Chapter 82: Disaster Protocol

April 1, 1989, McKinley, Ohio

On Saturday morning, I arrived at the hospital just before 6:00am to cover part of Jim North's ICU shift due to the scheduling SNAFU. I changed into purple scrubs and reported to the ICU. I was expecting a quiet routine day, and that's what I had until just before 10:00am.

"Mike?" Nurse Wendy said from the door to the lounge. "There's a Level II Disaster Protocol in effect. You and Doctor White are assigned to the ED."

It was April Fool's Day, but declaring a protocol was no laughing matter, and not something to joke about, so I was positive it was the real thing. Doctor White and me responding would leave only the Attending and nurses for the ICU, but in my experience, a single doctor could handle it, at least for a time.

"What happened?" I asked, getting up.

"A Greyhound bus was involved in a multi-vehicle accident on Route 50. That's all I know. See Doctor Gabriel in the ED, please."

"On my way," I said, getting up.

I hurried to the stairs, following the protocol of only using elevators when strictly necessary for patient transport during a Level II or Level III emergency. I bounded down the stairs, exited on the first floor and hurried to the ED where the staff was assembling. At Level II, in addition to calling in an Attending, two Residents, and the other medical students assigned to the service, it also meant bringing in the ED Chief, if he wasn't in the hospital, as well as two surgical Residents, two Internal Medicine Residents, and an Attending from Internal Medicine.

"Mike," Doctor Gabriel said when he saw me. "I want you to handle walk-in triage. I can't' spare any doctors for that."

"How bad?"

"At least sixty from the bus, which turned over, and as many as a dozen from the other vehicles involved. Flight for Life is responding, but we'll get everyone else by ambulance, cruiser, or private vehicle. You'll have Traci and Tim with you, but they're both Third Years on their first rotation. ETA is ten minutes."

'Wonderful' was my first thought, because it was the first day of a new rotation, which meant effectively untrained Third Years. The Fourth Years assigned to the service would be working with the Attendings and Residents treating the most severely injured, and I was a 'known quantity' having done triage before.

"Tim, Traci," he said to a pair of Third Years who looked like deer in the headlights, "this is Mike Loucks, Fourth Year and Matched to this ED. Do exactly what he says, no more, no less. And keep your wits about you."

"Let's go," I said to the two bewildered students.

They followed me to the supply room.

"Baptism by fire, I guess," Tim observed.

"You'll both be fine," I replied. "What are the principles of triage?"

"Identify patients who need immediate treatment," Tim replied, "then categorize the rest in order of severity."

"Traci, how do we grade them?" I asked.

"Red is immediate, yellow is severe but stable, and green is minor. By law, everyone has to be evaluated and seen by a physician."

"And black," I replied, "though with walk-ins we won't need those tags. Do you know how to use the tags?"

"No."

I picked one up from the shelf and held it up.

"You put this on the patient, either around their neck on a lanyard, around their wrist or ankle with elastic, or pinned to their clothing on their upper body. Each color is a tear off. If they're green, you just leave the tag intact. If they're yellow, you tear off and discard the green portion, and so on. If a patient's condition worsens, you tear off the next portion. And each chart gets a properly color-coded sticker."

"What if the patient improves?"

"Leave their grade because a relapse is often likely. We need a hundred tags, plus a hundred blank charts. Tim, grab those. Traci, we need bandages, surgical tape, and alcohol wipes."

We grabbed the supplies and carried everything out to the waiting room.

"Hi, Mike," Nate called out. "Couldn't wait for your shift on Monday?"

"I took an ICU shift today to help out, which is why I'm in purple scrubs. Any more information?"

"The EMS scanner says there was a fire on site, at least three fatalities, and FFL dispatched two helicopters to take patients to Columbus or Dayton. Cruisers should be here with the ambulatory patients in about two minutes."

"Thanks."

There were several people in the waiting room, so I went over to Nate and reviewed the check-in list. None of those patients were going to be seen for hours, at least, but I couldn't advise them to leave. Instead, I went to each one, explained what had happened, and said we'd get to them as soon as possible. All but one were understanding, and that one became instantly belligerent.

"I WAS FUCKING HERE FIRST!" he insisted.

I nodded, "I acknowledge that, but our triage protocols say we have to evaluate, then treat, patients based on the severity of their injuries. Your hand is cut, but not bleeding profusely, so as much as I'd like to help you immediately, there simply isn't anyone who can suture your hand at the moment. As soon as someone is available, I'll let you know."

"THIS HOSPITAL IS FUCKING USELESS! WHERE'S YOUR SUPERVISOR?"

"I'll let him know you want to speak to him, but I hear sirens from ambulances pulling up, so it might be a few hours before he comes to see you. There is nothing I can do about that."

"OH YEAH?" he asked, reaching into his pocket.

I was reasonably sure he was going for a handgun, and I also knew there would be a dozen Sheriff's Deputies coming through the doors within a minute. The problem was, if he actually got the gun out of his pocket, things could go bad very fast. The bigger problem was I was forbidden from taking any physical action to stop him until he actually pulled the gun. Intuition wasn't enough. I split the difference, and as soon as I saw the butt of the pistol, I executed a wrist lock as I'd been taught by my karate instructors.

"Don't!" I warned when he struggled. "Let go, and I'll let go. If not, the first Deputy through that door, which will happen in less than thirty seconds, will ensure you're treated for a gunshot wound, assuming he doesn't kill you outright, which is a distinct possibility."

He struggled more, but because he was sitting and I was standing, he couldn't gain the leverage he needed. He tried to stand, but I pushed him back down, just as Deputy Turner came through the door with two young women, both holding bloody bandages to their heads.

"DEPUTY TURNER!" I said sharply. "THIS MAN HAS A GUN!"

The Deputy instantly drew his service revolver and advanced closer.

"Think about it," I said, releasing the patient's wrist and stepping back.

In the end, he relented, but that didn't stop him from being cuffed and searched while I went to check on the two young women.

"Tim, scribe, please. Tracy, fresh bandages, please."

I quickly assessed both young women and decided their head lacs were minor, and might not even need sutures, but both had hit their heads, which meant potential concussions or hematomas. I checked their vitals, calling out to Tim, who wrote down the details. I tagged them green and had Tim put green stickers on the charts.

"Just hold the bandages Traci is giving you to your wounds," I said to the two young women. "If you feel faint, nauseated, your vision blurs, or you hear ringing in your ears, let one of us know. Otherwise, someone will see you as soon as possible."

I directed Tim to give the preliminary charts to Nate, and the next cruiser arrived, the second in a steady stream. Whoever was making decisions on site was doing a good job, with nearly every patient brought in by cruiser or private vehicle being green tagged, the exceptions being yellows going to a pair of broken arms, a severely sprained knee, and two with deep lacerations, which would absolutely need suturing.

It took nearly six hours to clear the waiting room, with the last patient who was seen being the handcuffed hand lac, who, in addition to needing sutures, was, in all likelihood, going to spend some time in jail. We'd only had one similar incident in the four years I'd been in medical school, and that had been a distraught parent of a child who had been declared brain dead, who had briefly brandished a handgun, but had been quickly talked down, and no charges had been pressed.

"Mike?" Deputy Turner called out when I left the waiting room and went into the ED.

"Yes?"

"I'll need you to sign a complaint for attempted assault with a deadly weapon, please."

"Is that the only charge?"

"No. He's prohibited from owning or carrying a gun because he's under a restraining order for beating up his wife. That's federal, and the Sheriff will file the complaint with the US Attorney."

"What do you need from me?"

"Just a statement of what happened. I can take it now, if you have time."

"Let me check with Doctor Gabriel and Doctor White."

I went to see Doctor Gabriel to let him know triage was complete and everyone had been seen.

"How did Tim and Traci do?"

"They simply scribed and handed out bandages under my direction, and escorted patients in. I can't really evaluate them beyond that. Is there something specific?"

"Step into my office, please."

I did and shut the door behind us.

"Tim Burg is similar to Felicity," he said. "But without the actual brains to back it up. He's dangerous. Basically, he thinks he's a hundred times smarter than he actually is and appears to be immune to correction. Doctor Collins personally called me and warned me not to let him near a patient alone."

"Why is he still here?" I asked.

"He's on his last chance. If he fails this rotation, he'll fail the year, and will probably be dismissed. He scraped by in pediatrics, cardiology, and OB because those are mostly observation for third years. That's not true for surgery or Medicine. He had a substandard grade in surgery and failed Medicine. Guess who he's going to be assigned to?"

"Seriously?" I asked, positive I sounded exasperated.

"Loretta and Ghost expressly requested that of Doctor Northrup. They know you'll either turn him around or tell them to fail him and won't mince words or play it safe."

"Great," I replied. "And, yes, of course, but I had hoped for a relatively calm, at least in ED terms, rotation."

"They're treating you like a Resident, Mike. And you know why?"

"Because at this point, now that we've Matched, it's literally playing out the string, as it were, and I would never do that."

"Exactly. So you know what to do."

"I do. Felicity was hoping to have some shifts with me."

"She will, but you have a special project."

"OK."

I left his office and found Doctor White and explained what had happened. He agreed I should give the statement, then report back to the ICU. I went back to Deputy Turner and gave him my version of events.

"I suspect you'll never be called to testify," Deputy Turner said. "The Feds get their shot first, and gun violations almost always result in federal time. The County Prosecutor will also have him on violating the terms of the restraining order, which will make the judge who issued it very unhappy. The attempted assault charge will probably be dismissed or pled out because it's mostly a probation offense, while the other two pretty much guarantee some federal time and state time after that."

"I take it I'll hear from the County Prosecutor?"

"Maybe. You will hear from one of the new 'victim advocates' from Social Services."

"I don't feel like a victim," I replied. "I stopped an idiot from doing something stupid that likely would have had you put one through his X-ring."

"You heard I won the department pistol competition?"

"I did. Your real challenge is one county over."

"Deputy Nelson, right?"

"Exactly. Best shot in both counties."

"I beg to differ! Maybe we need one of those Magnum Force shooting contests!"

"Make the challenge," I replied. "I know Emmy well enough that she'll accept!"

"I'll talk to my captain and see what he thinks. Just sign at the bottom, please."

He handed me the clipboard. I scanned the complaint, signed it, and handed the clipboard back to him.

"You responded well," Deputy Turner said. "Right on the edge of what the hospital rules say."

"That did flash through my mind," I replied. "As soon as he reached into his pocket, I knew what he was doing, but I also knew the rules."

"The Department would back you even if you had tackled him beforehand. No way you'd suffer any real discipline."

"I hear you," I replied. "But right now, I cannot afford even a slight breach. I have less than two months to graduation."

"Well, you'll get a commendation from the Sheriff for quick thinking."

"I'd prefer we dispense with that and not draw any attention."

Deputy Turner nodded, "I'll make sure they know."

"Thanks."

We shook hands, and I headed back to the ICU for what I hoped was a quiet late afternoon and evening. Just before 6:00pm, Clarissa came into the lounge, an hour before her 7:00pm to 7:00pm Medicine shift was due to begin.

"My shift starts at 7:00pm," she said. "Can you take your dinner break?"

"Let me check with Doctor White. I take it you heard about the excitement today?"

"No. What?"

"Level II disaster protocol. I'll tell you about it at dinner. One sec."

I went to see Doctor White, who authorized a thirty-minute meal break, and Clarissa and I headed to the cafeteria.

"A Greyhound bus, two minivans, and a semi were involved in an accident on Route 50. The bus turned over, and we ended up treating seventy-seven patients, the majority for cuts, bumps, and bruises. We received about two dozen serious injuries, two were taken by helicopter to Columbus, and three in one of the minivans were fatalities at the site."

"Damn! I take it you were called down?"

"Yes, to run triage. It's the first day of the new rotations, so the two Third Years I was assigned were on their very first emergency medicine rotation. The other two were running labs, and the Fourth Years were doing procedures because none of the Third years had any experience."

"I bet that was fun."

"Triage was fairly easy, except for the guy who tried to pull a gun on me."

"WHAT?!" Clarissa gasped.

"A patient with a cut hand was in the waiting room when the protocol was activated. When I told him he would have to wait for us to triage all the accident victims, he became belligerent. He asked for my supervisor, and that was just as EMS was bringing patients by ambulance, so I told the guy it might be a few hours before my supervisor could see him.

"He reached into his pocket, and I instantly knew what he was doing. You know we're supposed to call security, but I decided if I saw the butt of the gun, I was going to act because Sheriff's cruisers were arriving, and the last thing we needed was a gunfight in the waiting room. I saw the butt of his pistol, put him in a wrist lock, and when Deputy Turner came through the doors, I called out to him that the guy had a gun.

"Deputy Turner drew down on the guy who decided getting shot was a bad idea. Turns out he had a restraining order for domestic violence, which made having the gun illegal, both state and federal. They're going to charge him with illegal possession of a firearm, attempted assault with a deadly weapon, and violating the terms of the restraining order."

"Jesus, Petrovich!" Clarissa exclaimed. "You could have been shot!"

"If I'd let him actually pull the gun from his coat pocket? Yes. But I used my karate training for the wrist lock, and he was seated, so he had no leverage. I also knew six Sheriff's Deputies were about to come through the door, and they'd have turned him into Swiss Cheese. And Deputy Turner is the best shot around, except for Emmy."

"You hit HER X-ring!" Clarissa teased.

"Ancient history," I replied. "Anyway, I had to sign the complaint, but Deputy Turner thinks the attempted assault charge will be pled out or dismissed because the guy will do federal time on a weapons charge."

"It's never not exciting with you, Petrovich!"

"That's what all the girls said!" I replied smugly.

"And Doctor Pig emerges!" Clarissa replied mirthfully.

We reached the cafeteria, went through the line, made our selections, then paid for them. We sat down away from others so we could ensure a private conversation.

"That wasn't even the worst thing that happened today," I said once I'd given the blessing.

"What was that? Losing a patient in the ICU?"

"No. Do you know a Third Year named Tim Burg?"

"I've heard about him. He failed his Medicine rotation because he made three significant errors. Well, four, but the fourth was a repeat."

"How the heck can you mess up a Medicine rotation so badly?" I asked.

"Twice he left out critical information from a report because he'd decided on a diagnosis and considered the actual data from the lab irrelevant."

"You're joking!" I exclaimed.

"I wish I was," Clarissa replied. "Fortunately, in both cases, the Resident caught it because everything he did was being double-checked. The other two were failing to follow instructions. His rep is that he's a know-it-all who is never wrong, even when he's proven wrong. Doctor Subramani and Doctor Vega recommended he be summarily dismissed, but Doctor Collins only failed him for the rotation."

"I know why, too," I sighted.

"Oh, shit!" Clarissa said, shaking her head. "No good deed goes unpunished, right?"

"Yep. He's assigned to me in the ED for the next two months on the recommendation of Doctor Casper and Doctor Gibbs. They want the 'Felicity treatment' but with the opposite results."

"If you recommend he fails, nobody will question it."

"Doctor Gabriel said they're treating me as if I were a Resident. I guess it's no surprise given I've Matched here, and this is my final rotation, and it's in the ED, where I'm a 'known quantity'. They let me run triage today without anyone even checking on me."