Health care systems' ability to treat mass injuries and casualties depend upon the number and type of hospitals, their capacity and preparedness and system wide plans to coordinate the response, emergency care experts say.
Still, Patrick Downes, who was severely injured with his wife in the Boston Marathon bombing in April 2013, says he can’t believe there was only one Level 1 trauma center in Nevada. “How do you care for 500-plus people?” he asks.
"There is an embarrassment of medical riches in Boston and all were used and under enormous stress," says Downes, noting that fewer than 300 people needed treatment after the bombing five years ago.
Downes and wife Jessica Kensky were treated at different Boston Level 1 trauma centers after the bombing. In 2014, they were transferred to Walter Reed National Military Medical Center where Kensky had about 10 more surgeries, the couple received rehabilitation and counseling and lived for three years until June.
Downes, who has a doctorate in psychology, and Kensky, a registered nurse, have become strong advocates for military hospitals to begin routinely treating civilian trauma patients to help both service members and trauma victims.
"Not to be disparaging of a community hospital, but some expertise lends itself to a situation like this," says Downes, citing a "whole other level of weapons." "It's not just about keeping people alive, but you want to maintain's someone's quality of life, brain function and internal organs."
Boston has seven Level 1 trauma centers, while Nevada only has University Medical Center (UMC) of Southern Nevada, which is in Las Vegas. The hospital, which received 104 of the shooting victims, quickly filled to capacity. Las Vegas' Sunrise Hospital and Medical Center, which is a Level 2 trauma center, received 180 shooting victims. Dignity Health-St. Rose Dominican in Henderson, Nev., is a Level 3 trauma center and received 58 patients.
Medical personnel from the Nellis Air Force Base in Nevada worked in University Medical Center (UMC) of Southern Nevada's emergency department during training with the Air Force's Sustained Medical and Readiness Trained (SMART) program.The best-equipped trauma centers for terror and other attacks have the Level 1 trauma designation, but also need enough space in emergency rooms, intensive care units and in-patient beds to handle an immediate surge of victims, according to a 2008 report to Congress.
Hospitals that aren't trauma centers also treated patients in Las Vegas. Community hospitals can still treat some critically injured patients, says Greg Brison, director of emergency management and security for the five-hospital Inova Health System in northern Virginia.
As of late Tuesday, 40 of UMC's patients had been released, 12 were in critical condition and the others were in fair to serious condition, according to hospital spokeswoman Danita Cohen. At least 527 were injured and 59 people died in the Las Vegas shooting spree.
UMC physician Zubin Damania, who blogs and appears on video at ZDoggMD.com, posted a plea for financial and blood donations for the hospital's foundation and the trauma center, which he noted already takes care of "our most vulnerable citizens." Hospitals in the area "are severely strained by this unprecedented mass casualty event," he said. The 2008 report to the House Oversight and Government Reform committee — the most recent national data available — found none of the Level 1 trauma centers in seven cities surveyed had the capacity to deal with surges of patients similar to the 2004 bombings on Madrid commuter trains that left 200 dead and more than 1,800 injured.
How other trauma centers have prepared:
• Boston. Massachusetts General Hospital emergency medicine physician Paul Biddinger says his hospital received 97 patients in its 49-bed emergency room after the marathon bombings. The hospital and its patients benefited from having a plan that included the "army of people who descended on the emergency department" from across the hospital, says Biddinger.
"The only way you can meet capacity is with the scripted actions numerous people took," says Biddinger, who is director of the hospital's Center for Disaster Medicine. "We didn’t have to tell people what to do." The hospital has also hosted emergency responders from attacks in London, Israel and Madrid, which has have helped it become "even faster and better than it was during the Boston Marathon," says Biddinger.
• Washington. After the 9-11 attack on the Pentagon, 15 Virginia hospitals created the Northern Virginia Hospital Alliance to help emergency medical services (EMS) determine where to send victims during an emergency, such as that in Las Vegas, says Brison. Within 10 minutes of an announced event, a coordinating center would allow all 15 hospitals to give EMS real time emergency room bed availability. This would allow EMS and hospitals to distribute patients so no one hospital gets overwhelmed. During a mass casualty incident, an electronic ICU would also use telemedicine to allow emergency room nurses and doctors to communicate with other ERs. The alliance, says Brison, would be critical "if we had a Vegas."
• Atlanta. Grady Memorial Hospital does mass casualty training twice a year, and would be prepared to coordinate treatment for up to 500 adult and 100 pediatric victims in the event of an incident, says surgeon Mark Shapiro, the hospital's trauma medical director and chief of trauma. There are two other Level 1 trauma centers and 27 other hospitals in the greater Atlanta area and all of the hospitals have agreed to accept a predetermined number of casualties based on injury severity, he says. Grady's Marcus Trauma Center treats about 7,000 trauma patients a year, including 4,500 in-patients, although its "surge capacity" at one time would be 20-30 patients, he says. "We will find a place for them," even if they were "near death" as up to 10% would likely be, he says.
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