The Las Vegas shooter is said to have perpetrated the worst mass casualty shooting in recent US history. At the end of his shooting rampage, he had left fifty-nine dead and over five hundred wounded, many of them on the critical list. The Las Vegas area only has one Level I trauma center and they were unable to handle the amount of patients, having to triage the overflow in ambulance bays or have those not critical transferred to neighboring hospitals.
What is a Certified Trauma Center?
In order to be a trauma center in the United States there is a two-step process that must be adhered to. The process is voluntary and all trauma centers must reapply for certification every three years. The two step process includes a verification and then a designation portion. The entire procedure is designed, implemented and conducted at the state level although there is a federal guideline that needs to be met, by evaluating what criteria is needed in the area that the trauma center will be serving. The process is then further examined by the American College of Surgeons who work with facilities to improve and evaluate trauma care by ensuring that the resources as outlined in the Resource for the Optimal Care of Injured Patients are met, these being commitment, readiness, resources, policies, patient care and performance improvement.
Trauma centers have a level designation of I, II, III, IV or V. What these numbers convey to those that need to know is just what level of care is available in those facilities. The criteria differ for adult and pediatric centers, so is there is an adult facility next to a pediatric one, they may both be level I centers that serve different populations.
A Level I trauma center will be one that can will be able to provide care for every aspect of the injured patient from preventative care all the way through to the rehabilitation phase. These facilities will and must include in order to qualify as Level I, twenty-four hour in house coverage for general surgeons as well as specialty surgeons such as orthopedics, plastics and neuro as well as anesthesiologists, radiologists and critical care. They provide resources such as public education and preventative measures for the communities that they inhabit and also for those that are nearby. This sort of center will also provide their healthcare trauma staff with access to continuing education, along with comprehensive quality assessment programs, teaching trauma programs, substance abuse screening programs and are innovative in trauma research care. They must also meet yearly volume of severely injured patient requirements.
A Level II trauma center will be able to initiate care for all types of injuries with twenty-four seven coverage of all type of surgeons including general and specialty, radiologists and anesthesiologists. It can also provide continuing education for staff and has comprehensive assessment programs.
A Level III trauma center will have less of the resources that a Level I and II will have but will still have twenty-four seven coverage. They will also be the backup for rural communities and regions and will typically have transfer agreements with Level I and II trauma centers to handle all of the casualties that their facility in unable to handle.
Level IV and V trauma centers will generally not have twenty-four seven access to cover all specialties and surgeries, but they are be able to provide resuscitation and stabilizing care for injured patients and will have transfer agreements with other higher level trauma centers.
Mass Casualty Triage in Action
When mass casualties happen, police, fire, paramedics and trauma centers work in tandem to ensure that the protocols they have in place work smoothly to deal with incoming patients. It will usually start off with the incoming paramedics radioing ahead to inform the emergency room physicians of the condition of the patient including all vitals, wounds and blood needs. The police and firefighters will also be on the scene where the injured are being taken from. They will assure that it is safe to paramedics to retrieve patients and that there is a clearing of traffic to the trauma center.
Paramedics will then evaluate patients taking those that are both most critical but the least life threatening to survive their injuries on to a trauma center for care. Colors are usually used to assign severity to patients on the scene with red signifying immediate transport need, yellow for urgency but not yet critical, green is for injured but not life threatening while black or grey is used for patients that have been found deceased.
Once arrived at the triage center it’s critical that patient have been thoroughly evaluated in the field so that physicians may make split second decisions for the care of the patient, be that opening up are airway when breath sounds are labored or having equipment on hand to stop an imminent cardiac event. Ambulances coming into the center will be directed to areas depending on the need of the patient being transported. All of these things must take place before patients enter the trauma center to ensure that adequate care is provided.
All Level I trauma centers have protocols in place to alert their personnel in the event of a mass casualty, a mass casualty is an all hands on deck situation and all non administrative personnel are required to report to their stations. Extensive training is usually done at scheduled times of the year and personnel are assigned roles to which they must adhere in the event of a mass casualty. There are also systems in place to for extra supplies such as bandages, gauze, additional medicines, machines and blood products to be on hand for those patients that may need them.
US Trauma Centers Unprepared for Mass Casualties
Although the Las Vegas trauma center is a Level I center, it’s no surprise that they were ill-equipped to handle all the patients that came their way after the event. The United States is one of only a handful of countries in the world that has not had many civil or military wars fought on their soils in the preceding century, as such the level of trauma readiness is at best theoretical. Countries in Europe, Africa, South and Central America and Asia will have much better trauma responses to mass casualties due to history of dealing with such in their own countries or because of close proximity to mass casualty sites in other countries.
In most countries that practice mass casualty triage, a physician is usually on the scene of the incident along with the paramedics to evaluate and treat patients in the field. In the US, field triage is generally conducted only by paramedics, this can lead to greater diagnostic mistakes as paramedics are not as highly trained as a physician that may be able to spot something that they may miss, but which could be critical. Research shows that the best triage is done by experienced medical providers using their more highly trained skill sets.
While the Las Vegas Trauma center was ill-prepared to handle the volume of victims that came their way, it’s once again understandable as the U.S. has not experienced a tragedy of this magnitude since September 11th. This event may have been daunting and disheartening for medical professionals, but it’s an opportunity to reevaluate the guidelines for mass casualties and perhaps streamline the process.