On Thursday 8th March 2007, Tropical Cyclone George crossed the coast just north of Port Hedland, it was a large, catgory 5 cyclone and it was unusual as it maintained its intensity for 100s of km inland where it struck Indee station and the Fortescue Metals Group Rail Village (FMG RV1). The destructive winds wreaked havoc in the work camp at RV1 and destroyed a number of the transportable “donga” units used to house the workers. The image below was taken from the helicopter as we approached the camp, the building in the foreground that has been flatttened was the Medical / First Aid post – so this created a unique logistical challenge! See the story below. For more pics / maps see the BOM Site report into Cyclone George
I was actually the Night Shift Doc in Karratha the night TC George hit Hedland – we were on Yellow alert for the impending cyclone, and as is usual – it was quiet – cyclone protocol means a curfew for the locals – so it was a good night, plenty of sleep for all. I arrived at the Karratha hospital for handover in the AM and there were a number of Admin-type staff wearing yellow vests – not a good sign. We had been asked to form a team to fly into the camp and evacuate the injured in helicopters commandeered from the local gas company. Time was critical – so we grabbed the Parry packs, all the pre-packed gear we have in store and headed off to the airport – 2 docs (myself and Dr Seb R-D – my registrar) and 3 nurses. We were joined by a crew of volunteer SES workers, 2 policemen and the local St John’s ambo vollies.
The brief was vague – at least 1 dead, one critically head-injured and about 25 – 30 other injuries. Port Hedland airport was out of action and RFDS could not land nearby. We sat through a weirdly boring helicopter safety briefing whilst our brains turned over the possibilities! Then there was a bit of argy-bargy with the Police and other agencies about who should go in and what gear we should take. Interesting how people’s priorities are set by their perspective – one Police officer wanted to take a box of 50 body bags…mmmmm, maybe not a high priority! After a bit of ‘negotiation’ we took off and saw just how much water a cyclone can dump – the desert looked like a swamp overnight!
About a mile out of the camp we could see the debris of buildings scattered over the desert. Landing was a bit scary – still gusts up to 100 kph! We landed a good 10 hours post impact so the workers had moved all the injured to – the cool rooms of the kitchen block – they were the strongest standing buildings! There was not much lighting, the walls were damaged / off and the floor was wet. The Pilbara sun had come out and it was getting humid. We were taken straight to the man with the head-injury, stepping over the other injured people. For me, this was worrying – am I focusing on one at the expense of the other potentially bleeding patients?
The critical man had been struck in the head by debris and then been lucid, apparently helping other victims. He then became drowsy and LOC. He had a large temporal scalp injury and had been vomiting – blood in the airway. Breathing but was gurgling secretions, no suction available.
At this point we decided to divide the team – triage the other patients whilst we tried to stabilize A, B and C in the critical man. This is the time where you just have to trust your team – one cannot do all, you need a team to divide and conquer.
I won’t bore you with the next 10 hours of what seemed like constant chaos at the time, but here are a few choice moments and lessons learned from working in an extreme environment with little resources.
So those are my “pearls” from TC George. I would love to hear what you have to say, and hear your war stories and what they have taught you. Dr Seb R-D has returned to be my Reg once again and I will be posting his lessons from this day soon.
Back to Sepsis soon
Casey
thanks for sharing the story Casey. I saw a presentation from RFDS WA about this disaster response a couple of years ago and its good to hear another viewpoint.
arriving 10 hrs post injury is always a challenge. The blood airway scenario with poor suction is always tough when you don’t have much resources. One South African doc I worked with told me how in a similar situation, he did not even have a laryngoscope, so he bent a spoon to make an improvised larygnoscope, got the nurse to shine a torch over the laryngeal area of the neck, then turned off the lights and intubated the patient! I have never done it that way but using darkened conditions does help to maximise the illumination from your laryngoscope as you would well know
IV access in a multicas situation. there are no hard and fast rules about this . Even US military are advising now oral fluids in select patients is fine to maintain hydration. trying to fluid resus 20 odd trauma patients is a stretch. IN fact it may do more harm than good.
IO gun..I assume the BIG device from the Israelis…we trialled it here but never won over any clinicians as we adopted the EZ-IO which I have used about 5 times in anger over last 2 years…its dead easy as you know. Funny story about using a hammer to bang the needle in..but glad to hear it worked fine in the end..do you still have the BIG device or something else like the EZ-IO or FAST sternal device?
Yes IMI sux and IMI ketamine work ok if you want to do an emergency intubation..its not pure RSI but nowadays I dont do pure RSI anymore..I imagine most of us don’t do textbook RSI anymore.
sending the most junior doc with the most injured patient…well it violates one of the tenets of retrieval medicine as in not reducing your level of care during transport…but I see why you decided that and you gotta be flexible and decide things on a case by case basis. Having experienced leadership remain on site makes sense..but staying together on site with the most injured till more help arrives is an alternative strategy. If he blew his pupil and you decided to do the craniotomy then having a second pair of hands always helps!
Hard to do that inflight !
all i can say is – sheeetttt… that all sounds a bit crazy! but great tips if i ever end up in a crazy situation like that!
andy
Thanks Minh / Andy for the comments
I think the big lesson here is how useless we are when removed from our hospital environment. You just simply cannot do the next logical / definitive move etc in such a difficult situation. Scoop and fly was the order of the day. Without some diagnostic certainty it is impossible to know what is happening – sure hte guy probably had an extradural on history- but it is a big step to drill a hole in the cranium when you have so little information. My thoughts were – prevent secondary injury, get him to care ASAP. Casey
That is hardcore Casey!
The strange syncope takes the cake…
Minh – the torch technique for intubation is described in King’s Primary Anesthesia – I have a post on it at LITFL (including the figure describing the technique):
http://lifeinthefastlane.com/2009/03/if-the-lights-go-out/
Cheers,
Chris
HI KAne
I will have to review my copy of King’s Anaesthesia! Its a great manual and every Doc out of Africa seems to have read it
Have you read King’s Surgery manuals including their excellent one on Trauma?
I got all of King’s books before I went to Zambia as a medical student – they are amazing.
There is a project to put all of the primary surgery text (vol 1 and 2) on the internet here:
http://www.primary-surgery.org/start.html
Also, Minh – if you ever want to do a guest post on LITFL just let us know!
Chris
Awesome post Casey.
Thanks for putting your experience out there, so many pearls and pitfalls everyone can take from this. Look forward to reading Dr Seb post.
Kane
Between your account and the one from Joplin here in the U.S., you guys really have me thinking long and hard about disaster medicine instead of tactical EM come fellowship time.