An emergency department after a mass casualty incident is the quintessence of the Mike Tyson rule: Everyone has a plan until they get punched in the mouth. On Sunday night, Las Vegas was more than punched in the mouth-after experiencing the new deadliest mass shooting in U.S. history, more than 50 have been pronounced dead. The 500 injured in the shooting were transported to local emergency departments, where my colleagues did everything they could to save them.
In moments like these, doctors, nurses, and technicians lean on their training for most of the required actions. But in every calamitous circumstance-and this is a calamitous medical emergency-there are intricacies that could never have been predicted. And that’s where improvisation comes in. Things that would never be done under normal circumstances can end up saving lives-police cars broke protocol after the 2013 Boston Marathon bombing and put bleeding victims into the back seats of their units and drove them to the hospital themselves, rather than waiting for ambulances. This move, which had also occurred after the Aurora, Colorado, shooting, likely lowered the death toll.
After each catastrophe, leaders such as my colleague Eric Goralnick, medical director for emergency preparedness at Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School and the T.H. Chan School of Public Health, share experiences, both domestically and internationally. Paris learns something from Boston: Tourniquets, long out of fashion, had turned out to be helpful in the field. In turn, Boston had learned something from Aurora: Mass casualty drills in Boston had never accounted for such a large number of victims until officials realized in the wake of Aurora that they needed to prepare for circumstances that had previously seemed too remote to train for.
Emergency departments like the ones that treated victims from Las Vegas are forced to develop their protocols based more on anecdote than evidence.
Man-made mass casualty incidents seem increasingly common. But are medical teams actually learning enough from them? Are we really getting any better? The answers are unclear because in the United States since 1996, there has been an effective ban on federally funded research on firearm injuries. At that time, pro-gun members of Congress actually tried to eliminate the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention simply because it was funding research on gun injuries. The members instead succeeded at removing $2.6 million from the House’s CDC budget-the exact amount of money allocated to firearm injury research. (The money was later reallocated specifically for research on traumatic brain injury.) At the time, Congress’ language was difficult to interpret, but the result of that language has been clear as day: The CDC stopped funding gun injury research. The National Institutes of Health followed suit. Almost everyone in the research community now errs on the “safe side.” Research on the epidemiology of who, why, and how people die as a result of gun injuries in America has virtually vanished.
Today, there are hundreds of federally funded studies on opioids, compared with approximately a dozen on gun injuries, says Megan L. Ranney, associate professor of emergency medicine at Brown University’s Alpert Medical School, even though opioids and guns kill roughly the same number of people. (President Obama clarified some of the language in 2013 in an effort to encourage new research, with only a modest effect on funding-the NIH briefly funded several firearm-related studies, but the funding was not renewed.)
Mass casualty incidents involving public scenes like Las Vegas actually account for just 0.3 percent of gun-related deaths (the rest are homicides, suicides, and, rarely, accidents, Ranney points out). But because of the “slippery slope” rationale held by the gun lobby, these markedly different issues have not been appropriately teased out. The entire topic is “political” and therefore untouchable. That means emergency departments like the ones that treated victims from Las Vegas Sunday night and Monday morning are forced to develop their protocols based more on anecdote than evidence.
What we know and have learned about mass casualty events amounts to ongoing oral and written histories, transmitted from locale to locale by experts like Goralnick. Physician veterans who have experienced it present their recollections at professional meetings and grand rounds presentations. I can personally recall the timeline of events presented by an emergency physician who was on duty at the receiving hospital after the Aurora shooting. It was harrowing: A time stamp. One-line descriptions of the victims, each seemingly more grotesque than the last. The treatments used. Their fates. The presentation reminded me of one of the small things we have learned: In order for a hospital to function smoothly in the face of a large influx of unidentified patients, something as simple as a standardized naming system can help treatment teams keep track of each unidentified patient and avoid confusing them.
Our inability to have a reasonable conversation about guns in this country has also hampered our ability, as medical professionals, to be as prepared as possible to save people’s lives during mass shootings. If we are going to have guns in our society, shouldn’t we at least know how to best treat those harmed by them? In reality, these are not warring propositions. But according to the gun lobby’s current lock on our lawmakers, the right to bear arms remains more sacred than their victims’ right to the best chance at life after a shooting, too.