It had been a late night for Leonard Weiss, MD. An assistant professor of emergency medicine in the University of Pittsburgh’s Department of Emergency Medicine and assistant medical director for the city’s bureau of EMS, Weiss had worked the ED till around 3, then come home and texted with his boss before retiring.
Even so, the commotion that erupted outside his window just a few hours later was impossible to sleep through.
The first odd noises—“like a rattling and kind of a loud clanking,” he recalls—Weiss attributed to construction, and he tried to go back to sleep. Then that gave way to rhythmic shouts, increasingly loud and urgent…and then automatic gunfire. “At that point,” Weiss says, “my heart started jumping, and I realized something was going on.”
He looked out his window and identified a source he’d long known could be a target: the Tree of Life synagogue, near Weiss’ home in Pittsburgh’s heavily Jewish Squirrel Hill neighborhood.
It was October 27, and Robert Bowers’ murderous rampage had begun.
Bowers would kill 11 and wound seven more, including police officers, before being apprehended. It would be the deadliest anti-Jewish attack in U.S. history. Weiss climbed from bed, grabbed his radio, and got ready to go to work.
As sirens pierced the air, frantic radio chatter began filling in details. A phone call got Weiss the confirmation he dreaded—an active shooter at the house of worship—and the location of a staging area. He threw on clothes, grabbed his bag, and stepped out his front door into the scene.
At that early point the response was still coalescing. “Everything was unclear,” Weiss recalls. “People were gathering all over, trying to establish what was where, and no one knew what had happened or where the shooter was.” He warned a dog-walking neighbor to get back inside, then found some officers and identified himself. They escorted him to the staging area down the block.
“We had two immediate goals at that point,” says Pittsburgh EMS Division Chief Mark Pinchalk, who’d diverted to the scene from previously assigned duty at the University of Pittsburgh’s football game that day. “No. 1 was to care for any walking wounded or wounded who came out of the building. In this case we had a couple of police officers who’d been wounded, so we set up and started doing care for them. And then our second priority was to start assembling personnel for a rescue team, so as soon as we could get police in the building and start taking some territory, we could move the rescue teams in and start taking care of people.”
In Pittsburgh’s system first-arriving EMS and police teams can form rescue task forces, but Bowers had already fired on cops, preventing their entry. Tactical teams finally got into the synagogue about 10:30—more than half an hour after the first 9-1-1 calls. They faced more fire and returned it, wounding Bowers (who also shot two more officers). He retreated to the building’s third floor before eventually surrendering shortly after 11 a.m.
An Atypical Response
Mass shootings are typically over quickly. An accident of timing contributed to the Tree of Life event’s unusual duration: Bowers apparently killed his 11 victims straight away, then was about to leave the synagogue when he ran into first-arriving officers. After that exchange of fire, he holed back up in the building. Had he departed successfully, the incident would have followed the more-typical short-duration pattern (though possibly spread into the neighborhood or elsewhere). “Unfortunately, I think he did his damage right off the bat and then hid,” says Weiss.
That meant an atypical response. Lengthy staging isn’t much favored in mass shootings anymore—the wounded can bleed into fatalities in the time it takes to secure a “safe” EMS entry. Progressive systems now push medics forward via mechanisms like RTFs, as well as training and equipping officers to control bleeding. But Bowers’ initial engagement with police forced a reversal in Pittsburgh. Entry had to wait for SWAT, accompanied by a tactical EMS contingent; then full care resources followed.
Expecting early in the response that police would get into the synagogue faster, Pinchalk assembled a hasty care team that included EMTs, medics, and officers. Using different radio channels, he didn’t yet know police had come under fire. “That meant we couldn’t get in as fast as we wanted,” he says, “but it allowed us to mass more resources to the site. So once we got in, we actually had a surplus of resources to handle what we needed.”
Obviously mass shootings devour a lot of resources—Pittsburgh EMS still had a big city to cover, including that football game, a gathering of nearly 32,000. It surged in five paramedic units, both its ALS rescues, three EMT units, and its mass-casualty unit, as well as calling a Level 1 county mutual-aid response, which yielded five more ambulances.
“That gives us some operational flexibility,” says Pinchalk. “We can dump them into the scene if we need them, or we can use them to backfill citywide operations. In this situation we ended up dumping them into the scene and putting them in a staging area for transport capability.”
Ultimately just five patients were transported, going to the two nearest trauma centers. Bowers was taken to a different facility, so as not to be at the same hospital with police or his victims.
Wounds and Care
The survivors suffered mostly extremity wounds, Pinchalk says; one had torso injuries. They were treated aggressively using the TECC (Tactical Emergency Casualty Care) model: tourniquets, hemostatics, pressure dressings, rapid care and extraction once it was safe.
Those killed fit a pattern observed in recent civilian mass-shooting research, with many wounds to the head and torso—places not amenable to tourniquets.
“Unfortunately this did fit that pattern,” says Weiss. “I’m a huge proponent of Stop the Bleed and putting tourniquets on people, but unfortunately that pattern is not what we’re seeing a majority of the time.”
The TECC approach worked well, though; using it has had the added benefit of improving Pittsburgh EMS’ regular daily care of penetrating trauma.
“The theory is that if you’re really good at what you do day to day, if you have an incident, you’re just stepping up your response a little bit,” says Pinchalk. “And that’s what happened. We QA all our penetrating trauma for scene times, field times, and critical interventions. The last year or so, we’ve been doing very well with that, and everyone just applied all the basics to the problem we were presented with.”
Joint training with fire and law enforcement has been ongoing for half a year, which also aided the synagogue response. A major-incident plan was activated despite still being in draft form and largely functioned well.
Pittsburgh also benefits from a 24/7 physician-response capability, and Weiss was one of four docs who ended up on scene, along with medical director Ron Roth, MD, chief of the EMS division in Pitt’s Department of Emergency Medicine; Donald Yealy, MD, the school’s chair of emergency medicine; and tactical EMS medical director Keith Murray, MD. That’s a pretty heavyweight contingent for an MCI, and Yealy told the Pittsburgh Business Times it paid off: “There was a lot of interaction right at the scene all the way through to the hospital about what’s the best care that needs to happen.”1
“Since the inception of our emergency medicine program, it was founded on a partnership with EMS,” adds Weiss. “We’ve had the luxury of responding with paramedics, being involved with their education process, training side by side with them, and having a heavy physician involvement in the QI program. I knew my paramedic and administrative colleagues on scene, and it allowed us to just kind of instantly read each other’s moves and preferences. There’s a respect that’s already established, and you just kind of snap into what you’ve already been doing every day.”
Communications worked but can always improve in an MCI. Responders used multiple channels—one for police, one for city operations, one for EMS operations, and others—but EMS kept updated by monitoring the others. Getting patient counts and situations was difficult without eyes in the building; Weiss hopes technology—perhaps robots or drones—may ultimately solve that problem.
“Operationally and clinically, I think everything went great,” says Pinchalk. “We just completed our after-action report, and it’s terrible that the lives were lost. But if a silver lining were taken out, it’s that once our tactical medics made entry with SWAT, no one else died. Everyone else who could be saved was saved, and we didn’t feel there were any survivable casualties among the people who were killed.”