Someone saved my life tonight

Some but not all reports on Las Vegas shooting show that team efforts saved lives

Press items on the health care response to the October 2017 mass shooting in Las Vegas ranged from a physician-centric Vox piece about how “doctors save lives,” to a team-oriented article in the New York Times, to a long Guardian feature with firsthand accounts from 10 hospital staff, many of them nurses

Las Vegas shooting nursing careNovember 16, 2017 – Press articles about the October 1 mass shooting at a Las Vegas concert offered a range of portrayals of the roles that health care professionals play in the wake of such events. An example of the physician-centric approach was Julia Belluz’s October 2 Vox piece, “How doctors save lives after a mass shooting.” The article clearly indicates that only what physicians think and do has any importance in such events. Indeed, the report relies heavily on physicians to explain key measures taken to save lives, and it does not even mention a single non-physician clinical professional. The item does focus more on recent advances in trauma care than the full experience of Las Vegas. But physicians are not the only ones responsible for such advances, and nurses are deeply involved in the care the piece describes. Fortunately, reports in the New York Times and the Guardian do a surprisingly fine job of conveying the diverse team of professionals required to handle such events. The New York Times piece is by Sheri Fink, herself a physician, whose reporting has not always shown much interest in non-physician contributions. But her October 2 article “Controlled Chaos at Las Vegas Hospital Trauma Center After Attack” actually focuses on the work and experiences of nurses, particularly a supervisor at University Trauma Center, Las Vegas’s only level one trauma center. It also relies on other team members, including a physician and a firefighter. And today, the Guardian ran Dan Hernandez’s vast account of what happened at Sunrise Hospital, a level two trauma center that saw about 200 shooting victims. The report consists mainly of interviews with a diverse group of 10 staff, among them two clearly identified nurses, a nursing student, a “house supervisor” identified as a “former trauma nurse,” and an “emergency department director” who is a nurse but is not identified as such. The piece has some small flaws, especially in specific descriptions of what nurses did. But like the Times piece it shows nurses playing key roles, including leadership roles, in the response to the tragedy. We thank the Times and the Guardian.

There’s no “d” in team

The clinical supervisor

A sea of blood and patients

There’s no “d” in team

How to save a lifeThe Vox piece by Julia Belluz highlights the response of University Medical Center (UMC) to the shooting, where more than 50 died and more than 500 were injured. But the report is mainly interested in the general availability of “surgical lessons learned on the battlefield.” The piece notes that U.S. gun fatalities have not risen, even as gun violence and nonfatal gun injuries have. The article attributes that mainly to “medical advancements born out of American wars,” with the key goals now being to stop patients’ bleeding, focus on small stopgap surgeries, and promote clotting. The piece relies on quotes from four outside experts, all physicians. Some highlights:

Doctors who specialize in trauma care — treating people with disabling or life-threatening injuries that have resulted from things like gun violence or car crashes — are using techniques honed by military doctors on the battlefields of Iraq and Afghanistan. … But doing all the necessary surgeries immediately in a mass casualty event is usually impossible. So doctors now do smaller and quicker surgeries first, with one key goal: saving lives. … Later, the doctors can go back and do a more definitive surgery to repair the broken blood vessel. … In the past, doctors would first respond by giving patients saline solutions (mixtures of sodium chloride in water) in addition to or followed by blood products. But in the recent wars, military doctors started to notice that patients actually fared better when they got the blood products immediately. … Studies conducted during the wars also helped doctors refine the ratios and amounts of blood products to give to the injured. … [At the previous Orlando shooting] doctors also were faced with less familiar injuries that are challenging to treat. … (Recent evidence from at least one hospital suggests the types of injuries doctors have seen in recent years are indeed more severe and potentially deadly.)

Oh, and did we mention the headline? “How doctors save lives after a mass shooting.” So if “doctors” aren’t providing all mass casualty care themselves, it’s clear that they deserve all the credit and only their views and experiences matter. In fairness, the piece does refer a couple times to the work of “health professionals,” but physicians are the only such professionals identified (unless you count UMC’s “chief experience officer”). And while it’s fair to quote trauma surgeons about trauma advances, many of the statements above are about the provision of trauma care generally, including tasks like giving saline and blood that nurses generally do. To say over and over again that “doctors” are doing all this work, and to consult only physicians as experts, basically erases nurses and other “health professionals” from trauma care.

You can contact the author at .

The clinical supervisor

CPR kneeling on a guerneySheri Fink’s New York Times article “Controlled Chaos at Las Vegas Hospital Trauma Center After Attack” relies mainly on Toni Mullan, a “clinical supervisor in the trauma resuscitation department” at UMC, as she is first identified. In the third paragraph, the piece says that she is “a registered nurse.” On the night of the shooting, having just finished a 12-hour shift, Mullan reportedly drove at “110 miles per hour on side streets” back to the hospital. There, her daughter Antoinette Cannon, “a trauma nurse,” stood outside with a physician’s assistant “taking injured patients out of vehicles as they drove up to the hospital and quickly assessing whose conditions were the most precarious.” Mullan rushed inside and asked, “How am I going to utilize my resources?” Fink explains that UMC is the only level-one trauma center in Nevada, which “means it is fully staffed with surgeons and trauma nurses day and night to handle injuries and mass casualties.” Mullan notes that some of the day shift was still there to help handle the flood of patients, who were doubled up in trauma bays and hallways. Gurneys and wheelchairs were also placed outside the hospital, “a lesson Ms. Mullan said came from a recent training session with a doctor who had served after the Orlando Pulse nightclub shooting.” The hospital set up areas for non-life threatening injuries and one for patients who would not survive to get comfort care. “Teams reassessed intensive care patients” to see who might be moved to make room for sicker ones from the shooting. “In the end, Ms. Mullan said, the systems in place were able to flex with the extra burden and bring care to those who needed it.” The key, she advised, was to be prepared and practice. The piece closes with Mullan’s comment that it was both her worst and her proudest moment in 30 years of nursing.

In the middle of Mullan’s account, the piece describes some other experiences. At Sunrise Hospital & Medical Center, which seems to have received even more patients, the piece quotes the chief medical officer, “Dr. Jeffrey Murawsky,” who discusses the range of wounds and methods of triage used. Dignity Health-St. Rose Dominican received many other patients, and the piece relies on spokeswoman Jennifer Cooper for the numbers. The article also describes the work of medics to get patients to hospitals. Clark County Fire Department deputy fire chief Jeff Buchanan says that the first responders were exposed to an unusual amount tragedy, noting that the concert scene “felt apocalyptic” with so much carnage. And Damon Schilling, a community affairs manager for two private ambulance companies, explains how they responded.

The overall impression here is of many organizations and professionals working creatively together to save lives—not how “doctors saved lives.” It’s partly the diversity of those Fink quotes, but also elements like her description of the trauma center as having “surgeons and trauma nurses.” That indicates that nurses are team members, with specialties. Mullan gets the most attention, perhaps as a coordinator of care, but the team focus is clear. And Mullan comes off as an expert on the hospital response. Many of the steps taken in that response are presented passively, and ideally we might have heard more about the specific care tasks the nurses did. At least we do get a little of that for her daughter, who did triage. And in any case, Mullan’s logistical decision-making (such as where to put different types of patients) itself surely saved lives. This portrait of a nurse as a supervising force in the response to a mass casualty event has real value.

You can send author Sheri Fink a message on Twitter @sherifink.

A sea of blood and patients

Blood spilling out of his pocketsThe Guardian piece by Dan Hernandez has real flaws, but it takes the team approach to an even greater level, and at multiple points it describes specific steps that nurses and others took to save lives. “Heroes of Las Vegas: the hospital staff called to action after the mass shooting” presents short accounts from 10 different health staff at Sunrise Hospital. They are two clearly identified nurses; a “house supervisor” identified in the text as a “former trauma nurse”; an “emergency department director” who is a nurse but sadly is not identified as such; a pharmacy technician who is a nursing student; a “director of infection prevention”; two physicians; a guest services director, and the CEO. An introductory statement explains that after the first reports of gunshots at the concert reached the hospital, “[d]octor Kevin Menes and nurse Rhonda Davis looked up from their charts.” Menes realized that Sunrise, large and close by, would likely get the most patients.

He and Davis started to prepare. Menes contacted house supervisor Kat Comanescu, who then summoned all available nurses to the ER to help move or discharge patients. Davis requested crash carts and gurneys. With only four ER doctors and one trauma surgeon on shift at the time, a mass casualty incident alert went out to bring in day-shift doctors, nurses and support staff.

The number of available physicians seems more important than the number of available nurses, but at least the nurses are not called “support staff.” In any case, the first of the 10 accounts is that of Menes, who does at points make it sound like he was directing everyone and like only physicians save lives. He is quoted as saying: “As ER doctors we bring people back to life and keep them alive for a short time, but surgeons are the ones who work the miracles. They’re the ones who get the bleeding to stop and continue to get them better over next days and weeks, and eventually get them home.” That last part in particular is a damaging misstatement, since it is nurses who do the majority of the life-saving in the hospital “over next days and weeks.” Menes describes the triage process outside the hospital, which he was apparently doing by himself until “a nurse” came to tell him he was needed inside to provide physician care. He also reportedly

told nurses to take every unit of O-negative from the blood bank and fill their pockets with the intubation drugs to save the precious time it normally takes to fill out paperwork and use digital devices that track supplies. “These are complete no-nos in nursing – carrying drugs in pockets that aren’t accounted for,” Menes admitted. “But we had to do it to save patients’ lives, and it worked.”

It’s hard to believe the nurses needed to be told all of this. The remainder of Menes’s account, fortunately, does not suggest that he was calling all the shots or that nurses needed him to.

“Rhonda Davis, trauma nurse,” is quoted as saying that after a short time “her ‘nurse brain’ kicked in.” It’s not clear how much of that Davis actually said, but nurses do seem to have been socialized to minimize their expertise and courage through externalizing and de-personalizing—in emergencies their skills often “kick in,” as if they were just a machine someone else had installed. We can’t recall hearing that physician skills “kicked in.” Fortunately, Davis does give a pretty good sense of the range of injuries and specific things she did, and the latter are especially helpful because they show a serious health professional trying to save lives.

“We were trying to do CPR, putting chest tubes in, all of the life-saving measures that you would do,” she said. … “We went patient to patient as quickly as possible, trying to help save them. I wasn’t thinking. You just kind of do. Quickly it turned into a sea of blood and patients.” … She recalled receiving a young female who had been shot in the chest. With every square inch of the trauma bay taken, Davis and an anesthesiologist worked on her in the hall. He was trying to put a chest tube in, because she wasn’t breathing, and when they could not detect a pulse Davis started doing CPR immediately. “I was leaning up on top of the gurney doing chest compressions, trying to save this poor girl’s life, and there’s just blood coming out of her chest from the wound.”

OK, but…“I wasn’t thinking?” We understand what she means, but as with the “kicking in,” it’s not very helpful to describe nursing activities that way. No one does CPR without “thinking.”

Dorita Sondereker, the “emergency department director,” has a few good quotes showing that she was involved in directing the flow of things: “You directed it, but it was surreal how things just happened; the flow was amazing. We’d call for more stretchers and recliners and they’d appear. The ER was full, so we moved people up and discharged from the top floors. … Hospitals have an option to divert [patients]. EMS kept asking me, ‘how many more can you take?’ I kept saying 10 more. It was an eyeball thing – like where are we at? How many have I moved to cardio, to ICU, to surgery?”” Unfortunately, the piece never identifies Sondereker as a nurse, even though she is one and is evidently close to earning her doctorate of nursing practice (DNP) degree. So nursing will probably not get much if any credit for her good work.

At least the “house supervisor” Ecaterina “Kat” Comanescu is identified as a “former trauma nurse,” although that formulation does suggest that now that she is a “supervisor” she is no longer a nurse, as if the two roles were incompatible. In fact, she is still very much engaged in nursing. Despite this problem, her section has good elements that show her acting decisively:

I was thinking we needed manpower, space and supplies if a lot of people are coming. Our hospital was almost full.” She broadcast to intensive care and telemetry units: “Send all your available nurses to the ER.

Pharmacy technician Thea Parish is a nursing student. She admits that she could only do “limited things,” but her account still manages to include lots of specifics, as she was reportedly able to “help…assess wounds, apply tourniquets, place IVs and monitor vital signs to notify doctors when patients crashed, until on-call staff nurses arrived.” Parish also notes that she had been losing hope about her career path in light of recent events in the wider world, but the life-saving spirit she saw during this crisis seems to have restored her confidence in her decision.

And Heather Brown, “intensive care unit nurse,” was part of a team that “help[ed] triage the emergency cases,” a first-line task that of course is not the usual job of ICU nurses. Brown notes that she “had to revert back to training” (at least she did not say the training just “kicked in”). Back in the ICU at 7:00 a.m., she took care of some patients she had “helped stabilize,” and in the weeks that followed, according to the piece, she “watched them further improve”—which is a pretty unfortunate way to describe what an ICU nurse does. It’s not just “watching” people improve–nurses cause people to improve through their skilled care. Unfortunately, the remaining quotes the piece includes from Brown are all about how some of the patients inspired her, for example by deciding to leave the ED to make room for more seriously injured shooting victims. That’s great, but it would have been nice if the piece had also included more specifics about what Brown actually did, for example in her triage work.

Still, on the whole, the Guardian piece offers a powerful look at the team effort required to save patients in the wake of the shooting, and in particular the key part that nurses played.

You can send author Dan Hernandez a message on Twitter @danielgene.

 

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