Hospital planners generally assume that the majority of patients from a mass-casualty event will have received some sort of field triage, that transport from the scene to the hospital will have been coordinated through on-scene incident command, and that hospitals will have received some sort of notification of incoming patients. Recent events, however, have invalidated such assumptions. In the 2017 Las Vegas active-shooter event, only 20 percent of the estimated 850 patients were transported by ambulance to local hospitals. While on a much smaller scale, the Orlando Regional Medical Center saw similar results in the wake of the Pulse Nightclub shooting, with initial transport from the scene being initiated by police and civilians using police units and privately owned vehicles.
These two events, taken together, would seem to indicate a shift in the way patients arrive at hospitals after active-shooter events. Why this shift is occurring is not entirely clear. Whatever the reason, this pattern of civilian and police transport of victims has been seen in virtually all the recent mass-casualty events reviewed for this research.
In all the cases reviewed, hospital emergency room (ER) staff initiated their mass-casualty response protocols. However, with the majority of patients not arriving by ambulance, ER nurses and physicians were forced to perform initial triage on large numbers of incoming patients and direct them to appropriate care areas. This lack of initial triage caused hospitals in both of the previously mentioned incidents to become overwhelmed rapidly. While non-emergency medical services (EMS) transport has generally been acknowledged to have improved victim survivability, case studies of mass-casualty incidents actually showed that the process could be improved with some kind of assistance in triage at the hospital. The question that this research seeks to answer is whether EMS can provide this assistance.
While the logistics of the response to the Boston Marathon were well outside the scope of what might usually be expected in a mass-casualty incident, the case was still reviewed due to the hybrid team of hospital and EMS personnel who responded to the event. What this review and analysis showed was that this hybrid team could provide initial triage and treatment in an expedient and efficient manner. While unlikely to be seen in future mass-casualty events, this incident certainly showed what was possible when EMS crews assist hospital personnel with triage.
As the largest mass-casualty incident to date, the Las Vegas shooting exposed the gaps in current response plans on an exponential scale. Of the approximately 850 victims of the shooting, only about 25% of them were triaged and transported by EMS resources on scene. This massive influx of patients, especially non-EMS triaged patients, quickly began to overwhelm local hospitals. One hospital even reported a quarter-mile long line of vehicles waiting to get in the parking lot at one point during the incident.
Reviewing the situation faced at the closest hospitals to the Route 91 shooting, St. Marks Hospital, as a part of its regularly scheduled disaster drill program, conducted an exercise to simulate the experience of Sunrise Metro Hospital. During the course of this drill, EMS was assigned to take over triage operations and nurses were relieved to return to the ER. Data collected during this drill showed that EMS crews were faster and more accurate at performing initial triage and treatment of patients arriving at the hospital, whether by EMS or non-EMS means.
With gaps exposed in the Las Vegas shooting and an exercise showing that EMS is potentially faster and more accurate than ER nurses are, the question remaining is whether EMS crews may possibly be spared from the field incident response to assist at the closest hospitals. In exploring current EMS responses to active-shooter incidents, several redundant areas of patient care appear to be performed at the same time. Triage and treatment is performed “under fire” using the tactical emergency casualty care (TECC) principals; a researched backed civilian variation of basic sorting and life-saving treatments utilized by military medics in combat situations. Casualties are then removed from the danger area and pass through another triage and treatment section where simple triage and rapid treatment (START) triage is applied. Finally, victims are moved to the transport area where they are sent to area hospitals, based on their level of severity.
TECC protocols and the tactical combat casualty care (TCCC) protocols on which they are based have a mounting body of evidence supporting their efficacy while START triage lacks any real evidentiary support in field operations. Thus, the need for these redundant processes to occur on scene seems to be invalidated. Victims instead could be moved directly to the transport area when being removed from where they were initially encountered by medical personnel. The EMS crews that would have otherwise been assigned to the triage and treatment operation could then be freed to be sent to assist with triage and treatment at hospitals, where they could capture both EMS and non-EMS transported patients.
It seems clear, given the gaps in response identified in this research, that the utilization of EMS in triage operations at the closest hospitals has the potential to enhance the response to mass-casualty events significantly. While further study is required to validate these results and much work remains to identify how best to implement this system, the results observed in this study indicate that these changes should be made in the very near future.