Although it has been repeatedly tested, the us emergency management system is not ready. This is not a drill. Multiple shootings occur so often that we and the media are numb with grief and helplessness. Survivors – if they can be called fortunate – may have access to a high-level trauma center. Whether they do determines their probability of survival and the extent of their ultimate disability.
This was true in Tucson, when Jared Lee Loughner murdered six and critically injured Rep. Gabrielle Giffords (D-Ariz.) and others in a mass shooting in 2011. University Medical Center Tucson performed heroically, and those who survived did so with lesser disability than if they were farther away and the trauma center was ill prepared. So goes Orlando, Fla., and Dallas’ recent mass-casualty incident (MCI). What does and doesn’t work is often a matter of chance and too often is determined by proximity to a Level I trauma center, its skills and depth of resources. Even these are tested and fail without exacting preparation, but fortunately 83 percent of US citizens live within that “golden hour” – the time to care for blunt trauma – of a Level I or II trauma center.
Key elements define all types of MCI’s. The type of event determines the number of survivors and time to treatment. Natural events create extreme barriers to response, rescue and resuscitation, while mass shootings and blast attacks create more immediate chaos and overload, to which hospitals and even trauma centers rarely react to perfectly.
The first element is discovery or communication via 911. Cell and smart phones have greatly enhanced communication and the ability to pinpoint the MCI’s location through GPS. However, multiple calls to 911 can overload dispatch centers reducing their effectiveness. In addition, lack of radio interoperability among police, fire and other responders can add confusion.
Further, the antiquated “surround and contain” active-shooter or crimescene response was found at the Columbine, Colo., high school massacre and Newtown Conn., Sandy Hook Elementary School shooting to cause many preventable deaths. This has led to active-shooter training nationwide to reduce intervention times and speed victim rescue and resuscitation efforts. Unlike the golden hour, the crucial time for care of gunshot wounds is within 27 minutes – the average time from injury to exsanguination from hemorrhage. Current training places emphasis on subduing the shooter(s) quickly using robots, SWAT teams, semimilitary tanks, etc., while medically trained law enforcement and fire department personnel rescue those injured using tourniquets, compression methods and rapid transport without much, if any, treatment at the scene. The ideal time for rescue, treatment and transport is 20 to 30 minutes – which is often delayed when a secondary attack on rescuers occurs.
Rapid transport places a horrendous burden on the receiving trauma center. Staff must assemble massive numbers of personnel and essential supplies – from endotracheal and chest tubes to ventilators and blood. Staff must triage those critical and survivable and leave the morbidly wounded. Surgery can occur wherever the patient lies: emergency department, intensive-care unit, hallway or wherever necessary. Nurses and techs may be left holding clamps on vessels while surgeons move on. Asepsis is sporadic and may leave most patients candidates for wound infection well after they survive their injury.
Patient arrival by private vehicle and police car, and walk-ins exaggerate the chaos, as worried loved ones, families, blood donors and others also arrive – from the well intentioned to posers. Lockdown must occur within five minutes of MCI notification to prevent converters from overwhelming security. Without prior attention to security, the emergency and other hospital entrances will be overrun. Decades of disaster responses teach that that establishing a secure perimeter and redirecting well-wishers and others away from care areas is essential, with nonessential personnel enhancing security and control. Communication also is crucial, and serious practice and preparation are necessary – although this can’t predict the various complications where only leadership, teamwork and creativity provide optimal outcomes.
Connie J. Potter is one of the foremost authorities on the nation’s trauma care industry who currently is CEO and owner of TraumaWorks LLC. She previously served as president and CEO of the Trauma Center Association of American, formerly the National Foundation for Trauma Care. She served as Assistant Director of Nursing, Emergency Services Administrator, University of California, Irvine Medical Center; Associate Director/Nurse Manager, Emergency and Trauma Services at Thomason Hospital in El Paso, Texas; and the Oregon Health Division Trauma System Manager.