Level 1 trauma centers the 'gold standard' of care in attacks like the Las Vegas shooting

Nevada's only Level 1 trauma center overflowed with victims of Sunday's shooting rampage that killed 58 people in Las Vegas, which forced neighboring hospitals with fewer resources devoted to trauma care to pick up the slack.

The University Medical Center (UMC) of Southern Nevada, which is in Las Vegas, received 104 of the shooting victims, while the city's Sunrise Hospital and Medical Center, which is a Level 2 trauma center, received 180 shooting victims. Dignity Health-St. Rose Dominican in nearby Henderson, Nev., is a Level 3 trauma center and received 58 patients. Several hospitals that don't have trauma centers also received patients. 

Patients with moderate to severe injuries taken to a Level 1 trauma center have about a 25 to 30% better chance of survival compared to those taken hospitals that are not trauma centers, according to a 2006 study in the New England Journal of Medicine (NEJM), the latest research available. Level 1 trauma centers must have certain personnel, such as trauma specialists within specialties including cardiology and orthopedics, equipment and quality improvement processes.

The Southern Nevada Health District, in a 2015 report, said the area wanted more "trauma coverage but does not want to be saturated with trauma centers or to have too many trauma centers so as to destabilize the existing centers." The report noted the "the number and location of trauma centers" need to be "periodically" studied.  

Level 1 trauma centers are the "gold standard" for the treatment and assessment of seriously injured patients, says trauma surgeon Ronny Stewart, who chairs the trauma committee at the American College of Surgeons' (ACS), which regularly verifies centers meet the criteria. 

"This is why mortality is significantly improved in these hospitals, and it is why I would always want to be taken to an ACS verified Level I trauma center if I were severely injured," Stewart said this summer. 

Although smaller or similarly-sized cities, including Washington, Baltimore and Atlanta, have two or more Level 1 trauma centers, American Trauma Society executive director Ian Weston says there may not be enough business to support the cost of certifying another Level 1 center in Las Vegas or even Nevada. 

Several western states, including Colorado and Oregon, only have one Level 1 center while some don't have any. 

"Locations have more to do with population and need and ability to keep the doors open," he says. 

The American College of Surgeons' trauma system committee has been trying to come up with a formula to determine how many trauma centers areas should have for about a dozen years, says surgeon Robert Winchell, who has heads the college of surgeons' committee. He says the answer involves "some science and some politics" and includes whether policymakers want to spend money to, say, prevent violence or treat it. 

"Like anything else, you shouldn’t plan only for the best case," says Winchell, who is a professor of surgery at Weill Cornell Medicine and the chief of trauma, burns, acute care and critical care. "But you can’t just plan for the worse case because the worst case will probably be worse than planned for in many ways." 

UMC physician Zubin Damania, who blogs and appears on video at ZDoggMD.com, posted a plea for financial and blood donations for the hospital's foundation and the trauma center, which he noted already takes care of "our most vulnerable citizens."  Hospitals in the area "are severely strained by this unprecedented mass casualty event," he said. 

Patrick Downes, who was severely injured with his wife in the Boston Marathon bombing in April 2013, says he can’t believe there was only one Level 1 trauma center in Nevada, while the Boston area has seven. “How do you care for 500-plus people?” he asks.

"There is an embarrassment of medical riches in Boston and all were used and under enormous stress," says Downes, noting that fewer than 300 people needed treatment after the bombing five years ago.

Downes and wife Jessica Kensky were treated at different Boston Level 1 trauma centers after the bombing. In 2014, they were transferred to Walter Reed National Military Medical Center where Kensky had about 10 more surgeries, the couple received rehabilitation and counseling and lived for three years until June. 

Downes, who has a doctorate in psychology, and Kensky, a registered nurse, have become strong advocates for military hospitals to begin routinely treating civilian trauma patients to help both service members and trauma victims. 

"Not to be disparaging of a community hospital, but some expertise lends itself to a situation like this," says Downes, citing a "whole other level of weapons."  "It's not just about keeping people alive, but you want to maintain's someone's quality of life, brain function and internal organs."

Medical personnel from the Nellis Air Force Base in Nevada worked in University Medical Center (UMC) of Southern Nevada's emergency department during training with the Air Force's Sustained Medical and Readiness Trained (SMART) program. 

The best-equipped trauma centers for terror and other attacks have the Level 1 trauma designation, but also need enough space in emergency rooms, intensive care units and in-patient beds to handle an immediate surge of victims, according to a 2008 report to Congress. 

Community hospitals can still treat some critically injured patients, says Greg Brison, director of emergency management and security for the five-hospital Inova Health System in northern Virginia. 

The 2008 report to the House Oversight and Government Reform committee — the most recent national data available — found none of the Level 1 trauma centers in seven cities surveyed had the capacity to deal with surges of patients similar to the 2004 bombings on Madrid commuter trains that left 200 dead and more than 1,800 injured.  

How other trauma centers have prepared: 

• Boston. Massachusetts General Hospital emergency medicine physician Paul Biddinger says his hospital received 97 patients in its 49-bed emergency room after the marathon bombings. The hospital and its patients benefited from having a plan that included the "army of people who descended on the emergency department" from across the hospital, says Biddinger.

"The only way you can meet capacity is with the scripted actions numerous people took," says Biddinger, who is director of the hospital's Center for Disaster Medicine. "We didn’t have to tell people what to do."  The hospital has also hosted emergency responders from attacks in London, Israel and Madrid, which has have helped it become "even faster and better than it was during the Boston Marathon," says Biddinger.   

• Washington. After the 9-11 attack on the Pentagon, 15 Virginia hospitals created the Northern Virginia Hospital Alliance to help emergency medical services (EMS) determine where to send victims during an emergency, such as that  in Las Vegas, says Brison. Within 10 minutes of an announced event, a coordinating center would allow all 15 hospitals to give EMS real time emergency room bed availability. This would allow EMS and hospitals to distribute patients so no one hospital gets overwhelmed. During a mass casualty incident, an electronic ICU would also use telemedicine to allow emergency room nurses and doctors to communicate with other ERs. The alliance, says Brison, would be critical "if we had a Vegas."  

• Atlanta. Grady Memorial Hospital does mass casualty training twice a year, and would be prepared to coordinate treatment for up to 500 adult and 100 pediatric victims in the event of an incident, says surgeon Mark Shapiro, the hospital's trauma medical director and chief of trauma. There are two other Level 1 trauma centers and 27 other hospitals in the greater Atlanta area and all of the hospitals have agreed to accept a predetermined number of casualties based on injury severity, he says. Grady's Marcus Trauma Center treats about 7,000 trauma patients a year, including 4,500 in-patients, although its "surge capacity" at one time would be 20-30 patients, he says. "We will find a place for them," even if they were "near death" as up to 10% would likely be, he says.

In July, UMC hosted a mass casualty training session that included Orlando physician Gary Parrish, who treated some of the victims of the Pulse nightclub massacre in 2016, CNBC reported. Until the Las Vegas shooting, the Pulse attack was the largest mass shooting in modern U.S. history.

Terrorism survivors’ plea to Maryland

Trauma centers' "surge capacity" includes having sufficient space in their emergency rooms, as well as enough "critical care resources", said the report to Congress. On the day of the 2008 survey, there were such severe shortages of critical care and inpatient beds that many of the hospitals were already housing admitted patients in their emergency room. 

More:Military hospitals like DC's Walter Reed could ease national ER overcrowding, save lives

More:Official trauma hospital for D.C. power brokers cuts costs amid sewage leaks, safety problems

While most areas don't need more trauma centers, preparedness for disasters and what are known as mass casualty incidents (MCI) "is a huge area for improvement for most trauma centers and communities," says Denver-based trauma surgeon Eric Campion.   

"I think that most communities and regions are woefully underprepared for an MCI such as Las Vegas," says Campion. "This should be a wake up call for more regional cooperation and MCI planning."