The Las Vegas Mass Casualty Incident

08-03-2018

“That music is going to keep me up all night.”

Without realizing the irony of my words, I went to bed at 2100 on October 1st. My phone started ringing around midnight with the words “every available physician report to Sunrise for a mass casualty event.” I responded to Sunrise Hospital & Medical Center in Las Vegas for duty at 0020 and walked into one of the largest mass shooting events in our country. My most enduring memory of that night was the strong smell of blood that permeated the ambulance entrance and throughout the emergency department.

The Las Vegas mass casualty incident (MCI) began a bit after 2200 on October 1 at the Harvest Festival Concert. The terrorist had planned his assault by reserving a room on the 32nd floor of a high-rise hotel with a view of the concert venue. The terrorist had assembled an arsenal of 27 weapons with hundreds of rounds of ammunition. His intent appears to have been indiscriminate mass killing. Over the course of 11 minutes, he rained down over 1,100 rounds in 12 volleys of bullets on the unsuspecting crowd of over 10,000 country music fans. The barricaded terrorist killed himself as law enforcement closed in on his location.

Over 500 people were injured with 59 deaths on that evening, 35 of which were pronounced at the scene, and 24 at area hospitals. The majority of these injuries, and all of the deaths, were from 5.56 mm and/or 7.62 mm military gunshot wounds. 16 Las Vegas hospitals were involved in the response with significant resource sharing between proximity hospitals and non-involved sister facilities. Sunrise Hospital was the closest trauma center to the event and received the majority of the casualties due to victim self-triage. Sixteen victims died at Sunrise, either pronounced dead upon arrival or after heroic resuscitation attempts.

At the time of my arrival, the on-duty physicians had implemented the “Code Triage” disaster plan and the emergency department functioned as an airway and hemorrhage stabilization station. “Red” casualties were stabilized and sent on to the operating rooms, or the intensive care units where definitive management was accomplished by specialists. The majority of the victims had arrived by self-triage and were not dispatched by scene command. My assignment was to re-triage over 100 “Yellow” casualties. Each treatment room contained between three and six victims, some of them family and friends, some of them strangers, all of whom were providing self-aid due to the overflow of patients. And so my night began.

After several hours of work, we realized that our rate limiting feature was registration and radiology. Because of the physician surplus at 0400, I left to return in a few hours and relieve the overnight crew. When I returned, the majority of victims had been dispositioned with a few remaining victims still needing care. However, family members of the victims had begun arriving and 16 families were told the most devastating of news. The hospital responded with a team of nursing, pastoral care, social work and physicians to assist the family members. Las Vegas is a vacation destination and many of the victims were celebrating engagements, marriages, birthdays, or reunions. The sudden shift from joy to tragic loss was excruciating for all of us.

The Las Vegas MCI was yet another example of terrorism in the United States. While the U.S. murder rate has diminished over the previous 10 years, both the rate and size of mass casualty events has increased. There are few barriers to the acquisition of firearms and a high vantage point over a crowd. Whether the terrorist chooses a firearm, a bomb, or a motor vehicle, mass casualty events are now a public health concern and should be treated as such. It is time for emergency medicine to take its place in advocating for data driven civilian hospital preparations for events such as these.

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