Records reveal medical response further delayed care for Uvalde shooting victims

ByZach Despart; Lomi Kriel; Alejandro Serrano; Joyce Sohyun Lee; Arelis R. Hernandez; Sarah Cahlan; Imogen Piper; Uriel J. Garcia, The Texas Tribune
Tuesday, December 20, 2022
Uvalde school shooting survivors tell their stories through photos
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Previously unreleased video, audio and interviews show for the first time how the medical response faltered after police finally confronted the Robb Elementary shooter.

UVALDE, Texas -- Bullets had pierced Eva Mireles' chest as she tried to shield students from a gunman's semiautomatic rifle. But the fourth grade teacher at Robb Elementary was still conscious when police carried her out of classroom 112 and through a hallway crowded with dead and dying victims.

The video above is from a related story.

This story includes graphic descriptions of injuries sustained in an elementary school shooting and graphic language. Graphic videos reviewed by reporters are not included.

"You're fine. You're fine," said her husband, Uvalde school district police officer Ruben Ruiz, who had been frantically trying to rescue her since the attack began. Mireles looked at him but could not speak. She'd been losing blood for more than an hour.

To see body camera footage and diagrams outlining the medical response, visit the Texas Tribune's website.

Officers placed Mireles on the sidewalk just beyond one of the school's exits and started treating her wounds. A medic later told investigators he did not see any ambulances, though video footage showed two parked just past the corner of the building, about 100 feet away.

The chaotic scene exemplified the flawed medical response - captured in video footage, investigative documents, interviews and radio traffic - that experts said undermined the chances of survival for some victims of the May 24 massacre. Two teachers and 19 students died.

Law enforcement's well-documented failure to confront the shooter who terrorized the school for 77 minutes was the most serious problem in getting victims timely care, experts said. But previously unreleased records obtained by ProPublica, The Texas Tribune and The Washington Post for the first time show that communication lapses and muddled lines of authority among medical responders further hampered treatment.

Three victims who emerged from the school with a pulse later died. In the case of two of those victims, critical resources were not available when medics expected they would be, delaying hospital treatment for Mireles, 44, and student Xavier Lopez, 10, records show.

Another student, Jacklyn "Jackie" Cazares, 9, likely survived for more than an hour after being shot and was promptly placed in an ambulance after medics finally gained access to her classroom. She died in transport.

The disjointed medical response frustrated medics while delaying efforts to get ambulances, air transport and other emergency services to victims. Medical helicopters with critical supplies of blood tried to land at the school, but an unidentified fire department official told them to wait at an airport 3 miles away. Dozens of parked police vehicles blocked the paths of ambulances trying to reach victims.

Multiple cameras worn by officers and one on the dashboard of a police car showed just two ambulances positioned outside the school when the shooter was killed. That was not nearly enough for the 10 or more gunshot victims then still alive, though additional ambulances began arriving 10 minutes later. Six students, including one who was seriously wounded, were taken to a hospital in a school bus with no trained medics on board, according to Texas EMS records.

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Dozens of officers from federal, state and local agencies, as well as school buses, parked in the street leading to the school.

Two ambulances were at the scene when police killed the gunman. But additional EMS responders struggled to get there.

Uvalde EMS radio traffic (12:58 p.m.) "10-4 we are [inaudible] at Grove Street and Grove Street is blocked off by law enforcement."

One minute later, six students, including one who was seriously wounded, were taken to a hospital in a school bus with no trained medics on board.

Some law enforcement cars were left locked and could not quickly be moved, forcing medics to frantically try various routes to the school, crisscrossing through residents' yards.

Thirty-three minutes after police killed the gunman, an ambulance struggled to access the school via South Grove Street.

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Although helicopters were available, none were used to carry victims directly from the school. At least four patients who survived were flown by helicopter to a more fully equipped trauma center in San Antonio after first being driven by ambulance to a nearby hospital or airport.

In public statements made since May, law enforcement officials have defended their officers' actions as reasonable under difficult circumstances. Federal, state and local agencies that responded to the shooting have not directly addressed the medical response, nor did they answer detailed questions from the news organizations that worked jointly on this investigation.

Eric Epley, executive director of the Southwest Texas Regional Advisory Council, a nonprofit that helps coordinate trauma care in Southwest Texas during mass-casualty events, said medics encountered challenges, including a faulty radio system.

"These scenes are inherently confusing, challenging, and chaotic," Epley said in an email. He later added, "We remain steadfast that the decisions by the on-scene medical leadership were sound and appropriate."

The Texas Rangers, an arm of the state Department of Public Safety, are investigating what went wrong in Uvalde, including whether any victims might have survived if they had received prompt medical care. The local district attorney has said she will use that investigation to determine whether to charge anyone with a crime, including law enforcement officers.

Mireles, an avid hiker and CrossFit enthusiast who was fiercely proud of her college-graduate daughter, was shot within the first minutes of the attack, according to interviews students gave to investigators and a DPS analysis of gunfire obtained by the news organizations.

It's difficult to know whether Mireles or anyone else who died that day might have survived their wounds, in part because local officials have refused to release autopsy reports. But footage shows that Mireles was conscious and responsive when she was pulled from the classroom, an indicator that she probably had survivable wounds, according to medical experts.

"Had medics gotten to her quickly, there's a good chance she would've survived," said Babak Sarani, director of critical care at George Washington University Hospital.

The flawed coordination among police and medical crews echoes missteps during other mass shootings, despite the development of recommended practices after the 1999 massacre at Columbine High School. In several of those cases, the communication problems resulted in delays in getting medical care for victims.

Medics on helicopters and in ambulances who responded to the Uvalde shooting told investigators they were confused about who was in charge, where they should be stationed and how many victims to expect. Some of them pleaded to be allowed closer to the scene. In the absence of clear guidance, experts said medics did the best they could while trying to save lives.

"They were told, essentially, to go to the airport and wait," according to an interview the Texas Rangers conducted with Julie Lewis, the regional manager for AirLIFE, an air medical transport service that sent three helicopters from the greater San Antonio area. "They couldn't figure out who was in command."

Pleading for help

The morning of May 24 was warm and sunny in Uvalde, the seat of a rural county of about 25,000 residents near the Texas border with Mexico. It was one of the last days of class, and teachers had planned a festive, celebratory day.

Mireles left her home wearing a flowery blouse and pair of black pants, feeling happy, her daughter said.

"My dad had just told her how beautiful she looked," Adalynn Ruiz, 23, recalled in a text message to a reporter.

About two dozen fourth graders were in Rooms 111 and 112, adjoining classrooms, that day. They included Jackie, who relished cherry limeades with extra cherries, and Xavier, who loved art class and couldn't wait to start middle school.

They'd just finished a student awards ceremony and settled into watching the Disney movie "Lilo & Stitch" when a teenage gunman dressed in black scaled the school's fence and fired shots at 11:32 a.m.

Hearing the gunfire, Mireles quickly called her husband.

"There's somebody shooting at the school," she said, Ruben Ruiz recalled in an interview with investigators.

"We're coming up," he told her as he drove to the school with a state police officer, who later described the comment to investigators. "We'll be there."

The gunman got there first, entering Mireles' classroom and firing his AR-15-style rifle. Officers rushed into the school minutes later and approached her classroom, but they retreated after the gunman fired through the door, grazing two of them.

Ruiz, who declined to comment for this report but spoke with state investigators, ran into the hallway at 11:36 a.m., according to video footage. But none of the officers tried to enter the classrooms, where the gunman continued to fire sporadically.

Desperate to reach his wife, Ruiz told the other officers what he knew.

"He's in my wife's classroom," he said, according to the footage. He later recalled to investigators that it felt "like my soul had left my body."

About twenty minutes later, his wife called again.

At 11:56 a.m., he shouted, "She says she's shot!"

That information was a key indication that officers were dealing with an active shooter, not a barricaded subject as school district police Chief Pete Arredondo incorrectly assumed, according to a legislative report on the shooting. But Ruiz's comment did not change how law enforcement officers, following Arredondo's lead, responded to the attack.

The school district's active-shooter protocol designated the chief as the incident commander. Arredondo has repeatedly defended his role in the delay, telling Texas lawmakers investigating the massacre that he did not consider himself to be in charge. The Uvalde school board fired Arredondo in August, amid sharp public criticism of the police response to the shooting.

Trapped inside her classroom, Mireles tied a plastic bag around her arm to help slow the blood loss, one of her students told investigators. Another child in Room 112 told investigators that Mireles tried to protect him. The boy was hit in the back of his shoulder but survived.

At least two students used Mireles' phone to call 911, begging officers to send help.

Officers confiscated Ruiz's gun and forced him to wait outside the school, where he told "anybody that would get next to me" that his wife was in danger, according to his law enforcement interview. He tried to get back in, but fellow officers stopped him. They later told investigators they had seized his gun for his own safety.

Inside Rooms 111 and 112, students anxiously tried to get officers' attention. They knew that for Mireles, there was little time to spare.

One girl later recalled to investigators that Mireles "was telling us she was going to die."

"We as a nation are not ready"

More than two decades after the Columbine school shooting shocked the nation, key failures continue to repeat themselves.

After that shooting, officers across the country received training on what they should do first when a mass shooting is reported: Subdue the shooter and stop the killing. Next, trainers tell first responders, they must "stop the dying."

Over time, that insistence on prompt, effective medical care became an established mantra, as did the idea that all first responders - police, fire and EMS - should work under a joint command overseeing and coordinating the response. An overall incident commander is supposed to coordinate with the head paramedic or lead fire department supervisor to organize the medical response, experts said.

"If you don't have a system, the whole response goes awry," said Bob Harrison, a former police chief and a homeland security researcher at the Rand Corp., a think tank based in California.

A Justice Department review of the response to the 2016 Pulse nightclub shooting in Orlando, Florida, that killed 49 people found that the police and fire departments' decision to operate separate command posts for hours led to a lack of coordination.

A review by local authorities of the 2012 Aurora, Colorado, movie theater shooting that killed 12 people discovered that the delayed establishment of a unified command led to communication problems between police and fire responders, slowing medical care for victims.

"We as a nation are not ready," said Sarani, the director of critical care at George Washington University Hospital. "The air assets and the ground assets do not talk to each other very well. The fire, the police do not talk to each other very well."

Experts said that the Uvalde shooting response appeared to lack both an overall incident commander and someone clearly in charge of coordinating the emergency medical response.

The rural community's emergency medical services are contracted out to private companies. On that day in May, Stephen Stephens, the director of Uvalde EMS, was in charge of organizing helicopters and ambulances responding to Robb Elementary, he later told investigators.

"My job was to manage assets," he said, noting that Juan Martinez, his deputy, instructed medics arriving at the scene.

After police breached the classrooms where the shooter had been holed up, Stephens said he handed command over to the fire chief of neighboring Medina County. The Medina fire chief declined to comment to the news organizations.

It's unclear what information Stephens had about how many victims first responders should expect to find. Multiple medics expressed confusion over who was in charge of the medical response and where to go.

"There was no EMS command and control," said Julio Perez, a medic for AirLIFE, who told investigators he was pleading to help. "Nobody could tell me anything."

His account was backed up by Lewis, the manager for the air transport service, who said several of her medics were upset. "They feel like the resources weren't used as they should have been."

The school district declined to release its active-shooter response plans or protocols and did not answer questions posed by ProPublica, the Tribune and The Post. Separately, the state has fought the release of the active-shooter plans it requires school districts to submit, with the backing of Texas Attorney General Ken Paxton, whose office determines whether government information is open to the public. The news organizations also have sued state and city officials for some records related to the shooting and its response.

The city of Uvalde did not respond to detailed questions about the communication between police and medics or about its training for mass shootings, citing ongoing litigation. But a spokesperson said in an email that the city's police department has not conducted any formal training with Uvalde EMS, a nonprofit that provides emergency medical services for the city and county.

A document from a March active shooter training conducted by the school district, later published by San Antonio television station KSAT, provides only general guidance on how police and EMS should work together.

The plan states that EMS, fire and law enforcement need to know "the exact location of the injured, as well as the number and types of injuries to expect upon their arrival." It does not detail a process for communicating that information.

Stephens, Martinez and representatives for Uvalde EMS did not respond to requests for comment, including queries sent by certified letter. Five other private ambulance companies seen responding to the shooting also did not answer written questions or phone calls seeking comment.

Confusion and delays

Martinez told investigators that he directed other medics to park their ambulances nearby until they knew whether it was safe to move closer. Experts said it's not unusual to keep ambulances at a short distance from crime scenes with active shooters.

He soon identified a pressing obstacle: As dozens of officers descended on the scene, they left their vehicles blocking the roads that ambulances needed to get to the school.

Martinez instructed the county's two dispatchers to ask law enforcement to create a clear path.

"We were anticipating essentially just grabbing whatever patients we had and running out," he later told investigators.

While outside, Martinez and a second medic treated a Uvalde police lieutenant who had been grazed in the head when the gunman shot through the classroom door. Then they waited, with no clear sense of the horror unfolding inside the school.

"We didn't know the numbers of patients, number of injuries, number of fatalities," Martinez recalled in interviews with investigators. "Nobody was relaying that."

Other emergency crews were also struggling to get crucial information and figure out where to go.

The crew of an AirLIFE helicopter grounded in Uvalde for maintenance heard the unfolding chaos on the radio and offered to help. The crew later told investigators that the emergency responders they talked to had rejected their assistance repeatedly. They did not provide the names of those responders.

"Nobody knew what was really going on," said Perez, one of the helicopter medics. He said the officials told his crew to "stand by, stay there - don't come."

With no one clearly in charge of the police or medical responses, an elite Border Patrol tactical team that began arriving at the school at 12:10 p.m. assumed both roles, according to a July report by a state House committee tasked with investigating the response.

The team, which typically handles dangerous situations involving migrants at the border, devised a plan to breach the adjoining classrooms while its medics set up a triage station.

At 12:50 p.m., a Border Patrol-led unit that included local police breached the classrooms. The gunman sprung from a closet and fired. They shot back, killing him.

The team gave the all-clear.

Officers who had packed the hallway now filled the classrooms. Ruiz ran back into the school, looking for his wife. Children lay on the floor, many near or on top of each other, most of them dead.

"I can still feel the heart"

Officers quickly began taking victims to a triage area inside the school, carrying some by their limbs. With so many law enforcement officers and first responders at the scene, there was little space to move. Some children were placed in a line on each side of the hallway.

One local medic later complained to investigators that the response was so chaotic that emergency crews were stepping on victims.

Several medics expressed frustration to investigators that law enforcement officers brought them students who could not be saved.

"You're doing this wrong," Martinez, the Uvalde EMS deputy supervisor, recalled yelling to police after being handed a child with a significant head injury. "There's nothing I can do for this patient."

Within minutes, medics determined that several critically wounded patients with pulses needed to be urgently taken to a hospital where surgeons could provide advanced care.

A girl matching the description of Jackie - wearing the same red shirt and black shorts she'd had on earlier in the day - was placed in one of the two ambulances at the school. The 9-year-old, described by her family as a "firecracker" for being so full of life, died on the way to the hospital.

Andrew Aviles, a regional trainer for the Border Patrol's medic team, began treating a young boy, doing everything he could to revive him.

"I can still feel the heart," Aviles yelled, as he later recounted to investigators in an interview punctuated with sobs. "I need a fucking plane. I need a helicopter down. I need to get a kid inside there!"

The boy needed to be taken to San Antonio's University Hospital, the nearest Level 1 trauma center, which is equipped to handle the most serious cases. It was about 45 minutes away by helicopter, 90 minutes in an ambulance.

The child seen in the police body-camera footage fits the description of Xavier. A law enforcement document listing what students were wearing indicates that Xavier had on a black shirt, blue jeans and black-and-white shoes. That is similar to the clothing worn by the boy Aviles was treating, the officer video shows.

Aviles had heard that the wounded were being airlifted from a field on the west side of the school, so he and other medics put the boy on a stretcher and began rushing him out to the dusty patch of grass at 12:56 p.m.

There was no helicopter.

Although at least five medical helicopters responded to the shooting, not one picked up anyone from Rooms 111 and 112 at the school, according to a review of flight data, satellite imagery and photographs, as well as interviews with air crew members by Texas Rangers.

Epley, the executive director of the regional coordinating agency for trauma care, said it was not safe to have medical helicopters at a scene with an active shooter. But Uvalde police could be heard on radio transmissions asking where medical helicopters were 10 minutes after the gunman was killed. It took 15 minutes more for the first to land near the school.

Spokespeople for the ambulance helicopter companies, Air Methods, which includes AirLIFE, and Air Evac Lifeteam, both of which responded to the shooting, said they rely on local medics to decide who should be airlifted. They declined to respond to detailed questions.

Each passing second dimmed the odds for the boy who appeared to be Xavier.

Dread set in when Aviles felt softness on the back of the child's head, indicating a significant injury. The wounds were consistent with those detailed in the autopsy report shared with Xavier's family, which revealed that the boy had been shot five times.

"I was like, 'Guys, he's ...,'" Aviles said, pausing for a moment to take a breath as he spoke with investigators. "That took the wind out of my sails."

First responders waited 11 minutes for a helicopter but decided to drive to San Antonio when it didn't arrive. At that point, the boy had already gone into cardiac arrest. Overwhelmed medics enlisted state Trooper Matthew Neese to help with CPR in the ambulance.

Once a gunshot victim's heart stops beating, the likelihood of survival diminishes sharply, experts said. A patient in that condition should immediately be brought to an operating room, where a surgeon can attempt to stop internal bleeding.

State records show that Neese did not have an EMT or paramedic license in Texas, but he performed CPR on Xavier for more than 30 minutes while a medic tried to treat the boy's wounds. The ambulance diverted to Medina Regional Hospital in Hondo, about 40 miles from Uvalde, where doctors declared the child dead shortly after 2 p.m., according to his family.

A helicopter arrived near Robb Elementary at 1:15 p.m., eight minutes after the ambulance departed.

Hospital officials did not respond to a request for comment and neither did Neese. The trooper later attended Xavier's funeral, according to the boy's family.

Reached on his cellphone, Aviles declined to comment, referring questions to his supervisors at U.S. Customs and Border Protection. In a statement, a CBP spokesperson said the agency is investigating the role of its officers in the response and could not comment while that was ongoing.

Xavier's mother, Felicha Martinez, said an awful premonition hit her as she stood outside the school waiting for news. Her body went limp and she collapsed. His father, Abel Lopez, searched for any sign of his son, peering between the buses blocking the view of the school.

They have since learned bits and pieces about what happened to their son but are left with questions, including why Xavier wasn't taken to a hospital by helicopter.

"If the cops had done their job, the medics might've had a chance," Lopez said.

Martinez added: "I'm so full of anger. I don't know how to put into words how much I am hurting."

"Don't give up"

On the day of the shooting, emergency responders frantically tried to keep Mireles alive on the sidewalk outside Robb Elementary. She was deteriorating quickly. Within minutes, her heart had stopped and first responders began to administer CPR.

More ambulances arrived at the school, but it wasn't until 16 minutes after the breach that medics put her inside one.

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Eva Mireles was carried out of her classroom, Room 112, and through the school hallway by four police officers, her husband following behind.

A Border Patrol medic said in an interview with investigators: "I asked the guys, 'Hey let's not work on her here.' But we look to the right and there's no ambulances. So we had to work on her there."

But there were two ambulances parked about 100 feet away.

Medics laid Mireles on the ground and performed chest compressions.

She lay on the ground for more than 10 minutes, during which six ambulances arrived and two left. It's unclear why Mireles was not immediately put into one of these ambulances.

Ultimately, medics moved Mireles off the ground and into an ambulance.

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"Come on, ma'am, don't give up," a voice can be heard saying in a state trooper's body-camera footage.

By then, the teacher's chances of survival had sunk.

In the ambulance, medics began a blood transfusion and used an automatic compression device to try to get the teacher's heart pumping again. They gave her fluids and intubated her.

But they did not take her to a hospital, a decision some experts described as a mistake and others said could indicate that medics thought Mireles had no chance of survival.

First responders continued CPR in the ambulance for about 40 minutes before the chief medic for Uvalde EMS declared her dead.

The ambulance that Mireles was inside never left the school curb.

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