MCI and the Peter Principle

A much less chaotic MCI training from a few weeks ago.  No pics from today, I'm afraid.

Current conditions:  Con3.  Temp 5ºF (windchill -16ºF).  Cloudy with snow.  Population = 916

The NSF has invested in a more-capable-than-average, small clinic here not because they want to care for colds and sprains but because they need to be prepared for a mass casualty.  Certainly, ample opportunity exists for disaster what with daily flights of aging, large aircraft, near constant flights of helicopters and small fixed-wing aircraft in harsh weather conditions, explosive use for base construction, and large vehicular travel on fragile ice.  In fact, there have been mass casualties here.  Seven years ago, a Korean fishing ship caught on fire with 37 people on board.  Three died on the ship and seven burn victims, two with severe burns, were treated here; all survived.  In 1987, a McMurdo LC-130 crashed on a flight to one of the field camps, killing two; the remaining 9 passengers were brought here, four with serious injuries, nearly overwhelming the clinic but all survived. 

LC-130 crash at D-59 field camp in 1987

Which brings us to the definition of a mass casualty: it's an incident in which available medical services are overwhelmed.  At McMurdo, depending on the day, we have between 1 and 5 doctors and 1-4 nurses.  Right now, we have 5 doctors--the Air Force flight surgeon, a NASA ER doc (who hasn't practiced for 10 years), a family medicine doctor visiting for 2 weeks, Dean and me.  We have three nurses--two flight nurses and the nurse manager (a critical care nurse) and we have a flight technician, a pharmacist and a physical therapist.  Only Dean and the civilian flight nurse have ever participated in a real mass casualty; only Dean has run a real mass casualty incident (a plane crash near Baghdad and some IED explosions). The three Air Force personnel, however, are well-rehearsed for one as is the nurse manager.  But the rest of us are not well prepared.  Moreover, we may not all be here at any given time.  For example, the Air Force flight nurse was away today on a medevac to Christchurch and the pharmacist is at the South Pole.  Needless to say, we would be overwhelmed by any mass casualty with more than 3 or 4 injuries.

So we train.  And then we train others.  And then we practice.   Dean has done an amazing job prepping us for a mass casualty.  He has not only gotten us to practice various skills (FAST exams, intubation, etc) but he has drawn McMurdians from around to the base to form six ancillary teams to assist us::

• The auxilliary (aux) team:  Trained to help with ABC's of patient care, putting on splints, bandages, tourniquets, taking vitals, helping to get equipment for the MDs, putting in IVs and drawing blood (those last two are pending)
• The recorders:  Trained to record what the care-providers are doing and to remind them of things they need to do.
• The comms team:  Trained to direct traffic throughout the clinic, getting patients to the right places and calling .
• The tech team:  Runs lab tests and does X-rays (I did the lab training)
• The stretcher-bearers: no description needed.
• The walking blood bank (not used today)

Triage card, attached to patients by fire department EMTs

When a mass casualty occurs, these teams disperse to five different rooms.  The bariatric chamber is the ambulance entrance for triage.  The trauma bay takes the critically ill "Red" patients (four max).  The medical ward takes up to six moderately injured "yellow" patients, the PT suite takes the walking-wounded "green" patients and the kitchen is for the mortally wounded "black" patients.  Overflow goes to the Fire Station (red and yellow) or the Galley (green).

Today, our mass casualty incident training event was a plane crash at Willy field.  The practice included not just the medical work but the evacuation from the airfield by the fire department both via helicopter and by ambulance (the ambulance beat the helicopter by 30 minutes).  There were approximately 15 wounded, three red (one who became yellow and one who went to black), six yellow (one who became red) and the rest green.  Marisa, the fantastic flight nurse, and I ran the Yellow room.  

Although the prep prior to patient arrival went well, our room was chaotic once the patients arrived (I wish I had a picture).  We had three in beds (a pelvic fracture with tib-fib fractures, a hemothorax, and a 30% second and third degree burns), one on a stretcher (neck fracture), two on the floor (a head injury with coma and tense abdomen, and a stable concussion) and one in a chair (dislocated shoulder with radial fracture) in a relatively small room.  With the three HCP, the four aux team, two recorders and a comm--too many people to fit the room and actually conduct patient care. I simply could not get to patients at the far end without tripping over care providers or a piece of equipment and I was the only doctor in the room (although Marisa and the visiting Kiwi medic were both amazing and knew much more than I about trauma).  We had trouble getting the medicines in a timely manner or getting labs sent off, we couldn't readily navigate equipment to the people who needed it (we had to intubate the pelvic fracture but couldn't get a ventilator to her), and no one actually went to look at X-ray results.  The pelvic fracture would have died from internal bleeding with my incompetent management (I was quite late putting on a binder) but she probably would have been grateful because  I didn't manage her pain well either.  To compensate, I think I overdosed the burn patient.  But at least my tech team came through with flying colors.

Which brings me to the Peter Principle.  The only mass casualty I'm trained to treat is one in which 15 latent TB patients roll into clinic asking for INH.   If that happens, I'm golden. Otherwise, I've still got lots of catching up to do.