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On September 11, 2001, Mammoth Hospital orthopedic surgeon Dr. Mike Karch was in his last year of residency at Georgetown University Hospital in Washington D.C.
When the al-Qaeda plane hit the Pentagon minutes after the Twin Towers came down in New York City, he said, he and his hospital braced for the casualties that were inevitable.
They didn’t come.
All outside access points to the center of the city, including roads and bridges, closed down, surrounding the heart of the country’s government with a protective shield.
Karch waited as long as he could, then got leave and made his way to Ground Zero later that day, one of only two surgeons at the site for the next three days.
The lessons he learned those three days Karch passed on to Mammoth Hospital staff, first responders and citizens last week in a multi-day series of sessions, beginning on Sept. 11.
Because of this past year, which included Hurricane Sandy, the Sandy Hook Elementary School shootings and the Boston Marathon bombings, he said it has become more clear to him how critical some kind of mass casualty training is, even for a community as small and isolated as Mammoth Lakes.
“In any mass casualty event, you are going to have people react in one of three different ways; fight, flight or freeze,” he said last Wednesday evening, Sept. 11.
“The fight or flight response has received much of the attention, but the ones that go toward the disaster to help, or the ones that leave it and flee, are not the problem,” he said.
It is the people who freeze—who are so emotionally compromised they cannot help and yet are still in the middle of the response effort—that are a problem in a disaster, he said.
That tendency to freeze, to become part of the problem, not the solution, is actually more likely in a community as small as Mammoth—precisely because everyone knows everyone, he said.
“So say we have this mass casualty event, in this case a school shooting,” he said.
“It’s something we don’t like to talk about, but statistically, your child is 13 times more likely to die from a school shooting in this country than in any other industrialized country; there is an average of a school shooting every 40 days in this country. This carries a huge potential for freezing, especially in a small town like Mammoth.
“So I have in front of me a boy, a six-year-old boy, with major injuries, and that’s already a huge distraction, there is a big chance I could freeze, I have to talk myself out of it. I know this is going to be hard, because I have a seven-year-old at home. His father is dead. The boy’s mother is a nurse at the hospital here.
“I have to look at this boy and I have to tell myself, ‘He’s not my kid, he’s a mannequin,’ or whatever I have to do to deal with what is in front of me, because there are 14 other victims lined up behind him. That sounds cold and detached, but that’s how it works, you have to become cold and detached or you won’t be effective.
“The next thing I have to do is deal with his mother. This is going to sound inhumane, but she is now a distractor. We have to get her out of here, we have to make her go away.”
That means calling for someone to help remove the distraction—in this case, hospital security if available and if not, possibly a neighbor or friend to that person as well—another example of the psychological challenges that Mammoth residents will face in a community-wide emergency.
“We want people to fight, we want people to help,” he said. “That’s the ideal. If they can’t do that, if they have to flee because they have children or an elderly parent or pets or simply because they cannot handle the situation, we understand that.
“But the people that freeze, that’s the problem.”
Mass casualty training, of both emergency responders and the general public, has been shown to be as critical a factor in determining whether or not people in a real disaster show up to help (fight) or become immobilized or flee (freeze/ flight) as more conventional disaster preparedness, such as having a three day supply of food, water and medicines or a family emergency response plan, he said.
“In any given mass casualty event that is widespread (versus a small and defined incident like a plane crash), about 60 percent of emergency responders show up,” he said.
“The main factors that determine who will show up is one, if they have no backup childcare plans, two, if they have an elderly parent with no backup care plan, three, if they have pets with no backup plan, four, if they have a spouse that is already responding to the disaster (in this case, the couple is most likely to only chose to have one of them respond) and, five, if they have not has any mass casualty or disaster training.”
“That’s why this kind of training is so critical,” he said.
Another vulnerability Mammoth has is that it has a small hospital: 25 beds and three surgical suites.
“In every mass casualty event, from Sandy Hook to the Boston Marathon bombing, the local medical system was overwhelmed, almost immediately, no matter how good it was,” he said.
“Look at the Boston bombing—even with the most sophisticated medical system in the world, the hospitals were overwhelmed.”
Another reason to train locals is because of something called the 72-hour rule.
“We’ve learned a lot about how to respond to a major disaster, especially since Hurricane Katrina,” he said. “But in every mass casualty event across the world, from Hurricane Sandy (with 48 hours of warning) to Haiti to the Iraq earthquakes, it took about 72 hours before emergency responders can get to the site, even under the best circumstances.”
That would be as true for an event in Mammoth, he said.
“It simply takes that long to mobilize the resources to respond,” he said. “So for that first 72 hours, we are on our own. I would rather grab the bull by the horns and be ready.”
Mono County Sheriff Ralph Obenberger attended the Sept. 11 talk Karch gave at the Mammoth Lakes Fire Station No. 1.
Training is critical, he said.
“When a mass casualty incident occurs the first responders, and anyone for that matter, really does not know what to expect when they first arrive on scene,” he said. “The incident will be traumatic but the responder must be able to get past emotions and do their job. As Dr. Karch explained, people have to train and expect the unexpected on something such as a mass casualty incident.”
Barbara Richter is a longtime Mammoth resident and an eight-year Community Emergency Response Team (CERT) member and the local chapter’s historian. She has been through extensive training in how to deal with local emergencies; she has a 72-hour bagin both her car and home, as does her husband, Fred Richter.
She attended Karch’s talk and said even with her training, she learned something new.
“First of all, Karch is an excellent speaker, clear, dynamic, he doesn’t do doctor-speak,” she said. “He’s logical, he uses common sense ideas. One of the things that really struck me was what he said about taking breaks. If you are exhausted, you begin to make mistakes, and then you are not helping anyone, you are part of the problem.
“The other thing I really took away was the Sharpie pen idea (Karch keeps a black Sharpie pen in his emergency bags so he can write on victims foreheads or bodies to inform the next medical responder after him what work he just did on the victim). I’m going to add some of those to all of my bags.”
On Sept. 12-13, Karch put much of the Mammoth Hospital staff through an extended mass casualty training session, using a mobile cadaver lab from a company called Synthes to train the teams on human cadavers. He had done the same thing last year, but this time, the training was open for more hospital staff.
At the end, minutes after the smoke and noise and chaos had cleared out of the mobile lab on the hospital grounds, general surgeon Dr. Fru Baheraei stood up and took off his mask.
“I’ve worked in a city of millions and have never had a better simulation,” he said.
If Karch has his way, what was a two-day training for the hospital staff and a three-hour talk on Sept. 11 to emergency responders and the public will turn into a full week of countywide disaster preparedness training.
“Right now, we do a one day ‘desk top’ training,” he said. “There is real value in that, but the research is clear that giving people more life-like experiences is even more effective. I’d like to see that extended to one week, and involve the entire county, including civilians, in a simulated event.
“Luck favors the prepared,” he said. “Unfortunately, living here in Mammoth, we are at risk. I would, as I have said before, rather grab the bull by the horns.”