Lessons Learned from Kevin Menes’ MCI Response to the 2017 Las Vegas Mass Shooting

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Principles of Mass Casualty Resuscitation:

• Preplan (resource use, whose in your team and which specialists are you mobilizing)
• Anticipate the hard stuff
• Devise/Improvise solutions to the hard stuff (staffing, bottlenecks, physical layout)
• Simulation/rehearsal of your solution (especially mentally! with workarounds) 

Common Triaging and Tagging System Heuristics: 

• START (Simple Triage And Rapid Treatment):
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  • Source: US Dept of Health and Human Services 
• SALT (Sort, Assess, Life-saving interventions, and/or Transport):
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  • Establish Command and control
  • Sort (Walkers VS the Wavers VS the Still)
  • Perform Assessment/Lifesaving Interventions

Kevin Menes’ Triaging System:

• Differs from SALT and START in that rapid visual inspection (skin color, mental status) + pulse + location + injury characteristics taken into account
  • Skin color + mental status + pulse => trump all
    • Basis for red & gray tagging
  • Trajectory of missile (penetrating trauma) identifies likely organs injured
  • Rates of blood loss from injury
    • Tourniquet necessity
    • Time management
  • If known, consider high vs low flow, caliber of weapon
• Tags/Triage Categories:
  • Inevitable Demise = (black triage tag)
  • Immediate = (red triage tag)
  • Expectant = (gray triage tag)
  • Delayed = (yellow triage tag)
  • Minimal = (green triage tag)
  • 
• Note that placing patients in color coded sections without tags may be the best way to keep up with a rapid influx of patients
  • If you do this, do frequent walk rounds in each section to ensure proper allocation
• Flow:
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  • Rapid dispo-ing of lower acuity cases:
    • Assign midlevel providers,
    • Bedside x-ray w/ tech + radiologist
    • Prescription pad to prescribe for neg reads on the spot
• Flow-planning considerations
  • Need to clear any potential bottlenecks:
    • ED rapid dispo’ing is one way
    • Need to clear Inpatient/ICU beds,
    • ORs need to be ready to receive patients
  • Initial triage can be an artificial “choke point” to funnel incoming patients, family, others
    • Site should be:
      1. safe for staff (Mumbai incident)!
      2. facilitate efficient flow
      3. Like NASCAR (designed to prevent missed injuries, security, loss of order/spawning of disorder)
    • Most experienced, skilled eyes at triage point for tagging (may need to be an RN!)
• Considerations for care delivery to a massive volume:
  • Should be based on color-coded salvagability timeline (ending of “golden” period)
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    • Gray tags (shortest time to expiration) go first then move to red –> orange –> yellow
  • After stabilizing Grey and Red tags, remember that some Orange and Yellow tags may have now become ‘Red Tag’ while you were treating the others
  • When you are one provider needing to treat multiple crashing patients, consider a “flower resuscitation” approach:
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Running out of ventilators?

• Dr. Menes’ suggests possible consideration of a potential theoretical workaround: using flow splitters and T tubes to allow a single ventilator to service up to 4 patients
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• Grey Neyman’s 2006 paper
• Pilot theoretical study run on test lungs
• Brief review of the paper’s limitations include:
  • Trial on test lungs (no patient data found),
  • duration of trial ~6 hours.
  • No study of adequate oxygenation,
  • inability to directly measure ventilator volumes
  • No study for ventilator-associated lung injury
  • Presumption of equal ventilation/ equal lung physiology for all 4 subjects sharing ventilation
    • Remember, patients w/ asthma & greater ventilator resistance may receive equal ventilation with this approach
  • No evaluation for potential infectious complications

Further Reading:

• https://epmonthly.com/article/ed-triage-systems-fail-in-mcis/