Notes From the ER: Am I Prepared for a Mass Shooting?

— If called upon to do the impossible, I too want to be able to step up

by Jeremy Faust, MD, MS, MA, Editor-in-Chief, �鶹��ý October 30, 2023

A photo of emergency room staff rushing down a hospital hallway.

Jeremy Faust is editor-in-chief of �鶹��ý, an emergency medicine physician at Brigham and Women's Hospital in Boston, and a public health researcher. He is author of the Substack column Inside Medicine.

Another week, another mass shooting in America. As an emergency room (ER) doctor, I often ask myself: Am I ready?

Do I possess the skills I need to save just a single life more than if someone else were in my shoes? If not, how can I get there?

I used to think about this all the time. But I've gotten a little complacent, due to the incredible talent I am surrounded by at work. In a truly catastrophic situation, though -- where dozens if not hundreds of dying patients could be in my care all at once -- I would need to be ready to go far beyond that. Others in my field have done it. They are heroes. If called upon, I too want to be able to step up.

This evening, I spent a lot of time thinking about how I might achieve that, and I'm going to share with you what that looks like ...

Heroes Among Us

I do not know the names of most of the shooters who have been responsible for the terrible atrocities that fill our screens. But I do know the names of many ER doctors whose experience with these tragedies I have learned from, and who one day may help me save a life, or maybe 5, or 10, or many more.

I often think about Kevin Menes, MD, an ER doctor in Las Vegas who probably saved more lives in one night than any ER doctor ever. Menes had mentally and physically trained for just the kind of nightmare he endured. That night, Menes and his team treated 215 victims, leading to 67 surgeries in 24 hours. They treated around 30 gunshot wound patients per hour for 7 hours.

Menes' about that night, published in a magazine for ER doctors, is legendary in my opinion, and is one of the few pieces I keep bookmarked on my phone. Some of his ideas were utilized in New York early on in COVID. I've only emailed with him, so I don't really know him personally. I'm just proud to be in the same field of medicine as he is. I hope I don't have to use any of his incredibly insightful suggestions. But I'm not counting on it. I'm counting on the opposite.

Last week, Sheldon Stevenson, DO, and his colleagues at Central Maine Medical Center of those like Menes -- called to do more than is possible. Something that Stevenson said resonated. When he got the call saying he needed to come into the ER to help with a mass shooting, his response was not, "What?" but rather, "Here it is." He'd been expecting this would one day happen. (It reminded me of the line said by FBI Agent Robert Hanssen, who, when arrested for espionage, asked "What took you so long?")

How Can I Prepare?

I often wonder whether I'm ready. I know I have the skills needed to manage a handful of traumas at once -- especially since I know that a phalanx of Harvard physicians, nurses, PAs, and technicians, would appear within minutes (if not seconds) to help out. But what if hundreds of patients were coming in? Would I be ready?

Maybe. When I was a resident, I decided that my skills as a musician could be applied to trauma procedures. The idea was based on an old quotation about preparation. "Amateurs practice until they get it right; Professionals practice until they can't get it wrong." The goal was to get really good at the "microskills" needed to do low-frequency high-stakes procedures. So, when I was a resident, I would literally sit at home watching Seinfeld reruns while practicing skills on models I made or acquired with leftover equipment from the hospital (that was going to be otherwise trashed). I also mentally rehearsed the steps of the procedures. In fact, I even Scott Weingart, MD, a mentor of mine, demonstrating some of these skills in 2015 (my voice makes a cameo at the end), which actually kind of led to a movement in our field (Weingart is pretty famous in emergency medicine, so when he started talking about this stuff, people got interested in it). Mental and physical rehearsal became a mantra to me, and many others in emergency medicine.

Weingart demonstrates a microskill needed for getting large needles and flimsy wires into hard-to-reach blood vessels. Photo credit: Faust, 2015.

A Recommitment to Excellence

Over time, I have to admit that some of my skills for procedures I do infrequently have faded a bit -- though on others I am better than ever. I still perform many procedures myself, but often, I'm guiding residents through these procedures and I only get my hands in there to troubleshoot (which is not that infrequent). I work at one hospital where I do not have residents, and so I keep my skills up a bit more there -- but that hospital is also not a trauma center, so I can count on two hands how many gunshot wounds I've treated there (i.e., without a big trauma team at the ready).

After one of my in-laws sent me the Boston Globe piece about Maine, I had a realization. I need to sharpen up. There are a few skills that I need to get some reps in before I confront a major mass casualty incident. So, I spent a couple hours this evening watching videos on some of these procedures -- each of them I have performed in the past, some more than others; but there are a couple that I have not done enough to rely on if a Vegas-like shooting scenario were to happen on my next shift. After watching these videos, taking notes, and mentally rehearsing a bit, I already feel remarkably more "refreshed" and a bit more prepared.

But that won't be enough. I'll also be making an appointment in our trauma simulation lab sometime soon and get some physical practice in. I also reached out to our mass casualty planning leader to make sure I am up-to-speed on our newest protocols, which have been updated to reflect lessons learned from expertise gained over decades in Israel, and also here in the U.S., including Parkland, Vegas, Orlando, and others (including what "we" learned from the Boston Marathon bombing, which predated my arrival here).

There's lots to do. Decompressing pressure from internal bleeding in the chest? Re-inflating a collapsed lung? Draining a bunch of blood from around the heart impeding its ability to pump with a long needle? Opening the chest wall to literally reach the heart with my gloved-hands to repair a possibly fatal wound? These are all things I've confidently done in the ER at one time or another -- though not often enough to be a true virtuoso. And with the weapons of war in our streets, when the time comes, I'll need to be one.

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