ER surgeon recalls lessons learned in Las Vegas shooting
Dr. Allan MacIntyre spoke about his experience in the ER after the Las Vegas shooting at the California Hospital Association’s Disaster Planning Conference
By Cathie Anderson
The Sacramento Bee
LAS VEGAS — Within 20 minutes of last year’s mass shooting in Las Vegas, doctors and nurses at Sunrise Hospital’s emergency room knew what horror was unfolding at the Route 91 Harvest Festival.
Trucks and cars had raced to the ER entrance by 10:25 that night – Oct. 1 will mark the first anniversary – even before ambulances could arrive. The vehicles, in some cases, were packed with the injured, bloody and sometimes naked.
Their clothes had come off, as they were dragged across a lawn or street or parking lot by people trying to get them to safety and then to medical care, said Dr. Allan D. “Dave” MacIntyre, a trauma surgeon who was on call at Sunrise that night. He spoke to health care workers in Sacramento this week for the California Hospital Association’s annual Disaster Planning Conference.
“The first people to arrive came in personal vehicles and then the ambulances followed,” he said. “Other people followed the ambulances. We had a lot of patients very quickly. We were overrun. Our ER had thousands of people in it in just a few minutes. I had very, very little space.”
MacIntyre set the scene for his audience, told them what to expect, offered up lessons, named challenges they should consider, but the one thing he had trouble doing was talking about how the event affected him. Overwhelmed by emotion, he said that he does a lot more teaching and public lecturing now than practicing trauma medicine because that has become too hard. He’s preparing to pursue an executive MBA.
It was MacIntyre who was tasked with ensuring the triage system was running effectively at Sunrise. Stephen Paddock had opened fire at a little after 10 p.m. on a crowd of thousands from his suite on the 32nd floor of the Mandalay Bay hotel. In the aftermath, 58 people died and more than 800 were injured in the deadliest mass shooting by a lone gunman in the nation’s history.
The first thing MacIntyre did, he said, was call two physicians who would have been his back-up, telling them there had been a mass-shooting and asking them to activate the phone tree to get as many doctors on duty as possible. He then made a similar call to a resident physician, he said, before turning his attention back to the ER.
Looking back, he said, he wished his team had set up patient intake outside the hospital in the parking lot. Gurneys should have been moved out there, he said, and their heads should have been sitting upright. Many patients, he said, were loaded onto gurneys the wrong way that night.
“Try moving an adult patient who’s paralyzed with tubes all around them,” he said. “It takes a lot of effort.”
Staffing quickly surged at the hospital as word spread, MacIntyre said, with nurses who typically practiced in other states showing up to help. Physicians and surgeons who practiced at other hospitals walked through the doors, seeking assignments.
“There were 200 nurses in the hospital,” MacIntyre said. “There were over 100 physicians and all the support staff, and still, we were overrun. This is the only picture you’re going to see of the … floor of the ER. It was littered with debris and blood everywhere.
“The fire department services kept cleaning up for us. We had a lot of contamination risk, so we were dropping a lot of contaminated debris to the ground, and they would come along behind us and make sure it was cleared up.”
Many patients had no identification, MacIntyre said, and they were too incapacitated to do formal registration. He and other physicians provided a lot of care that night that couldn’t be tracked easily because so many people were unidentified.
MacIntyre said he wished that he’d had something as simple as a Polaroid camera and a grease pencil, so he could have taken pictures of the patients’ faces and identifying marks. He could have used the grease pencil, he said, to write treatment codes on the back of the photos.
Asked what he would have done with those Polaroid photos, MacIntyre said he would have kept them with him and updated them as he went back to patients.
Whatever the system, he said, hospitals must consider the challenge of how to log care for dozens of unidentified people. People have suggested, he said, that he could have written codes directly on patients with a Sharpie, but he would have needed a new Sharpie each time to avoid contamination. Remember, he said, patients have been dragged through dirt and trash, and in some cases, they may have been laid on top of each other during transport.
The mantra that remained with MacIntyre that night was: Keep it simple.
He said he had worked on scenes with the Las Vegas police department’s SWAT team, something he recommends that all trauma surgeons do with their local law enforcement, and that work had taught him what was essential and how to improvise.
In initial surgeries, he said, medical teams took a combat-style focus, working to stop bleeding and stop contamination from gut wounds rather than trying to put the patients back together. In the emergency room, he said, commonly needed medications had been put on a tray accessible to ER staff.
Many patients received treatment on gurneys in the hallways, he said, and all communications were done face-to-face. Even hospital administrators set up their command center within view of ER staff, MacIntyre said, and he applauded them for doing so.
All the manuals say that the command center should be farther away, back in some conference room, he said, but with roughly 220 patients seeking care, it was invaluable to have administrators hearing what doctors and nurses needed and seeing the challenges and then immediately making calls for equipment, medications and supplies.
“We had 124 gunshot wounds,” MacIntyre said. “We did 58 surgeries in the first 24 hours. ... I have the feeling he (Paddock) had a scope because I was seeing a lot of head shots, chest shots, belly shots. We had a lot of orthopedic issues. And we did a total of 83 surgeries over the next 48 hours.”
But by the next morning, MacIntyre said, the ER looked as it normally did because first responders and health care workers all pitched in to set everything right.
Preparing a hospital for a mass casualty
Dr. Allan D. “Dave” MacIntyre was the trauma surgeon on duty at Sunrise Hospital in Las Vegas the night of Oct. 1 when Stephen Paddock fired into a crowd of country music lovers at the Route 91 Harvest Festival. Earlier this week in Sacramento, he shared observations and recommendations he felt would benefit health-care workers. Here are highlights:
Experience pays off: Every Dec. 31, the New Year’s Eve festivities in Las Vegas provide an opportunity for Sunrise Hospital’s ER staff to re-evaluate how to handle a surge in trauma patients, and the medical team there also has had to deal with airport incidents. That experience made it easier, MacIntyre said, but the mass shooting posed unexpected challenges. He suggested hospital leaders coordinate a drill for their ER teams to see how phone trees work and to see what happens when they have to quickly move 100 or more patients through their facility. Trauma doctors should consider attaching themselves to a police SWAT unit or other such team as practice.
Hospital access: Patients will likely come to your hospital’s emergency entrance. What bottlenecks will be created there? If doctors and nurses from outside your facility come to help, how can you make it easy for them to get to parking and into your building?
Nurse-patient engagement: The nurse-patient ratio that night was one to one in the emergency department. MacIntyre said this was invaluable.
Resident doctors: How will your organization position first-, second- and third-year residents? At Sunrise, they used some first- and second-year residents for initial triage of patients and others to assist ER doctors. Third-year ER residents assisted with surgeries and, in many cases, were the first doctor in the operating room, getting things prepared.
Outside the box: Pediatric surgeons joined with pediatric nurses to work on adults that night and did a marvelous job, MacIntyre said.
Logistics management: MacIntyre said he liked having administrators close enough to see what the ER team needed. They made the necessary calls to get additional supplies, equipment and medications.
Tracking treatment: How will your hospital track registration and treatments on multiple patients who have no identifications and no personal effects? MacIntyre said he wished he’d had a Polaroid camera and grease pencils. He would have snapped pictures of the patient and written treatment codes on the back of the picture, keeping the info with him and referencing it when he returned to the patient.
Family/decedent management: After patients were admitted to rooms, relatives and friends often were sleeping in hallways outside patient rooms, and when doctors would do rounds, they were often assailed by questions and unable to work on patients. Since the Oct. 1 mass shooting, Sunrise Hospital has restricted access to floors with patient rooms. Hospitals should discuss how to effectively communicate with the patients’ families.
Communication: Consider how you will communicate information to hospital and medical staff on site. MacIntyre said he felt face-to-face communication worked well at Sunrise because exceptions and follow-up questions could be quickly addressed. Also, cell phone communication may go down. Do you have an alternate protocol for reaching staff outside the building?
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