Triaging an Earthquake: Michelle Khare's Simulated Mass Casualty Shift
Michelle Khare
In this episode of Challenge Accepted, Michelle Khare tries to act as triage officer in an emergency department during a mass casualty incident (MCI). She is not a doctor, and the hospital is not real. The production built what the team calls a "live-action hospital video game": a one-hour simulated MCI with more than 30 actors playing patients and real doctors and nurses as staff. Michelle has to make split-second decisions with only one day of training. The episode asks how close the TV version of emergency medicine is to the real thing, and what it feels like to decide who gets care when there isn't enough to go around.
The Setup: An Earthquake and an Unknown Number of Patients
The scenario opens with simulated news reports: the largest earthquake to hit Southern California in two decades, more than 160 aftershocks, and about 500 people hurt. Patients will arrive by ambulance, on foot, crawling, and in private cars, and nobody knows how many are coming. The trainers say that uncertainty is why triage matters. Michelle has to sort everyone who arrives.
Her job as triage officer is to quickly assess each arriving patient and assign a color based on injury severity, with the goal of saving as many lives as possible. One of the organizers compares the experience to the TV show The Pit, with one big difference. On TV the actors have scripts. Michelle does not know what is coming and has only a one-day crash course to rely on.
The training team includes Dr. Mike Varshavski, a board-certified family medicine physician and online medical educator, along with Ryan and Brett. The production says Dr. Mike was brought in to make the simulation as realistic as possible because he still sees patients every week. Dr. Mike says family medicine training does not fully prepare him for an MCI either. He calls Ryan and Brett the experts who both handle these situations in real life and teach them to doctors, and says he expects to learn a lot himself. One trainer says what Michelle will go through is very similar to the training they give all their emergency department staff.
The START Triage Algorithm
The core tool is START triage, a flowchart that gives medical professionals a starting guideline for assessing patients quickly as they arrive. The stated aim is to do the most good for the greatest number of patients. It uses four categories.
Green is for the most minimally injured. The first question is whether the patient can walk. If they can, they are green right away. The trainers demonstrate by asking a simulated patient to walk toward them.
Yellow, or "delayed," is for patients who definitely need care but not immediately. They cannot walk but still have stable vital signs and mental status. Michelle learns the checks in order:
- Is the patient breathing, and is the respiratory rate under 30?
- Perfusion: press on a fingernail, and if the color returns from white to normal in under two seconds, move on.
- Mental status: can the patient follow a simple command, such as waving a hand?
Red is for the most critical patients who need immediate care. Something is abnormal in their breathing rate, their perfusion, or their ability to respond to and follow commands. In the demonstration, a patient who cannot walk and is breathing at 40 breaths per minute is tagged red.
Black is for patients who have died or for whom little can be done. The trainers stress that this does not mean ignoring them. These patients still receive palliative care, but the resources available on a normal day are not there. In the practice run, a patient is not walking and not breathing. Michelle is taught to reposition the airway with a head tilt–chin lift. When she asks about CPR, the trainers say it is not part of the algorithm: with about a minute per patient, they cannot commit that many staff and resources to one person. They tell her they like that she thought of it, but the patient gets a black tag.
Michelle says she hesitates to put the black wristband on anyone. A trainer replies that the algorithm exists for this reason. It lets you do a calculated evaluation that "takes the emotion out of it." They also warn her that after real incidents, staff often break down because they have been suppressing their emotions for so long, and that she should expect to feel very stressed after the simulation.
The First Wave: Easy Greens, Then Ambiguity
The first challenge is a wave of patients from a collapsed apartment building. The first few are simple. They are walking, talking, and responding, so they get green tags and are sent inside. One man with cut-up knees tells her to help someone else first.
Things get harder quickly. One woman can walk but is confused and doesn't seem to understand that she has cuts on her forehead. Michelle tags her yellow. She describes triaging this kind of patient as trying to hold a conversation while doing a math problem in your head: calming the patient while trying to picture the flowchart. A trainer points out that patients are human and give imperfect answers. If you ask for a thumbs-up and don't get one, you can easily put someone in the wrong category. Meanwhile staff keep reminding her that more patients are waiting and that one of hers is wandering off.
Then a man arrives with his intestines exposed. A trainer tells her the visible injury is not the important part and asks what she is basing her decision on. She tags him red because he can't walk and is short of breath. On closer look, he is actually breathing very slowly, but he stays red.
Treating the Red Patients: An Evisceration
Triage is only part of Michelle's job. She also has to perform procedures on the red patients. The trainers put it this way: in front of the hospital you triage, inside the hospital you treat. All the medical professionals in the simulation are real doctors and nurses, and they have been told to carry out her orders even when she is wrong.
The first treatment case is the man with the evisceration, meaning bowel protruding through a cut in the abdominal wall. He is tachycardic and on oxygen. Michelle correctly says the wound needs to be covered and dressed and a surgeon called right away. The trainers explain that you should never push the abdominal contents back in. The patient needs surgery, and the immediate goal is to protect the bowel. They walk her through it: a large trauma dressing soaked in sterile saline over the exposed bowel, then an occlusive dressing to hold in moisture, then tape. The operating room is called and she moves on.
In an aside, Michelle explains that the real "Dr. Khare" is her father. She was once on track to become a physician like him before becoming a YouTuber, and she calls this episode her chance to make him proud.
Mistakes and the Domino Effect
The trainers soon see a serious problem. Michelle is miscategorizing patients, panic is setting in, and she is freezing. One man with a chest injury can walk, but only with help. She first says green, then switches to red. A man who says his wife cannot walk gets both of them tagged green. A bystander yells "Green, red, green, red. You're an idiot."
The trainers explain why this matters. Each color sends a patient to a room with a limited number of beds, staff, and supplies. An over-categorized patient takes resources from someone who needs them more. An under-categorized patient may not get the care they need and could die. They call this a domino effect: an early mistake can cause a lot of harm later. Michelle sums it up as a resource allocation problem, and the trainers agree.
After the first round, Michelle says she felt completely overwhelmed. The trainers remind her that secondary triage always follows. Patients' conditions change, usually for the worse, so there is a built-in reassessment step to catch mistakes early. She says she will try to be more confident.
Secondary Triage and the Primary Assessment
Inside, the trainers teach her the primary assessment, a basic trauma check in a fixed order. A is airway: is it clear? B is breathing: is it affected, and are breath sounds good on both sides? C is circulation: is there a pulse, and is there major bleeding? The trainers say most life-threatening problems show up in these three areas. They also add a practical warning not to run inside, because it is easy to get hurt around sharps.
Using this check, a red patient turns out to be more stable than her tag suggested. A trainer asks why she was classified red and suggests moving her down to yellow. Michelle realizes she has wasted two gurneys. The trainers note that fixing this is not free either. Moving patients between zones takes staff time, and in an MCI that can cost lives.
Patients in Pain and Being Honest
Michelle treats a woman who has glass in one eye, blindness on her left side, and an ankle injury that keeps her from walking. The woman is frightened and asks whether she will ever see out of that eye again. Michelle has an IV placed and orders morphine. A trainer says they try not to lie to patients, and that they don't tell people "you're going to be okay," but that reassurance matters a lot in these moments. Michelle tells her they are doing the best they can.
Next is a construction site lead with a crush injury to his abdomen who keeps asking about his crew. Michelle agrees he needs pain medication and a CT scan, and 4 milligrams of morphine is ordered. In the chaos there is confusion about whether the order was for anxiety or for pain, and a trainer urges her to ask questions rather than guess.
Intubation
A patient on an EMS gurney becomes unresponsive with very low oxygen saturation. A trainer comments that disruptions you can't plan for keep coming, and being pulled in different directions is one of the hardest parts. The team bags the patient, with one breath about every six seconds, while an IV is started so medications can be given for intubation. The trainers explain that intubation secures the airway with a tube down the throat and also lets staff breathe for a patient who isn't breathing.
Michelle holds the laryngoscope in her non-dominant hand so she can control the tube with her dominant hand. She looks for the epiglottis and chips a tooth along the way, then jokes "Malpractice." With step-by-step coaching she places the tube, removes the stylet, and attaches the bag. She checks the stomach first to confirm the tube is not in the esophagus, then hears breath sounds on the right. Oxygen saturation rises to 94. She has the tube secured and orders 50 micrograms of fentanyl, 2 milligrams of Versed, and a propofol drip. Following protocol, she asks someone to repeat the order back.
A Child, a Language Barrier, and a Woman in Labor
The trainers say an earthquake produces many scenarios at once, plus surprises. A young girl arrives who can move but cannot walk. Her caregiver speaks Spanish, and Michelle tries to communicate in limited Spanish. The girl seems disoriented and appears to have a fracture, but she is breathing and has a pulse. Michelle tags her yellow and is told to inform her staff.
Then a woman says her water broke 20 minutes ago and her contractions are two minutes apart. The trainers point out that people with problems unrelated to the disaster still come to the hospital, and during an MCI they also go through triage because everyone is drawing on the same limited resources. Michelle first tags her green, then changes her to red because she is about to give birth. She says plainly that this is "not on the algorithm" and she doesn't know what to do.
This is where her earlier mistakes catch up with her. Because she over-categorized so many patients, every operating room is full. To make room, she has to finish a procedure on one of her red patients.
The Cricothyrotomy
That patient's airway is swelling shut. Rapid intubation is considered, but the swelling is severe, so Michelle decides on a cric (cricothyrotomy). She finds the thyroid cartilage and makes a vertical incision between it and the cricoid ring, cutting through the skin. When asked how far to insert the tube, she says only a few inches so it doesn't go down into the lungs, and the trainer confirms. The cuff is inflated, the CO2 detector attached, and she listens to confirm air is reaching both lungs, not just one.
All of this happens while other patients interrupt constantly. Patients argue about who arrived first, one asks why a coworker's condition still hasn't been explained, a relative is angry that a promised phone call never happened, and staff try to keep the woman in labor in bed.
Deciding Where the Baby Is Delivered
The woman in labor is close to delivering. Michelle mentions she made a video on delivering a baby two years earlier but says she doesn't remember any of it. Staff tell her to do her best and open the delivery kit, and they prepare to cut off the patient's jeans. Then OB calls: they are upstairs, and the obstetrician would much rather deliver the baby there. Michelle agrees, decides the patient should go to the operating room, and tells the patient. The OB team says they'll be ready in five minutes.
Critical Mass and Patients Who Wait
Meanwhile her staff have kept triaging new arrivals, and every room is full. A man whose wife has the eye injury becomes increasingly angry. He says they have waited four times longer than anyone else, that newer patients keep getting ahead of them, and that his wife is going to go blind. He asks whether checking vitals is the best they can do. He is told yes, because there are so many patients.
Michelle reflects that on a normal day many of these debilitating injuries could be treated. In an MCI, you have to pick and choose to save the most lives, which can mean allowing a patient to lose her sight so resources go to saving someone else's life. She points out that this was a patient she had miscategorized, and wonders whether the woman might have been treated sooner if she hadn't made that mistake.
The trainers say the biggest risk at this stage is freezing under the noise of screaming patients and angry family members. A trainer says you need to be able to snap out of it quickly in order to respond to your patients.
A Black Tag
A man Michelle had tagged red has been unresponsive since she first saw him and is now breathing agonally. A trainer tells her he needs to be moved to black and urges her to make a decision. Michelle says that because of her mistakes every red room is full. If she had allocated resources more efficiently, there might have been space, and the patient might have been saved. She gives him the black tag. She says it is horrible to be that objective, especially knowing that outside an MCI they could have done chest compressions, and that actively walking away from someone is very hard.
Afterward she describes being so overloaded with stimuli and decision fatigue that she wants to sit and stare at a wall for a few hours. She also says she has no good news for anyone, and that not being able to give people closure is hard for her.
The black-tagged man, Brunson, turns out to have been part of the same construction crew as the injured site lead. Michelle checks with Brett whether HIPAA allows her to tell him, and then does. She explains that Brunson was found and brought to the hospital, but was unresponsive when he arrived and has died. She tells him she is very sorry.
The Grades and What the Team Wants Viewers to Take Away
The trainers grade Michelle in three categories. Triage gets an F, because she panicked at times and got caught up. Treatment gets a B-minus, since she often didn't know exactly what to do, which they say was not surprising. Communication is where they say she really shone. Working with the team, moving people around, prioritizing, and continuing to check in are what they say would actually save lives in a situation like this.
One member of the medical team connects the simulation to the real healthcare system. They argue that what this MCI showed is happening at scale, with tremendous shortages and stress as workers try to care for patients with limited resources. If people don't want "MCI style" healthcare, they say, changes are needed, starting with being kind to frontline healthcare workers and remembering they are human and under enormous stress. They add a second point: life is beautiful and limited, can be taken away at any moment, and people should be grateful for it. Another team member says most people are not sick at any given moment, but everyone will be at some point and will need care. They encourage viewers to think about habits they could change to have a better quality of life for longer.
Michelle closes by saying that even this "microscopic taste" of being the person who makes these decisions gave her infinite love and admiration for anyone in the profession. She dedicates the episode to healthcare professionals.
This week on Challenge Accepted, I'm going to see what it's like to be a triage officer in an emergency room during a mass casualty incident.
And what are the catches?
I'm not a doctor and this entire hospital, it's not real.
We're putting Michelle through a real-life simulation of a one-hour mass casualty incident. This is where real doctors, nurses learn. We've essentially designed a live-action hospital video game. Over 30 actors playing patients, real nurses and doctors, where Michelle will have to make split-second life-or-death decisions.
50 micrograms fentanyl to start.
Her. Her airway's closing up.
To make the vertical incision?
How do you tell someone that someone has died?
We've seen it a million times on TV, but how close is it to the real thing?
Everyone needs a tag. Everyone needs a tag.
Find out on this week's episode of Challenge Accepted.
Simulation starts in three, two, one.
We want to get to Southern California on alert this morning after getting hit by the largest earthquake there in two decades, sparking more than 160 aftershocks.
See the damage to
Power lines
500 people were hurt.
All right, there's an earthquake, so we're going to get people coming in left, right, and center. Ambulances, people walking in, crawling in, personal cars. Do we know how many are coming?
We have no idea, so we have to prepare for anything and that's where your triage skills are really going to be essential, that you need to sort all these patients that are coming in.
My role as a triage officer is to quickly assess the patients arriving at the emergency department and assign them a color based on their injury severity level with the hope of saving as many lives as possible.
So, if you've seen The Pitt, what Michelle is going to be experiencing today during an MCI is very similar with one big distinction. They're actors, they have lines. Michelle does not know what she's walking into. She has to rely on this one-day quick education that we presented to her. So, I don't envy her.
Dr. Mike, good to see you again.
You, yes.
I'm Dr. Mike Varshavski, board-certified family medicine physician and content creator online, especially on YouTube.
Start triaging the patients!
One of the most influential medical educators online.
25 million followers.
The legendary Dr. Mike Varshavski.
Be honest, Dr. Mike is in our video!
So, Dr. Mike has the incredible experience of not only being a healthcare and science communicator, but also practicing every single week in the field on real patients. So, I asked Dr. Mike to come in and make this simulation as real as possible.
In one day, we're going to try and simulate four years of medical school to teach Michelle what to do during an MCI.
What you're going to be going through tomorrow is very similar to what we train all our emergency department staff on.
Yes, I'm a doctor. I'm a family medicine physician. So, the training I have doesn't really prepare me fully for an MCI. It's the experts like Ryan, like Brett. They're the ones who have the experience to not just practice it in real life, but also to teach it on a very high level to doctors like myself. So, I'll be getting a lot of value today, too.
So, we're going to teach you how to sort patients so that we make sure that we can do the most good for the greatest number of patients possible.
How do I do that?
So, there will be four categories I can sort patients into.
Whoa! What the
So, we have a simulated patient here.
I can be the
Fortunately, there's a tool available. It's called START triage and we have a flowchart here that will direct you through the algorithm.
I love flowcharts!
The START triage flowchart gives medical professionals a starting guideline to quickly assess patients as they are brought into the emergency room.
Starting with the green, we have the patients that are going to be your most minimally injured.
The first question is, is the patient able to walk? If yes, they're immediately assigned to green. Please walk towards me. Yes, that's our degree.
Easy, we're done.
Going on to yellow, this is called delayed. So, the patients that are definitely going to need care, but they don't need it right away.
Yellow means the patient cannot walk, but might still have stable vitals and mental status. Breathing, they are breathing. Respiratory rate is less than 30. Okay, perfusion. When you check for perfusion, you push down on their nail, and when you let go, if it goes from white to normal color in less than two seconds, we move on to check their mental status. Can you wave your hand? Okay, so yellow, final answer.
The red patients are going to be your most critical patients, the ones that need immediate medical care. They have something that you're detecting is abnormal in either their breathing rate, their perfusion, or the way that they're responding to and following commands.
They're not walking. Heavy breathing, respiratory rate is
40.
High respiratory rate, that's a red. These are the patients that have the most emergent needs.
The black category are the patients that are either deceased or unfortunately there's not a lot that can be done to save them. It doesn't mean that we ignore them. We're still going to provide palliative care, but unfortunately just there aren't the resources available like there might be on a daily basis. He is not walking.
Okay, are they breathing? Able to... No. Can we position their airway?
So, you would go over there, do a head tilt, chin lift.
This does not include CPR.
Unfortunately, again, because we only have one minute and we don't have the resources to devote that many people and that many resources to a single patient at this point.
But I like where you're going. I like that you're thinking about it.
Okay.
So, unfortunately, we're going to have to tag this patient into the black category.
That just sucks. I hesitate to put the black wristband on a patient.
It can be extremely challenging, and this algorithm helps you do a calculated evaluation on them that takes the emotion out of it.
After the incident, people start to break down. They have big emotional outbursts because they were putting away their emotions for so long. So, expect after your simulation tomorrow to feel quite stressed out.
Simulation starts in three, two, one. Let's get started with our first set here.
My first challenge is to perform triage on an incoming wave of patients who were injured in a collapsed apartment building during the earthquake.
Ma'am, are you injured? She's walking, so it's green. I'm just going to put this here. But, if you're able to walk, go ahead and head this way.
Excuse me.
Where do you feel pain, sir?
My knees are all cut up.
Okay. Hi, are you able to walk towards my voice?
Yeah, I'm okay. You can probably help somebody else while you help me.
Okay. Well, I'm just going to tag you here. This is going to tell us how to treat even the hospital. Please head in this way.
This thing out?
No, do not touch it. So, the first couple of people I see, they're walking, they're breathing, they're talking, they're responding. I'm green. Are you able to walk towards my voice?
There's confusion here. There's confusion. He's airway.
Are we tagging? She's breathing. She has airway.
Actually talking about? There's confusion.
I don't know what to tag her because she can walk, but her mental status... I'm going to say yellow.
You have another patient. You have to be quick. Get your staff to help out. Michelle, your patient is leaving.
My God.
But, then the cases start to become trickier and a little more complex. Like a patient who appears and they're able to walk, they're able to talk, but they don't seem all there mentally. Trying to triage this patient is sort of like trying to have a conversation with someone while also doing a math problem in your head because I am trying to calm down the patient at the same time trying to visually remember what the flowchart looks like and how I'm supposed to assign them.
Ma'am, you have lots of cuts. We need to take care of you.
Cuts?
Yeah, on your forehead.
Cuts?
Ah!
These are humans, so they're going to give you imperfect answers at times. So, when you're trying to evaluate someone's mental status, you say, "Give me a thumbs up." And they don't give you a thumbs up, you can miscategorize them.
Hi. What are you working with here? Okay, can you hear my voice?
Their guts are coming out of there.
Yeah, yeah. That's not important.
Okay.
What's important?
Walk. Okay, I'm going to put a red on this.
Okay, based on what? Why do you do that?
Based on shortness of breath. Can't walk.
What are we getting breaths-wise here?
He's breathing really slow, actually.
He is breathing really slow.
Okay.
Okay, so you're going red, okay.
Okay, I'm just giving you
That's okay.
The triage isn't my only responsibility. It is also my job to perform procedures on the patients that are most high risk, that I categorize as red.
When you're in front of the hospital, you're triaging. When you're inside the hospital, you're treating.
So, this guy has an evisceration. He's full blown on oxygen. Still able to wake up a little bit. Sir, are you still with us?
Yeah, what do you think of the vitals so far here?
His heart rate is somewhat elevated.
Yes, he's tachycardic. But what is the issue right here?
We need to cover it and dress it and call the surgeon immediately. Yes, he should go in right now.
So, we're going to take a look at a patient that has an evisceration. An evisceration happens when you cut through your abdominal wall and some of your bowel comes out. Yeah, so
It's a really bad day.
It is a bad day. You do not want to ever push the abdominal contents back in because forcing them back in is actually not the correct move. So, this patient is going to have to go to the OR and see a surgeon to get it put back in, but what you're going to do is you're going to try to preserve the bowel.
All of the medical professionals in this simulation are actual doctors and nurses who have been instructed to carry out my commands even if I'm wrong.
What you want to get first is a big trauma dressing. This is sterile saline and you're just going to pour some in there. Now go ahead and pull it out and cover the bowel with that.
We are just going to cover the wound for now and prepare you to go into surgery.
And now this is like an occlusive type dressing that's going to help keep that moisture in.
It has a very strong smell.
Yeah, there we go. Let's put one there. And now I want you to grab that roll of tape. Perfect.
Okay.
Yeah, there you go.
For the assist. Okay, did we call the OR? Can we call them?
Yep, I'll call the OR. Okay, we'll get the OR prepped. Okay, move on right away.
How are we doing in here? We're done here.
The real Dr. Khare is actually not me. It is my dad. Growing up, I was actually on a course to become a physician just like my dad. Instead, I became a YouTuber. So, doing this episode is my one opportunity to hopefully make him proud. Also, my dad says to subscribe, so doctor's orders. You better subscribe.
The biggest issue that I'm seeing in Michelle right now is that she's making mistakes triaging patients.
Sir, can you hear my voice?
Yes.
Okay, red.
I'm starting to see emotions creep up, panic set in. She's freezing.
Can you walk towards my voice? Can he walk on his own?
Yeah, yeah.
Okay, that's green.
Yeah.
Okay, do you have a chest injury?
Yes. You see that?
Well, okay, chest injury. He is walking, but he's not walking by himself.
Does anyone know what their
Okay, red, red, red, red. We're just going to do red on that.
Once you miscategorize a patient, you're starting to give resources to that patient they didn't need. You could be losing resources for people who can be helped. This is the domino effect that if you make a mistake early, it can cause you a lot of harm down the road.
Hey. Hey, can we get some help?
Walk towards my voice.
My wife cannot walk.
Okay. They can walk too. They're both green.
Somebody over here, please.
Okay. We're... Okay, my name is Dr. Khare and we're going to treat you inside. Keep going inside.
After I assign a color to each patient, they will be put into a room based on that color. Now, each of these rooms have limited beds, staff, and resources. And the problem is if you miscategorize someone, it creates a chain reaction of problems in the future. For example, if a patient is overcategorized
Green, red, green, red. You're an idiot.
That patient will end up taking resources from someone who needs them more. And a patient who is undercategorized will ultimately not receive the resources they need and thus be at risk of death.
So, this is kind of like a resource allocation challenge.
It sure is. Okay, how do you feel?
That was so overwhelming.
Remember, you have secondary triage always after the fact.
Okay. I'm going to be more confident. Okay.
While mistakes are bound to happen because patients are going to be changing their severity level, usually that severity only gets worse. That's why there's always a consideration made for secondary triage where that we can adjust for that and catch those mistakes early.
We're just sort of wondering when we can be seen. You know, get her on some vitals.
I don't see any of those guys.
When inside, try not to run. Very easy with sharps to get hurt.
Okay.
Remember, take care of yourself first. All right, start.
Vomiting with head trauma. Can you tell me what happened?
Something fell, like a beam
ABC. You have patients. I'm going to teach you this basic trauma assessment. It's called the primary assessment. So, first thing you want to know is just do I have an airway?
So, that's A. Airway clear. I'm going to check breathing.
The next one is B. It's breathing. Now, we're seeing if their breathing is affected.
Breathing is okay. You hear good breath sounds on both sides.
Yeah, I mean she
Do you want me to double-check?
Yeah. Yeah.
And then after that, we're going to move to circulation. There's two big things you want to know about circulation. One, you want to know if they have a pulse. Then the second thing we're going to check is we're going to look for any major bleeds. But so now we've done airway, breathing, circulation. Most of our problems are going to happen in those three areas and we'll have to address them to save that person's life.
Is there a reason why you classified her as red? We could secondary triage her and change her.
Move her down to yellow. We only have so many beds.
Yeah.
So I just wasted two gurneys.
Yep. Make moves. If you put someone into the red zone when they should be in the yellow zone, just switching them could cause people to lose their lives. You're using staff to mobilize those patients and that can be really difficult.
Can we get this female right here? So she's been complaining of blindness in her left side and some pain.
And I just have a lot of pain and also my right ankle. I can't
She cannot walk. She's blind in one of her eyes. She's got glass sticking out of it. I'm like
Starting to kick in. Like is this going to be like a forever thing in my eye? Going to be able to see out of my eye? I'm just freaking out a little bit.
Okay.
Yeah, yeah. I understand.
Get some care like
So right now, are you okay if I just put an IV here and I give her some pain medication? Can we give her some morphine again?
Yeah, okay, great. I will make that happen.
And it'll help with the pain. Okay? It's going to be
I try not to lie to patients, right? I
Don't say you're going to be okay. But I do try to—I think reassurance is very important during this stuff.
It's going to be... We're doing the best we can.
Okay. Thank you so much.
Okay. This gentleman here has some abdominal trauma. He had a crush injury.
Just find my people.
I need pain medications and a CT scan.
Okay. That sounds good. I agree with that.
4 milligrams sounds good. We're just waiting.
Here?
Nothing.
Literally nothing.
Keaton Everett.
He was the lead in the construction site. He's concerned about his men. Okay, we'll just give him something for the anxiety.
My anxiety?
Yeah, you—why didn't...
Why didn't order for pain?
4 mg morphine. Okay.
Is she allergic to morphine?
Are you allergic to morphine?
No, I'm...
Then I think we need to prioritize other patients.
Okay, then let's do it.
Oh my God. Okay.
Okay, what are you doing? What are you doing? Ask questions. Ask questions.
She's unresponsive.
Brooke, if you need to manage your airway on the EMS gurney, feel free to do it.
Mike, I'm...
To listen? You want to listen first?
Yeah, yeah, yeah.
Listen. Get some vitals. So there's a lot of things that could be happening that are disruptive that you can't even plan for. Being pulled in one direction, then another direction, is really difficult. How much should they be squeezing?
Okay. Every 6 seconds, right?
Yep.
Okay. And then we should prep an IV for intubation so that we can give her medication so we can intubate.
I'll get an IV started. Okay.
We're going to work on intubation. And that's where we're going to secure somebody's airway. We would have to put a tube down their throat to help them maintain their airway. But the other thing it could be useful is breathing, too. Because if somebody's not breathing, we could breathe for them.
Your vital signs are coming up. Her sats are terrible.
Okay, sats are terrible.
Can I get IV started?
Non-dominant hand. There we go. Because you want to control the tube with your dominant hand. And this has to be in a place that you can see it, not where the nurses can see it.
I am ready. Yes.
Okay. 120 sux is in.
Okay.
You have your monitor. What are you looking for? What are you seeing?
I'm looking for the epiglottis.
And then just slide that in there. Nice. You see, that's the epiglottis. There you go. So try to hit in the middle of the epiglottis. Back up. Oh.
Oh, I hurt teeth.
Oh.
Broke someone's tooth.
Malpractice.
Okay. Oh my God.
And you're going to take that.
And then this is the twisting thing once it's in there.
Twist it. There you go. Push it just a little bit further. Boom. Okay, good. Now then, pop this out with your thumb.
Out towards the stomach. Out towards the stomach. Out.
Then bring forward. Grab it with your other hand.
This.
Good. So then I will come up here. And bagging it means assist ventilations.
Attach.
Put on your stethoscope. Put on your stethoscope, quick.
Check the stomach first.
Okay, it's not in the stomach.
Okay.
Breath sounds are present. Good on the right.
O2 sats coming up to 94.
Okay, that's good.
Okay, do you want them to secure the tube?
Yes, secure the tube.
She's stable. What do you want to do?
Now I'm going to push up 50 micrograms fentanyl, 2 milligrams Versed and a propofol drip, please.
Okay. Do you want to repeat that?
Can someone repeat that back to me?
Okay. 50 fentanyl, two Versed, propofol drip.
Yes, thank you. Okay.
During an earthquake, you're having all sorts of scenarios happen at the same time. But then you're also having really surprising incidents. Seeing a young child, someone you feel bad for.
Hi, can you hear me? Can you come towards me? Okay, she's able to move.
Okay.
Let's see if she can walk.
I can't walk.
You can't walk. Let me feel her pulse. Is she serious? Did that hurt?
Okay, you have multiple patients.
Got it.
There's lots of different people speaking lots of different languages.
Sophia, mia Sophia, don't...
Okay.
Lo siento, hablo español. Muy malo.
Can she walk? Can she walk?
She doesn't know where she is.
Mia Sophia, don't understand. Tú no sabes dónde eres.
About that?
Fracture, but she can breathe. She has a pulse. I think it's yellow. I think it's yellow.
Fair. Tell your staff. Tell your staff.
And that's why during an MCI like this, you have to be prepared for absolutely anything.
My water broke about 20 minutes ago.
What about...
Okay.
Michelle, you...
Can we get a stretcher for her? Her water just broke.
Michelle, there's two people.
We're still going to have patients that are coming to the hospital for other things that were not related to this specific incident.
We should still triage them because we're overflowing.
Correct. It's for everyone because it is balancing the resources that are available for everyone with the number of people that are coming in.
Hi, can you talk to me?
Yes.
Tell me what your name is.
Genevieve Fink.
Okay, and what's going on?
My water broke 20 minutes ago.
20 minutes ago? Are you having contractions right now?
Yeah, I started this morning.
How far apart are they?
2 minutes.
2 minutes? Okay. Yeah, let's proceed with green.
The lady's still going to deliver a baby, I think.
Do we have a delivery room, babe?
Yeah, I called OB. I called OB.
And any response?
No.
Why did you change her red?
Because she's about to deliver a baby.
Okay.
And that's not on the algorithm. I don't know what to do about that.
So, this patient is about to give birth. But because of all of the mistakes I've made overcategorizing people, all of the operating rooms are now full.
See, her contractions are getting closer and closer. If she starts to deliver, I told her we're going to have to cut her pants off. We're out in the open, so...
Meaning, I now need to perform a procedure on one of the red-tagged patients so that I can create space.
I should have done that. Okay, I got to see what I'm seeing.
I got another co-worker. I still haven't been told what's going on with him.
That's right.
This is not going well.
I'm worried about her. Her airway's closing up. Her airway's just swelling up.
Rapid intubation.
Yeah, we could try. She's got a lot of swelling. And she's...
Can we go through cric?
That would make sense.
Then we need to prepare for a cric.
Okay, okay. We're waiting for you. When you're ready, he's ready. Are you ready?
Great, great. I need the scalpel.
There you go. Okay.
All right, now I am going to be feeling for the thyroid cartilage.
Good.
And I'm going to make the vertical incision between thyroid cartilage and the cricoid ring. Okay, I'm cutting through the skin now.
Okay.
It just seems like after the pain medicine, she started to feel really dizzy. Sorry, my dear. Follow you. We're going to get her into the yellow. We need to order. We need to order...
Okay. Think this is right.
How far are you going to push this in?
Just a few inches so that we don't go down into the lungs.
Correct. Is that the direction?
Thank you.
Can somebody pay attention to me, please, for a moment?
Hey, you're last in line, bro.
Dude, I got here before you.
Care. He can't feel his legs.
She can't see.
Okay, can we prepare the syringe so I can inflate it?
Dude, put it on the tube.
No. Can we do this? Now this comes out. Now this comes out. Now this comes out. And switch the CO2 onto that.
Okay.
And I promise I'll call them and we'll make sure that you get taken care of. Okay?
And they have not been called?
That I speak to you, I can't get on the phone.
Okay, but can you... How would you not call them when we talked about 20 minutes ago?
Yo, dude, dude, dude, get back in bed.
The baby's coming.
Get back in bed. So, hey, what's going on here? Get back in bed. Hey, real quick.
Okay. Gold is good. Let me listen to see if it's working.
Okay. What are you listening for?
I'm listening to make sure that it's both lungs and not just one. Wait, I think I know you. Wait, I know you.
Okay, make sure that this is an emergency. Go ahead.
I just saw you. Why are you not listening to me? What is happening?
Keep back on your side. I think it's working.
Okay.
Okay.
Okay.
Brenda, do you feel good?
Yeah, I'll check it out.
Okay.
Okay. And can I see... Hey, can we get that on her?
Speak kit?
We have got to get her jeans off because that baby is going to come out.
I'll get it off.
Yeah, I think she's going to deliver any second. What do you think? Should we cut her jeans off?
Where's my doctor?
Get the scissors. All right, come on.
Okay, okay. We did a video on how to deliver a baby 2 years ago. But that was 2 years ago. I don't remember anything on how to do this.
Do your best. Open the kit. Start the process. Ma'am, Dr. Khare's here. She's going to do a great job.
Oh, my back hurts so bad.
She's going to cut your jeans, okay? Set this up. Set this up.
I... This is crazy. This is actually crazy. So, we should cut her clothes off.
Yes. Hey, listen real quick. OB just called. They are upstairs. The doc said he'd much rather deliver this baby upstairs.
I would much rather that, too.
Are you okay? Is she stable enough for that? Or do you want to deliver here?
I think she's got to go to the operating room.
It's much better upstairs for this.
I'm going to tell the—tell the patient. Tell the patient.
We're sending her to the operating room.
Okay? Give us 5 minutes. We'll be there in 5 minutes, okay? Okay, thanks.
Oh, thank God.
Easy breaths. Easy breaths. You're doing well.
But the chaos still isn't over. While I was treating my patients, my staff was triaging even more patients who were now flooding into the hospital.
Mom. This is Mom?
Who's Mom?
What's Mom's name?
It's Ruth.
Who's Ruth?
It's Jackie. Hey.
The hospital is quickly approaching critical mass with every room at full capacity.
My wife was planning on suing you guys. I don't know what to tell you.
We get it.
No, you don't.
Most important person.
Here four times longer than anybody.
I just checked in on this. You're still in line.
What position in line? How do I know if we're moving closer or farther? And all these people are coming, and we just get bumped down again and again. And my wife is going to go blind.
I just checked in and you're still in line.
Look good. Do you want to check vitals? That's the best you can do?
It's the best we can do. There are tons of people here.
Yeah, I see that. We've been here longer than all of them.
I think what's really difficult to grapple with is that on a normal day in the emergency room, many of these debilitating injuries could be resolved. But because it is a mass casualty incident, you have to pick and choose and ultimately try to save the most number of lives possible. This means making really difficult decisions like choosing to allow a patient to go blind because those resources need to be used to save the life of someone else. This is a patient that I miscategorized. Maybe she could have gotten treatment sooner if I hadn't messed that up.
I'm leaving.
Sir, sir.
I have scratches on my legs and I have a dog that's locked in...
These are all her current vitals. She got 2 milligrams of morphine and she has an IV in place.
Ma'am, Sophia and the child...
She's still looking for her child. Did we call...
What about the young child that came in earlier? Could that be her child?
Will you please get a child and a child leash?
Michelle, they want to see CT scan.
She's got a CT in.
Ma'am, it's very easy to freeze, to feel overwhelmed. And I'm worried about Michelle feeling that emotion in the midst of all of the drama that's ongoing, patients screaming, family members getting angry about time. Hello?
Oh. I didn't close it. Sir, if you continue to raise your voice, I'm going to have to ask you to leave. Please, please, please cooperate with her.
Come on, squeeze, squeeze, squeeze, squeeze. You need to be able to snap yourself out of it quickly in order to respond to the call that is your patients.
Can you talk to us?
Started a BVM.
Can you wake up? Can we just move him down a couple more inches, get her out, and then we can put her on the table?
Sir, you called him red, but he's agonally breathing. He hasn't been responsive since you've seen him. Then I think we need to have to move him to black.
Okay.
Make choices. Make choices.
Go with the...
Due to my mistakes, every red room is completely full. And there was a chance that if I had been more efficient with my resource allocation, there would have been space available, and we could have saved this patient. But I didn't, and so I have to make the really difficult choice to give him a black tag.
Having to be so objective about black tag is horrible, especially in a situation where if it wasn't an MCI, we could have done chest compressions to try and save them. But to actively have to say we have to walk away from this person, that's so hard.
So we will have to get the name, which I'll go get with the EMTs, just for the toe tag.
I feel so overloaded with stimuli and decision-making fatigue that I feel like I just need to sit in the quiet for a minute and look at a wall for a few hours.
Yeah.
I have no good news for anyone and emotionally, not being able to provide closure is very difficult for me and in general. Brett?
Yes.
The black-tag patient that came in...
Yeah.
Was he at the construction site with the other two?
That is part of the construction crew.
With HIPAA, are we allowed to tell them?
Just making sure.
On this.
Sir, can you hear my voice? They did recover Brunson. He came to the hospital, but when he arrived, he was unresponsive. He's unfortunately passed. I just wanted to tell you because you were asking about him.
Thank you.
I'm very sorry to tell you this news.
What we're going to experience and show the general public with this MCI is happening at scale with our healthcare system. We are facing a tremendous shortage, stress, difficulties trying to give them care with limited resources. So, if you don't want this MCI style of healthcare, we need to make changes, and I'm hoping that it starts with being kind to our healthcare frontline workers, being gracious when you're going in and understanding that they too are humans first and are under tremendous amount of stress. Second, understanding how beautiful and limited life is, that it can be pulled away from you at any moment, and you need to be grateful for it.
You ready for your grade?
Okay. If we had to break up the categories for which we grade Michelle, we start with triage, so we're going to have to give her an F on that one because there were times where she was a bit panicked, she was starting to get caught up. Treatment, I'll give her a B minus. She didn't know exactly what to do in a lot of the scenarios, not surprisingly so, but then where she really was shining is in communication.
Just being able to work with your team and to move people around and to prioritize and to keep checking in, that is really what would save lives in a situation like this.
For a human being to have to be the decision-maker, even just today having the microscopic taste of what that means and what that feels like, I have infinite love and admiration for anyone who does this profession.
Most people at any given moment are not sick, but I can say with a 100% certainty there will be a moment where
They will be sick, where they need care. Think about habits that you can change in your life that you can improve your health to perhaps have a better quality of life for longer.
This episode is dedicated to healthcare professionals everywhere who save lives every single day in real life. If you enjoyed this episode, please consider subscribing, and you can check out this other episode I did where I worked a real 24-hour paramedic shift in a real ambulance. If you enjoyed this episode, I think you're going to love that one. Till then, I'll see you in the next challenge.
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