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How Doctors Save Lives after a Mass Shooting

How Doctors Save Lives after a Mass Shooting
10/06/2017
vox.com

vox.com

Nevada’s University Medical Center was grappling Monday with an influx of patients after a gunman opened fire on a Las Vegas country music festival Sunday night, killing more than 50 people and injuring more than 500 in what is one of the deadliest mass shootings in modern U.S. history.

We don’t yet know the details about the injuries sustained by the victims, but an executive at the medical center, where many of the injured are being treated, told CBS News she was hopeful for one key reason: Her trauma center has a 97 percent survival rate, even in the most dire cases. “Hopefully [the victims] will all be able to be treated and released after some surgical procedures and some very good care here in our intensive care units,” said Danita Cohen, UMC’s chief experience officer.

It’s not just UMC that’s better equipped to handle gunshot wounds after these chilling mass shooting events. Americans today are more likely survive gunshot wounds than they were in the past. Since 2002, gun fatalities have held stable even though gun violence has been on the rise and the overall rate of nonfatal gunshot injuries has increased.

For that, we can largely thank medical advancements born out of American wars.

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.

"During the height of the wars,” said Col. Todd Rasmussen, a medical doctor and professor of surgery who served in both wars, “we were treating injury patterns at a rate that was 10 to 100 times [that which] you would treat in any given city.”

That unprecedented burden of injury translated into instructive medical research, researchers say, that has made gun fatalities more survivable over the long run.

Rasmussen calls this "once-in-a-generation burden of injury" on the battlefields one of the few "silver linings of the wars." Or, as he put it in a recent paper, "the only beneficiary of war is medicine."

In the coming days, these recent advances from the battlefields will be tested yet again on the victims in Las Vegas.

1) Stop the bleeding

The most common reason people die at the scene of a mass shooting event is bleeding. (The second most common cause of death at these events is a massive brain injury.)

Before the Iraq and Afghanistan wars, the use of tourniquets in medicine had fallen out of favor. "Tourniquets to control extremity bleeding were not used, and best practice was that they shouldn't be used," said Rasmussen. But new evidence changed the practice: Military health professionals saw early on that patients on whom tourniquets were used were more likely to survive their injuries.

This change in practice is why the Department of Homeland Security launched the Stop the Bleed campaign in 2015, encouraging bystanders in violent attacks to compress the wounds of victims if health professionals haven’t yet arrived at the scene. And people who were at the Las Vegas country music festival when the shooting happened reported seeing bystanders using belts as tourniquets.

“In the past 15 years of war," Margaret Knudson, a professor of surgery at the University of California San Francisco, added, "those techniques have saved many lives on the battlefield."

2) Small stopgap surgeries

Some gunshot victims need immediate surgery.

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. This type of care was perfected in Iraq and Afghanistan, and it’s called damage control surgery.

For example, for a patient with a minor blood vessel injury on the leg, doctors may put a small piece of plastic in place (called a "shunt") to keep the blood flowing. That can allow them to move on to do other, more critical surgeries on the same patient or help other patients in a more critical state. Later, the doctors can go back and do a more definitive surgery to repair the broken blood vessel.

"We do these abbreviated surgeries whenever we can," and they help save lives, said Knudson.

3) Helpclotting by giving blood plasma and platelets first

Patients wounded by gunshot typically have lost a lot of blood. If they need surgery, they’ll also probably need blood transfusions.

Blood transfusions often involve supplementing patients with specific blood components (also known as products) — like blood plasma, including red blood cells, which carry oxygen, or platelets, which are essential for making blood clot.

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.

"When someone loses 20 to 30 percent of their blood volume from a gunshot wound," said Rasmussen, "we don't give them ... saline solutions. We try to give plasma, platelets, and packed red blood cells right away."

Studies conducted during the wars also helped doctors refine the ratios and amounts of blood products to give to the injured. "We learned from military experience that it’s really important to give clotting factors almost first, and in a better ratio," Knudson said.

That decreased mortality in military wounds, and it’s dramatically changing the way we care for patients in the civilian world. "Not only does it save some of the blood by using products judiciously but it also allows you to [better] direct what you give," said Knudson.

Despite these advancements in trauma care, there’s still a lot to learn

As part of their emergency preparedness plans, all trauma centers have been trained to handle terror attacks and mass shootings. (Cohen said Nevada’s UMC is extra prepared for the Las Vegas victims because of training they got from a doctor on duty during the Pulse nightclub shooting in Orlando in 2016.) Yet the mass tragedies in the US in recent years still present these facilities with unforeseen hurdles.

The tragedy in Orlando — which was the largest mass shooting in recent US history until Las Vegas — turned the hospital there into "a war scene" where "patient after patient after patient" overwhelmed the hospital’s capacity, doctors there said at a press briefing last year.

The doctors also were faced with less familiar injuries that are challenging to treat. Joseph Ibrahim, the trauma medical director at Orlando Regional Medical Center, told reporters, "We saw the gamut of wounds — from wounds to the extremities, the chest, abdomen, and pelvis area — as if they were shot from below ... something we’re not used to seeing." (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.)

These moments remind us of the urgent need to translate even more lessons from the battlefields back home, said Boston Medical Center vascular surgeon Jeffrey Kalish, who treated victims of the Boston Marathon bombings.

At that time in 2013, Kalish said he looked to the military for expertise about how to care for the victims "from day one," applying their experience on treating wounds from an improvised explosive device and related complications — such as ear trauma from the blast and infection.

"We have an amazing wealth of knowledge with the military," he said, "I’m trying to bridge the gap between military and civilian worlds."

Others in the scientific community see the opportunity, too. The National Academies of Sciences released a report in 2016 detailing "how military advances can be sustained and translated to the civilian sector."

According to the report, the leading cause of death for Americans under the age of 46 is trauma — and with a national trauma care strategy focused on bringing medical know-how from war zones to hospitals across the US, an estimated 20 percent of those deaths could be prevented.

Kalish added: "Something like Boston or Orlando, I can almost guarantee it’s going to happen again." Applying the best evidence from war can save lives when the battlefield moves closer to home.

 

 

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