Specialized training enables trauma and non-trauma teams to effectively manage 500 plus injuries
When a gunman perched on the 32nd floor of the Mandalay Bay hotel in Las Vegas rained gunfire on the crowd attending a Sunday night country music concert, the scores of wounded began flooding the city's emergency departments. Orthopaedic surgeons stepped up to provide care for the injured.

Amid the chaos and the carnage, the patients arrived at area hospital, sometimes five to a vehicle, in ambulances, limousines, and pickup trucks pressed into service, many driven by valiant civilians.

Medical professionals recounting the horrific episode—which would take 59 lives and injure some 500—said the overall impressive and effective response in the rescue and care of patients began with the responders on the scene. The field triage routed the most severely injured—especially those with head, chest, or abdominal wounds—to University Medical Center (UMC) and Sunrise Hospital & Medical Center. Sunrise, a Level 2 trauma facility, was the closest hospital and took in 199 patients (16 of whom later died). The Level 1 trauma designated UMC accepted approximately 100 patients.

"The orthopaedic community rose to the occasion," said Michael Daubs, MD, chair of orthopaedics at the University of Nevada Las Vegas Medical School (UNLV) and a spine surgeon at UMC. "The community of physicians and orthopaedic surgeons came together and took care of it."

David Silverberg, MD, director of orthopaedic trauma at Sunrise, described the scene at his institution that night. "Around 11 p.m., the administration knew it was a mass-casualty event and were in touch with all levels of needed medical personnel," he said. The flow of incoming trauma victims was heaviest between 11 p.m. and 12 a.m. Onsite were two orthopaedic surgeons—Holman Chan, MD, who was on call, and Jessica Kingsberg, MD, who voluntarily came in to help with the triage.

Orthopaedic surgeons on the scene reported that, of the many musculoskeletal injuries, only a few were limb-threatening injuries. Dr. Silverberg added that most of the wounds seen at Sunrise were isolated, "meaning if they had a gunshot wound to the head, that's all they had." Once the most critical injuries were addressed, Drs. Chan and Kingsberg, along with Dr. Silverberg, Fred C. Redfern, MD, and Roger A. Fontes, Jr, MD, attended to the 22 patients with the most urgent orthopaedic injuries.

At the UMC trauma center, Erik Kubiak, MD, chief of orthopaedic trauma for UNLV, said the story was also one of a well-coordinated response to an event for which the hospital and staff were prepared, horrendous as it was. He agreed that the initial assessment and routing of patients led to prompt and appropriate delivery of care, with all the region's medical resources contributing.

"There were a lot of extremity injuries that were appropriately triaged based on the number of head, chest, and abdomen injuries," Dr. Kubiak said. "We had the preponderance of head, chest, and abdomen because we have the neurosurgery department. Isolated extremity injuries were appropriately triaged. You could say the field triage worked the way it was supposed to. The surrounding hospitals may have felt a bit inundated with the extremity injuries." In fact, he said UMC had just a few operative, isolated extremity injuries. Mark Sylvain, MD, the orthopaedic surgeon on call, handled the isolated orthopaedic cases.

All-around effort
Dr. Daubs said credit goes to all the surgeons who served, including those working away from the two top trauma centers. "The Level 1 and Level 2 trauma centers performed incredibly," he said. "But many patients ended up at community hospitals that may not have been used to dealing with this kind of orthopaedic trauma, with gunshot wounds. All the men and women in the orthopaedic community rose to the occasion and did their job in taking care of these patients."

Dr. Kubiak agreed and credited initiatives, including work by the Academy, to foster and promote the readiness of non–trauma specialists to respond to mass-casualty events such as this one. "The Academy has done a good job in helping to keep surgeons in the call pool and in keeping generalists up to date on taking care of extremity trauma. In a situation like this, we really rely on a well-trained group of generalists to deal with the overflow of trauma. At the Level 1 facility, where the trauma-trained guys are, we don't necessarily see all the isolated extremity trauma," he said.

The overall response to such events would be well-served, Dr. Kubiak added, if obstacles to versatile deployment of medical professionals were suspended. "Consider making some accommodations regarding privileges, so that people can move around and not be locked out of systems. Some of us didn't have privileges at certain hospitals." In the aftermath of the Las Vegas shooting, the governor of Nevada stepped in with emergency approvals for lifting practice barriers.
All three surgeons agreed that overall the hospitals and emergency care shined in terms of its preparedness for an event that can never be precisely anticipated. Reflecting on lessons learned, Dr. Silverberg said, "In addition to having the necessary anesthesiologists, ER physicians, and general surgeons ready to respond immediately, I think there needs to be a way to put counselors in place immediately—clergy and professionals who can help people handle the enormity of the situation. That needs to be in place during triage and the initial period, because there are family members who are alone and need immediate support," he said.
"We also need a fool-proof
system that communicates with all the doctors who need to be on site," said Dr. Silverberg. "There has to be a central number and a hospital blast and text that everybody receives without fail—instead of the hospital administration having to make many phone calls to get physicians down to the ER."

Dr. Daubs commented: "You never expect something like this is going to happen, to have a mass shooting in your city. You have to take emergency drills and preparation seriously."

Seeing devastating injuries and badly broken bodies on a regular basis is a stark reality for orthopaedic trauma surgeons. However, their professional training and discipline doesn't make them immune to experiencing an emotional response to horrific events such as the one that occurred in Las Vegas.

"It's a few days afterward that as doctors, we take a deep breath and mourn with the rest of the city," Dr. Daubs said. "You do your job, you take care of everybody, and then later you deal with the emotional part of it with your family and your colleagues."

Dr. Silverberg said that some possible benefit can be salvaged from the tragedy. "Our hospital staff has been working together for a long time. Now we have this common thread of history, which, in misfortune, has strengthened our bond. That would be the one consolation."

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.