The mass shooting that occurred Oct. 1, 2017, at the Route 91 Harvest music festival on the Las Vegas Strip left 546 injured and 59 dead, including the shooter. Though initial reporting underestimated the extent of the carnage, emergency care personnel were immediately confronted with the realities of the worst mass shooting in the history of the United States. Husband and wife alumni of the Boonshoft School of Medicine and the Emergency Medicine Residency Program were called in that night: Brian Emil Syska, B.S., M.D., ’00, ’04, ’07, and Heidi Kabler, M.D., ’04, ’07. Syska is chief of emergency medicine at Dignity Health St. Rose Dominican Hospitals – Siena and DeLima Campuses – Henderson. Kabler is medical director and principal investigator at eStudySite, research director of the Sunrise Health GME Residency Program in emergency medicine, and a clinical assistant professor of emergency medicine at University of Nevada, Reno School of Medicine and Touro University.
Vital Signs: How did you learn of the tragedy that night?
Emil Syska: I currently serve as chief of emergency medicine for two of our community hospitals in Henderson, Nevada. Our emergency medicine group staffs seven of the hospitals in Las Vegas and Henderson. Shortly after the incident occurred, all of the group medical directors were notified of a possible mass casualty event and the need for assistance. At that time, we did not understand the scope of the tragedy that was unfolding on the Strip. My wife, Heidi Kabler, M.D., and I were able to access electronically our emergency departments. We assessed which hospitals had the greatest need based on the arrival patterns and acuity. The overwhelming need was at our level-two trauma center, Sunrise Hospital. We were quickly able to mobilize and guide resources to the facility. Sunrise Hospital treated more than 200 victims within the first few hours of the shooting.
Heidi Kabler: As a director, Emil was notified of a possible mass casualty event, and we quickly turned on the news. Initially, the news was only reporting 24 injured and two deaths; however, one of our mid-level providers was at the concert and was able to notify our directors by text that it was in fact much, much worse. When we pulled up the tracking boards for the departments, the devastating truth that an actual mass casualty event was occurring in our back yard became a tragic reality. Luckily we had someone who could come stay with our two children, so we could go try to help in any way possible.
VS: How does one train for a tragedy like this?
Syska: There is no amount of training that can prepare anyone for what we saw or did that night. This was the worst mass casualty event in U.S. history. It felt like being in a war zone with casualties coming en masse from a killing field. As emergency medicine physicians, we are trained to think on our toes, react quickly, stabilize with the tools we have available, and multi-task. These qualities that have been instilled in us over years of training allowed us to move quickly, efficiently, and effectively. This is the core of what we do. We recognize within seconds which patients are critical and have a life threat requiring emergent intervention and which patients are less critical. That evening, patients were banded on arrival based on their acuity. We treated patients in any space we could find. Our highest-acuity patients were placed in beds. As the beds filled, patients were placed in chairs that lined the hallways of the emergency room, waiting room, and any space we could find. The surge of patients made it difficult to register their names, which subsequently made it difficult to locate them for treatment. Patients were continually re-evaluated, re-assessed, and re-vitaled when equipment was available.
Kabler: Hospitals and first responders conduct numerous drills to attempt to prepare for something like this and it certainly helps, because I felt like things were going as smoothly as could be expected. Patients were being taken directly to the operating rooms and post-anesthesia care unit who needed to go immediately to surgery. The walking wounded were being directed to our pediatric emergency department where our mid-level providers were able to apply splints or sutures. The police were able to keep the non-wounded family and friends out of the department because there just wasn’t space for people’s loved ones to be by their sides. The people involved were so understanding about that, though I’m sure it was adding insult to injury to not be able to be with their loved ones. Everyone from the first responders, the physicians, and other providers to the nurses, technicians, registration personnel, and housekeeping was doing their part quickly and efficiently and many, many lives were saved by the teamwork that occurred that night. The fact that everyone was trained in their own part, and we all came together working fluidly as a team is what made the difference.
VS: What was the coordination like with first responders?
Syska: Our first responders were overwhelmed with hundreds of people needing transport. Their resources were at capacity. Crews were responding from all over the city as quickly as possible. They were dropping off numerous patients in the same rig and, after a quick report, sped back to the scene to continue transport. We had patients arrive in cars and in the back of pick-up truck beds, sometimes four and five at a time. Many had tourniquets or makeshift devices attempting to stop bleeding. Friends, family, and complete strangers were helping with transport and care of the critical. The swift and prompt responses of the people of Las Vegas saved lives that night. Their actions were heroic in every way.
VS: What injuries were most common?
Syska: The overwhelming majority of injuries were gunshot wounds. We also saw shrapnel wounds and complex lacerations as people attempted to scale fences and barricades. Many patients had been trampled after the shooting began as people tried to escape the scene. Essentially, they were all traumatic injuries.
Kabler: One thing that keeps flashing into my mind is the horrifying look of shock on the faces of every victim we saw that terrible night. I can’t shake the eerily quiet chaos we experienced. Typically the emergency room is loud with beeping from all directions, and patients calling out from their rooms asking for pain medications or help to the bathroom, but that night the patients were still, the entire department was chillingly quiet. The shock in their eyes was palpable. We treated the physical wounds, but what continues to devastate me is that every single one of those patients that night has emotional scars that lie beneath and go much, much deeper. The physical scars may fade over time, but the emotional wounds will remain.
VS: How do emergency physicians deal with this? Is something like this just “part of the job” or does it affect one differently?
Syska: There are no words to describe what happened that dreadful night. No one could predict the hostility, hate, and carnage that pure evil unleashed with such furor, for no apparent reason. No one expects this sort of thing to happen, much less in his or her backyard. Everyone involved that night was traumatized, there is nothing that can prepare you emotionally and physically for what happened. The hospital personnel did what they do best, they take the emotion out of what’s going on and save lives. I think all of us who work in the emergency room have become comfortable and expect some sort of tragedy when we go to work. In a way, it is an expected part of what we do. However, when you’re experiencing more than 200 tragedies within a matter of a few hours, it becomes far from ordinary, it’s extraordinary in every sense. It was not until the next day that the true processing began. There was a host of counselors, psychologists, and psychiatric personnel available to help everyone who had been involved that night. In the hours, days, and weeks since that night, it continues to be difficult to cope with such senseless loss and devastation, the shock of seeing so many innocent faces in our emergency rooms maimed and scarred for life. That’s what keeps me up at night. My wife and I have solace in knowing we have each other to discuss and replay the events that unfolded that evening. We have been very fortunate in that regard.
Kabler: I think everyone deals with tragedy in different ways, and the important thing is that we do what we can to support each other through it. Our group provided a debriefing to all of the providers who were involved. It wasn’t mandatory, but it was encouraged. At first, I wasn’t going to do it. I felt like I should be fine, that I didn’t go through anything like the victims, it wasn’t necessary to talk to a professional. But one of my colleagues said he was going to do it, so I decided I would call in as well. I found it to be extremely helpful. The woman I spoke to was kind and understanding, and she helped me to realize that there shouldn’t be an expected way for me to feel. She explained that this type of extraordinary tragedy can bring up emotions from other tragic times in our lives and that it is OK to allow ourselves to cry, and it is OK to experience this grief in different ways. This was definitely not something that felt like just part of the job, for me at least. Sure we see death every day, and we often carry with us the grief of our patients, but this was different. This was unimaginable tragedy. This was an unimaginable and brutal massacre of hundreds of innocent people in our backyard. This did not feel like just part of the job.
VS: How did your emergency medicine training prepare you for it?
Syska: We are blessed to have been trained at the Boonshoft School of Medicine as well as the Boonshoft Emergency Medicine Residency Program. Having spent more than 11 years of education and training at Wright State, I can truly say I was as prepared as one could be. The benefit of being community- based allows you to adapt to different environments, different electronic medical records, different cultures, and prepares you to be versatile, which is directly applicable to what we do every day in the emergency department.
Kabler: We always talk about how incredibly lucky we feel to have come from such a solid medical school education and tremendous residency program. We have worked in several rural departments without any specialists or backup and time and time again our training carries us through. In addition to the community-based training, I think one of the things that continues to be evident for me is the hands-on education we received throughout our training. Reading in a book is one thing, but having the opportunities to work through scenarios in a simulation lab truly helps cement things to memory. Since graduation, we have worked in several departments without any specialists or backup, and time and time again our training carries us through.
VS: What lessons do you think were learned?
Syska: I believe the main lesson learned is that we should all be prepared. No one thought that a peaceful and quiet night at a country music festival could lead to the deadliest mass shooting in U.S. history. Simply put, we live in a different world today — a world where any citizen can obtain an arsenal of automatic and semi-automatic weapons and unleash hatred and devastation in minutes. No one dreamed that more than 500 victims could flood our valley’s emergency departments within hours, but it happened.
Kabler: It happened and, sadly, it will happen again in someone else’s backyard. I agree we all need to be prepared — prepared and aware. Have a plan. As Louis Pasteur once said, “Chance favors the prepared mind.”
Syska: I think it’s important to recognize all of the people that were there that night at the Route 91 concert. Those people driving their cars on the Strip who saw the injured and wounded fleeing in droves; they stopped to put people in their back seats or truck beds and quickly transported them to help. Some willingly allowed others to take their vehicles so that the injured could be transported, and didn’t think twice about it. The people at the concert who helped others get to safety, or shielded their loved ones to protect them. These were the real heroes of the evening. We pray for all of the victims and their families, many of which are still in our hospitals and have had their worlds collapse around them. We hope they will find the way to move forward. Lastly, the outpouring and support from all of the great people in Las Vegas and from across the country has truly been overwhelming. In many ways this has helped allow our city to start healing and has personally helped me move forward. #VegasStrong.
Kabler: The way people from all walks of life come together in the face of tragedy is astonishing to me. If we can all rise up in the face of tragedy, it seems we should be able to open up the conversations to find a way to try to prevent such senseless devastation to countless people.
- Daniel Kelly