Editor’s Note: Paramedic Oscar Monterrosa didn’t hear the first volley of gunshots. It was just after 10 p.m. on Oct. 1, 2017, the night of the Route 91 Harvest music festival, in the medical tent in Las Vegas. When he heard the second volley, the former combat medic began grabbing supplies, intending to go search for victims, when the first victim, a man with a gunshot wound to his arm, walked into the tent.
Monterossa instructed the man to lay on the ground and used his knee to stop any arterial bleeding. Before he could apply a tourniquet, another victim entered the tent. “They were holding their loved one,” he remembers. “I don’t know who it was – a father or brother – who was shot in the head.”
Read more about Monterrosa’s triage, treatment and reflections as the lead paramedic in charge in this piece by award-winning EMS1 Senior Associate Editor, Rachel Engel, “Under fire in Iraq, then Las Vegas,” and read Monterrosa’s reflections on the fifth anniversary of the shooting in 2022, below.
I can recall the morning of Oct. 1, 2017, very clearly. I remember arriving at the station after sleeping a few hours after my night shift to meet up with the lead special events representative. We were going to take a sprinter ambulance to the Route 91 Harvest Festival event location to help set up the medical tent, so I stopped by a gas station to pick up some snacks for the event.
My role was the paramedic in the medical tent to manage ALS level patients, and there were several EMTs on duty to help triage incoming patients.
The day started off slow; I was mostly studying for my pre-med classes in an empty tent, with patrons coming in and out – picking up band aids for their foot blisters. As the day progressed, more patrons entered the medical tent with complaints ranging from dehydration to minor cuts and abrasions, and as the night approached, the over-intoxicated patients started to come into the tent.
There was one ALS-level patient who required transport to the hospital, an elderly patient complaining of chest pain, who I rode with. I remember our operations supervisor was present at that time, and he would jokingly call me “young blood” and tell his stories of how chest pains used to be managed back in the day.
Upon returning to the event, it was evident that the amount of intoxicated patients had increased; cots were set up to allow them to rest.
The most memorable image
Shortly after 10 p.m., the first volley of shots went off. I personally did not notice the first volley, but I did notice a police officer becoming alarmed after hearing them. Then, when the second volley went off, the officer ran out of the tent to investigate, and we then knew shots were being fired. We were quick to take cover behind foldable tables and cases of water as the shots continued.
I remember the first couple patients that entered the tent. A man shot in the arm came in, and I put hands on him to begin treatment, but then quickly delegated to an EMT to take over care as a GSW to the head was being assisted into the tent.
From that point on, patients began flooding into the tent, with various gunshot wounds – head, chest and back wounds primarily. The situation soon became overwhelming, but not long after patients began entering the tent, many people from different medical backgrounds came in to assist – even some off-duty employees of the ambulance company.
It was incredibly humbling to see people helping each other and staying behind to help in the medical tent. The biggest stressor of the night was our inability to get ambulances into the scene and get patients out – as there were concerns that there was still an active shooter. We were literally attempting to stabilize and triage patients as they were dying in front of us, in need of higher levels of care.
The decision was made to start evacuating patients and loading them up into personal vehicles, and shortly thereafter, ambulances began arriving on scene.
At the end of the night, when all patients had been evacuated, the medical tent was a complete disaster with jump bags sprawled open, empty wrappers from various types of medical supplies, and everything coated in blood. One of the most memorable moments of the night was seeing the line of ambulances with lights flashing from every agency in Las Vegas, lined up and ready to transport patients out of the scene, which brought a sense of relief.
A frightening moment
It’s easy to be complacent in the field of special events, as there are infrequently any medical emergencies occurring, other than minor injuries. As the Route 91 Harvest Festival attack showed us, it’s important to maintain your level of readiness.
Make sure your staff are well trained in the event of a mass casualty incident and make sure that every employee has a radio or a means of communication with dispatch. During the event, there was a frightening moment when we did not have complete accountability of all the EMTs – there were concerns that they may have become casualties during the shooting.
Have resources available for your employees after these critical incidents. Something I appreciated about my agency after 1 October: we had a formal debrief as we returned to station, and an experienced psychologist was brought in to check in on crews and offer on-site counseling for those struggling with acute stress disorder or PTSD. Periodically check in on your crews as well; oftentimes there’s a culture in EMS to not talk about what bothers us, but as an agency, there should at least be a platform for people to seek out if needed.
The unique challenges and opportunities in EMS
As the fifth year anniversary of the Oct. 1, 2017, shooting approaches, I have incidentally been on my internal medicine and ICU rotations as a third-year medical student, where I have rounded on patients who have had prolonged hospital stays due to traumatic injuries. It’s made me think of the many people injured at Route 91 and how their hospital stays may have been similar.
How long were they hospitalized?
Did they endure prolonged periods of pain post operatively?
Did they suffer from a hospital-acquired infection?
Did they struggle with physical therapists to regain their strength?
Did case management struggle to find placement for them at skilled nursing facilities once they were ready to be discharged?
These are not the things that we think about as prehospital providers, and it’s often quite unfortunate that we don’t get to follow our patients throughout their hospital course. I couldn’t help but feel a sense of regret, or a sense of uncertainty about whether everything was done correctly. I had a similar feeling in the days following the event, where I wondered if the tourniquets were tight enough, if the angiocaths were adequately decompressing the chest, or if that patient who was very evidently in shock received enough direct observation amongst the many critically injured patients flooding the tent.
EMS is a unique profession in that it is a field that experiences unique challenges not encountered in a hospital setting; environmental hazards, entering homes, and having to make medical decisions based on limited available resources. People who work in EMS are exposed to significant amounts of hazards on a day-to-day basis, from code 3 driving and clearing intersections, to exposure to infectious diseases, potentially violent patients with sometimes minimal backup, and of course being under direct fire during mass casualty incidents, all under low pay or entirely volunteer services.
Seven years later, I’m still working in EMS, as an educator and still running calls, although now mostly in the critical care transport realm, as well as dipping my feet in flight paramedicine. But I do get the “911 itch” at times, which I relieve as a volunteer firefighter in a rural town outside of Las Vegas.
I’m in my third year of medical school exploring different specialties, and I’ve come to realize that due to my experiences – to include my time as an Army combat medic and a paramedic here in Las Vegas present during the largest mass shooting in U.S. history – I value skill sets that allow me to care for the critically ill and injured.
I will most likely end up in a specialty leading to critical care, but I will always be involved in EMS, either through education, being a medical director and/or owning my own ambulance company, or being involved with a fire department.
This article, originally published in September 2022, has been updated.
