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.

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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.

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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.

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.

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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.