The phrase “service design” usually conjures up images of safe, trivial spaces like mall kiosks and Starbucks counters. But some services are literally matters of life and death—and they must be designed, too.
Case in point: on the night of October 1, Stephen Paddock opened fire on a crowd of 22,000 concertgoers in Las Vegas, killing 58 and injuring hundreds more. Those wounded people all had to go somewhere—fast—or else they’d die too. More than 200 of them went to Sunrise Hospital, where Dr. Kevin Menes was the attending physician in charge. Emergency rooms are already designed for a specific kind of “service:” triaging, stabilizing, and resuscitating people in medical distress.
But Sunrise wasn’t designed to accommodate a wave of gunshot victims all at once. Menes had to design a system that could, on top of the one he had. In a riveting first-person account published in Emergency Physicians Monthly, he breaks down how he and his team did it.
Preparing for the unthinkable
Every ER doctor ends up improvising under pressure, but this wasn’t the kind of situation anyone would’ve been able to just wing it through. Luckily Menes didn’t have to: he’d had prior experience supporting a local SWAT team, which had inspired him to think out in advance how he’d respond to a “mass casualty incident,” or MCI. “For years I had been planning how I would handle a MCI, but I rarely shared it because people might think I was crazy,” he told EP Monthly.
The plan, he says, “was all about flow:” maintaining movement of patients and doctors between the ambulances and the ER, within the ER itself, and from the ER to the operating rooms. This required Menes to know in advance how he planned to use the ER’s limited physical space.
One tactic Menes took was to put one part of the ER—Station 3—totally off limits to incoming patients. With victims arriving “four to a car” to a facility with limited beds, this might not seem to make sense. But Station 3 only had “death beds” in it–isolated rooms with doors and no clear line of sight to the nurse’s desk. Menes decided that using these beds would cause more of a potentially deadly disruption to his “flow” than avoiding them altogether. “In my mind, that was the worst place to put any of these traumas, so I told the nurses to not put anybody into those rooms,” he tells Emergency Physicians Monthly.
Tweaking the tags
Menes had to get his team up to speed quickly on how he wanted to use the space, and also update other doctors and nurses who arrived later in the night to help. As usual, he triaged victims by “tag”—red, yellow, and green—signifying how severe their injuries were and how likely they were to die within the next hour (or few minutes). But he also relied heavily on an intermediate zone called the “Orange tag,” which corresponded to victims who were critically injured and likely to crash at any moment—red tags, essentially—but hadn’t done so yet. With so many victims to handle, this extra tier made it easier to focus on true red tags while also keeping “a very close eye” on the next wave of orange patients who’d soon join their ranks.
He also dedicated specific ER stations to specific tags, which he used in lieu of the actual tags themselves. “Instead of wasting valuable resuscitation time actually tagging the patients, they were sent to their respective tagged areas. I would look at these patients as they came in, and I would grade them red to green,” he told EP Monthly. But he also took care to err on the side of redundancy: rather than flag dead victims as “black tags”, he deemed them red tags instead because he wanted another doctor to verify any assessment that a victim had expired. “I pulled at least 10 people from cars that I knew were dead—and sent them straight back to Station 1 so that another doc could see them,” he recalled. “If the two of us ended up thinking that this person was dead, then I knew that it was a legitimate black tag.”
The other key to managing the overflow of patients turned out to be, as he puts it, noticing subtle procedural “choke points” in his system. For instance, nurses usually use a machine called a Pyxis to automatically dispense doses of medication by pressing their finger to a scanner. Menes noticed that this was simply taking too long—and told the staff pharmacist to just stuff the nurses’s pockets and stations with whatever they needed.
Menes also noticed later in the night that when patients needed CT scans, the technician would (as is normal) wheel the patients to the machine himself and then perform the scan. This was causing a bottleneck, so Menes ordered the tech to park in his chair and not move: “You’re just going to press buttons for the rest of the night.” Meanwhile, extra nurses who had come to the hospital were tasked with moving patients through the “CT Conga line,” as they mordantly dubbed it.
Seemingly minor “traffic cop” moves like these saved precious seconds and minutes on every patient. They cascaded into a river of frenzied activity that lasted seven hours, in which 215 gunshot wounds were officially treated. That’s an average of 30 per hour.
It’s a kind of “service design” that counts as heroism—and every ER should plan for.