As a young Air Force flight surgeon, I despised nothing more than drill week. I was stationed in the Republic of Korea, which meant 24-hour war games for a week.
These drills were very high fidelity. We doctors have responded to a variety of complex mass casualty scenarios. Sometimes we were assaulted while providing care; other times we were trapped outside in freezing temperatures due to a mock chemical weapons attack.
I spent one weekend a month during EM residency a few years later attached to a specialized Air National Guard disaster response team. This involved running mass casualty scenarios on a larger scale. Both contexts were stressful, difficult and even frightening. Mistakes were often made. Our patients “died”. Sometimes we even “died”. The training was second to none, but it was just an exercise, all imaginary, not real life.
the real thing
I was on vacation in Latin America earlier this year. I was riding an ATV with a friend one evening, and we passed a crowd of people in the midst of flashing police lights. We are arrested; it was clear that something tragic had happened, but no medical vehicles were present.
Two motorbikes at the scene were twisted into a single heap of metal, surrounded by pools of blood, moans and moans, a growing group of onlookers and much mayhem. I introduced myself as an American emergency doctor to a police officer and offered to help. I had no idea how this would be received given the obvious fact that I was a passing tourist.
But the officer immediately took me through the yellow tape and introduced me as a medic to the other aides and assigned someone to be my interpreter. It was me, two local lifeguards and an off duty paramedic. It seemed that I was now the de facto stage manager.
By definition, a mass casualty scenario occurs when demand exceeds resources. We had virtually no medical supplies or medical transportation, and the nearest hospital was over an hour away, so we clearly fit that definition. My mind started to swirl. I was presented with a deluge of quick questions that I barely understood. I stifled the mounting panic by remembering the quote: “You don’t rise to the occasion; you fall back on your training. So that’s what I did, step by step.
Step 1: Establish scene security. I took a look around me. This had been accomplished by the local police. No obvious threats.
Step 2: Write a status report. The police officer provided me with a brief summary of the events, including the number of casualties and the types of injuries. I soon learned that two motorcycles had collided, each with two riders. No one was wearing a helmet. Firefighters and an ambulance were on the way. The wounded were lying far from each other.
Step 3: Create a casualty collection point. I asked to be taken to the most seriously injured person and asked others to try to bring others closer so that I could provide simultaneous care.
Step 4: Triage and Prioritize Care. The military triage system uses four categories: immediate, deferred, minimal, and expected. A rapid assessment of the sickest patient clearly indicated that he was deceased (pending triage category). His family was present. It was terrible, but we couldn’t do anything. We covered his body. The next two were also young men, both with head trauma, a significantly more critical one. The two immediate triage categories. The last patient was a young woman with a large right thigh laceration and probable jaw fracture, delayed triage category.
Step 5: Perform medical procedures and transport. Our most critically ill patient had a better GCS of 6 and obvious head, facial, chest and abdominal trauma. His breathing was labored and he had chest wall instability. The firefighters arrived, so our medical team grew and we now had basic medical supplies.
The patient had oral trauma and loss of airway was a real problem, but we had no way to intubate, only a suction bulb. He was mildly hypoxic, tachycardic and hypotensive. An ambulance arrived. We put him on a back board and put him in a C-neck. I asked the paramedic to suck the blood out of his mouth and hold him as straight as possible. We put him on oxygen, performed bilateral needle decompressions, and immediately dispatched the ambulance with the off-duty paramedic in the back.
The third victim had a GCS of 11. He had obvious head trauma. Blood was flowing from his right ear. We put him in a C-neck and on a backboard. His vital signs were solid. We bandaged the bleeding laceration in the leg of our fourth casualty to stop the bleeding. We loaded these two patients into private vehicles because we were told no more ambulances would come. They set off, each with a medic in the back to provide assistance.
I was on that stage for almost two hours. There was a lot of expectation, reassuring, reassessing and generally feeling helpless. The last vehicle left and I returned to my friend. Blood was all over my sandals and my shirt. I felt drained but accomplished.
I am a qualified emergency physician, but that day I was called upon to practice medicine in a foreign setting, both literally and figuratively. I had none of the resources or supplies enjoyed by an American emergency service. The language barrier was a real obstacle. But I had my unique background. The dozens of simulated mass casualty scenarios that I had carried out gave me great comfort in managing this scene.
This is what emergency physicians do daily in the face of potentially fatal emerging cases. We fall back on our training. We show calm in times of crisis. We do the work.
There’s really nothing unexpected or heroic about it. We are operating as intended, as we were trained, which is why I am so grateful for my unique training in military and emergency medicine. I hope to continue to fall back on it for the rest of my career.
Dr. Jedickis a board-certified emergency physician who works in the Las Vegas emergency departments and as a clinical professor at the University of Utah. He also practices aviation medicine, previously serving as an active duty flight surgeon in the US Air Force with several fighter squadrons and now in the Utah Air National Guard. He is also an FAA Aviation Medical Examiner and previously completed a space medicine internship at NASA. Follow him on Twitter@RockyJedickMD.