Episode 23 – 2017 Vegas Attack: Handling a Mass Casualty Incident – Dr. Kevin Menes

Jon Becker: My guest today is Dr. Kevin Menes. Kevin is an emergency room physician and tactical team doctor who led a team that managed to treat and save hundreds of patients following the active sniper attack in Las Vegas on October 1st, 2017.

Kevin's insights into the Las Vegas attack are unique and offer us clear lessons learned in preparing for mass casualties. Too often, active shooter preparation ends at the tactical level and fails to consider the effect on all involved agencies.

This discussion with Kevin clearly shows that saving lives after a mass killing event is dependent upon the preparation and training for all of the responding organizations.

My name is Jon Becker.

For the past four decades, I've dedicated my life to protecting tactical operators. During this time, I've worked with many of the world's top law enforcement and military units. As a result, I've had the privilege of working with the amazing leaders who take teams into the world's most dangerous situations.

The goal of this podcast is to share their stories in hopes of making us all better leaders, better thinkers, and better people.

Welcome to The Debrief!

Kevin, I appreciate you being here today! It's great to sit down with you!

Dr. Kevin Menes: Thank you for having me!

Jon Becker: So why don't we start with kind of your personal bio? Because I think it's important to give context to your role in the story. So where'd you go to medical school? Kind of give me the 30 seconds speech on Kevin's childhood and life history.

Dr. Kevin Menes: So born here in Los Angeles to two Filipino immigrant parents who ended up going to college at University of California, Riverside, also known as the University of California, rejected at the time, because if you couldn't make it to UCLA, you could make it to UC Riverside. I don't think that's the case now, but that's where I had gone. Graduated from medical school, worked for the government as a scientist for a year at Los Alamos National Laboratory before then coming back here to Loma Linda, and I went to medical school at Loma Linda.

Normally, medical school is a four year degree, but I made it a five year degree. And when you make it a five year degree and you end up at the bottom of your med school class, you don't necessarily get your pick of where you want to go.

And at that time, emergency medicine was the most competitive specialty. When that year that I graduated, and so I had thought that I had a spot at, you know, La County USC, where I'd done a couple of rotations at. To me, it was the epitome of trauma and emergency medicine at the time.

That's where I wanted to go, but I ended up in Detroit, and it was the biggest opportunity I have ever had. And I trained under some of the best ER doctors in the business, many of which people never will ever know because, you know, they don't write papers, they're not famous, not world famous by any means, but they taught me a lot about what emergency medicine or what an ER doctor should do. Sort of the, like, accountability stuff and teamwork, doing the best you can with what you have.

Those were lessons that I learned that aren't necessarily taught as lectures, but I learned from those people there and then I was also working at the trauma center on the east side of Detroit, which saw more gunshot wounds than, I think, most any trauma center during that time, that year, those years I was there, I think we were only beat out by Flint, Michigan. And Detroit was the murder capita of the United States of America. But surrounding murders are also the number of attempted murders. And those are opportunities as doctors to try to save a patient.

So I got a lot of hands on experience in that arena. And it really opened my eyes to just handling catastrophic situations in a very short amount of time. And I thought I was prepared to get out when I got out. And I think I was from a mechanical standpoint. I mean, I could do the work, but there was so much more you learn, I think once you get out, I think that's in any profession, right? You go through schooling, but when you're out on the job, you sort of learn and you learn more. And I ended up coming from Detroit and moving to Las Vegas, where I ended up working and somehow found myself working the night that the shooting had occurred.

Jon Becker: So talk to me about in the Vegas area there, like LA has. I think you said 17 different trauma centers in Vegas. There are a total of two. That accurate?

Dr. Kevin Menes: Yeah, that's. Yeah, it's the, I think there's 9 million plus people in Los Angeles. When I was looking up statistics in Las Vegas, it's about 2 million. And there are about 17 level one and two trauma centers in the Los Angeles area. And there are two level one slash two trauma centers in Las Vegas. And the way that a trauma center works is level one. And two have an in house trauma surgeon. So that means in the hospital, there is a trauma surgeon ready to take a patient, stabilize patient, take them to the operating room, where all the magic happens.

Jon Becker: Is that 24/7?

Dr. Kevin Menes: 24/7. 365. That means at most, in the Los Angeles area, you can take 17 patients within the golden hour, you know, whatever time period the golden hour is on that victim to the operating room. To perform what we call damage control surgery, which is getting the bleeding to stop so that they can somehow stabilize and survive this injury.

In the ER, we just prolong their life. We get them, usually 1ft gets into through death's door. One foot's in the casket, and all we do is we take 1ft out, get them to the operating room. Sometimes both feet are in, sometimes we can get both feet out. But that's our job. In the ER, the trauma surgeons really are the ones who stop the bleeding and save the life, because without that surgery, you know, the victim doesn't make it.

So, yeah, there's, you know, at one point in time in LA, you can take 17 patients. Theoretically, you can take 17 patients into the operating room on the first go around. So, you know, mass casualty incident is anything where you're having an incident where there are more victims than what can be handled, and different types of mass casualties have different types of timelines. You take somebody who's been shot with a bullet, and it hits them and nicks their heart, they have a very short window that you can save them. You take that same injury and you nick the kidney, and that patient has a bit more time.

So if you're talking about a penetrating mass casualty incident where a few or hundred or hundreds of gunshot victims occur, take your city that you live in, count the number of trauma centers, that's how many you're gonna be able to take to the operating room on the first go around. And that is the nightmare that every single emergency doctor and trauma surgeon secretly has, but never says.

Jon Becker: Yeah, because if there are two trauma surgeons working at any given point and you have three gunshot victims, if you can't keep them alive long enough to get them on the table with a trauma surgeon, they're gonna die.

Dr. Kevin Menes: Going to die.

Jon Becker: Yes. Yeah. I had this explained to me by a soft medic who I think put it best. He said, when, when, when something happens, you get shot. There's a certain amount of time until you're going to die, and that that time might be 5 seconds or that time might be an hour. And he said, my job, as he said, you know, the job of any Tac medic is to take, let's say you have an hour and turn that hour into 2 hours or into an hour and a half.

He said, my job as a soft medic, and they do a lot more advanced life saving stuff. He said, if you're in Afghanistan, is to turn that hour into 12 hours or 11 hours and do everything I can. To keep you alive long enough that I can get you to a trauma surgeon who in some cases is going to be in Ramstein air base. They're going to med evacuate you a long distance.

And I think that's one of the common misconceptions is that the emergency doc is the guy that's going to save your life, bring you back, but in the end, he's going to hand you off to somebody else who's going to have to do, whether it's surgery or whatever, to, to fix the, the underlying problem.

Dr. Kevin Menes: Yeah. The. It is a misconception. And, you know, those soft medics, those guys are doing all that out of a backpack.

Jon Becker: Yeah.

Dr. Kevin Menes: Right. You know, amazing work. Oh, it's crazy what they do out of. And, you know, we are in hospital environment and we have a lot more help, a lot more equipment. It's expected that we could do more, but, you know, there's always a rate limiting factor, and that rate limiting factor is the number of doctors that are available to do the resuscitations. And then how do you keep those same patients alive while you wait for surgery? And that's a, you know, that's a whole nother topic that we can delve into.

Jon Becker: Yeah. Because, I mean, as you're explaining that, I'm thinking, okay, so you've got, you've got, let's say there's one doctor, one surgeon. That one surgeon, if the surgery takes an hour, he can treat a patient an hour and, you know, assuming, you know, cleaning and all the stuff that he has to do, he can treat a patient an hour. If it's a 30 minutes surgery, he can treat two patients. But if you've got ten patients, you've got to keep them all alive long enough that he's going to be able to, you know, they're going to be alive when they hit the table to give him a chance to actually long term save their lives.

Dr. Kevin Menes: Yeah. So that means while he's taking care of that one, the other nine, the ER doctor has to keep alive. Yeah.

Jon Becker: Yeah. So you're the ER doc's the one that's juggling the chainsaws and ultimately handing them one at a time to the trauma search.

Dr. Kevin Menes: Yeah.

Jon Becker: Hopefully keeping all the chainsaws in the air at the same time.

Dr. Kevin Menes: Yeah.

Jon Becker: So I want to, before we talk about the actual event, I want to go back a minute because you had an interest in mass casualty events and in this type of medicine that you kind of described as starting in Detroit. So walk me through when you become interested in mass casualty events and this kind of event.

Dr. Kevin Menes: So I started in Detroit in 2005, and the Super Bowl came into town soon after that. I was a first year ER resident, and this is soon after 911. So the Super Bowl was one of the prime terrorist targets, and there was a lot of preparedness going out ahead of time to make sure that the hospitals were ready to handle anything that could come their way.

And so the medical directors, the doctors in Detroit, were the ones who had come up with these ideas. And emergency medicine started in Detroit. It wasn't really a specialty until, you know, much later, but some of the first ER doctors started off in and created the specialty in a place called Detroit receiving.

And it was, you know, doctors who had graduated with surgery as surgeons. Some of them graduated as medicine doctors. Just this hodgepodge of physicians who gravitated towards, you know, stabilizing and taking care of, you know, sick, sick patients. And so I eventually found this out. And since these were the guys who had come up with the plans, me as this brand new first year ER doctor, listening to these plans of how we were going to handle this huge flow of patients, now, I'm not gonna question it. You know, who am I to judge?

I mean, these guys are what I want to be, you know? Fast forward, I finished my training. Nothing happened. Well, fast forward, nothing happened during the Super Bowl, and I move out to Las Vegas, and I had gotten into a shooting in the ER, and because of that shooting, I ended up volunteering to be a doc for the SWAT team in Las Vegas. And I had met some amazing people there.

And one of the men who I had met was a gentleman by the name of Chuck Collingwood. Chuck was one of the early guys who was in Delta and was very, very intelligent in the tactical arena, which I knew very little about. But as an ER doctor working for, volunteering for the team, we're there to save their life if they get shot. And so he turned around and said, hey, doc, I got to take you shooting one day. And I said, okay.

And that's how they always would try to pay us back. They would try to give us skills and things that we didn't know. I told him, look, I don't know how to do any of this stuff. I mean, I have a rifle that can shoot distance, but I don't know how to use it at all. He's like, I could teach you that stuff. And I said, okay, but I really don't know what I'm doing. I don't know how to read the reticle. He's like, no, I could do that for you. He goes, we'll go up onto this ridge line and we'll shoot down at these targets I've set up in the valley. And he would regularly go up there, or he would go up there into the ridge and shoot down at these targets because he was one of the snipers.

And that day it clicked. I had asked, well, if you can shoot from that target, and you could teach me, a guy who knows nothing about shooting down, how to shoot down into target, what would happen if somebody got into one of these hotels and shot down at, you know, everybody during New Year's Eve? New Year's Eve? And he went into this lecture off the top of his head about elevated platform shooting. My mind was blown.

And in that short time period there, I knew that we as a medical community were not prepared. I heard, you know, what the greatest minds in emergency medicine in Detroit had come up with for, you know, to be ready for the Super Bowl, and it wasn't going to handle this. And that is, you know, that's the prevailing thought across the United States. This is how you run mass casualties. And so I started to, look, what could we do to potentially be ready for something like this? And that's how my journey began. It really started there, and it was sort of a frantic search before, you know, before the brown stuff hit the fan.

Jon Becker: So I think one of the things that we forget with mass casualty and you and I talked about was, you know, there are two trauma centers in Las Vegas at the time. Those two trauma centers are getting patients at different times. You know, somebody's in a car crash, somebody gets shot. So at any given .1 of them may be tied up and the other one might not be, or one of them may be, you know, have two patients stacked up and one might not be.

But there's a differential between when all of those cases are happening and the timing of them all with a mass casualty event. You know, if you think about the golden hour that they talk about and, you know, like you and I talked about, it's not always an hour. It might be 30 seconds or it might be three days. But, you know, whatever that golden amount of time is, in a normal trauma situation, everybody's clock starts at a different time. And so your hour may start five minutes before a trauma surgeon frees up with a mass casualty. Everybody's clock starts at exactly the same time.

So if you have two doctors, you have two people you can treat, two surgeons, you have two people you can take into the ER right now, but everybody else is waiting and burning that golden hour while those two people are on the table.

Dr. Kevin Menes: Yeah, it's, I call it time until death. I started to notice when I was in Detroit that there was this pattern. I started to develop this pattern that I can guesstimate between when you got shot and how much time it would take before you would, you would tank or you would head downhill. And then when you resuscitate the patient, you bring them back up. You can kind of watch the slow trickle that happens afterwards and there was another time period associated with that.

So over the years of just being seeing a lot of these injuries, I developed this mental portfolio or mental idea of time until death. You get shot here. This is how much, how much time you're going to have before you die. And I can tell you all the places that will get you killed in your time until death to be in seconds or instantaneous.

And then I can tell you the ones that are in between and I can time it pretty closely. But in a mass casualty, when you're talking about these time until deaths, Vegas, for example, you know, 1100 rounds were shot in about, you know, over a thousand rounds were shot in eleven minute span. So everybody's time until death started at the same time, within minutes of each other. So even if you add that extra someone shot at time zero and someone shot at time eleven, everybody is injured at the same time. And how are you?

Jon Becker: Yeah, it's a negligible difference for purposes of the flow into the ER. You know, everybody gets to chick fil a at exactly the same time. It's, you know, everybody's lunch hour starts at minute one. Yeah.

Dr. Kevin Menes: So it would be, you know, 500 people deciding to go to one chick fil a at 12:00 at the same time.

Jon Becker: To take this analogy a step further, there's only two operators of the chick fil a, right? You have two surgeons that are available.

Dr. Kevin Menes: Yeah.

Jon Becker: Okay, so let's, so that gets you interested in this and you start to research this and do your own homework. Why don't we start with the day of the event? What, what are you doing? Where are you? Give me kind of background story.

Dr. Kevin Menes: So I'm a night guy, so I work at night, night shifts, weekend nights. And my normal work week was Friday, Saturday, Sunday, Monday for most people. That's insane. First off, I mean, you don't, why would you work every weekend and why would you work at night? And there was. It worked for my family schedule that I was off during the week, but there was also. That's when all the good stuff happened, was on the weekends of the population of Vegas ebbs and flows with the weekend. You know, we're a weekend city, and, you know, all the good stuff happens then, so all the action happens then, too. And if action was going to happen, I wanted to be there.

Jon Becker: You're the doctor equivalent of a guy that worked graveyards in the ghetto.

Dr. Kevin Menes: Yeah.

Jon Becker: And you're actively seeking trouble. You're looking for the stuff that everybody else is afraid of.

Dr. Kevin Menes: There's that element to it. And I think part of it is you want to be able to test your mettle. Can you do it? I always say this. I don't like when people are injured, but I don't like when people are dying, but if they're dying, I want to be there. And being there on those weekends was the opportunity to potentially be there.

And so my typical schedule is either Wednesday, Tuesday, Wednesday, or Thursday. And depending. If I did too many of those days, my wife would be very mad. I'd be out with the SWAT team, doing whatever they were doing. And then Friday, Saturday, Sunday, Monday, I was. I was at work, and that was a Sunday night, and it had been actually a pretty slow night.

My shifts were 08:00 p to 06;00 a, so I had come in at eight, and, you know, I had seen a couple of patients, but. And our overlap for nights is there are four docks that start. There's a 04:00 p.m. to 02:00 a.m. shift, then a 06:00 p.m. to 04:00 a.m. and then an 08:00 to 06:00 and a 10:00 to 08:00.

So there's four docs at overnight, and the two docs who would come in before me were already prepping to go home. They're like, this is, you know, you and you and jaywalk James Walker. They were one of the other docs I was working with at night. Good friend of mine, amazing ER doctor, lifesaver. They were the other two docs. Dr. Flores, another good friend of mine, amazing ER doctor also, and Dr. Tang, who was – He had just actually graduated from residency in July, and this happened in October, so he'd been out for four months.

Jon Becker: Oh, boy.

Dr. Kevin Menes: Yeah. So, again, amazing ER doctor couldn't have done it without him. But the four of us were scheduled to overlap overnight, and Flores and Tang were already talking about wrapping up and going home because they're like, yeah, you and Jay walk and see all these people. You can handle the, you know, whatever we're dealing with.

And the Flores and Tang had been setting up to go home, and just at that point in time, there was this call overhead, because that's how they would call docs. They would say, er doctor to bed 40. And we didn't carry phones, we didn't carry pagers. You just get called by that and you knew that somebody was dying in bed 40 and you needed to get there. You never said stat, never said anything, those things. But that call overhead was menace to tell you now. So why were you calling me? And why do we need to get to the radio and why now? So I take off running.

Jon Becker: Get telemedicine, or?

Dr. Kevin Menes: Yeah, telling the telemedicine. So I get over to the radio and just that. That as I'm listening to the radio, I'm hearing or the radio call comes as, you know, prepare for mass casualty, multiple shooting victims. That's it. And I turn around and there's an officer who is standing right behind me, unrelated case. And I can see him looking into his lapel mic, kind of listening to his earpiece. And you can tell he's taking in a radio transmission. And once he's done, he kind of looks up at me. I lock eyes with him and I say, hey, is this real? He goes, yeah, man.

And in that point in time, I knew, well, you know, this is it, you know, all of those. All that time you had thought about this, you're going to have to make that decision now. And so we started to get things moving. I had told the secretaries, hey, get every operating room open, call all the surgeons, get them going here to the hospital now. Get all the staff, anybody who's in the operating room, because that's really our rate limiting factor. Right? Or we had talked about that. You have one. We had one trauma surgeon in house. We had four Er docs in house.

So that's four resuscitations at one time, one or case at one time. And that's the maximum amount that we should be capable of doing. But if you can get everybody else in, you could potentially save more.

Jon Becker: So, because how many, like, how many trauma surgeons are there that are affiliated with the hospital? How many can you put your hands on in an hour?

Dr. Kevin Menes: I think there are. I think in the group at the time, there was maybe seven. And trauma surgeons have to, even when you're on second call. So the other thing is, there is a someone who's in house, and there's always a backup call. So backup call has to be in within 30 minutes. So most of the time you live less than 30 minutes away. So you can get in at about 15.

So if you make that call soon enough, you can get the operating rooms open pretty quickly. And that's the call. First call we had made. And I told the nurses, clear out all of these areas because I had already, you know, again, talking with chuck over the years, there's this. The way that mass casualties are taught is you take a tag, put it on the patient. In triage, you tear off all the other colors except for the one you want to leave on.

So if they're a red tag, you tear off yellow and green and you leave the red tag on them. If they're green, you tell you leave it as is. Or if they're yellow, you pull off the green. And red is the most serious, yellow is the next serious, and green is the, you know, the not so serious wounds. So that's how it's taught in school.

But I knew that number one, that isn't the best way to differentiate this big group. Better way to do it is red, orange, yellow and green, meaning red is the worst. Red is where they're going to die in the first few minutes. Orange is the next group who's going to die. Yellow is the next group who's going to die after that.

And then the greens are all the people who aren't going to die no matter what you do. So instead of using a tag system. What I had thought about in pre planning was instead dividing the different parts of the ER into a red, orange, yellow section and then the green section. And so that area, station one, the main area, was going to be where all the red tags were going to be.

So I told them, the secretary, get everybody on the. Get all the doctors in house, and I told the nurses, clear all these beds out. And then I took off running, and I took off running because I wanted to get down to my car and get my own police radio. So get down to my car, open up the back, pull out my radio, and I turned it on. And now I'm listening, you know, in real time, just the radio traffic that's coming across, and it's chaos, you know, pure chaos. Everybody is just saying so much over the radio.

And, you know, I started deciphering out words and the things that I wanted to know was what was the scale of what we were dealing with and what should I expect on the receiving end and I heard concert. So concerts are thousands of people and I heard automatic gunfire. And you take those two together, so you got thousands of people and you're going to shoot a, I mean, you could shoot an automatic pistol at somebody, but if you're going to choose, you know, to hurt people, you probably use something more like an AK.

So I'm thinking if you're thinking worst case scenario, rifle caliber rounds into crowds of thousands and, you know, it was, you know, the nightmare that we as doctors, you know, never want to experience. And I found myself, you know, having to stare at that and you don't have chance to think about it. It's time to work. You just got to put your head down and. But it made me realize that that's what we were about to deal with.

And so I made my way back up the ER past the driveway where I knew where you go. We were going to take all the victims and do the triage at. And I left. I get up the ambulance hallway, get into the next station, which is station two, where all the orange tags were going to go. And I told the nurses, ivies and everybody let me know when they're going to crash. And, you know, word trickles pretty quickly through the ER when something big happens, you know, when a gunshot wound comes in, you'll always see, like nurses from far ends of the ER or staff work their way towards where all the action's happening because you want to watch and see how things go.

It's, to me, it's interesting. And, you know, being a student before, I know the draw that it has to be even near when a life is being saved. And so they knew what was going on and the, I guess, types of cases and things we've done before. I didn't have to say much, but they trusted me and they heard what I said and I just kept moving on. I didn't tell them that they were going to be, they were going to take the second sickest patients, but they, you know, they heard what I, we were going to do.

I went over to the next station, which is station four, and I told them same thing. Ivys and everybody call me when they're crashing. And that was where we were going to put the yellow tags, then moved over to the green tag section. I told them the exact same thing.

And then there was a couple of areas that had these private rooms, which are rooms that had closed doors. And I told the nurses, don't use those rooms because I was concerned, because we were going so far off of the beaten path that if somebody had died behind one of those doors, they would have blamed all of the things that we had done as the cause, root cause for that.

And at the same time, you just can't see people once the door closes. So we were giving up real estate in order to be able to see everything that was going on, because it's not very big department, but within eyesight, you can see. You can see things happen faster. And so I had made my loop through. I had told somewhere along the way, I'd asked them to bring all the gurneys and wheelchairs out to the ambulance bay.

And so I came back out into the ambulance bay, had my radio in one hand, and I'm listening to the transmissions. The staff who weren't ready to take the resuscitations, who are EKG techs or laboratory techs, people who weren't our housekeepers, they were out there with us, ready to move all of these patients to wherever they needed to go. And it was eerily silent, I remember. So over the years, I had watched that show emergency, the one that was filmed here in LA as a kid, where the ER doctor would meet the paramedics out in the ambulance bay for all the cases. And I thought, well, that's what ER doctors do. I guess I should do that, too. If I ever became an ER doctor, I would do that all the time.

And what it did was it gave me this few seconds, because most of the time, you're just supposed to sit in the room where the case is coming, wait for the case to come to you. Then you'd hear what's going on, and then you'd start working. I would go out to the ambulance bay, cut that little time in between short, get a little bit of what's going on, have an idea, even do part of an exam already.

So I had 5, 10 seconds to start thinking about what I was going to do before I even hit the room. And then once I hit, hit the room with the patient, wed be off and running. So for years, I had been out in the ambulance bay doing that. And so I know the sound that you hear when the ambulances come, and its always this, like, ambulance wailing away in the distance. And it kind of, you can hear it get louder and louder. It holds as it clears the intersection, then it gets louder, and then it holds. It clears another intersection, so you can kind of guess where you're at.

And I remember this wasn't that sound because you'd hear the high pitched whale and the low pitched whale at the same time. Most of the time, it's either high or low, right, when it's a single siren. And at that. And it was loud. It was really loud. Much louder than normal, but still distant. I don't know how to describe loud but distant, but that's, like, muffled. But it was also high and low pitched.

And at that point in time, I realized that, you know, it wasn't one. There were a bunch of sirens coming our way. Little did I know at that time that a good friend of mine who was a medic, he had been a transport medic, eventually became a paramedic with one of the departments. He had been at the scene where all of the victims had self extricated to.

So all of the victims actually ran away from the scene and ended up on this one, the farthest northwest corner of the venue, and his one truck. He knew that he was. There was no way he can handle all these victims. So there's two things wrapped up into that that I think are really key that I teach when I travel and I talk about this.

Number one, the two heroes that night were those who were there at the venue and why I say that is most people in this dog eat dog world where it's every man for himself and take care of yourself first. When people were getting shot right next to them, instead of running for cover on their own, they would pick up these victims and move them off of the x towards this, you know, casualty collection point, right? And so all of this, the victims who or the victims who had chance were moved from that scene far before, you know, EMS can get in.

So another thing about these sort of mass casualties are shootings, right? Imagine if a shooting happens in a mall. EMS is unarmed, so they do not go into scene hot because scene safety first, right? So police have to clear it, and then EMS has to come in back, backfill behind them. And then take the victims out. That time period is time taken out of time until death. Right? It's subtracted from resuscitation time. It's time that we have to save the patient.

So those heroes that night who despite, you know, bullets cracking over their head, the snapping, you know, they're hearing in their ear, knowing that they're being shot at, watching people next to them dropping and dying, they pick them up under gun fire and run with them to the, that area. And then what ended up happening at that casualty collection point? Because they knew they were overwhelmed. They ended up hijack. They convinced every vehicle at that intersection to become a makeshift ambulance.

And so behind the initial police vehicles. So I can't remember how many police vehicles ended up coming. Those were the ones who made up the sound of the sirens. All the other vehicles behind them, the pickup trucks, the limos, they were. That they were the part of the silent parade of, you know, victims who made it to the hospital in that amount of time where we could potentially, you know, save them.

So I'm sitting there, I'm hearing this whale of sirens coming, and as they pull up, the first vehicle pulls up, and it's a police vehicle. He tries to get out. I slam his door shut and I tell him, just stay in. When we get all these patients out, I'm going to tap your car and you go. I look through his driver's side, I look through his window, and there's two in the front seat. I opened up the back seat, and there's two on the floorboards, two on the back seat. And I looked at all of them and I knew they were dead.

And there was more police vehicles right behind him. And I just knew at that point in time, this is, you know, this is the real thing. And how in the world am I supposed to do this? And, yeah, I've been doing this triage system for a long time. I've been kind of developing this idea of what to do, but is it really going to work?

And, you know, there's no real time to second guess what you're going to do. You just, you know, again, I think pre preparing for difficult situations makes it so that the hurdle for actually making the decision when it comes is just. It's split second. I don't even think the idea crossed my mind, to be honest. When that occurred, I already knew we were going to do it.

There's no other option because the systems that are out there, which are salt and start, there's no way they would have differentiated those patients. So doors opened up. I'm like, station one, station two, station four, you know, rapid track. That's what I would tell the staff that corresponded to red, orange, yellow, green in my book, but they didn't have to know that. They knew where those areas were in the ER.

So I'm opening up the door, I look at the wounds, you know, station two, that one goes to station one that wasn't goes station four. And they just – They keep coming, they keep coming. The pickup trucks come, and I pop up onto the back of the bed. I look inside, and there's like 15 people in there. And I'm thinking, how am I supposed to triage all these people? And again, I can't say this enough, but the people there were the true heroes that night, because even being shot themselves, they would be, doc, this is the one you need to take care of first. They did my job for me. They pulled out that red tag. Who needed to go to station one. We'd grab that one, move, move them out, and then I would triage the rest of them.

So, you know, the pickup trucks, the first one was the scariest, but, you know, once I got through that one, I was like, okay. And then the other ones came, and I was like, okay, I can do this again. It wasn't a isolated incident. This was every single vehicle. You know, all of those people, you know, we're willing to sacrifice being first in line, to have somebody else skip the line because they needed it first. And then the first limo came, and I was like, oh, this is not good.

And I remember looking into the limo was dark. Same thing, doc. This is the one. And you'd see this body getting past, like, crowd surf through the limousine up to the front, and, you know, we would take that one, station one to the red tags.

And then I had to work on everybody else. And so we're triaging, and I'm mentally counting in the back of my head, my adds going, and I'm like, okay, I have this and that and this and this. I know that Flores, Walker and tang are inside. They're doing this. They're probably going to get overwhelmed soon. Sure enough, just at that point, you know, one of the nurses comes out and says, hey, menace, they need you inside. They're behind.

And I looked at Deb. You seen what I've been doing, right? And she goes, yeah. I said, do you think you can do this? And she. She gave me one of those, like, hard swallows and a nod. I don't think she ever said yes. I think that was the extent of it. And, you know, I was going to commit her to, you know, to having PTSD because she would second guess every decision that she would make in the future from this.

And, you know, fast forward, spoiler alert. I mean, she did an amazing job and triaged more patients than I did over the next couple of hours. But in that first brief flurry, I don't know how long I was out. There could have been 10. I've heard anywhere from 10 to 20 minutes. Most of the people I've talked to said about 10. I think we triaged about 100 people in that short amount of time.

Jon Becker: So how many total did you see that night? How many total did your hospital see that night?

Dr. Kevin Menes: So the official number is 215. I think the real numbers far north of that, there are a lot of people who walked out, a lot of people who weren't registered. These are people who got graze wounds. But, you know, I think the real numbers north of 300, and that's just the consensus of everybody I've talked to. You know, you go room to room and they're like, yeah, this many, this many, this many. When you add it up.

Jon Becker: It's, you know, close to 300.

Dr. Kevin Menes: Yeah, over 300 of those.

Jon Becker: 300 that showed up. Ballpark, what was the split between red, orange, yellow and green?

Dr. Kevin Menes: So I can't tell you the exact percentage, but red, orange, yellow are all your sick ones. I think we did over 100 of those at night.

Jon Becker: How many showed up DOA at the hospital?

Dr. Kevin Menes: So 10 showed up DOA.

Jon Becker: And did those cause you see roughly 100 their red orange green or red orange yellow? 10 show up DOA. Of the 100 that show up that are not dead when they get there, how many die by the time the night's over?

Dr. Kevin Menes: So of all the ones who made it to the hospital, we had 16 total deaths. So 10 were those DOAs like those ones I told you in the first police vehicle, there were four that we, as the ER, had stabilized and resuscitated. But they're pouring blood out of their chest wound so fast. And this was at a time where a typical thoracic gunshot wound, like a really bad one. Thoracotomy would be an hour plus surgery.

Jon Becker: Thoracotomy is opening up the chest.

Dr. Kevin Menes: Yeah, opening up the entire chest and trying to patch the holes. So. Right, that's heart, that's aorta, that's lungs. I mean, all the important stuff, that's the. A box of a target. Right? Those injuries. The trauma surgeons knew at that point in time, they were overwhelmed. They couldn't take care of them. So four of them, they determined, were. When we were just gonna. They were gonna let them go. So that's four.

And then one was found to be brain dead even. You know, a couple of days later, they were stabilized, but they were. They were found to be brain dead because of the wound to the brain. And one died in the operating room when they couldn't control.

Jon Becker: So out of 100 patients, 6 of whom, as the ten weren't treated?

Dr. Kevin Menes: Yeah. Well, we. I still so one of the things that it's taught is black tags should just be sent immediately to the morgue. And I knew that the triage system I was doing, you know, it had its limitations, and one of them was, you were working fast, and you might be wrong, and when you're the filling a pulse, you might miss something.

So, you know, if two docs thought the same thing, then you. You know, then the patient really is dead. So if I thought it was dead, I'd still send him back for another guy to look at. And so we sent everybody back. And so, yeah, ten still were DOA that that day.

Jon Becker: Got it. And then. So the rest of them, you treat. I mean, after you're doing the triage, the nurse takes over for triage. Where do you go from there?

Dr. Kevin Menes: So Flores, Walker, and Tang are in one, and they're frantically resuscitating. I jump in and try to stabilize patients, too, and I go from room to room, and I'm working on the initial resuscitations. Intubate, chest tubes, blood. Intubate, chest tubes, blood, airway, breathing, circulation. Airway, breathing, circulation. And I'm cycling through every single patient, you know, as you're going down the line, trying to pick out the ones that look sickest to you and working on those next.

And I remember coming out of one of the rooms, and there were three GSWs to the head all together at one area, and Flores and Walker were standing right next to them, and I was like, hey, what are you guys waiting for? And they were like, we're waiting for drugs. Because when, even though you have an injury to your head, you might still fight getting the breathing tube put in. And if you're just fighting breathing the tube, then you can't go to CAT scan either, because you'll probably move, and it won't be helpful.

So we needed to put them to sleep and get them stabilized for the neurosurgeons to make it into help them. And they were waiting for drugs. I was like, that's what you're waiting for, right? They're like, yeah. I turn around the corner, get to where the pyxis machine is, which is, you know, this machine where you put your fingerprint, and then you can pull drugs out for the nurses. And the nurse is frantically trying to get drugs out, and she opens it up, and there's only, like, two or three vials of these meds, and they're in station one alone. I don't know, 50, you know, red tags in there.

So I knew we were in trouble and in pre planning, I thought about a lot of things, and I thought about a lot of contingencies and had plans for a lot of those things, I did not think about that. I did not have a contingency plan for that.

And I remember coming around the corner, and I looked right at that moment, I heard this voice. And it was the same voice that I had heard when I had ducked under the bullets and that shooting when I was brand new attending and almost got me a voice that told me to duck. It was the same voice that said, just ask. And I believe that it was God speaking to me.

And I thought, just ask who? And the ER pharmacist. So we have a pharmacist who works in the ER, helps the nurses grab drugs, do all these things. She walked right in front of me just at that moment in time, and I looked at her. And over the years, because of the relationships that you developed, just being. Trying to save patience, and you don't normally you have to go in and put an order before something happens, in the computer.

But, when you develop this rapport or trust, and even though you're going off of what the normal algorithm is, if you've proven yourself and you don't throw anybody under the bus, meaning if you ask for a verbal order and you're wrong, you still sign it. You don't ever. You know, I remember there was a – One of the lessons I had learned in residency was there was a resident who had asked the nurse for a verbal order. It turned out that the resident had actually ordered the wrong drug in a situation that had caused a bad outcome. And the resident would not sign the order, and the nurses would never write a. Do a verbal order for that.

Jon Becker: Oh, yeah. Because he left him hanging out to dry.

Dr. Kevin Menes: And so I knew at from a early, you know, from a young age, as an ER doc, don't ever do that, right? You're accountable for the words that come out of your mouth and everything that you do. You have to stand by it. So think about before you do something. And because the staff trusted me, I could throw out these orders which were, you know, not the textbook stuff, and then they would work down the line and they'd be like, oh, yeah, yeah, sure. Next time you just ask, and we'll do what you ask.

And so I asked her. I asked the pharmacist, hey, can you go down to the stockroom and grab every single one of this, this, this and this drug? And she goes, okay, what do you want me to do? With them. And I said, just pass them to everybody. And for those who don't know, I mean, that is probably the most illegal thing you can do. Yeah.

Jon Becker: You're literally handing out narcotics.

Dr. Kevin Menes: Yeah. And paralytics and things that are just highly dangerous. And the nurses were having these drugs in their pocket, but cutting out the step of having to go to a pyxis machine, put your fingerprint and all the other things you have to do. We were doing split second resuscitations, you know, because we can go back to back to back to back as everything was there.

And one of the other things that I thought about, I remembered at that point in time was I thought, well, if we needed blood, we should have it ready. And so I turned to one of the nurses, and I said, hey, can you get all the blood out of the blood bank?

And so she passed it off to one of the other nurses, and that nurse went to the blood bank, asked them for blood, and the blood bank said, well, where's your order for the blood? And in not so many words, she goes, do you see what's going on here? And the tech poked their head out of the. Cause the window for the lab is, like, hidden, you know, off in a way that they can't really see. The ER, they poked their head out, saw the chaos that was going on, and next thing you know, every box or every unit of blood was coming through this little window. And so we had pre staged all of the drugs, all the blood, and that's how we, you know, we were res

uscitating people at just, like, breakneck speed, because everything we needed was there. So I had gone through one, I had stabilized everyone in one, and then they. Walker, I'm sorry. That. So going back to those three GSLs of the head at that point in time, Walker said he was going to intubate them. And I told him, okay, to him, and then get him out of here, go to CT, and then go to the ICU so that they can wait for the neurosurgeons.

And that two things, it opened up real estate for us because of small ER. And you imagine three beds, that's three more patients that can come in on gurneys so that we could do resuscitations. And so they opened up those three areas so that we can take in more victims. And that became part of our little algorithm, what we were going to do that night.

But after I left there, I remember heading back out into the hallway, and one of the nurses flagged me down from station two. Where all the orange tags were. And she was like, man, it's over here. And I get over there and these two were shot in the chest.

And I remember, I remember her grabbing. I told her, grab me a thoracotomy tray, which is, you know, surgeons are supposed to do thoracotomies in the operating room under sterile conditions, full gown, all that stuff. In an emergency situation, you do it in the ER with minimal sterility because it's choice of life and death. And you have like, a less than 1% chance of surviving when we open up your chest, you know, at bedside.

But I wasn't going to open their chest. I was going to put chest tubes in. And I needed that thoracotomy tray to have enough tools to work on two patients at the same time. So I tube both of them. I intubate and put them both on the ventilator. And then I put in four chest tubes on the two of them.

And then I tell the nurse, how many units of blood I want on each. And then I walk away and turn around and go to the next one. And I work on that next one. And I go and work on the next one. And I work on the next one. And I'm cycling through two while, you know, the other three yard docs are still in one with these sicker red tags. We get through one, I end up circling back around. And now I'm just doing these loops looking for people who are dying, knowing that I have it, you know, sectioned off by color, knowing that yellow is going to die soon.

So I go through yellow, come to green, go to red, help out in red a little bit, go back to orange. But everybody in orange had been stabilized. Knowing that yellow was going to go next. Some point in stabilizing the oranges, we run out of chest tubes, and so we switch to the intubation tubes.

So I'd stick the tubes that go down the throat, put those in the chest, inflate the balloon, and it holds it inside the chest. And it's almost a standard et tube or, I'm sorry, standard chest tube, but it kind of holds itself in place. But that was kind of some of the ideas that had come out, you know, I had thought about over the years. I get over to yellow as the yellows start to crash and the guys are still in one, stabilizing the patients.

And one of the nurses goes, hey, menace, I need you to stabilize. I need this. I need your help on this one. I need help. And then another one's like, no, no, no, I need your help on this one. And then I need your help on this one. And at that point in time, everybody's yellow tag patients were crashing at the same time. So I said, okay, bring them all over here. And so we brought them together. I stood in the center. It was me, my scribe, who wasn't doing any charting. She was holding a bag full of equipment and a respiratory therapist.

And then I told the nurses, are you ready? Push the drugs, idente them, listen to see if they needed chest tubes. And then we'd hang blood. And then I would go all in a circle and I put all of those patients on a ventilator. You know, in that time it took me to do it.

At that point in time, the respiratory therapist looked at me and she said, we don't have enough ventilators to get all these patients on a vent. I said, it's okay, you know, we can just grab some tubing. And she goes, what do you mean it's okay? And what are you going to do with tubing? And so a ventilator is a machine that breathes for you. And when you're in a coma or we put you in a medically induced coma, the machine acts like your diaphragm does and breathes for you so that you can stay alive and your body can rest.

So happened that one of the doctors who had trained, who had graduated a year before me in Detroit, had done a study with one of my attendings, Dr. Babcock, and they had came up with this idea that in a disaster you can put multiple patients on a single ventilator. If you just multiply the amount of air you'll give by four.

So if there's four people on there, you just, you just multiply it times four. So typically you give somebody 500 CC's or 500 oxygen or air per cycle. That means if you set your ventilator to 2000, you can potentially keep four people alive on one ventilator. If you split the tubing. That's a study that they had come up with using balloons. Never been tried on people.

Jon Becker: Oh boy!

Dr. Kevin Menes: So, you know, in pre planning, I was like, oh, I know about this study, four sounds crazy. Maybe I'll do two. So the idea was to do two on event until we ran out of vents and then go to four. And so I remember I told the respiratory therapists that and they kind of looked at me puzzlingly. But when I circled back around later, two of the patients that I had put on a ventilator because they were shot in the neck and they were choking, were on a split vent.

And so it was the first time that it had been, you know, a theoretical study had been done in real life. Fast forward to 2020, as COVID came along and we were hearing rumors that Italy was running out of ventilators, there was a frantic search to figure out what could be done at that point in time. And Dr. Babcock released this, you know, video on YouTube about it, what she did. And I think the video is still out there. And then they were contacted by, you know, the administration, and they've developed a theoretical plan on how to split event, you know, what to do for COVID with split vents.

And so, yeah, I just happened to be in the right place at the right time on that day. They were lecturing about their, their study. And most of the time, that was, you know, when you're working, you know, six days, seven days a week, you come to lecture, to take a nap, you know, for 4 hours. And I don't know why at that moment in time, I happened to hear that part of the lecture, and I never forgot it. And, you know, I put it to. We put it to use that night.

And so that was all the yellow tag patients. We'd circle back around. But about at that time was when we had stabilized, you know, most of the patients. I had my last big resuscitation just about that time, as you know, the ER doctors started to show up and help out. I mean, the trauma surgeons had already been there. And we're taking patients to the operating room.

But as ER docs, we don't take call. You know, we don't carry pagers. And so it took, one of my friends told me that he got there about almost 2 hours after the shooting started because just getting the call, feeling the call, and then having to make it through all of the roadblocks between his house and the hospital. A normal commute that takes 25 minutes took, you know, took much longer.

But, you know, at that point in time, we had gotten our head up above, a little bit above water. And then we still had, you know, a lot of patients that we had to deal with. And there were a lot of patients that had to go through the CAT scan. And we developed this sort of conveyor. Well, it was a system that Henry Ford would have been proud of. I mean, we put a bunch of patients in line ready to go into the CAT scan. We put them on the CT, scan them from head to toe, pull them off the CAT scan and wheel them off the table and move. And they just scanned all of these patients from head to toe, looking for the wounds that were stable. But somehow we knew the bullet was in theme, and they had cycled through, I don't know, something like 100 CTs in an hour.

Jon Becker: Wow!

Dr. Kevin Menes: I mean, it's just an unbelievable number. When. And again, I think a lot of this, when people ask me, like, how were you successful? Or how do you do the things that you did, the things that you did that night, I think a lot of it is formed in just the fact that trust, working together for years, always backing up your people and being responsible, making good choices, because no one wants to be with a loser. You make bad choices, they stop wanting to listen to you, but you make good choices and you build this trust.

And so I asked them to do things that were not of the norm, and, you know, they did it, and in an amazing fashion. So we ended up getting all those patients through the cat scan, and then there were a lot of people who were shot through the extremities. And, you know, extremity injuries are not as life threatening. You know, the arteries, you know, the femoral artery is about the size of a pinky. So the chance of hitting the femoral artery in a gunshot wound in the leg is very small.

So we know we had time on some of these, especially if it wasn't hit directly, you know, if you're missing it, your chances of hitting it were pretty low. So those – A lot of those injuries were green tag victims, and we needed to know if they had an open fracture, needed to stay in the hospital.

Jon Becker: So if you. That night, if you came into the hospital with a gunshot wound in the leg, you were probably getting green tagged. Unless it was fomory bleed.

Dr. Kevin Menes: Yes.

Jon Becker: That's kind of insane. A gunshot wound to the leg sends you to the waiting room.

Dr. Kevin Menes: Yeah.

Jon Becker: That gives you the magnitude of the problem.

Dr. Kevin Menes: Yeah. It…

Jon Becker: There's a gunshot wound to the. To the leg on any other Sunday night in the trauma center has a trauma team working on you.

Dr. Kevin Menes: Yeah. Like, most typical criteria for gunshot wound above the knees, above the knees or closer than the elbow is a high level gunshot wound because those are the biggest part of the artery in the leg, right?

Jon Becker: Yeah. Femoral and brachial artery.

Dr. Kevin Menes: Yeah, femoral and brachial. And I can count on my hand the number of femoral and actual femoral and brachial injuries had happened that night. And so, yeah, I can count on one hand and so the rest of those other injuries, we needed to make sure they didn't have an open fracture. And we had two PAs who were on with us that night, and they were – I tasked them to do the green tags and I told them, look, if this is early on in, the night before the gunshots had come, I told them, if you think it's an open fracture, they need an x-ray. If not, and they have a distal pulse, meaning you can feel the heart beating, you know, the pulse, like at the foot or at the wrist, you can assume that it missed the artery.

And if you don't think they have an open fracture, antibiotics, tetanus shot, pain meds, and get them out, because we need the room. And so those guys did amazing work. And psych, because the green tags are actually going to be your biggest section. And they can take up more, more real estate if they are. And so they ended up moving all of those patients out. And that's how they, you know, the. They took care of more patients than we did as the docs.

Jon Becker: And when you say moving them out, you mean sending them home?

Dr. Kevin Menes: Sending them home, yeah, getting them home.

Jon Becker: So you have a gunshot wound to the leg and you are being discharged from the hospital.

Dr. Kevin Menes: Yes, I know. You know, contrary to what happens in the movies, yeah.

Jon Becker: It's just insane to think, like, oh, yeah, now you shot in the leg. Yeah, you're good. Go ahead and go home. Well, here's an antibiotic. And, you know, go see your normal GP tomorrow and get your gun. Get the bullet dug out of your leg.

Dr. Kevin Menes: Well, oftentimes, I mean, in the movies, you dig out the bullet. In real life, we leave them. So.

Jon Becker: And then just send them to a surgeon to remove it or just leave it.

Dr. Kevin Menes: Or you just leave it. You know, some people walk around with bullets inside their body for the rest of their life, and if it's superficial enough, the body will eventually kind of pocket it and then push it towards the skin. And you'll hear about people who push out shrapnel or push out bullets, you know, years down the line.

And so, yeah, there is no need to dig it out. You just leave it in. It's tough. Technically sterile. It's hot. It was a hot piece of metal that went in you. And so you give them a bit of antibiotics to make sure it doesn't get infected. And, you know, they, you know, you. They get better over time.

So, yeah, the gunshot wounds to the extremities, those are – Our PA has did an amazing job moving those patients out. And that's where you – When the incoming team would come in, they would help with those and some of the other stuff and all the other stuff, too. You know, it wasn't just that, but that was where the big bulk of the. The victims were at – So one of the slow parts was of it was getting an x-ray and then finding out if they had an open fracture and then getting them out.

So I approached one of the hierarchy with a crazy plan of getting a radiologist. So a doctor who reads x-rays, who normally sits in a dark room somewhere in the hospital, or you can actually do it remotely, aka, you can do it from your house in your pajamas on a really nice computer and computer screen, you can read x-rays from home.

But either way, we had a radiologist come in that night, walk around with an x-ray attack on a machine, shoot the x-ray, read the x-ray, say that the bone wasn't broken, prescriptions were given, and that patient was out. And so we cycled through those patients really quickly, too.

Jon Becker: And so how long did it take for you guys to cycle through to the point that it got stable, like where you're thinking about going home?

Dr. Kevin Menes: So I didn't go home. You know, I was thinking the entire time that, you know, the boys were still working on trying to take care of the – This threat, the gunman who was either holed up in wherever he was, or my last radio transmissions were, you know, active shooter at Tropicana, active shooter at New York, active shooter, you know, at Monte Carlo.

Jon Becker: So, yeah, like every active shooter, there's multiple shooters.

Dr. Kevin Menes: There's multiple shooters because everybody had left the scene with a bulletin, then they would call 911 the second they get into the hotel. And it got called as an active shooter in all those different scenarios. There's no way to know that at the time. And I heard that transmission before cutting out my radio. When the victims, sometime in the night, I can't remember, but pretty early. So I knew that they were probably going to be dealing with a Mumbai style attack, you know, and we would have. They would have to be working for hours.

So in my mind, I was looking to get out of the ER and go to help them. And about, I think it was about 04:34 o'clock, 04:30, I think is when I finally left. But about 04:00 is when I thought that we were starting to. We'd get to that point. And I quickly wrapped up, and I was told by everybody else there, by the time day shift came, you couldn't tell except for the blood that lingered. You couldn't have told how many patients had just come through the ER that night.

Jon Becker: So 10 hours, 8 hours, 7 hours, 22 minutes, and 22 seconds, they cleared 100 patients and sent them home, stabilized them, performed surgery.

Dr. Kevin Menes: Well, they were. I mean, the surgery team continue to do so. I mean, we do the stabilization process in the ER, and, I mean, we create problems for everybody else because, you know, what we stabilize becomes a, you know, ours going down the river to….

Jon Becker: The neurosurgeons and the trauma surgeons and orthopedic surgeons and everybody else.

Dr. Kevin Menes: So everyone that we stabilize, they had, you know, days of work, months of work down the line. So our part was done. Their part where they had taken to the operating room, let them heal, take them back. You know, that was. That was days and weeks. But we had cleared. We had done all the resuscitations in about that time. So by the time day shift had come, yeah, there was. They told me there was nothing.

Jon Becker: All right, so, doc, I mean, obviously, you've had extremely unique experience through this event. You've seen kind of the worst case scenario for trauma medicine and also worst case scenario for first responders. Our end user, you know, our listener, is a tactical operator. He's a tactical medic. He's a, he's a, you know, police captain. He's, he's, you know, firefighter. He's somebody who is on the upstream from you, from the hospital. I'd love to talk about some of the lessons learned from this thing and things that, not only from a personal leadership skill development, but also you're now teaching all over the country to physicians and tactical teams and other stuff, some of the things that you're telling these agencies.

So why don't we start with one of the first things that stuck out to me as you were describing this is instead of waiting for paramedics, instead of having tactical medics dealing with people, one of the points that you highlighted was that one of the EMTs that got there started flagging down cars and putting patients into them. That seems kind of counterintuitive. We've been more and more pushing towards tactical medicine and putting tourniquets on and trying to stabilize people and then transporting. And it almost seemed to be the opposite here, that a lot of these people survived because they got to the hospital quickly. Help me understand that.

Dr. Kevin Menes: Okay. This is a very loaded question with a lot of facets, so I'm going to answer that question, and it's not the 100% biblical truth in every scenario. There's no such one thing as a single algorithm. That's. I'm going to preface that. And there's no one way to do things.

There's some general rules in that the farther you are from a trauma center, the more you have to do in the field. And a lot of this, what we call scoop and run, came from my training in Detroit, where that, that's the, that is how things are done there. You know, they'd scoop people from the scene. Whatever they can do in the ambulance is what gets done before you get to the ER, and then you, you have to work on them from there. So that's kind of the first sort of hard, fast rule. Not hard fast, but sort of fluid rule.

Another rule is there's this idea that, well, the research out there is that, you know, the most survivable wounds when looking at the trauma data are from extremity injuries. Right. And that's extrapolated from the fact that in the military, you know, they wear helmets and body armor. And so some of the injuries that they would experience, they could experience in the battlefield isn't necessarily the same that happens in the civilian sector. So you can't take these hard, fast stances and say, this is the only way to do things right. You have to be more fluid than that.

And so in this scenario in Vegas, with a trauma center that close and the torso and headshots being way more deadly than the extremity injuries, what you, you, you're essentially saying is the scoop and run allowed us to be able to save those torso and head injuries. And I 100% agree. And that was something that I saw in the events leading up to this, like Aurora, Colorado, where the police officers scooped and ran the victims because the scene was not safe and fire couldn't get into the scene, and so they cut the time down to the ER.

And, you know, some people survived because of that. So you have to extrapolate that to a scenario where you can get thousands of people. Then how do you handle, you know, that many, like what we did in that short amount of time with that, you know, the time until death all starting at the same time. So that's kind of the borders I would give you to that answer. But again, there's never a hard and fast rule.

Jon Becker: Yeah. So, like you said a lot there, but if you're dealing with the mass casualty situation, somebody who obviously has a torso or head wound is at a much greater risk than somebody with an extremity wound. Somebody with an extremity wound is easier to stabilize. So if you are choosing between who you're going to scoop and run on, scoop the guy with the chest or head wound and tourniquet the guy with the extremity wound.

But ideally, if you are close enough to transport, it's not a bad idea to get them moving towards the hospital, because that may be the time you save by taking them to the hospital may be greater than the time you gain by stabilizing them.

Dr. Kevin Menes: Yeah, and, well, I think Orlando really changed that, because the two medics who were on scene that day, instead of taking one victim per ambulance, they filled their ambulance with any victim they could. So you take your torso injury and your extremity injury at the same time, and then you let the hospital sort it out on your own.

Jon Becker: Before this event, had you, as a hospital, ever done a mass casualty drill with the police department?

Dr. Kevin Menes: No.

Jon Becker: It strikes me that that is, if nothing else, an opportunity for agencies to really shake down the process and think about, you know. Cause it's a different problem. So just look at the drugs as a perfect example of where, like, there's never an instance in a normal hospital that you're gonna run around and just pull all the drugs out of the safe. But here, it makes perfect sense. But if nobody has thought about that stuff beforehand, how do you do that? Do you advocate, agent, like, when you're working with doctors and hospitals, do you encourage them to wargame these kinds of things?

Dr. Kevin Menes: Yeah, you know, we would. We would do that during a barricade pretty often, right? You're sitting in a barricade. It's 99.9%, you know, sitting and waiting, .1%, you know, sheer terror. Sure. Terror, you know, or like a hostage rescue. Right. The same thing. You know, it's even longer. And then for that split second where you're. You're doing something. So in the time in between while, you know, if. If it. If allowed to, we would. I would talk with the guys or afterwards, you know, that next week, you know, I would have try to pick their brains. Hey, what were you thinking? Why did you do this? Oh, okay, then how can we solve that problem?

So I got, you know, this great education on, I think it's difficult to make difficult decisions, but it's more difficult to make the slight, nuanced decisions that you have to make in the tactical arena. And it's even harder to make those when you're having to do it in real time. So learning to see how they work through their problems and coming up with a solution and then sort of cataloging all those different solutions.

And then in the future, when another similar solution came up, I'd be like, oh, yeah, they're probably going to do this. Sure enough, they came pretty close to doing that. Right. Because it's the, you come up with these scenarios and you just, you have a couple of solutions for that type of problem.

Jon Becker: But how can a police department get their hospitals and get their doctors engaged? Like, like, what's the best strategy? If you're chief of police in Laverne, California, how do you get your local hospital to care about this?

Dr. Kevin Menes: I think the unfortunate truth is it's when something happens, is when people ask that question, there's, I don't think there's much accountability when afterwards nobody asks the question, well, why weren't you guys even thinking about this? Right. And you can always make that distinction.

Well, the hospital does this, the doctor, the agent, the law enforcement does this. EMs and fire do this. There are a bunch of hands, but nobody ever talks to each other. Right. You know, there's very few handshakes that go across amongst each other. You know, they work in separate environments. So, yeah, unfortunately, often it's just when something does happen, then you see the cracks and then oftentimes those are just discounted as well. There's nothing we could have done.

Jon Becker: Yeah. This is a frequent problem in my world, right? Because, like, part of my day job is helping agencies to prepare for disasters, right. Whether it's a mass casualty event or, you know, terrorism attack or something along those lines. That is a big part of what we do. And, you know, I always tell agencies, the day you go through the training and get the gear is the most prepared you will be until the next time you reset your program. Because the learning curve, or mass casualty events is a vertical line followed by a diagonal line, right?

There's no, like, it's not maintained. It's not, you know, you learn it and then you maintain those capabilities. Unless, you know, unless it's inspected, it doesn't exist. And I can tell you, in the last 40 years, I have helped the same agencies prepare for riots five or six different times. And every time it started with, hey, what do we do about riot control?

And the same is true for, you know, mass hemorrhage control stuff. It's true for medic bags, it's true for a variety of things. I think that if it isn't something that somebody is tasked with doing and they are constantly tickling. Right?

Once a year, you get together with the hospital, once a quarter, you get together with the ER docs. It is very difficult to maintain that capability until the event happens. What is it about your preparation and the preparation of your coworkers that you think allowed you guys to perform at such a high level?

Dr. Kevin Menes: I think there's. I'll start with the team aspect of that. First, when you're in an inner city, high volume emergency department, it automatically selects for itself who wants to continue to work in that environment, right? Yeah, there is a small subset of people who are, who come back for more each time and enjoy the thrill of, you know, just pure chaos and busyness. So most who don't, who can't handle that leave that environment.

So that automatically selected four staff and docs who wanted to be, who were used to being busy. Now, this, that night was, you know, 10, 15 times that amount. But I, you know, the staff who was there were just amazing, you know, the nurses, some of them were under a year and, you know, but they kept coming back for more.

And I think that plus, you know, forging relationships, trust, you know, that sort of accountability that when you ask for something and even if you're wrong, you don't back out of, you know, taking responsibility for it is what slowly builds trust and cohesion amongst, amongst teammates in, in that type of environment.

So, I mean, I've never taken any leadership classes. I don't really read books on leadership. I don't know all the buzzwords on leadership. I just know what I needed to keep my department running. And those are one of the, that was kind of the important things that I always thought me as a doctor could bring to the team is, is always backing up, you know, my staff and, and never throwing them out under the bus.

And so that paid dividends whenever I needed to, you know, veer off of the beaten path. And there were so many times before that where that occurred. And so that's sort of the team aspect now, the individual aspect where I think, you know, you have to, you have to push past what's comfortable as often as possible. And we do that in training, you know, whenever you train.

And, I mean, I don't have dedicated pt time, you know, cut out of my shift. I don't get, you know, chance to work out. If I wanted to work out and exercise, it was added to my already busy workday. So being able to run through an emergency department the entire night was. I mean, that part was something that I had to do on my off time or getting to that level of something I'd have to do on my off time.

And so, and that's everybody's choice. It's hard enough to go to work and finish your job, you know, if you want to strive for. I mean, I looked at the guys who I worked with on the SWAT team and I wanted to get to their level of fitness. I never got to it, but I wanted to. I wish I could. I wish I had the time to, but, you know, I tried my best to keep up, you know, or get, just get to kind of somewhere near that.

And then there's this feeling you get when, when you're in ER, doc, and there are a lot of patients and everybody's dying. It's this feeling of drowning. Everything around you is falling apart and you inoculate yourself to this sort of stress by picking at it one at a time and getting to the point where what used to drown you doesn't drown you anymore. So you make it harder and then you make it even harder than that and then you make it harder.

So in training, we would be given twelve beds that we were responsible for. So that's twelve patients. And then that soon became doubled up for each bed when I was there. And so 24 patients, I would just start picking up even more patients after that. I'd pick up the patients that my attending would be responsible for. So I got used to this feeling of drowning in impatience and still trying to keep everything straight. And I kept that. I sort of, I kept that level of or that drive continuing on as it was intending. So.

Jon Becker: So you intentionally seek discomfort?

Dr. Kevin Menes: Yes. I think, you know, we talk about it, but, you know, I can tell you that when I'd come back from vacation, I hadn't worked for a couple, like a week. If I took a week off with the family, I could feel when I wasn't at that level again, and then I would strive to get back up there. And it was this level of discomfort that, you know, you're not always the nicest guy on the back end of it. And your customer service sure isn't four stars or five stars, but, you know, can you save one, you know, one really sick victim and then maybe two at the same time? Maybe even three? How about four? And while you're carrying all these other patients.

So this level of discomfort was something that I constantly strive to achieve because, number one, it fed my add. Number two, it was fun to keep myself going at that level. In that fun as in it fed my add meaning. I was constantly thinking and moving. Then number three on the back end, you're able to do something that is, even when you first started, you knew you couldn't do. So I think those are sort of the personal things separate from the team that everybody that I tried to touch.

Jon Becker: Kevin, I think that's a great place for us to stop. I so appreciate you doing this with me and, you know, amazing performance. There's a lot of people that are live because of what you guys did, and I should be very proud of that.

Dr. Kevin Menes: Thank you for having me! Thank you for giving us a chance to share our story!

Jon Becker: My pleasure, brother! Thank you!