How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History

The night that Stephen Paddock opened fire on thousands of people at a Las Vegas country music concert, nearby Sunrise Hospital received more than 200 penetrating gunshot wound victims. Dr. Kevin Menes was the attending in charge of the ED that night, and thanks to his experience supporting a local SWAT team, he’d thought ahead about how he might mobilize his department in the event of a mass casualty incident.

This is his story, as told to Judith Tintinalli, MD, MS
Edited by Logan Plaster

I’m a night shift doc. My work week is Friday to Monday, 8 p.m. to 6 a.m. Most people don’t want to work those shifts. But that’s when most of the action comes in, so that’s when I work. It was a Sunday night when the EMS telemetry call came in to alert Sunrise Hospital of a mass casualty incident. All hospitals in Las Vegas are notified in a MCI to prepare for incoming patients.

As I listened to the tele, there happened to be a police officer who was there for an unrelated incident. I saw him looking at his radio. I asked him, “Hey. Is this real?” and he said, “Yeah, man.” I ran down to my car and grabbed my police radio. The first thing that I heard when I turned it on to the area command was officers yelling, “Automatic fire…country music concert.” Ten o’clock at night at an open air concert, automatic fire into 10-20 thousand people or more in an open field—that’s a lot of people who could get hurt.

At that point, I put into action a plan that I had thought of beforehand. It might sound odd, but I had thought about these problems well ahead of time because of the way I always approached resuscitations:

  1. Preplan ahead
  2. Ask hard questions
  3. Figure out solutions
  4. Mentally rehearse plans so that when the problem arrives, you don’t have to jump over a mental hurdle since the solution is already worked out
It’s an open secret that Las Vegas is a big target because of its large crowds. For years I had been planning how I would handle a MCI, but I rarely shared it because people might think I was crazy.

She’s a ‘phenomenal’ kindergarten teacher’s assistant. She also has Down syndrome.

Some over-inspirational pap, and some significant inaccuracy, but describes a path for personal freedom and empowerment....

Megan McCormick is a paraeducator — a teacher’s assistant — at Lexington’s Millcreek Elementary. The Fayette County Public Schools employee is passionate about helping students and is pursuing a four-year college degree to further her career..

McCormick, 29, also has Down syndrome. It is a genetic disorder than can result in mild to moderate intellectual disabilities.

“We are very proud of Megan,” Millcreek principal Greg Ross said. “She does a phenomenal job. She does whatever we ask of her.”

McCormick, a 2013 graduate of Bluegrass Community and Technical College, started as a substitute paraeducator, but this school year, she has been hired to work both in a kindergarten classroom and as an assistant in the school’s front office, Ross said.

Study: Too Much Hypoglycemia in Diabetic Hospice Patients

When it comes to hospice patients with type 2 diabetes, avoiding hypoglycemia may be more important than strict glycemic control, researchers argued.

In a researcher letter appearing in JAMA Internal Medicine, about 12% of hospice patients with type 2 diabetes residing in nursing home experienced hypoglycemia within 180 days of admission -- a glucose reading under 70 mg/dL.

As for severe hypoglycemia -- a glucose reading under 50 mg/dL -- this was experienced by approximately 5% of hospice patients in nursing homes within 180 days of admission, reported Laura A. Petrillo, MD, of Massachusetts General Hospital in Boston, and colleagues.

Study: Too Much Hypoglycemia in Diabetic Hospice Patients

When it comes to hospice patients with type 2 diabetes, avoiding hypoglycemia may be more important than strict glycemic control, researchers argued.

In a researcher letter appearing in JAMA Internal Medicine, about 12% of hospice patients with type 2 diabetes residing in nursing home experienced hypoglycemia within 180 days of admission -- a glucose reading under 70 mg/dL.

As for severe hypoglycemia -- a glucose reading under 50 mg/dL -- this was experienced by approximately 5% of hospice patients in nursing homes within 180 days of admission, reported Laura A. Petrillo, MD, of Massachusetts General Hospital in Boston, and colleagues.

The risk was even greater for those receiving insulin: cumulative incidence of 38% for all hypoglycemia and 18% for severe episodes within 180 days of admission, with the peak risk occurring during the initial 20 days. Hyperglycemia incidence was 9% overall; 35% among those on insulin.

"[H]ypoglycemia is not consistent with a goal of comfort, and these data demonstrate suboptimal avoidance of dysglycemia among patients with type 2 diabetes on hospice in nursing homes," wrote Petrillo and colleagues.

According to the 2016 guidelines from the American Diabetes Association, people with diabetes receiving end-of-life care should relax glycemic control targets and eventually discontinue diabetes medication in order to avoid hypoglycemia, which Petrillo's group calls a "potentially preventable cause of suffering among hospice patients."

"Patients treated with insulin lived longer and experienced more hyperglycemia than patients not treated with insulin, which suggests that clinicians may be choosing to continue insulin for those hospice patients with a longer life expectancy and more severe diabetes at hospice admission," the research group noted

Newer Epilepsy Drugs Haven't Boosted Seizure Control

Despite the arrival of newer anti-epileptic drugs (AEDs), seizure control hasn't improved in the last several decades, researchers found.

Throughout the trial, there was a marked increase in the use of newer AEDs: the first decade was dominated by carbamazepine, valproate, and phenytoin as initial therapy, while the latter decade was dominated by valproate, levetiracetam, and lamotrigine as initial monotherapy.

"While some modern AEDs have novel anti-seizure mechanisms, their increasing use did not seem to have improved overall long-term seizure control," the authors wrote. "This may be attributed to deficiencies in the preclinical and clinical strategies of AED development," such as enrollees being required to have established epilepsy and a high frequency of seizures.

"The results of this study suggest that the advent of new pharmacological therapies has had little impact on the proportion of newly diagnosed people rendered seizure-free" -- a finding that "is not new and should not be surprising."

Even with the best management, Hauser wrote, "only about two-thirds of people with newly diagnosed epilepsy will be successfully treated ... Resources need to be dedicated to developing anti-epilepsy therapies that interfere with or reverse the underlying disease process, rather than merely identifying agents that suppress seizures."

People Are Taking Ubers to Avoid Ambulance Fees

Using an ambulance to travel to the hospital in an emergency can cost upwards of $1,000 USD. Now research demonstrates that a significant number of people are instead choosing Uber to perform the same service.

The paper – currently being peer reviewed – examines the effect on ambulance usage as Uber was introduced to 766 cities across 43 states. According its findings, even the most conservative estimate shows a seven percent reduction in people traveling via ambulance where the service is available.

“I think it’s, in general, a good thing,” said co-author David Slusky, an assistant professor of economics at the University of Kansas, speaking to Futurism over the phone. “Certainly, we can think of cases where it’s a worrying trend, but in general, it’s a good thing.” Slusky went on to acknowledge the importance of “bending the cost curve” for healthcare in the U.S., given that residents spend more per capita on healthcare than anywhere else in the world.

Of course, it’s crucial that people are only using Uber drivers as an impromptu ambulance when it’s safe to do so. While in some cases it makes sense to save money using this strategy, there are certain situations when it would be ineffective or even downright dangerous to do so.

For example, you may end up in the wrong hospital, said Marc Eckstein, the Los Angeles City Fire Department’s medical director, speaking with CBS.

Not all hospitals offer the same services, so if you get a ride to the nearest one which is not equipped to treat your problem, that hospital will then call 911 and move you to the right facility. “That difference of 30 minutes or more could mean the difference between life and death,” Eckstein said.


The fact that the cost of taking an ambulance to the hospital is inaccessible for a lot of people in the U.S. is a big problem, and the use of ride-sharing services is a workaround at best. However, there are certain advantages to the idea of people taking an Uber when an ambulance isn’t necessary.

“If ambulances aren’t used when they’re less needed, that improves response time when they are needed,” explained Slusky. Again, it’s troubling to think that people might have to weigh the financial repercussions of getting to the hospital in an emergency, but there could be a benefit to giving people a less expensive alternative in non-emergency situations.

Slusky argues that educating the public about what sort of conditions need immediate treatment, as well as an effective method of remote triage before the patient ever reaches the hospital, could help modernize our emergency healthcare. Some kind of sanctioned ride-sharing service could play a role, with ambulances serving as one component of a broader fleet of vehicles with various levels of specialization.

Technology is poised to revolutionize the healthcare industry as we know it, and the current experience of heading to the hospital could be unrecognizable in a few years time. When it comes to emergency services, the biggest problem is re-educating the public. People know the established process for emergency care, and ingraining a new approach will take time and effort.

Should More EMS Responders Be Allowed to Give Glucagon?

For the treatment of hypoglycemia, glucagon may be underused in outpatient settings, researchers argued.

In a nationwide analysis, most states only permit paramedics to carry and administer glucagon for a severe hypoglycemia event -- leaving around 76% of all emergency medical service providers unable to give the agent, reported Peter A. Kahn, MD, of Yale School of Medicine in New Haven, Connecticut, and colleagues.

In some states, emergency medical service responders aren't even permitted to check blood glucose levels, according to a research letter online in Annals of Internal Medicine.

"Patients receiving insulin or certain oral hypoglycemic agents are at increased risk for hypoglycemia, which results in more than 100,000 emergency department visits incurring approximately $120 million in costs annually," Kahn's group wrote, adding that family members often routinely administer glucagon.

The analysis included cases of glucagon administration from the National EMS Information System between 2013 to 2015, as well as prescriptions of glucagon from 2014 Medicare Part D data.

Within this time frame, glucagon was administered in only 89,263 cases in a prehospital setting. Among such instances where glucagon was administered, the average response time to calls for emergency medical services was 15.34 minutes (SD 11.50). Of these, only 3,944 patients reported having any adverse events due to glucagon.

"Emergency medical service response times to episodes of hypoglycemia are crucial in the diabetes chain of survival," the group wrote. "The average response time of more than 15 minutes suggests that policy changes may be needed, because such a delay coupled with policies preventing basic emergency medicine providers from administering glucagon may increase patients' risk for neurologic sequelae, death, or both."

Everything you know about toxic shock syndrome is probably wrong

First off, it’s not just a tampon thing.

TSS is back in the news because a model — who lost her leg to the disease in 2012 — is on an awareness campaign to teach young girls about the dangers of tamponsHer story is horrifying, and is only more depressing now that she may have to have a second leg amputated. It seems all the scarier when you realize that she hadn’t even left the offending tampon in for very long (in fact, based on her telling of it, she felt ill before she put one in).

Every woman I know heard these tales as a kid and had one takeaway: we were all definitely going to get TSS if we left a tampon in for even a minute longer than the prescribed eight hours. In 9th grade I accidentally left one in for 12 hours and genuinely thought I’d narrowly escaped death. But it turns out almost everything that I and other girls my age believed about TSS is flat-out wrong. Let’s clear up a few misconceptions, starting with the basics.

Could you remind me ahem, my friend what TSS actually is?

Don’t be embarrassed. I would venture a guess that most folks don’t really know what TSS is, besides “a horrifying disease that you get from tampons.”

Toxic shock syndrome isn’t really a disease in and of itself. It’s a complication of a bacterial infection. There are two kinds of bacteria, staphylococcus aureus and group A streptococcus, that can produce a toxin called TSST-1 (toxic shock syndrome toxin 1). TSST-1 is a superantigen, which means it prompts the immune system to massively overreact to an infection. The resulting storm of immune cells causes the body to go into shock as inflammation spreads and a fever rises, and if left unchecked will eventually cause multi-organ failure. And the toxin can enter the bloodstream even if the bacteria are isolated to one area, so an infection in a single part of the body can end up killing you. Other toxins can also cause TSS, but TSST-1 is the most common one for tampon-related cases.

TSS is actually really rare

In 2016, the CDC reported a grand total of 323 cases. That’s not insignificant, but is pretty tiny when you consider that there are roughly 63 million women between the ages of 15 and 44 in the United States. That’s a rate of 0.0005 percent. Even fewer people died of it that year — just 26 men and women. This isn’t to minimize those losses, because for the victims and their families, TSS was devastating. But on the spectrum of possible causes of death to worry about, toxic shock syndrome is exceedingly unlikely.

And for all you youths out there who are terrified to leave a tampon in for more than a few hours, rest assured that millions of adults regularly fail to remove tampons in a timely fashion. It’s generally not a problem, and TSS doesn’t often have much to do with tampons anyhow.

A third of all TSS cases happen in men

That’s right — men. Do you know who is arguably the most famous person to die from TSS? Jim Henson, the creator of The Muppets.

Toxic shock syndrome isn’t unique to tampon use, it’s just more common in the tampon-using population. Less than half of all cases involve a tampon, however. The rest of the women have an infected wound of some kind, like a surgical incision from a c-section.

Regular Aspirin Use May Slow COPD Progression

This is startlingly good news.....

Analysis showed 50% reduction in emphysema progression.

Regular aspirin use was associated with a more than 50% reduction in emphysema/chronic obstructive pulmonary disease (COPD) progression in an elderly cohort over a decade in a longitudinal analysis of data from a large lung study.

The association was seen across aspirin doses and was greatest in older study participants with significant airflow obstruction.

Results were similar in ever-smokers and for doses of 81 mg and 300-325 mg. A greater magnitude effect was seen among participants with airflow limitations.

Antidepressant May Help Combat the Course of Multiple Sclerosis

The antidepressant clomipramine may also alleviate symptoms of multiple sclerosis (MS), specifically in its progressive form, i.e. when it occurs without relapses or remissions. As yet, drugs for this type of MS have been virtually non-existent. Researchers collaborating with Prof V. Wee Yong, PhD, from the University of Calgary and Dr Simon Faissner from Ruhr-Universität Bochum screened 1,040 generic therapeutics and, based on preclinical studies, identified one that is suitable for the treatment of multiple sclerosis. They published their results in the journal Nature Communications from December 19, 2017.

Today, twelve drugs have been approved for the treatment of relapsing-remitting multiple sclerosis; for the progressive types, on the other hand, only a few therapy approaches exist. “The mechanisms causing damage in progressive MS are not always the same as in relapsing-remitting MS. This is why the latter requires different therapeutic approaches,” says Simon Faissner. As postdoctoral researcher of the Department of Neurology at St Josef-Hospital in Bochum, he contributed to a study carried out at the Cumming School of Medicine, University of Calgary as a visiting scholar, funded by the grant for medical research awarded by the Ruhr-Universität’s Faculty of Medicine.

Potential side effects already well-documented

The team worked with approved drugs, the side effects of which have already been amply documented. From among those drugs, the researchers selected 249 well-tolerated therapeutics that enter the nervous system safely; this is where chronic inflammation occurs in progressive MS. Using cell cultures, they tested which of the 249 substances are capable of protecting nerve cells from the damaging influence of iron. In MS patients, iron is released due to cell damage, damaging nerve cells in turn.

Following those tests, 35 potential candidates were identified; the researchers subsequently analysed them with regard to additional properties: investigating, for example, if they can reduce damage to mitochondria – the powerhouses of the cells – or if they minimise the activity of leucocytes that attack the insulation of nerve cells in MS patients. In the process, the drug clomipramine proved promising.

Positive results in preclinical studies

In the next step, the researchers analysed the substance in mice suffering from a disease comparable with relapsing-remitting multiple sclerosis in humans. The therapy suppressed the neurological disturbances completely; as a result, damages to the nerve cells and inflammation were minimised.

In a subsequent test, they treated mice with a disease that resembles progressive MS in humans. Here, too, the therapy proved effective, provided the researchers applied it immediately after the first clinical symptoms became apparent. Symptoms such as paralysis were thus reduced – unlike in control animals that were treated with placebo drugs.