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.
Bloody airway – lost in the dark…
Our patient had lots of blood in the airway and we had no good suction. As soon as you slide in the laryngoscope blade the bulb is coated in blood and all looks dark! My tip – have 3 or 4 laryngoscopes at hand and use the first few to find the landmarks, suck what you can then quickly replace the blade with a new, fresh one to light up the cords
IV access in extremis!
My mate was struggling to get an IV in this patient – and I needed Sux to get the airway in. So we went for the intraosseous gun into the tibia. Unfortunately the gun didn’t go right through the cortex…Doh! So he asked for a hammer – being a mining camp, a large hairy man brought in a 2 foot sledge hammer! This has to go down as one of the more surreal moments in my career. There was Seb attempting to ‘tap’ in an IO needle with a massive tool. In retrospect we could have gone for the IM or SL injection. But it worked!
Should I stay or should I go?
After tubing and stabilising the head-injured man we had a dilemma – we needed to get him out ASAP, but that would mean one of the team leaving and using precious resources before we really knew how bad the rest were. So as the senior Doc, I decided to send the more junior Doc out with the severe patient and stay behind to sort the rest. Don’t know if this was the right call, but we had to decide quick. Seb did a great job after a 2 minute tutorial in ventilating the head-injured patient. (Note: never keep the muscle relaxant in your top pocket.)
Who can walk out?
So the next challenge – sorting out 20 odd patients with a range of injuries / symptoms – all roughly as bad as one another, no obvious crashing patient. A bit tricky to allocate triage… We sorted them into – ‘spinal precautions’ vs. ‘walkers’ as a good number had mechanisms and symptoms that suggested spinal injury. We immobilised those with ?spinal injury and then triaged the others. More helicopters were incoming – so we had to decide who to send next.
Move to wards the light
Light – we take this for granted in our bright, white hospital environs. Having to work in the dim light of a commercial cool room was an eye-opener! Get the patients into a well lit area, this sounds obvious, but it takes some doing in the real world of a disaster. However, it makes all the other work so much easier. So many cues we take from visual information when clinical exam is all you have to go on in the field.
IV pearls
I wanted to get IV access into anyone who looked like they might have a risk of bleeding – just in case. However, puting 2 large-bore IVs into 20 people is not as easy as you might think, especially when you are crawling in the dark and have to jump over people to get to others. We ED docs take the IV trolley for-granted. It is really tricky to carry enough gear to do all this in quick time and safely dispose of the sharps. My Tip: pre-pack specimen bags with all the gear you need for 2 drips. Take it to the “bed”side and have a small sharp container in the other hand. This might sound obvious, but it took me an hour to figure it out!
Fluid counting for dummies!
So you have put in 40 IVs into 20 patients and you want to give fluids. You have no way of documenting or recording how much fluid each patient has received. So here is what you need: 1 magic marker. You just write a big “1” on the first bag, then when you change the bags you write “2” on the next bag…. This sounds simple, too simple for our huge doctor brains, it really beats trying to remember the ins and outs of 20 people! This trick is so simple I have taken it back to my ED / anaesthetic practice. When you are doing a big case, or a massive transfusion – it is gold, at a glance you can look and see where you are up to.
Human, all too human…
So how do 3 nurses keep an eye on 20 odd patients scattered around a wrecked building? They can’t – this is what I observed. I was keen to keep up frequent pulse / BP / RR etc on the injured, so that we might detect occult bleeds / shock etc early in the injured. But that takes serious manpower. So I thought we could enlist the help of the un-injured folk who were there trying to help. I line each patient up with a “buddy” and gave instructions to stay and feel the pulse, watch for new symptoms / distress – and let us know if anything changed. Sounds like a good idea? Maybe not. I think I underestimated the effect this trauma had on the workers. I think half an hour later and about 50% of the “buddies” ha all excused themselves – they were not coping
Strange syncope
There was one chap – fit looking guy who was not in the original group of “patients”, he admitted to a few bangs and scrapes. He had a few episodes of syncope towards the middle of the day. I was sure he was probably bleeding or worse. We have him IV fluids and kept a close eye on him, flew him out on the next transport…. he turned out to have a coincidental chronic leukemia with a Hb in his boots. I certainly didn’t pick the anaemia clinically, and in the context wasn’t looking for it!
Lucky spleen!
Of the serious blunt trauma – there was a chap with a left upper quadrant injury / left flail chest. To look at he had a crushed left lower rib-cage. I got to him and put in IVs, gave some morphine for pain, and got a quick medical history. This guy was lucky – he had had his spleen removed a year prior for what sounded like a low platelet count. I could have kissed him – I was sure he was gonna have a splenic injury when I saw his chest, he did well from a lung point-of-view.
Headache, pelvic pain…
So after working solid for a few hours in a hot, sweaty, stressful situation we all get a headache, and a burning desire to pee. Not sure about you , but I don’t think straight with a full bladder and moderate dehydration. If you are in this scenario – pee and drink – you have to do it. I think I kept putting it off for paranoid ideas that I would leave for a minute and something bad would happen!
For those you cannot help…
One woman was killed prior to our arrival, she was crushed by a building. Once the dust had settled on the injured, I was asked to certify her death by the Police in attendance. I was surprised as to how meaningful this act was to the other survivors. Not sure if it gave some “finality” to the other victims or in some way validated the grief they were feeling. The disaster courses always talk about resource allocation – don’t waste time on the unsalvageable – but I think there is a place for this once the situation is under some control. No evidence for this as usual, just my gut-feeling
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.