AMR Las Vegas response to the mass shooting of 1st October 2017

The Night of October 1, 2017
In the late evening of October 1, 2017, a gunman opened fire from an elevated position on the 32nd floor of the Las Vegas Mandalay Bay hotel into a crowd of 22,000 concert attendees. AMR and MedicWest, along with Clark County Fire Department, Las Vegas Fire & Rescue, North Las Vegas Fire Department, Henderson Fire Department, and Community Ambulance responded. At the end of the rampage, 58 people were killed and more than 450 wounded, creating a catastrophic mass casualty incident (MCI). The concert was held at the Mandalay Bay and MGM Grand festival lot, located in the AMR service area. Here is AMR’s perspective on what has been called the worst mass shooting in U.S. history.

Any given night in the tourist-heavy city of Las Vegas, NV could be fraught with events that seem unusual. But for Paramedic Instructor Michael Whitehead Jr. it seemed like a normal night in his town. It was almost time to relax and go to bed, he turned on the TV, and that’s when the mundaneness of a normal Sunday night erupted into a horrific scene. He saw on the news that there was an active shooter situation next to Mandalay Bay. He got in his car and headed straight to the closest station – not his regular station, but that night it didn’t matter.

Brett Dragun, Operations Supervisor, was on duty. Initial reports were that nine people had been shot, then 20.The numbers kept rising. He started calling in reinforcements; the focus was on immediately sending crews to help those who were injured. But because the law enforcement teams were still trying to contain the situation, there was no way to tell if the active scene was safe.
“It didn’t matter,” said Chris Cutting, dispatcher.“We were going in there and helping people.The first 15 minutes we were sending anybody we could towards the strip.”

 

Dragun explained the chaos of incoming information for that night. An incident command was immediately established near the shooting, but there was disarray up and down the Las Vegas strip. “There were reports of active shooters at pretty much every casino,” he said. “Patients were fleeing far away from the shooting scene and we were picking them up. There were people with gunshot wounds from miles away, even at hotels that were five miles from the scene. They got there after they had been shot. So, while it all happened in one spot, it affected the entire strip. Everybody was on high alert.”
When Whitehead got to the station he said: “I started to see the most amazing thing. Cars just pulling in after me and we have a line of ambulances down the side of the station.” He grabbed a partner and they just headed to the scene. “I wasn’t thinking about anything else other than ‘my people are down there.’ And not only the people of MedicWest, AMR, Community Ambulance, Fire and PD [Las Vegas Police Department], but the people of my community were down there. They needed help – and that’s what we do.”

By the end of the night, 383 AMR and MedicWest employees and 106 ambulance units responded. Additionally, 136 Community Ambulance and firefighter personnel along with 24 ambulances were dispatched. After the event, Clark County Fire Chief Greg Cassell said, “I have never seen so many ambulances.”

 

Adaptive Decision-Making Amid a Chaotic Situation
Because catastrophic MCIs are different from natural mass casualty events, AMR/ MedicWest leaders and crews had to think quickly and make smart, adaptive decisions for situations that weren’t in their traditional MCI planning scenarios.

Deploying Every Available Resource to Get Providers on Scene
AMR brought in 45-50 additional ambulances from the closest operation within 45 minutes of the initial call. Off- duty personnel started pouring into the stations so they could be deployed. However, in the situation of transporting scores of patients quickly to hospitals and trauma centers, having fully-stocked and available vehicles became a challenge. AMR supervisors formed teams of 3-5 providers and assigned ambulances prepped by Vehicle Service Technicians. In less than 90 minutes, all available units had been assigned and dispatched. Wheelchair van drivers shuttled remaining EMTs and paramedics to triage and treatment zones to provide care to the hundreds of victims.

LAS VEGAS, NV – OCTOBER 01: People lie on the ground at the Route 91 Harvest country music festival after apparent gun fire was hear on October 1, 2017 in Las Vegas, Nevada. There are reports of an active shooter around the Mandalay Bay Resort and Casino. (Photo by David Becker/Getty Images)

 

Engaging Civilians as First Responders
The night of the shooting everyday citizens became first responders. Numerous people used their own vehicles to start taking the wounded to nearby hospitals, and AMR teams, grateful for these bystander “first responders,” engaged willing people to help. In one instance, an AMR supervisor who was one of the first on the scene, was separated from the designated triage site by about 1000 yards when people fleeing from the shooter overran him. He took command and established a triage to separate the deceased from the critically wounded. He also formed task groups of willing civilians to load vehicles and drive the wounded to get medical care.

Using EMS Staff to Decompress Receiving Facilities
Two of the hospitals nearest to the shooting were not equipped for trauma patients, but because of their proximity to the shooting, they started receiving casualties from civilian transports. AMR’s local Medical Director Dr Mike Barnum along with a strike team loaded a bus with patients to transfer them to outlying hospitals. AMR also sent paramedics to perform triage and basic care in the Emergency Department waiting rooms so nurses could concentrate on other patients.

 

Flexing Regional Resources
As the primary EMS responder to MCI shootings in San Bernardino, CA, in 2016 and Orlando, FL, in 2015, AMR executive leaders were acutely aware that there could be secondary attacks or that the shooting could be part of a multi-site terror attack.They immediately sent mutual aid from nearby operations to be ready for secondary events and to support the primary response. Even as the shooter was still active, the AMR leadership team had mobilized a virtual command center and immediately began moving regional ambulance units from nearby Arizona and California to staging areas. In total, 15 additional ambulances and two supervisors were activated; three Arizona units came into the operating theater while others staged regionally to respond in case there were additional threats. All units were demobilized once it was confirmed the shooter was contained.

Returning to Service
The 911 emergency system was barraged with calls. Yet even as the events were unfolding and the teams were treating and transporting incident victims, AMR and MedicWest teams continued to maintain the Las Vegas 911 system. As the event concluded and fatigued crews started to return to base with empty units, the reality started to set in:

• Vehicle Supply Technicians cleaned and restocked units for incoming crews.

• The crews were able to collect and share experiences before going home. This provided immediate validation to the scope of the incident

• Requests from local, national and international media started pouring in for stories and statistics. The local operation has people trained in media relations, so they were able to respond to media inquiries.

• Data collection processes started immediately. Local managers began reviewing documentation of what happened: dispatch records, patient care reports, etc. to understand the full picture.

Planning for the Inconceivable
Preparing for these types of Active Shooter situations is one of the things AMR does regularly as an organization, and they have experiences with real-life situations. The company participates in frequent task force deployments as part of AMR’s national FEMA (United States Federal Emergency Management Agency) responses and trains disaster response teams for catastrophic events. In Las Vegas in particular, the teams train regularly for Mass Casualty Incidents (MCIs). Because of the heavy tourism in the city there is potential for higher proportion of MCI incidents due to bus crashes, concert events, etc. A task force and ICS system are routinely used for MCI responses. All field providers trained in ICS: 100, 200, 700 and 800; supervisors also have 300 and 400. There is also a mandatory participation in annual MCI drills with Clark County Fire Department, Las Vegas Fire & Rescue, Las Vegas Metro Police Department, and other public safety agencies.

Capturing the Lessons Learned
Even with all the training that AMR does to prepare for these types of situations, this MCI was unprecedented. “We recognized this is an unusual event and we knew it was important to debrief immediately,” said Scott White, Regional Director who leads the Las Vegas-based AMR and MedicWest teams. He and other AMR leaders regrouped shortly after to develop lessons learned to share with the larger organization as well as other ambulance providers. Here were the key learnings from this mass casualty incident:

• The most valuable tool for first responders is experience and training. Everything moved to a basic level with the goal of stabilizing lives with very few resources.

• Providers must adapt their assessment to the situation. First responders encountered hundreds of dazed patients soaked in blood and had to separate those who were truly injured from those covered with blood of other victims. They also had to ask each other, “are you hit?”

• The EMS focus was separating critical injuries from the deceased. Those with critical injuries were transported immediately and those with non-critical injuries self-evacuated.

• About 200 patients came to the hospitals from outside of the EMS system. In these situations, embracing alternative transport options, such as ride-share services, is necessary.

• Hospitals will be overwhelmed, so EMS can send additional resources to assist hospital staff.

• Send more resources than are requested because people only report what they can see immediately.

Also, some people understandably flee and hide during mass shootings, so once they are discovered, additional resources could provide care for them.

An unconventional event requires an unconventional response
While there is extensive preparation for MCIs, in the end no amount of training or experience could approach the scale of the October 1st incident from a human standpoint. “Our teams responded with speed, care, professionalism and compassion,” said Ted Van Horne, AMR President and CEO.“And they do that every day. October 1st was an inconceivable situation and I am incredibly proud of them for doing what they do best.”

Aerial view of Las Vegas, focusing on the Luxor Hotel “pyramid.”

 

As the sun began to rise in Las Vegas, Van Horne, who is based in Dallas and on a business trip in California, was already en route to Las Vegas with Randel Owen, President of Ambulatory Services at AMR’s parent company.

A former paramedic,Van Horne knew what they would be experiencing and he wanted to get them everything they needed on their own personal paths to recovering from the horrific shooting. In a message to all AMR employees the following morning, Van Horne said that he knows firsthand that these events can take their toll. “As with any tragic event, it takes time to process everything that has occurred, and I want to assure you the AMR leadership team is here to help,” he wrote.

“The AMR community is deeply saddened by the heartbreaking events in Las Vegas on October 1st,” said Randel Owen, President of Ambulatory Services at AMR’s parent company. “I am so proud of the work that our team did and the coordinated response from firefighters and law enforcement first responders in that situation and appreciate what all first responders do to prepare, protect and care for people in communities every day.”

By early-morning October 2,Van Horne, Owen and other leaders from across AMR arrived in Las Vegas to see how they could help with recovery efforts.

“At this point, no idea was off the table,” said Jeff McCollom, AMR South Region CEO. “The wellbeing of these teams was of utmost importance to us. We sent therapy dogs from Texas, CISD (Critical Incident Stress Debriefing) crews arrived immediately, and we started communicating with teams to let them know all the resources available to them.”

Some employees expressed feelings of guilt over not being on duty during the time. Others were in shock as the adrenaline subsided. And many didn’t want to be called a hero. “The images last forever,” one employee said. Operations Manager Greg Schowen said, “Folks started coming back in around 5am and most of them didn’t know how to feel. I didn’t know how to feel. The stories started happening and you don’t realize how this is going to affect not only the people that were there but all of us here.”
Responders’ mental health needs became AMR’s primary concern. Public Information Officer Damon Schilling said that he recognized in the middle of the situation that the newer, younger medics and EMTs might be in a little shock at what they were about to experience. He said, “I was checking on the crews we were sending in and asking them, ‘Are you ok? Do you know what you’re about to get into? ’They were about to enter into an incident that was going to forever change their lives. I knew when this incident was over we would need to do everything we could to help them process this unimaginable situation.”

Vehicle Service Technician (VST) Supervisor Bessy Bautista said, “I’ve never seen my station this way. I saw so much blood, so many people. It was scary.” Bautista and other VSTs played a particularly important role because they ensured the additional vehicles were stocked, then cleaned and restocked again so they could go back into service. The enormity of the events that night was hitting people.

The AMR leadership team immediately focused on helping the crews in multiple ways:

• Nine Las Vegas employees trained for CISD started to help employees process.

• AMR sent additional CISD teams from Rural/Metro (Tucson,AZ) and Northern California.

• A regional CISD team from Kingman, AZ volunteered to go to Las Vegas immediately.

• They activated public safety-specific Employee Assistance Program (EAP) resources and actively connected crews to resources.

• The leadership team brought in a videographer recognizing that crews may be more comfortable speaking to a camera than to a counselor.

• Local managers committed to ongoing surveillance of employees to identify signs of stress.

• AMR also dispatched two specially- trained therapy dogs and their handlers from Amarillo and Houston, TX. Their unique ability to brighten moods was well received by the AMR and MedicWest crews.

Support and attention from the public also came in from everywhere. Local restaurants, hotels and even out of state fire departments and hospitals sent meals, signs, letters, notes and support. Strangers on the streets applauded and hugged the crews. There was even a visiting EMS team from Sweden that reached out to offer help. And local lawmakers visited the teams to thank them. The attention was a bit overwhelming at times, but the crews understood that people in the communities and across the United States just wanted to find a way to help, to say thank you and to say they supported them.
Visits from the Nevada Governor Brian Sandoval, Senator Catherine Cortez Masto, Congresswoman Dina Titus and other elected officials helped the healing process for the crews by confirming the magnitude of the event. During the initial days after, White felt the need to be available to crews who might want to talk at any time. He sent several messages, held meetings at the MedicWest and AMR operations, which comprises nearly 800 employees. The idea was to ensure every person understood that they played a significant role and they might be experiencing a range of emotions.

“At times, I couldn’t sleep. Even if I didn’t have any specific reason to be there, I had to be there. Somebody might need to talk to me. This isn’t going to go away. We have to recognize that, and it’s not about somebody’s ability to hack it. We’re throwing the macho stuff away. We’re going to be here doing this as long as it takes.

I’m not sure if that’s being done in other organizations. It’s being done at AMR and MedicWest. We’re probably rewriting the way we handle these things post-incident. There’s nothing usual about what happened that Sunday night, so nothing should be usual about the days that followed. We’re going to get through it together. And we’re going to provide everything we can for our folks to make sure they feel comfortable.”

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