EMS Providers in Vegas Trained on Tactical Emergency Casualty Care
Updated: Dec 21, 2018
The Las Vegas media often refers to the night of October 1, 2017, as “that awful night,” but the night didn’t start out awful at all.
Dressed in cut-off jeans, flip-flops and cowboy hats, 22,000 moms, dads, kids and teens had all come out to enjoy the last of three full days of the Route 91 Harvest Festival, which featured performances by some of the top country-western singers, songwriters and entertainers.
Seated in lawn chairs and on picnic blankets, spectators covered a 15-acre fenced-in space in the Las Vegas Village area, which was made available by MGM Resorts International.
The outdoor concert was similar to the many other large-scale events for which Community Ambulance—one of Clark County, Nevada’s, 9-1-1 providers—regularly provides EMS medical standby services.
The company’s special event division, led by Glen Simpson, AEMT, offers medical services for more than 1.6 million spectators and participants every year. The growing list of events and venues include the National Finals Rodeo, the Colosseum at Caesars Palace, USA 7’s Rugby, House of Blues, PGA Tournament and Electric Daisy Carnival—North America’s largest music festival.
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For the Route 91 Festival, Simpson and his staff of 16 had planned well, ensuring the crowd’s safe egress through six large gates located on the West, North and East sides of the Las Vegas Village venue.
The Clark County Fire Department, the Las Vegas Metropolitan Police Department (LVMPD), on-site security, as well as Live Nation Entertainment and MGM Resorts International—the festival’s promoters—were all in communications.
As part of preparations, the event medical division leaders actually discussed an active shooter scenario. As a result of these discussions, Community Ambulance’s medical tent, located at Gate 4A at the northeast corner of the venue, offered immediate onsite access to EMS services for ambulance access/loading.
Community Ambulance’s onsite personnel included primarily long-term, highly-experienced EMS personnel, as well as a few new EMTs with only a few months experience working at special events.
Roving uniformed EMS crews were positioned at strategic points within the venue. Locations included stage right (behind the barricade), at the main gates, and “front of house” positions to provide the best access for the calls for EMS service.
In addition, Community Ambulance had three dedicated ambulances strategically parked in a church parking lot immediately across from Gate 4A, which is where the venue’s medical tent was located.
On the south side of the venue, Route 91’s concert promoter had erected a massive stage and lighting structure where the country western stars performed in high-tech, sequined splendor.
There was a VIP tent located on the west side of the venue, as well as specially erected suites placed on both the east and west sides of the stage area.
The concessions were located at the venue’s northeast end, near the main entrance and the medical tent.
Up until 10:05 p.m., it was a beautiful, temperate Southern Nevada evening. Jason Aldean had taken to the stage around 9:40 p.m. He was playing the first strains of When She Says Baby, when the first shots rang out.
“I had just closed a taxi cab’s doors before it transported the inebriated concertgoers I had escorted to the curb,” says Simpson. “I, and five Las Vegas Metro officers who had accompanied me there, were getting ready to head back to the medical tent. That’s when I heard what turned out to be the first gun shots in the distance. In the moment it took me to remember there wasn’t supposed to be any pyrotechnics during the show and to realize what I was hearing, the officer next to me said, ‘This is real.’”
The towering Mandalay Bay hotel, with its gold-windowed façade, echoed the gunshots, making them sound like they were coming from at least two different directions. Simpson adds, “Initially, we speculated multiple shooters on the ground. The wounded were coming from all different locations throughout the venue.”
Focused on the safety of his onsite crews, Simpson bolted toward the first aid tent against the flow of the fleeing concertgoers, who were running toward the venue’s established exits.
As he ran into the venue, bullets rained down around him. Simpson radioed for additional resources on a secondary channel directly linked to the Community Ambulance communications center. He passed by the obviously deceased. Horrified yet surprisingly in control, he motioned for people helping the wounded to take victims to the medical tent.
Simpson says, “As the shots continued to ring out, panic ensued and people who only needed to exit just a few feet away through clearly marked venue gates, attempted to climb over the fences.”
A MANAGER’S NIGHTMARE
Community Ambulance COO and Partner Brian Rogers, who wasn’t at the festival, answered a call on his cellphone and heard what any father would dread hearing. “Dad, someone’s shooting at us! I don’t know what to do!” His daughter and Community Ambulance staffer Kaitlyn Rogers, had called him from the concert stage area as bullets penetrated nearby objects—and people.
“Run! Get to the first aid tent. I’m on my way,” Rogers said, knowing he would soon take on a leadership role in an event that would forever change his life.
As he raced down to the festival grounds, Rogers called dispatch to confirm that additional ambulances were being mobilized and was assured that a massive police and fire response had been initiated. Personnel from multiple agencies began responding and the police helicopter was being staffed and prepped for flight.
Soon, Rogers arrived at the medical tent and ensured that his daughter and employees were out of harm’s way.
“There is a lot of personal responsibility being the owner, or just their boss,” says Rogers. “You feel like you put people in harm’s way when something like that happens.”
Rogers’ business partner and co-owner, Chief Executive Officer Rob Richardson, along with General Manager Brian Anderson, responded to the company’s headquarters immediately upon being alerted at their homes, so they could help mobilize all available ambulances, maintain 9-1-1 coverage in the company’s service areas and assist with informing area hospitals about incoming wounded.
Howard Sheppard, EMD, Community Ambulance’s communications manager, responded from home to take over the communications center.
“When I entered the comm center,” says Sheppard, “I noticed the looks on the dispatchers’ faces were calm. They didn’t skip a beat. And, I was proud of the way that it was handled from the traffic coming in and the logistics of getting the crews out of there.”
An all-call notification was pushed out for Community Ambulance employees, and they responded in droves to man every available ambulance.
“We emptied our entire lot responding staffed ambulances in less than a half hour,” notes Anderson.
Community Ambulance provides standby medical services for more than 1.6 million spectators and participants every year. Photo courtesy Community Ambulance
SPRINGING TO ACTION
The Clark County disaster plan and incident command system (ICS) training and planning process was developed with methodical disaster response thinking. However, with a shooter firing 1,100 rounds of high-caliber bullets from high above the venue, hitting attendees as well as EMS personnel and police officers, this incident demanded a more improvised approach. A more formalized ICS process was adopted after the shooting stopped and more information was obtained from law enforcement.
At their own peril, four off-duty Community Ambulance personnel, who had been enjoying the concert, immediately assumed on-duty status so that they could care for victims.
‘We were not first responders, we were the responders.’ —Glen Simpson, AEMT
“We were not first responders, we were the responders,” Simpson recalls. “We didn’t go in, we responded from within.”
Jimmy Grovom, EMT-P,a former Community Ambulance employee who had recently moved to California, also sprang into action to assist his former co-workers sequestered in the medical tent.
While automatic fire continued to hit victims and the pavement only a few feet away, the first aid tent became quickly overwhelmed with victims.
“They just kept bringing us people,” remembers Rachel Kole, AEMT, who was stationed inside the medical tent.
Sadly, but out of necessity, several deceased and mortally wounded victims had to be moved outside the tent as medics worked feverishly to save the potentially viable victims.
Oscar Monterrosa, the paramedic in charge of the medical tent that night, was focused on getting the team to apply tourniquets to stave off severe hemorrhaging, replace fluids for internal bleeding and immobilize trampled limbs. (Of the 546 victims, there were surprisingly few trampling injuries.)
Due to the sheer numbers of injured victims, on-scene medical supplies and stores were quickly exhausted.
Although multiple brands of tourniquets where available and used by EMS and police responders, the two found to be most effective were the CAT and SAM XT tourniquets. Makeshift and other types of tourniquets proved difficult in maintaining a grip and had to be replaced by the CAT and SXT tourniquets.
“These younger people were presented with injuries from shrapnel to minor gunshot wounds to people in traumatic cardiac arrest,” marvels operations administrator Bob Byrd. “There were people with gunshots to the head or chest or massive arterial bleeds.”
“It was so strange to see patients with gunshot wounds to the face or skull, still talking to us,” says Simpson. “There was blood everywhere. People were either bleeding from wounds or covered with the blood of those they tried to help.”
When crews learned that an LVMPD police officer was on the ground wounded, Byrd and Troy Goldbaum, AEMT, supported by armed LVMPD police officers, raced out to find and care for him.
As the crews raced to find the wounded officer, several LVMPD police officers climbed up into a small 35-foot tower. Originally designed as a watch tower over what used to be a parking lot, they took positions with long rifles, to protect and defend the medical tent from what they thought might be a ground assault by multiple individuals.
A complete power outage in the first aid tent further complicated the scene, forcing medics to work in the dark until they were able to evacuate the tent when the shooting finally stopped, and LVMPD gave them an all clear.
The top priority was to take care of as many people as they could with all the chaos going on around them.
Fearing that the shooter was on the ground, onsite EMS crews, despite normal instincts to run, refused to leave their patients in the tent. Surrounded by armed officers, they continued their work.
As automatic gunfire continued to rain down on the panicked crowd, Simpson and Byrd established the initial command post at the medical tent, calling into Community Ambulance’s communications center for additional ambulances and first responders.
Finally, the shooting stopped, although there still wasn’t much information about what happened, if there was still a threat and where the threats were coming from.
It was much later when hotel security and law enforcement stormed the shooter’s hotel suite and confirmed the shooter was down.
TRIAGE & TRANSPORT
After the active shooting melee, an incident command structure was put in place and Clark County Deputy Fire Chief Jon Klassen and Rogers established East Division along Giles Street, just south of Reno Avenue.
At the concert venue, attendees demonstrated an amazing willingness to help the injured. Uber vehicles, police cruisers, pick-up trucks and passenger vehicles became makeshift ambulances, taking victims to 13 hospitals in overwhelming numbers.
Complicating triage and ambulance placement were reports coming from numerous surrounding hotels reporting “active shooters.” Several injured Route 91 victims reportedly made it to these other hotels saying, “I’ve been shot.”
Security at those hotels hadn’t yet been informed of the Route 91 shooter and therefore called in their own active shooter status. It took some time to sort out the source of all the active shooter reports at these other victim sites.
Because of the multiple shooter reports the LVMPD and Nevada Highway Patrol shut down surrounding streets as well as the I-15 freeway, which flanks the backside of every hotel on the west side of the Las Vegas Strip.
Only ambulances, fire apparatus and law enforcement vehicles were allowed to use this main north/south traffic artery throughout the city.
Ambulance travel to the city’s Level 1 trauma center, University Medical Center, became easy with the freeway cleared.
Community Ambulance dispatched ambulances to three staging areas. Initially, they were staged at Reno Avenue and Giles Street. Later, ambulances were also staged near incident command, at Las Vegas Boulevard and Russell Road, as well as at Tropicana Avenue and Koval Lane.
American Medical Response (AMR), another county EMS provider, sent all the ambulances they could staff to the incident. With additional ambulances available, Richardson sent Community Ambulance personnel to AMR to staff the additional rigs.
As soon as the medical tent could be evacuated, the curb area of the closest street, Giles Street, was turned into the triage Red Zone. The Yellow Zone was established just across the street.
All green-tagged patients (i.e., walking wounded and bystanders), were told to keep moving towards safety outside the venue. It wasn’t practical to keep to a rigid crime scene protocol. Since people were so gravely injured, their families and loved ones were permitted to stay with the dead and injured until they could be moved.
Community Ambulance and other responders didn’t use triage tags at this event because of the active shooting going on around them. They did, however, place abandoned cowboy hats they found over the faces of the deceased to indicate victims that had died.
“If you don’t know where the danger is originating from, you keep moving out of necessity,” says Simpson. “We were like fish in a barrel. If we had established a collection point for evacuating concert attendees out in the open, we may have ended up with a second scene—a killing zone.”
Roughly 50% of the shooting victims, 264 patients, were transported by ambulance to 13 area hospitals, with the rest plucked up and transported by other vehicles and bystanders.
By 11:00 p.m. all critical patients had been transported to the hospital and plenty of ambulances were still available.
Police declared a warm zone at midnight, less than two hours after the initial shots were fired. Ultimately, and much later, all remaining staff and private citizens were evacuated from the venue via passenger buses.
Sunrise Hospital, a Level 2 trauma center close to the venue, treated 199 patients—the largest number of wounded—150 of which arrived within about 40 minutes. University Medical Center, a nearby Level 1 trauma center, treated 104 patients.
Because there were so many gunshot victims, ED treatment rooms became surgery suites out of necessity. The halls were lined with gurneys and the usually pristine hospital floors were awash with blood.
Dispatchers remained calm as they handled the traffic coming in and the logistics of getting crews out as personnel responded to an all-call notification. Photo courtesy Community Ambulance
At the time of writing this article, the official after-action report is still in process. This was a very unique and complex event. However, there are many things that worked well and many suggested ideas that will be used moving forward.
Command/control: At mass casualty incidents, the onsite event medical supervisor should serve as the initial incident commander. This person would ideally have already fostered a working relationship with area public safety leadership.
As he was responding to the incident, Community Ambulance COO and Partner Brian Rogers assumed this role after contacting his friend and colleague, Clark County Deputy Fire Chief Jon Klassen.
Communications: Every individual crew member should have a radio to call for additional supplies and assistance.
Crowd/bystander involvement and care: Bystanders became willing and brave first responders at the incident. In the future, Stop the Bleed kits should be on hand and distributed. At the beginning of any large event, organizers should be encouraged to offer a quick first aid message and identify the location of Stop the Bleed kits.
Media relations: Local and national news media will be quickly on scene, interviewing responders, victims and event planners. Rogers and Simpson served as company spokespeople for Community Ambulance. They immediately contacted their contracted public relations team, 10e Media, to solicit assistance navigating the multitude of media inquiries, answering media questions and facilitating interviews. Providers should have a plan in place indicating who they should contact.
Search teams: After the gunfire ended, and victims were triaged and moved from the venue, several critically wounded victims who ran or were carried by concert attendees, were found in or under vehicles in nearby parking lots. Some were found injured or deceased two blocks away. This highlighted the need for search teams that include EMS responders at future incidents of this nature.
Psychological support: Community Ambulance solicited the immediate assistance of Nadine Leone, MA, MFT, an EMS specialist psychologist from the Las Vegas area for critical incident support. Leone maintained office hours at Community Ambulance for several weeks following the incident.Almost all personnel sought counsel in the weeks that followed.
Ongoing psychological support is being offered to all responders involved in this tragic and emotionally challenging event. One of the most powerful support solutions was the ability to have peer-to-peer interaction and discussion. Knowing that another person had experienced the same horrible incident gave solace to each participant as they talked through the event.
‘ABOVE & BEYOND’
At least 851 people were injured, and a total of 460 shooting victims with more than 500 gunshot wounds were cared for that night. Excluding the shooter, a total of 58 people—36 women and 22 men—lost their lives. The oldest victim was 67 years old and the youngest victim was 20. The Clark County Coroner’s office determined that all 58 victims died as a result of gunshot wounds.
EMS agencies and personnel in the Las Vegas area came together quickly, working in a unified effort. More than 100 ambulances responded to the scene including 22 from Community Ambulance. Clark County Fire Department, Las Vegas Fire Department, Henderson Fire Department and AMR/MedicWest also sent ambulances and personnel.
Community Ambulance staff and leadership displayed remarkable heroism that night.
“We had 16 employees who were on duty that night, including five who were off duty that stepped up to help. That is not something that you hear on a regular basis,” observes Byrd. “These people went above and beyond and have set the bar for everybody else.”
“These were unarmed medical personnel in polo shirts and pants, who stayed while under heavy gunfire because they weren’t willing to leave their patients,” acknowledges Richardson. “It’s more than awesome. They have a heroism and human kindness that is second to none.”
Janet Smith is the owner and president of Janet Smith & Associates - On Assignment Studios. She specializes in EMS public relations/business communications and new business development as well as still photography and corporate video production for EMS agencies.
Glen Simpson, AEMT, is the director of special operations at Community Ambulance in Las Vegas. Oversees the efficiency and effectiveness of personnel and operations in special events, fleet and IT. Contact him at email@example.com.
Editor-in-chief of JEMS, A.J. Heightman is a former EMS director and EMS operations director who has researched and specialized in MCI management training for 30 years.