By Dorothy Brooks
As mass shooting events continue, healthcare leaders are focused on how the medical response is effective and expeditious. Frontline providers who have experienced such events have firsthand knowledge about where the weak links are and can offer unique insight on how organizations can work within their regions to be better prepared. That was the thinking behind a unique consensus conference hosted by Uniformed Services University’s National Center for Disaster Medicine and Public Health in Bethesda, MD, last fall.
Conference planners gathered clinicians from six regions that had responded to a mass shooting in recent years that involved more than 15 individuals who were killed or injured. Attendees included EMS clinicians, emergency physicians, and surgeons. They shared their experiences and developed recommendations they believed could help other organizations maximize their mass shooting responses.
Formal guidance was published in July.1 Two authors shared with ED Management input on what they learned from their own experience in responding to a mass shooting event, and how the conference attendees came together on the recommendations.
David Slattery, MD, FACEP, FAAEM, director of research for emergency medicine at the University of Nevada, Las Vegas, says mass shootings do not always occur in proximity to a trauma center. That was certainly the case with respect to the mass shooting that occurred in his region in 2017.
“Bystanders were caring for [some victims] and were transporting them in their own vehicles or pickup trucks to the closest hospitals ... but the closest hospitals were not level I trauma centers,” explains Slattery, an emergency medicine physician at University Medical Center of Southern Nevada in Las Vegas. (Learn more about the response to that event at this link.)
While Slattery emphasizes EDs conducted incredible work at each hospital, it would have been more appropriate for these patients to go directly to a level I or II trauma center. Further, he notes some other conference attendees experienced the same challenge during responses in their communities.
Thus, conference members are advising hospitals to work with their partnering organizations and communities to find a way to direct the public so shooting victims transported by private vehicles are taken to the closest trauma center. Slattery says leveraging technology can help.
Another issue that received considerable attention at the conference was how communications tends to break down during a mass shooting event. “There is a huge impact on our 911 communications specialists by not only the public calling using cellphones from the incident, resulting in hundreds and hundreds of calls, but at the same time [these specialists] are trying to manage the response to the incident,” Slattery explains. “Also, people from home are calling.”
Consequently, responders should practice managing a spike in communications traffic. “We always include the hospitals, EMS, and the fire departments in our emergency disaster drills. You can never do enough of those,” Slattery says. “But you should also be including 911 communications specialists and the communications centers in those drills to maximize communications during a disaster.”
When it comes to triage and mass shooting events, conference attendees agreed anatomic triage (directing patients based on where their wounds are) is fast and efficient. “At trauma centers, this works very well,” Slattery reports. “At our trauma center, central wounds — wounds in the neck, chest, and abdomen — are preferentially brought into one specific area of the trauma center. The other wounds are distributed to other EDs and other areas of our hospital.”
Anatomic triage is widely used, well understood, and it does not require much thinking or analysis in the field. This allows responders to move quickly, which is critical when managing a mass casualty event. Slattery acknowledges there is not yet much science behind the concept, but he is hopeful the approach will undergo more rigorous study.
Nancy Weber, DO, MBA, FACOEP, FACEP, vice chair of quality and patient experience at Texas Tech University Health Sciences Center, recalls the mass shooting event that occurred in El Paso in 2019. During that event, medical providers struggled to find and activate other responders. “To address this problem, there is now a monthly task alert for the emergency medicine providers,” she explains. “That is a way for our department to know that we can quickly mobilize resources if the need arises.” When the monthly task alert is sent to providers, they are asked to indicate whether they are on the medical campus, available but off campus, or unavailable.
Tracking all the patients who quickly arrived at the hospital from the scene of the El Paso shooting proved challenging, too, particularly as they began to move through the system. However, during the consensus conference last year, Weber learned the electronic medical record (EMR) her system uses includes a disaster tab. This allows users to activate up to 40 patients at a time.
In addition, Weber observes Texas is rolling out prehospital wrist bands that are supposed to follow patients involved with mass casualty events through their healthcare journey for up to 48 hours. It will take time for that system to be developed and integrated.
Ultimately, conference participants prepared eight broad recommendations that were relevant for all participants:
• Readiness training: Hold regular, multidomain training activities that mirror the realism of actual events. The goal is to ensure the readiness of the entire community system.
• Public education: Provide this or immediate direction from web-based mapping programs to guide the public regarding appropriate hospitals for the victims of mass shooting events.
• Triage: Use a staged and iterative triage process at the scene and in the ED to prioritize operative care.
• Communication: Ensure effective communication between prehospital personnel at the scene and hospitals.
• Patient tracking: Implement a patient tracking system that will function from the point of injury through all subsequent healthcare.
• Medical records: Identify an alternative method of patient documentation and order entry; rehearse the rapid implementation and use of this method.
• Family reunification: Provide for the rapid implementation of organized and well-communicated family reunification and assistance services.
• Mental health services: Employ tailored, after-action mental health services for professionals responding to these events.
REFERENCE
1. Goolsby C, Shuler K, Krohmer J, et al. Mass Shootings in America: Consensus Recommendations for Healthcare Response. J Am Coll Surg 2022.
As mass shooting events continue, healthcare leaders are focused on how the medical response is effective and expeditious. Frontline providers who have experienced such events have first-hand knowledge about where the weak links are and can offer unique insight on how organizations can work within their regions to be better prepared.
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