The night that Stephen Paddock opened fire on thousands of people at a Las Vegas country music concert, nearby Sunrise Hospital received more than 200 penetrating gunshot wound victims. Dr. Kevin Menes was the attending in charge of the ED that night, and thanks to his experience supporting a local SWAT team, he’d thought ahead about how he might mobilize his department in the event of a mass casualty incident.
This is his story, as told to Judith Tintinalli, MD, MS
Edited by Logan Plaster
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:
- Preplan ahead
- Ask hard questions
- Figure out solutions
- 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.
The first thing I did was tell the secretaries I needed every operating room open. I needed every scrub tech, every nurse, every perfusionist, every anesthesiologist, every surgeon—they all need to get here right away. They immediately began making phone calls. I told the trauma nurses that I needed all the treatment areas completely clear. Nurses were instructed to keep an eye out for crashing patients and make sure that all patients had bilateral 14-18 gauge IVs ready for the moment that they would decompensate.
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.”
When the shooting started, there were four emergency physicians, one trauma surgeon, and a trauma resident in the ER. That night I was working with Dr. Patrick Flores and Dr. James Walker, two physicians I’ve worked with for over five years. We’ve gotten in trouble together many times for doing thoracotomies before the surgeon could arrive. I know how these guys work. We’ve done major resuscitations together. We are like brothers. We also had a new guy, Dr. Michael Tang, who just graduated residency and had been there for a few months. Dr. Allan MacIntyre was the Trauma Surgeon working that night.
Front (L-R): Kevin Menes, MD, James Walker, DO
Rear (L-R): Patrick Flores, DO, Michael Tang, DO
Here is how our emergency department is laid out. Station 1 has a central desk with four trauma bays. Trauma 1 and 2 have two beds in each bay. Trauma 3 and 4 have one bed in each bay. The most critical care traumas usually go to Trauma 3 and 4. Also attached to Station 1 is our critical care pod. That has four beds in it. Adjacent to that is our psychiatric area where we fit eight beds close together. Station 2 is down the hallway from Station 1. Station 2 has a central nurse desk surrounded by eight beds that are in line of sight. Station 4 is the end of the hallway after Station 2. It opens up to a large room with a central desk with eight beds surrounding a wide U-shaped hallway. Taking the U-shaped hallway of Station 4 all the way around will lead you to the Med Room to the left, Rapid Track, and Station 3 to the right. The Med Room is an open room with recliners typically used to give medications. Rapid Track is a row of chairs in the hallway. Station 3 has multiple “Death Beds,” rooms that are isolated and private rooms with a door, out of line of sight from the nurse’s desk. In my mind, that was the worst place to put any of these traumas, so I told the nurses to not put anybody into those rooms.
THE MCI TRIAGE PLAN
My plan was that we were going to take care of all of our major resuscitations (red tags) in Station 1. Station 2 was going to have our orange tags, patients with threatening gunshots in critical areas, but had not crashed yet. This is not in the textbook. In my mind, these orange tags were expected to crump near the end of the Golden Hour. Station 4 was going to have the yellow tags, patients that had torso/neck or proximal extremity shots that looked very stable and were expected to survive past the Golden Hour. Rapid Track and Med room would hold the green tags, staffed by two PAs, were just going to end up sitting on the floor or stuffed into an area with people watching over and making sure that none of them crumped. The ER doctors would resuscitate and send the resuscitated patients to Trauma 3 or 4 for the trauma surgeon to prioritize to the OR.
In preplanning, I knew that as we started to get some of these red tags stabilized, the anesthesiologists and surgeons would start arriving and we could open up more ORs. That’s the first major choke point. I can resuscitate four or five people, but that operating room was going to be the key to stopping the bleeding and saving lives. In a high volume penetrating MCI like this, you really need flow. You need people to get stabilized and into the operating room, not sitting around perseverating about what test to order next. Getting those ORs staffed and opened was my biggest priority. With potentially hundreds of incoming patients, it was going to be a matter of eyeballing patients or feeling for carotid pulses because we didn’t have enough monitors. Everything was 100% clinical judgment. You’re looking at all these patients, and you’re just waiting for them to declare themselves—and then you start to work on them.
THEY ARRIVED FOUR TO A CAR
I was out in the ambulance bay when the first police cars arrived with patients. There were three to four people inside each cruiser. Two people on the floorboards and two in the back seat, and they were in bad shape. These patients were “scoop and run”—minimal to no prior medical care but brought in a timely manner. They had thready pulses, so they went directly to Station 1, our red tag area. By textbook standards, some of these first arrivals should have been black tags, but I sent them to the red tag area anyway. I didn’t black tag a single one. We took everybody that came in—I pulled at least 10 people from cars that I knew were dead—and sent them straight back to Station 1 so that another doc could see them. If the two of us ended up thinking that this person was dead, then I knew that it was a legitimate black tag.
I would pull a patient and yell “Rapid track. Station four. Station two. Station one.” The staff would then wheel the patients in gurneys or wheelchairs to those areas, drop then off, and come back for more.
Over the years in the ED and working with SWAT, I’ve honed what I call Applied Ballistics and Wound Estimation. It’s a visual CT scanner. We all do it as emergency physicians. You look at a GSW and guess the trajectory and the potential internal injuries. Then you decide if they’re dying now, in a few minutes, or in an hour. Instead of wasting valuable resuscitation time actually tagging the patients, they were sent to their respective tagged areas. I would look at these patients as they came in, and I would grade them red to green.
Some were shot in the neck or shot in the chest, but they were still awake and talking to me. These went into my orange area because I knew that I probably had 30 minutes before they crashed. Inside, the Red Tags were getting resuscitated and brought to the Trauma surgeon who would prioritize the patients to the OR. It was important to get the red tags into the operating room because the orange tags would start to crump and become the next red tags. The yellow tags would start becoming orange tags. After 30 or 40 minutes, I’d triaged the sickest group of patients I had ever seen. About 150 patients had come into the emergency department. I was pulling people five or six at a time out of patrol cars, pickup trucks, ambulances, you name it. I noticed that the first cars carried most of the red tags, and now most of the vehicles had stable yellow and green tags. 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?
I ran to Station 1. There were people all over the place, adhering somewhat to the triage plan. But due to the large bolus of patients, the patients overflowed into the hallways. One of the first images I can remember is Dr. Walker, Dr. Flores, and I intubating three GSWs to the head. 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 0 negative in their pockets or nearby,
I realized that these GSWs to the head were going to clog up the ER. Neurosurgery had not arrived yet, and I was expecting another bolus of patients. I told the three other ER doctors that altered, isolated GSWs to the head would get intubated, sent to CT scan, then up to Trauma ICU to wait for the Neurosurgeons to arrive. This helped offload some of the volume, and it freed up our nurses to help with the orange tags that were becoming reds. As planned, all of the early red tags in Station 1 were shuffled into the operating room as our orange tags started crashing.
NO MORE THORACOSTOMY TRAYS OR VENTILATORS – TIME TO IMPROVISE
My partners were busy in Station 1, so I went over to Station 2. I remember intubating and dropping four chest tubes on two women in a single room, then shuffling them into Station 1 to get prioritized for the operating room. More patients started crumping in Station 2, so I started doing multiple stabilization measures. Then I sent these patients off to Station 1 for prioritization to the OR. We didn’t do any FAST or CTs on these initial red tags. We didn’t do any central lines or needle decompressions; we went straight to chest tube. If they were crumping with a GSW to the chest, they’d get a diagnostic chest tube.
We ran out of thoracostomy trays, so I used suture kits and scalpels. I would cut down to the ribs, pop the pleura with a needle driver or Mosquito clamp, then take the same suture kit and stitch it in place. When I ran out of chest tubes, I used an ET tube as a temporary chest tube while we waited for more supplies. We didn’t do any thorocotomies that night. That was valuable time we used to save the red and orange tag patients.
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.
Eventually, the yellow tag patients in Station 4 started turning into red tags. This was later into the Golden Hour, and there were only 4 resuscitologists in the ER. I remember there were two girls who got shot in the neck, both of whom had expanding hematomas. I ended up intubating both of them. I did a chest tube on one, then moved them both to Station 1 and eventually the OR.
I had just stabilized those two girls, when the yellow tags started crumping down the line. The other ER docs were still working hard in Station 1. One Station 4 nurse would shout, “Menes! I need you here!” and then another would pull me to another patient. I said, “Bring all your patients together.” They brought them all towards me, and I was at the head of multiple beds, spiraling out like flower petals around its center. We pushed drugs on all of them, and they all got intubated, transfused, chest tubed, and then shuffled to Station 1.
Around that time the respiratory therapist, said, “Menes, we don’t have any more ventilators.” I said, “It’s fine,” and requested some Y tubing. Dr. Greg Neyman, a resident a year ahead of me in residency, had done a study on the use of ventilators in a mass casualty situation. What he came up with was that if you have two people who are roughly the same size and tidal volume, you can just double the tidal volume and stick them on Y tubing on one ventilator.
“YOU’RE A SHARK. GET OUT THERE AND FIND BLOOD!”
As fresh ER doctors would arrive, I would brief them on the layout, the list of workarounds we were doing, and tell them, “You’re a shark. Get out there and find blood!” I wanted them to find those dying patients in the sea of patients still there. Within hours, we had hundreds of doctors, nurses, and midlevels arrive at the hospital to help.
Around this time was my last big resuscitation, a middle-aged woman with a GSW to the lateral right chest who developed shock from a contralateral pneumothorax. She received a diagnostic left chest tube and blood, and her blood pressure stabilized. She was taken back to the OR after I secured her chest tube. She was eventually found to have a transected aorta. I heard just recently that she survived and got discharged.
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.
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.
It was around four o’clock when I started trying to look at a CAT scan report. I tried to read it, but I think I burned every neurotransmitter that night. I remember looking at it and not understanding a single word that was on there. At that point, I knew I was more dangerous to the patients than helpful. These were stable yellow tags that needed a set of fresh eyes. By then, we had a lot of doctors who had arrived, so I turned that aspect of care over to them.
AFTER THE DUST SETTLED
When I thought about it afterwards, I realized that it was all about flow. If you eliminate these narrow choke points that occur along the way, you can get people seen and evaluated sooner by the correct specialist. As ER doctors, we can resuscitate and stabilize, but it is up to the surgeons to do damage control surgery. Prompt damage control is the key to saving somebody in a penetrating trauma.
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.
- 8 GSWs to the chest
- 10 GSWs to the head
- 13 GSWs to the abdomen
- 17 Ortho GSWs
- 33 GSWs to the neck or major extremities
CONTROLLED CHAOS: MCI LESSONS LEARNED
- Flow is king. Destroy the choke points to allow patients to flow to definitive care.
- By organizing patients into clear physical zones, they were able to avoid wasting time writing too many tags. That’s precious time that could be spent with resuscitations.
- The Orange tag in triage allowed Menes’s team to focus on the most critically wounded while keeping a very close eye on those who were badly wounded but would soon crash.
- Don’t have enough ventilators? Pair patients of similar size, double the tidal volume, and use Y tubing to ventilate two patients on one vent.
- Mentally rehearse difficult scenarios ahead of time. This can be just as valuable as actual practice. Think through what you will do if/when your current plan of action fails.
- Not enough monitors? Place all patients in line of sight, and use clinical judgment to find the crashing patients.
Special thanks to Anne Tintinalli, MD, for assistance with this story.
83 Comments
I had chills reading this. Kudos to all of you. My worst night in trauma was 8 major traumas in 8 hours. I can’t even fathom this. You’re amazing. God bless you all!
Me too…I have worked in emergency rooms and understand how efficient ER staff can and will be. I am so impressed with their knowledge, kindness and actions…This is a well written and educational article about working together…
BRAVISSIMO!
Excellent job!
Incredible. Good work. This needs to be shared far and wide.
As one of the neurosurgeons working there that night, I found that having all the nsg patients with GSW head or spine being sent to the TICU and being co-located there was extremely helpful and efficient. It allowed my partner and I to essentially do a second “neuro triage” and prioritize patients to CT scan and to the OR. With patients being sent all over the hospital, I think this was an important part of the process that really helped with flow of patients for definitive treatment after initial ER eval and resuscitation. We did end up black tagging one patient there, did total of 4 craniotomies and 1 laminectomy for GSW that night along with 2 additional bedside procedures. Two more spinal surgeries over the next few days in stable patients. The early effort by Kevin to get all the OR’s open and running made a huge difference! There was essentially no delay at all in taking patients to surgery throughout the night.
Wow… Words fall short. Heroic, I guess is the closest description of the superb job.
This is amazing! I learned so much from reading this article, thank you.
COMPLETELY AMAZING…..TRUE HEROES……
Amazing work!..I learned so much. I am an RN in San Diego in charge of our ED MCI/Disaster plan in our hospital. Ironically we already had a mock MCI drill planned for this coming week with 50+ GSW pts coming to us. I will share this story with my colleagues. Thank you so much for sharing!
Thank you. I got this article from at least three different doctors. We’ll learn from your hard-won experience.
A brilliant example of multidisciplinary teamwork, and a huge effort by all. As an RN, the only disappointment from this re-telling & analysis is the lack of acknowledgement of the nurses’ part in the success of the treatment plan. Only doctors in the photo, no mention in the summation of the nurse’s role in keeping the flow going. An extra point at the end, I think, could be “trust the abilities of your multidisciplinary team, and delegate accordingly”. It’s obvious that you did, but it would be great, in an extreme situation such as this, if nurses were acknowledged for the important role they had in keeping these patients alive as well.
You Go Girl! Without the high quality nursing staff that night, the doctors couldn’t have accomplished the great work they did. Nurses seem to always be at the back of the line when really they are the doers. The doc gives the orders and then go on to the next patient. Nurses do everything else. I hope the author reflects on this and at least writes a letter to all of the nursing staff who did their best to make sure everyone of those patients got the care they were entitled to get. Congrats to all of the staff for their dedication to keeping the patients alive and well.
The physicians and admins all personally recognized the nursing staffs efforts during this MCI. Dr Menes himself brought us to the front of the stage @ ENA conference, stepped aside and commended us for our work done, took the focus away from himself. It was TRULY a team effort not just doctors, nurses, our technicians, radiology, transport, ANY staff member that could move a patient had a role that night and completed it to the best of their ability.
I read how the nurses participated and how Dr. Menes turned over at least one of his roles to a nurse. I came away realizing the nurses were the very reason the flow worked.
You read the entire article and this is what you chose to say? What a ridiculous comment.
This is an incredible account of forethought, bravery and tenacity. I am overwhelmed by how Dr Menes and his team pulled through.
Dr. Anson,
Did the bullet wounds you saw match the caliber of weapon used in the shooting? I ask because wounds would have been more severe than what is being reported. Thanks.
There were single bullet-pass through-multiple extremity wounds, entrance/exit through narrow torso, and entrance only through dense torso consistent with 5.56 ballistics.
Thanks for the reply.
outstanding work- this should be a standard teaching case for all ER docs . Kevin Menes said his MCI triage plan ” is not in the textbooks” — it should be. ” The Menes method”
Super great but ur comment about triage and “leaving it to the nurse-what else could u do?” Quite frankly leaves me thinking, wow, how disrespectful, like that was the biggest risk you too all night. Great job but by making that traumatic sentence and putting it all by itself, is beyond disappointing-hopefully it was just an editorial decision. Even then as a nurse myself, it cuts.
Well said. It’s a shame these comments don’t have up-votes – yours should be nearer the top.
I read that sentence a little differently, as in the doctor who goes by the book has to throw the book out because the chaos of the situation demanded a different approach.
I don’t think that comment is intended to be a slight on nurses or their abilities. Clearly the nursing staff, along with the rest of the department did a phenomenal job that night, and that comes across in the text. It’s just, like he said, triage is supposed to be run by the most experienced doctor.
Agree with the nursing comments. Easy to overlook but impossible to do without. Ironically, the better we do as nurses, the more invisible we are. It is when we make mistakes that the break in the flow becomes evident.
Thank you to all the nurses AND CNAs in the hospital that night. Other nurses and CNAs know EXACTLY how vital you were and are.
Humbled…
Firstly, WELL DONE! This is everyone’s worst nightmare… handling so many critical patients at once. To my knowledge, every major city has a stockpile of ventilators to use in case of a federal emergency. Although this was local, maybe we ALL need to find out who our Federal contacts are to mobilize these vents whenever needed. Although I hope this is the LAST disaster of this type we will ever see, one more preparation step might not hurt.
Absolutely brilliant proactive visualizing and planning by Dr. Menes, done on his own initiative, played out like a symphony in real life with the help of his colleagues and staff. All ER directors, providers and staff need to read this. It is much to the credit of Sunrise ED and others that the largest mass shooting in US history did not become the deadliest (during the Wounded Knee Massacre in 1890, 350 Native American men, women and children were shot, and almost 300 died).
While taking nothing away from this well intended comment, let’s be clear about one thing. The 2017 Las Vegas Massacre by no means was the worst mass shooting in US history. To use your own example, the 1890 Wounded Knee Massacre in South Dakota claimed nearly 7 times as many casualties and 6 times as many fatalities of Sioux at the hands of the US Cavalry. Between 1831 and 1850, approximately 4,000 Cherokee lost their lives under the forced deportation from their Georgia homeland to their designated Oklahoma reservation, a move instigated by our first Bigot-in-Chief, Andrew Jackson, a man whose portrait was chosen to hang prominently behind the desk of our current Bigot-in-Chief, Donald Trump. While doing nothing to detract from the shameful way in which we historically have treated our African Americans, our Latin Americans, and our Asian Americans, among many others, our own Native Americans continue to remain at the same time the original owners and occupants of our land and the last major minority group formally to be acknowledged as in need of redress for their grievances. The fact that to this day, we fail to undertake the same same equality remedies which we have attempted to afford, albeit still a long way from successfully, every other minority group, is an enormous blight on the integrity of our nation’s people who righteously profess to be bound by the principles laid out by our Founding Fathers. We can begin by placing the Las Vegas Tragedy, however horrific, in its proper historic context. By any metric it is one of the worst, but by no means the worst, mass shooting in a United States history which has been blighted by needless, pointless domestic violence and bloodshed.
Did you really have to politicize this amazing story of humanity at its best ? Save your rant for some other venue.
Actually, Peter’s comments are appropriate and needed and are also undeniable. It would be different if what he said wasn’t true. It is those who stay silent on the topic, and worse, those who demand silence who do the damage.
The amazing forethought and leadership of Dr. Menes allowed an unimaginable number of trauma patients to be treated. His points of flow echo the talk at the annual AAEM conference where the Docs in Orlando described their response to the Pulse nightclub shootings. We should study both and codify as much as possible to be able to spread the knowledge. Heroic work.
In a world in need of real heroes you need to look no further than the staff of Sunrise. From the ER doctors and nurses to the staff transporting the patients, to those who found supplies and cleaned up afterwards— you are all heroes and we thank you for everything you did that night and the days that followed. We also thank you for sharing the events for others to learn from your experience.
Cindy Pellegrino, retired hospital CEO
May God bless all of you. You were placed by the hand of God to supervise this necessary work and the results. Congratulations!!!!
Superb work! Thank you for sharing. This will help thousands of hospitals, ERs, and clinicians worldwide.
As a long-time emergency physician, I am in awe of the amazing feats performed by the entire hospital staff. Dr Menes is indeed a wonderful example of the dedicated physicians, nurses, and all other hospital staff who work night shifts, and provide excellent care to all-comers, during the most difficult hours. This is truly an inspirational story amidst a mass horror.
Chancey Boye RN Wow! Brilliant. I can not imagine sorting that much chaos. Stunning good work doctors!!! and everyone else involved. I hope this is published somewhere in our hospital.
As an ED nurse for 17 years at the busiest ED in my state, I’ve read this article many times and sent it to colleagues. This story still gives me chills and amazes me. Strong work, team.
I’m just shaking my head in amazement. This is the highest example of situational awareness in an extreme clinical emergency – treating individual patients while overseeing multiple processes.
What I admire is streamlining things on the spot, and skipping some unnecessary steps that we are trained to do (like tagging the patients). This could not have been done if Dr. Menes had not created a mental model of a MCI beforehand. It goes to show that while drills are needed, the best way is figuring out the potential landscape, mapping it out in one’s mind, and following the map while allowing for detours. Bravo to Dr. Menes and to the entire staff.
Plans fail.
Even planning fails. (“But the planning process is invaluable.” – Gen. Eisenhower)
But people – especially the good ones, and who can improvise on the spot – will save the day.
And in this case, 250 patients.
Love the orange tag level, and moving the patients past the practitioners is Henry Ford’s assembly line at its medical best. Plus you’ve identified several bottlenecks (Pyxis/pharmacy, CT/Radiology) for everyone to consider in updating their plans in light of this incident.
Mental exercise: Now imagine the power’s out, and we’ve lost our shiny new single-point-of-failure computer-driven EMR. Discuss that with your disaster management teams. (Because power never goes out amidst earthquakes, tornados, and hurricanes, right?)
STRONG WORK to all of you folks at Sunrise, top to bottom, start to finish.
You’re rockstars.
And you are my people!
Stunning work and planning. Thank you Dr. Menes and your team for such skill, courage and dedication.
Incredible, and awe inspiring. You are a true real-life hero.
As someone who work in incident response planning this is was truly amazing feat. I would recommend that ECs not only rehearse these types of incidents in there own head, but actually work with there departments to develop written plans for different catastrophic incidents , and find ways to rehearse the plans with their staff, and then use those rehearsals to further refine the plans. Your teams success is a testament to thinking such situations through.
If you can find some wildfire response people, talk to them about how they prepare and respond for firefighting. They are the pros when it comes to preparedness. You will probably be able to find a lot of applicable practices.
Kudos to an amazing job. I loved how you shared the ventilators between patients by essentially creating a circuit. Truly admirable ability to think on your feet.
Such an amazing story. The innovation and forward thinking that occurred that night certainly saved many lives. The number of heros that helped during this tragedy will never be truly known, but this article clearly shined a light on a few more!
Amazing work by you and your team. Preplanning and thinking outside the box. Love it!
Thank you for sharing this extraordinary experience so that all of us working in and around healthcare can benefit from the actions taken and lessons learned. I am still reeling from this account that so clearly articulates application of collaboration, critical thinking and trust under difficult and dynamic circumstances. What I applaud the most is your candor in sharing the details here from which others may learn. All too often healthcare facilities are reluctant to fully prepare for such events. Be it for reasons such as understaffing, funding priorities or simply ignorance, like an ostrich with its head in the sand, training and exercising plans, policies, practices, and procedures and often not fully done and certainly not with a multidisciplinary approach. Hopefully, an account like this will get the CEOs, COOs, CFOs, EMS, and, anyone else in the hospital industrial complex, to recognize the responsibility to fully prepare for, mitigate against, and respond to such events, and to do so with public safety partners so that when such an unfortunate event occurs, there is ‘success’ whatever that means in a mass casualty incident. Thank you, Dr. Menes for your incredible work and p,ease remember your own self-care as you move forward following this incident.
Strong work, Kevin. BTW- I looked you up in HealthGrades and had to give you 5 stars for your MCI work. You got it when and where it counts.
https://www.healthgrades.com/physician/dr-kevin-menes-yy2s9
I learned a lot by reading this article. Thank you. Heroic work by lots of professionals. Great team work.
I have a hunch this might change more than a few reference guides on what to do in a MCI. You may have changed history, Dr. Menes.
Thank you for your efforts that night and for writing this up.
Unfortunately I spent my whole time reading with the poem “the ambulance down in the valley” in my head.
Being a citizen of Australia and Canada, both with restrictive gun control laws; I have to wonder how this whole ‘freedom’ thing works in the USA.
One man exercised his ‘freedom’ to shoot people (or is that a second amendment ‘right’?) and at least 1000 people had to deal with his actions.
If this person had his ‘freedoms’ restricted a thousand people would have said they had a boring day instead of the most traumatic of their lives.
I don’t know how to solve this issue in the USA but these other two countries have figured out how to allow gun ownership yet have per-capita gun violence rates on the order of 1% of the US rates.
Anyway, good luck with that. This information will be very helpful when you have to deal with another of these, and another, and another.
Thanks Bryan, for trolling an otherwise wonderfully pristine comment thread.
Why do you feel the need to share the poem in your head? It isn’t relevant here.
It is sad that you don’t know what freedom is, but this isn’t the place to help you.
Trolling? I guess my freedom to be shot is being infringed in Canada.
Bryan, you need to stay in Canada. You deserve that.
I heard you on a podcast and was very impressed……I am looking for a resource on use of the shared vent strategy
https://www.ncbi.nlm.nih.gov/pubmed/16885402
First let me say I am amazed at the work done by everyone involved during this disaster. It is hard to find the words to say Thank you for everything you did that night and everyday. I appreciate the innovation of this work on the shared vent strategy and disaster preparedness as disaster preparedness is one of my passions. I have been in the field of respiratory care for over 25 years and have been down to Alabama for FEMA training. I have some very strong hesitations to anyone considering this application and will explain my concern. If at any point, there is a difference in the lung compliance of either patient hooked up to the ventilator it would alter the volume going to the patients and change how much each of them are receiving. You would be over-ventilating one and under-ventilating the other and no way of knowing since all volume returning to the ventilator is mixed. Compliance/resistance readings are also mixed. Pneumothorax, or something as simple as mucous plugging, biting, coughing, etc. This is a very dangerous concept especially in the midst of a disaster scenario when no one has the time to carefully monitor the patient. It would be much safer to take two seconds and train anyone to manually ventilate the patient than it would be to utilize this method. Could be anyone free, environmental services, dietary, etc. At least then they have eyes on the patient.
These are all real concerns. But remember this is a last ditch effort in a Mass Casualty Incident; for which the definition requires overwhelming the available medical resources. There were not enough RTs, not enough staff to manually vent, not enough vents, and multiple GSWs requiring ventilator support. I agree with your concerns, but these were chest tubed and paralyzed patients(so no PTX, no biting, no coughing). This vent strategy was intended, and used a temporizing measure while they sat for a short time period waiting to go to Damage Control Surgery. These patients survived. I think this final outcome is the forest, not the trees.
As if I am listening to a symphony. Bravo.
I am so amazed at how well people in the medical field are able to keep level heads. They are real-life heroes. Digitalization tech has thankfully been able to save a lot more lives now than ever before. What an impressive hospital team. You guys are amazing.
I am truly amazed at the writing and the description – a truly wonderful description of a horrific incident.
WRANGLING CHAOS
I think Dr Menes is a archetypal example of the ability to creatively think “outside the box”. We need to try to teach this if it is even possible.
Respectively,
Thomas Carlisle RN
if only the criminals in congress could learn something from this continuing epidemic of gun violence, stories like this might become things of the past. kudos to the ER staffs everywhere
Kevin –
Makes me proud to be an emergency medicine doc.
You and your colleagues were kick-ass brilliant!
This is one of the most impressive situational response narratives that I’ve ever read. I hope it becomes a required part of the teaching syllabus – not simply because of the specific steps taken, but also because (as others have noted) Dr. Menes’ responded with clarity, decisiveness, and an extremely high degree of professionalism to an incredibly stressful situation. Dr. Menes is a credit to himself, his profession, and to his community.
But Dr. Menes, however did you document your level 5 charts, procedures and crit care time? Resuscitation does not happen in the trauma bay, it happens at the EMR. /tongueincheek
Thanks for a great reminder on the mindset of “when” rather than the cop-out of “if.”
An additional takeaway in the article: have awesome nurses/techs who can stick the big pipes reliably and early.
How many DOA’s were officially recorded by the sunrise hospital and how many people died in the sunrise hospital because of gun shot injury’s .
Impressive work by Dr Menes and his team including nurses.
I do share Sheryl’s concerns about multiple patients on 1 vent. The Neyman study was on 4 simulated lungs, not real people. The limitation would be pt-vent asynchrony, probably long before VT’s became inadequate. The problem with vent control for 1 patient is the vent is a pump, and the pt is a pump. For the vent to work, both pumps have to be in sync, and when they don’t there are increases in lung injury and death rates. Already there can be a problem with supply and ethical use of vent-control meds in a Life-Support/Palliative Triage situation, but adding 1-3 more pt’s in and try to get them all in sync with the vent is simply a bigger problem. Sheri Fink describes that companies are making vents smaller now for use in MCEs and this sounds like the safer alternative to invest in.
That said, I’d encourage Dr Menes to publish his data on multi-pt vent usage, with outcomes including cross-infection (a risk we may have to tolerate in an MCE).
Sheryl and David. These are all real concerns. But remember multiple patients on 1 vent is a last ditch effort in a Mass Casualty Incident; for which the definition requires overwhelming the available medical resources. There were not enough RTs, not enough staff to manually vent, not enough vents, and multiple GSWs requiring ventilator support. I agree with your concerns, but these were chest tubed and paralyzed patients(so no PTX, no biting, no coughing). This vent strategy was intended, and used a temporizing measure while they sat for a short time period waiting to go to Damage Control Surgery. These patients survived. I think this final outcome is the forest, not the trees.
Amazing work from the Sunrise Hospital team! Awe-inspiring to read! Is anyone able to clarify a few things for the benefit of Emergency Medicine?
How busy was the department and waiting room when the mass casualty code was called? Are you able to describe what happened to the patients in these areas prior to the arrival of the first casualties? Was there a similar move to create space across all hospital wards? Who physically began making calls to staff at home to come in ASAP?
What took place as far as debriefing (hot and cold debriefs) for the staff that night?
Many thanks,
Fergus Morris, ED Registrar, Western Australia
thanks
Another example that exemplifies the acronym for TEAM:
T ogether
E veryone
A chieves
M ore
Pass it forward!
Retired, San Antonio Fire Department
UNREAL!!! I am currently enrolled in paramedic school, and we are currently going over MCI’s. It is amazing to see how pre-incident planning (something that is stressed constantly on the fire ground) and having critical judgement skills can make a huge difference. I can only hope that I can reciprocate some of these lessons taught in this article.
Dang,,,,,, Great job rising to the occasion.
Great job on thinking ahead. We really never know about things in this day or age. This world is lucky to have people like you. Thank you
Very tactical approach and precise. Did an outstanding job utilizing your resources, and getting all the recourses in route to the facility. Outstanding job on your training and seeing choking problems in the flow and correcting them as they appeared.
Awesome job at being able to react and overcome challenges as they were thrown at the ER staff. The thing that I took from this was to mentally rehearse difficult situations and prepare for them ahead of time.
This is what I call thinking outside of the box. I definitely like the idea of not immediately black tagging and allowing for a second opinion even in a crisis. I do believe every organization that would be involved in saving MCI patients should rehearse many times over.
This is such a great article! Not all people are born with the ability to keep there composure when events like this happen. Thank you for everything ya’ll do day in and day out.
The way Dr. Menes approached this MCI was magnificent. Having his plan in place well before hand and checking things off like a pilot’s pre-flight checklist really helped keep this chaotic event in line. Being able to see the big picture, be aware of the changing conditions and solving the problems as they came up are true leadership qualities. He was able to trust his team to do the work that needed to be done while he continued to move throughout to assist in keeping the flow going. Great job to the guys and girls who worked that night.
This MCI was magnificent.
i agree with you 100%
Amazing, thank you for sharing. In awe of you all.