Help! Medic!

“In the real world, you don’t rise to the challenge; you fall back to your level of training.”

On the afternoon of April 12, a disaster that authorities have termed a “vehicle ejection incident” occurred in front of Mass Row, leaving about twenty casualties.  Some shrieked piteously, “Help me!” while others appeared inconsolable over the loss of their children. Teams of Emergency Medical Service (EMS) medics set to work; armed with bright orange first aid bags containing triage tags, splints, oxygen masks, and other accouterments, they dodged gawking bystanders to treat the wounded and began putting chaotic violent bystanders into custody. Each team would shout, “Pulse?” or “Breathing rate?” or “Injuries?” Replies would come: “Ninety-eight,” or “Eighteen, but shallow,” or “Abrasions to the arm and bone sticking out of the right leg.”

Despite the dramatic description, this event was a practice “Mass Casualty Incident” (MCI), part of the annual Northern New England Collegiate EMS Conference, and was held for the fifth year in a row at Dartmouth this month.  In an all-day affair, seventy attendees from seven schools listened to guest speakers, participated in role-playing scenarios, and performed the MCI drill.  In what seemed to be a common thread throughout the day, the conference attendees trained to deal with worst-case scenarios, the kind of cases no one wants to face but everyone must prepare for.

The three guest speakers emphasized this idea in different ways.  The first, Mike Lauria, ’05, gave a talk on “Making the Call: Cognition, Decision Making, and the Tactics of Emergency Medical Care.”   As a former Air Force paramedic and current DART member (Dartmouth-Hitchcock Advanced Response Team, DHMC’s helicopter squad), Lauria had several insights into the nature of decision-making — a skill essential to both elite soldiers in foreign war zones and medics responding to emergencies at home.  He emphasized “training to one hundred-thirty percent” in intentionally stressful situations, because in the real world, “You don’t rise to the challenge, you fall back to your level of training.”  While the collegiate EMS groups in attendance probably will not throw initiates bound hand and foot into pools, they may consider Lauria’s suggestions of practicing procedures in distracting environments: in the dark, in noisy environments, or with a fog machine, for example.  According to the next speaker, Dr. Kurt Rhynhart, many emergency procedures have the all-important job of preventing blood loss. In the trauma bay, where he works as surgeon, the success of damage control surgery depends on preventing hypothermia, coagulopathy, and acidosis (the so-called “lethal triad”).  This surgery depends on preventing excessive hemorrhaging in the field with tourniquets and controlled hypotension (lowered blood pressure).  The last speaker, Boston University EMS director Aaron Gettinger, described how EMS personnel responded to the Boston Marathon bombings last year.  While the various private and Boston ambulance crews performed well in bringing the wounded to hospitals, Gettinger pointed out issues that would have cropped up had a similar disaster occurred under different conditions. Earlier in the race, for example, there were fewer hospitals and ambulances than were in Boston itself; many emergency services in other locations have issues in communications, including ambulance radios that function on different frequencies.  Gettinger recommended that the collegiate groups in attendance take pains to avoid such problems by coordinating with local police, fire departments and ambulance providers and by making plans to deal with various contingencies, major or minor.

After the lectures, the attendees went off to practice scenarios.  In these meetings, groups of five or six medics-in-training took turns acting out roles as patients, bystanders, or medics in possible campus situations, ranging from the mundane (a student has fallen from a fraternity balcony and can’t get up) to the flashy, yet plausible (a feverish, twitching student is rolling around a dormitory floor clad in glow-sticks and sunglasses extolling feelings of being “awesome”).  In each case, those acting as the medics had to figure out what was wrong with the patient and determine the proper treatment.  Dartmouth EMS members who were running these exercises explained that participating in these simulations was a productive way to practice treatment, as on-the-job training was obviously more than a little impractical.

The skills practiced in the scenarios were put to the test in the Mass Casualty Incident drill.  According to EMS Executive Director Ethan Thomas ’14, Dartmouth freshmen plan the annual event, which is then coordinated by the sophomores. Many different types of disasters can be considered MCIs. Both the 2012 and 2013 Boston Marathons were considered mass casualty incidents; last year’s race was bombed, while 2012’s had a significant amount of runners falling to heat-related issues.

This year’s MCI drill was a “vehicular ejection incident” (which, thanks to paperwork issues, lacked an actual vehicle).  Props aside, both the “victims” and the EMS attendees performed well.  Daubed with crimson makeup, stage blood and the occasional fake bone sticking from the skin,  actors screamed, wandered around in either simulated drunkenness or a post-traumatic daze, and sometimes became angry and belligerent with the medics for not treating this or that patient (“He was my friend…are you doing your job?!”).  The EMS technicians, for their part, remained professional throughout the whole ordeal, putting triage tags on patients signifying their medical condition, removing the walking wounded, and trying to put the remaining humans in as stable a shape as possible before ambulances could arrive at the disaster’s epicenter.  Gettinger, who stuck around to observe the MCI drill, had some comments to this effect during the debriefing. He noted that communication could have been better between each of the three-man teams, pointing out a situation where a woman actor labeled as an “altered mental-state yellow [a triage tag indication]” was told to stay in place, to prevent her wandering off and pestering other teams. However, the practicing medics’ coolness under fire could not be faulted; Gettinger confessed that he would have wanted to smite a particularly confrontational bystander, something the conference attendees avoided doing.

In a conversation with the event’s Executive Director Ethan Thomas, he explained that the EMS is a “state-licensed [Basic Life Support] squad staffed and run completely by students,” whose main job is to be “on-call during the night” and during certain events.  Describing the procedure used to determine placement of the injured, Thomas explained that “If S&S gets a call for a medical issue while we’re on, then we’ll come to evaluate and treat … before deciding whether Dick’s House is the best option or [Hanover Fire Department ambulance delivery to] DHMC is.”  Thomas was pleased with how the conference turned out and plans to integrate the conference’s motif of vigilance into the group’s Weltanschauung, making sure to cover “those things that are really severe, that you never see…that you have to keep on the back of your mind the most, because those are the things you forget how to do if you don’t train enough.”

Following Thomas’s postmortem, the EMS technicians dispersed.  Technicians who had come from distant locales (Boston University, Mt. Holyoke, Colby, Tufts, Rensselaer Polytechnic Institute, and the University of New Hampshire students at McGregor Memorial EMS) started the trek home, while Dartmouth EMS members began preparing for another night’s duty.  After all, it was a Saturday night, and the job is an important one.