'The best for the most'; training our own for a mass casualty event

It is a cold November morning.

It is 3 a.m., 29 minutes after a 6.0 earthquake hit the Mammoth Lakes area hard and sharp.

Unlike many buildings, Mammoth Hospital is standing, but the lights are out and the power is out.
Somewhere outside the building, a fire burns, filling the air with smoke.

People panic, and screams are heard from all over.

Doctors, nurses, and surgical technicians come tumbling out of vehicles in the parking lot, some half-dressed, pulling on coats and boots. Some are running, carless, leaving on foot from their homes where the street was blocked by debris.

Some are bleeding, but they assemble at the hospital.

They begin to file toward the doors and then another quake hits. The ground shakes and rumbles, people are thrown to the ground.

A doctor stops the flight to the doors.

“We can’t work in there. There might be even more aftershocks,” he says into the rising wind. “We’re going to get hit with mass casualties in the next few minutes and we need to be ready. Let’s go! Let’s go! Let’s go!”

He gives orders to the team of medical professionals. Sending them here, then there, after emergency supplies the hospital has prepared in case of a disaster emergency.

Sirens scream, adding to the chaos. The wind, in full Mammoth fury, blows hard and cold, flapping tarps and clothing, chilling the bones.

It is pitch dark, except the fire burning north of the building.

People begin to arrive with crushed arms and legs, propane tank explosion burns—all the injuries associated with a serious earthquake. Tarps are down on the ground now, surgical teams fitted with headlamps and down parkas gather in groups. S.R. 203 is closed east of Meridian and no one from Crowley Lake can get into town, including a good chunk of the hospital’s staff.

Some run into the damaged building, risking their lives to retrieve supplies.

It’s going to be a while before any out-of-area help arrives. Many people are dead, and more are dying, suffering from crushed chests, blocked lungs, and burns too severe to sustain.

Doctors, nurses, fly through the chaos, pulling together teams.

In moments, they are inundated with victims.

“Don’t look up, just look down. Focus. Focus,” a doctor says to one team, working on a girl with a crushed trachea.

Twenty other injured people are lined up behind her.


He knows people are going to die in the next few minutes as airway and circulation injuries meet their deadliest enemy—time.

It won’t do anyone any good to work on the people that are going to die, no matter what medical personnel do, and they are separated from the group, added to a black tarp lying on the ground, next to green tarps, yellow tarps, red tarps.

Red is his first concern, it’s all of their first concerns now, red. It means without intervention, death is imminent.

“He’s going to go black,” he says to another team, working on man. “It’s too late, let him go, there’s ten right behind him you might be able to save.”

This didn’t really happen.

But in Mammoth, one of the most earthquake-prone towns in the country, it’s a matter of when, not if.
Mammoth Hospital Orthopedic Surgeon, Dr. Mike Karch knows from experience that the more prepared he is and the more prepared the hospital personnel is, the more people are likely to survive the first critical minutes, hours, and days after a mass casualty event.

On September 11, 2001, Karch was in his last year of residency at a hospital just outside of Washington D.C. When the third airplane hit the Pentagon, the hospital braced for the hundreds of casualties that were inevitable.

They didn’t come. They couldn’t.

When the Twin Towers were hit, the city did what it is designed to do—shut down all outside access points to the city, including roads and bridges, surrounding the heart of the country’s government with a protective shield.

No one could get in. No one could get out, either.

Karch and his medical staffs waited in vain for patients that never came.

After a few hours, he couldn’t wait any longer. He grabbed a backpack, some emergency gear, and found a train still running. He arrived at Ground Zero later that day, one of only three doctor’s to reach the site in the first day or so.

For the next several days, he hardly slept or ate. He dodged falling buildings, camped on dust and blood, saw grown firemen cry and scream, carried buckets of dirt and debris to free trapped survivors, cut and sewed and bandaged and cleaned hundreds of wounds, and covered too many faces with too many blankets.

He used a Sharpie pen to write on victims’ foreheads: red, yellow, green, black, adding simple instructions on the forehead for the next medical personnel who would follow his care.

He watched one of the three doctors leave the scene and disappear.

When trained surgical help arrived on the third day, he got home and fell sleep in his yard, too tired to make it into the house.

What he saw those days seared him—the profound lack of medical readiness for such an event in one of the richest cities in the richest country in the world.

He wrote about his experience, what he thought should have gone differently, and sent it to some friends and colleagues.

It went viral and in the past few years, he’s been one of the driving forces behind mass casualty training programs and procedures across the country. He’s trained with the military, been to Haiti during the earthquake, and worked with the Department of Homeland Security before it was called that.

He has already put his own hospital surgical staff through some of the same training. In normal medical life, he said, it’s all about doing “the most for every patient, or “everything for everyone.”

In mass casualty situations, it’s about something far different—“the best for the most.”

On Friday, Nov. 2, he took the training a step farther.

With the hospital’s blessing, and a $40,000 donation by a cadaver lab training company called Synthes, he put his surgical team and much of the hospital medical staff in a dark, smoky room with a bunch of body parts.

He started the clock, turned on the sirens and noise, shut off the lights, and gave each team 15 minutes to stop death before the next patient would arrive.

“You’ve got one minute, do what you gotta do to get it done, next one’s coming in 30 seconds,” he told one team, working on a burst aorta.

“His wife is screaming in the room, what are you going to do?” Karch asked.

“Get her out,” a participant said. “Get her out, before she triggers more panic.”

“Good,” Karch said, “Good. Now here’s the next one.”

“That’s how it will go for six, eight hours, then maybe days,” he said later that day, after the day-long training exercise was complete.

“The only way to prepare for it, mentally, emotionally, is to do it, and that’s why we set this up. There won’t be enough medical personnel to handle the volume. We’ll be calling on whoever’s around to help, even if they’ve never seen blood before. That’s why I wanted to extend the training to the group.”

“My heart rate was up, for sure,” said emergency room physician Dr. Jennie Walker this week. “I knew what he was going to do, I’m an emergency room doctor and I’ve been in stressful situations. When he told me about the smoke and dark scenario, I thought it was kind of silly, like, ‘I’ve been there before, what could I learn?’

“But something changed about seven minutes in. I felt my heart pumping. I could sense the urgency of another patient coming in right behind. And even though I’ve been an ER doctor in urban areas—very high stress and high volume—it’s been in a hospital. This would be different, maybe outside, maybe without any light or shelter or heat. It makes you think, for sure.”

Which was exactly what Karch was hoping for. He’d like to get more cadavers next year, noting that even many medical people have never had to deal with a dead body. He’s hoping, too, to extend the training for firemen and paramedics and other first responders. Medical training and emergency situation training are one thing, but the mental health issues, both for trained emergency responders and for the general public, are often overlooked.

Thinking about pitfalls in advance of an emergency might stave off some of the problems, he said.
“I can guarantee you, after six to eight hours, someone on your team is going to freak,” Karch said. “It always happens, especially if they are dealing with someone they know, and in Mammoth, that’s very likely since we all know each other. And they aren’t going to want to go. They will want to stay and help and you are going to have to be able to identify the warning signals and get them out of there.

“Panic is contagious. It spreads and contaminates an entire site,” he said. “This kind of training, done before something happens, primes us. We have to ask ourselves, am I going to participate?”

“In any emergency, there are three ways humans deal with it: fight, flight, or freeze. If you are going to fight, you will be more effective if you have your own life in order, have an emergency plan with your families, know your dog will be taken care of, have your bags packed with what you will need to stay alive for three days, which is pretty much the minimum for help to arrive in most cases.”

Mono and Inyo County Public Health Officer Dr. Rick Johnson is the Medical Health Operation Area Coordinator for the region.

If anything happens, he’s the man who will coordinate the response.

Over the years, he has assessed the Eastern Sierra for the most likely mass casualty situation and concluded a “moderate” earthquake is the biggest risk—which is the reason Karch was emphasizing crushed limbs in his cadaver training.

He thinks training all the county’s first responders through a similar exercise like Karch did Friday is important. He would also like to add mental health professionals to the next training.

“I think the only way to be ready—we will never be ready—but as ready as we can be, is to get ahead of this, think about it, and make ourselves ready,” Johnson said. “Karch has the real life experience and training to back up this training. He’s an invaluable resource for this community.”

Next week, the entire county, including Mammoth Lakes, will embark on another disaster preparedness exercise, emphasizing communications in a time of no power.

You can be sure Dr. Mike Karch will be right in the middle of it.