Five Questions With: Babak Sarani, MD, on the Pulse Fatalities

Five Questions With: Babak Sarani, MD, on the Pulse Fatalities

By John Erich May 15, 2018

The June 2016 mass shooting at Orlando’s Pulse nightclub killed 49 and wounded 53 more. Three researchers with experience investigating the wounding profiles of such events—E. Reed Smith, MD, operational medical director for the Arlington County (Va.) Fire Department; Geoff Shapiro, director of EMS and operational medicine training at George Washington University’s School of Medicine & Health Sciences; and Babak Sarani, MD, FACS, FCCM, associate professor of surgery and director of the Center for Trauma and Critical Care at GWU—have produced a new study examining the fatal wounding patterns and causes of potentially preventable death among Pulse victims.1 Sarani told EMS World about it. 

EMS World: What were you hoping to learn by reviewing the Pulse victims’ autopsy data?

Sarani: We were hoping to better understand two things: 1) the exact causes of death in this event in order to build on our first paper regarding CPMS (civilian public mass shooting events); and 2) opportunities for rescue (i.e., the rate of those with potentially preventable deaths). 

Ultimately, goal #1 is meant to inform our policy-makers on the nature of injuries following these events. As an example, seat belts, helmets, drunk driving laws, etc., were implemented once people understood the gravity of the problem. We cannot hope for meaningful gun reform until we understand the exact causes and mortal nature of CPMS events. 

Goal #2 is meant to inform operational leaders in police, fire, and EMS departments as well as hospitals. Once we know the types of injuries that are resulting in potentially preventable deaths, we can alter response and resuscitation strategies and tactics to minimize their risk. This is no different than the military’s approach and evolution in the management of battlefield injuries from WWI (IV fluids) to WWII (blood transfusion/antibiotics) to Korea (MASH units, helicopters) to Vietnam (advanced medical gear in forward hospitals, better helicopter transport) to the current wars (damage-control resuscitation and TCCC). None of these advances would have occurred if the military leadership didn’t know the reasons underlying the death of our warriors and opportunities to mitigate their risk. 

How would you characterize what you discovered? Were there findings that surprised you?

Our most surprising finding was the very high rate of potentially preventable deaths. Our first study of CPMS found a 7% potentially preventable death rate—and we considered that to be surprisingly high. The high number noted in the Pulse paper really speaks to the need to examine strategies and tactics used by responding personnel. 

It is imperative that people understand that this is not a criticism of the persons who responded to Pulse; they carried out what their protocols and training told them to do. Our paper asks the question: Should these policies and procedures be examined and revised? This question holds true not only for the Pulse event but for all CPMS events and, in fact, all injuries. The question is no different than the question asked by all trauma medical directors and accrediting bodies when we examine any death following injury, shooting or otherwise. 

Of the 16 victims with potentially survivable injuries, what kinds of help could have made a difference? 

We found four victims where timely application of a tourniquet may have been lifesaving. Having said that, we found many other instances where other simple maneuvers would also have been lifesaving. 

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For example, we found a patient with a spinal cord injury below the level of the phrenic nerve, suggesting this person would have been paralyzed but should have been able to breathe. As best as we can gather, we think the person collapsed in a way that occluded his or her airway. All someone had to do was roll this person over, and he or she might have survived. We found another person with a gunshot to the intestines and minimal blood loss. Timely transport of this person to a trauma center would have been lifesaving. Lastly, we found persons with gunshots to the chest but no hemothorax. Presumably these persons died of pneumothorax—something that can be very easily treated by a paramedic via needle or open thoracostomy. 

In the end both the Pulse paper and our initial study on CPMS suggest that: 1) Simple maneuvers by civilians (including but not limited to tourniquets) can be lifesaving; and 2) rapid extrication of victims to EMS/hospitals is a critical intervention in preventing death. The days of EMS staging until the scene is secure have to end, and EMS and law enforcement have to work together to allow early access to victims. The adage of the platinum 10 minutes holds true in CPMS events just as it holds true in any trauma event. 

How do these findings align with your widely reported previous findings2 on the differences in civilian vs. military wounding patterns (i.e., civilians take more damage to the head and body, as opposed to the extremities)?

The findings from Pulse are completely in line with our first paper comparing outcomes from civilian vs. military woundings. In the Pulse paper we again found a much higher case fatality rate (about 45%) and a significantly higher number of fatal injuries to the head and torso for the same reasons as before: close proximity of the shooter to the victims, lack of ballistic armor/protection for the victims, and delay to extrication of victims to trauma care. 

Again, we (the civilian side) have to start looking more like the military side if we are to rescue people after CPMS events. In that light, we call (again) for aligning processes via the guidelines of Tactical Emergency Casualty Care (TECC), which are, in turn, based on the Tactical Combat Casualty Care (TCCC) guidelines. 

How do these findings square with our current efforts to improve mass-shooting survival (Stop the Bleed, etc.)? Do they suggest any potential tweaks or changes in approach?

The results of this paper are in line with STB. However, they point out that STB alone is not enough. STB is a starting point. It should not be thought of as a panacea that will result in a significant number of persons saved following CPMS. At Pulse 4 of 16 persons might have survived if people implemented the teachings of STB. However, that still leaves 12 persons for whom STB wouldn’t have been enough. We have to teach and empower civilians to move people and reposition them to make sure their airway is open, and we have to work with our fellow first responders to make sure we can extricate people quickly. 

STB has been a huge success, and we commend the American College of Surgeons for this initiative, but we feel we (EMS, surgeons, emergency physicians) need to build on it to address all causes of possibly preventable death following CPMS, not just extremity hemorrhage. We also describe this in another paper we wrote.3 


1. Smith ER, Shapiro G, Sarani B. Fatal wounding pattern and causes of potentially preventable death following the Pulse night club shooting event. Prehosp Emerg Care, 2018 Apr 25 [e-pub online];

2. Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg, 2016 Jul; 81(1): 86–92.

3. Callaway D, Bobko J, Smith ER, Shapiro G, McKay S, Anderson K, Sarani B. Building community resilience to dynamic mass casualty incidents: A multiagency white paper in support of the first care provider. J Trauma Acute Care Surg, 2016 Apr; 80(4): 665–9.


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