greg on LinkedIn.