How Hospitals Train to Treat Victims of Mass Shootings

During drills to prepare for treating victims of a mass shooting, staff members at the 12 Sentara Healthcare hospitals in Virginia and North Carolina ask people who are portraying victims to change into a hospital gown, regardless of whether their injuries are grave or minor. The request has nothing to do with providing medical care — rather, it’s a safety measure that would help determine whether any of the people streaming into the hospital is concealing a weapon.

“We have to be cognizant that an [unapprehended] shooter may be among our victims, and we have to be prepared for that,” says Patti Montes, manager of Sentara Healthcare’s emergency management system. “We don’t pat people down; we’re not allowed to search people. We can certainly ask them to get undressed and put on a gown.”

Throughout the country, health care officials are conducting real-life simulations to prepare to treat victims of a mass shooting. For decades, hospital officials have conducted drills to prepare for mass casualty events, like hurricanes, earthquakes and even volcano eruptions. Now, as mass shootings occur with greater frequency, many hospitals and health care systems are conducting drills to prepare specifically for treating victims of a mass firearms attack. Such simulations acknowledge the grim reality that another mass shooting could happen at any time.

“It’s not a question of if it’s going to happen again, but when it’s going to happen again,” says Dr. Scott Scherr, regional medical director for TeamHealth, Emergency Medicine West Group and chairman of emergency services for Sunrise Hospital and Medical Center in Las Vegas. Scherr was in charge the October night when a gunman shot and killed 58 people attending an outdoor concert and injured more than 800 other people. Some of the injured were shot and wounded, and others were trampled and hurt as terrified concertgoers tried to flee the attack. Sunrise treated 215 victims that night.

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Scherr’s observation is borne out by FBI statistics. The FBI began tracking active shooter incidents — defined by the bureau as someone who’s actively killing or trying to kill victims in a populated space — in 2000. In 2016 and 2017, collectively, there were 50 active shooting incidents, which killed 221 people and left 722 others wounded. Several mass shootings have occurred in the U.S. in the 11 months since the Las Vegas attack: Last February, for example, a gunman fatally shot 14 students and three staff members at Marjory Stoneman High School in Parkland, Florida, and three months later, in May, a gunman killed eight students and two teachers at a high school in Santa Fe, Texas.

One grim aspect of the mass shooting training doctors are undergoing is shifting physicians’ mindsets from doing everything possible to save the life of someone who’s grievously wounded to prioritizing who gets treated based on which patients have the best chance of surviving, says Dr. Stephanie Davis, a board member with the American College of Osteopathic Emergency Physicians. “In a mass casualty situation, you may [have] 20 patients come in all at once,” Davis says. “We have to change our mindset, and think: ‘Who can I save? Who can I not save?’ It goes completely against everything our training tells us, which is that the sickest or most badly wounded person gets the most attention. I can’t save everybody; I have to prioritize. It’s something an [emergency room] physician has to train [himself or herself] to do.”

This concept will be part of the training Davis oversees Oct. 20 in Chicago, where the ACOEP, in collaboration with Chicago public safety departments that include first responders, will conduct a mass casualty incident simulation. “The goal of the training is for doctors to know exactly what it’s like to operate inside the epicenter of these tragedies, and to enable them to return home and create action plans specific to their hospital. We want communities across the country to be ready,” Davis says.

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In preparing to treat victims of a mass shooting, hospital officials and personnel are focusing on these four key concepts.

Expanding the capacity of the emergency department quickly. Typically, emergency first responders notify hospital officials when they’re transporting a victim or victims, providing some notice about the flow of incoming patients. But in a mass shooting, many victims will get to the hospital “in Ubers, taxis, in the back of a truck, by wheelbarrow — however they can,” Scherr says. Minutes following the Las Vegas shootings, committed with high-powered rifles by Stephen Paddock, who fired from the 32nd floor of a nearby hotel, 100 people streamed into Sunrise without the assistance of emergency responders. A report by the Federal Emergency Management Agency found that local civilians assisted greatly in transporting victims out of the shooting area. Some victims had been shot and wounded; others had been knocked down and trampled as terrified concertgoers tried to escape the gunfire. “We tripled or quadrupled the capacity of our emergency department in a matter of minutes,” Scherr says. Hospital personnel placed victims in hallways and in every available room not only in the emergency department, but in the pediatric emergency department and in the post-anesthesia care unit.

Mobilize doctors, nurses and first responders. When the scope of the Las Vegas attack became clear, Sunrise officials texted and called dozens of additional doctors and nurses to respond to the facility. At about 10 p.m. that night, before any of the shooting victims had arrived, the emergency department had four physicians and a handful of nurse practitioners or physician’s assistants on duty. Within hours, more than 100 doctors and and about 200 nurses, nurse practitioners and other support staff were on hand to treat victims, Scherr says. Hospital officials also called in trained paramedics and emergency medical technicians from local fire departments, who helped conduct initial assessments of patients.

Devise a triage system to promptly assess large numbers of victims. Deciding which patients need to go immediately to the operating room and who can wait is crucial, Davis says. Depending on the number of casualties they’re dealing with, officials at some hospitals may set up small tents outside their facility’s entrance to quickly evaluate which patients need immediate assistance. Assigning a doctor exclusively to triage duty could be useful in responding to mass casualties. So could assessing victims by the START method, which stands for “simple triage and rapid treatment,” Davis says. This approach is commonly used by hospital officials when they’re responding to a mass casualty incident. “Patients are normally triaged based on their chief complaint or the possibility of they’re having a severe injury or illness,” she says. “However, in the START triage system during an MCI [mass casualty incident], patients are triaged based on their ability to walk, if they are breathing and how well they’re breathing, and their mental status. That is, are they alert and answering questions?” With the START approach, a doctor or other medical provider would assess patients based on the severity and location of his or her wounds and assign a color to each victim: black for someone who’s dead, red for those patients in critical condition who need immediate attention, yellow for victims with moderate injuries and green for those with less severe wounds.

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Stop the bleeding as soon as possible. Bleeding from even a seemingly moderate wound or injury can cause someone to die within minutes. Nurses, support staff and even civilian bystanders can save lives by using tourniquets, applying direct pressure to a wound or packing it with gauze or other material, says Adam Zwislewski, a registered nurse and trauma educator and outreach coordinator at Hahnemann University Hospital in Philadelphia. In a crisis, such as the aftermath of a mass shooting, nurses and other medical personnel can quickly teach civilians how to help stanch a patient’s bleeding. “Anybody with a pair of hands can do it,” Zwislewski says. Such on-the-fly training is common during mass casualty incidents, and ACOEP would like to see it become a routine part of medical providers’ response, Davis says. “This is a major aspect of ACOEP’s MCI training,” she says. “We have to train physicians to teach bystanders effectively and quickly how to provide care.”

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