- Email: [email protected]
Reaping the Whirlwind
Dr. Sachetti added that he actually finds physicians of his generation more willing to work punishing schedules than physicians just out of training, who were raised with different expectations of work-life balance. “We had one young person who said, ‘I need 2 days off after a nightshift’; he didn’t quite fit,” Dr. Sachetti said. “I have colleagues about my age who have busy departments, who have told me the same thing.” At the moment, all of the medical specialties, emergency medicine included, assume that their diplomates are like Dr. Sachetti: sharp, current in their skills, and engaged in their practice. Similarly, they all rely on physicians to selfassess their competence. None so far have taken steps that would help institutions or groups evaluate physicians whose selfassessment is incomplete. Richard Goldberg, MD, clinical professor of emergency medicine at University of Southern California and a member of the ACEP’s Task Force on Emergency Physicians in the Pre-Retirement Years, offers himself as an example. “As a 68-year-old, I am well aware of what limitations I should put on my practice,” he said. “I have a tremor that interferes with my fine motor control, to the point where I should not suture or remove a foreign body from an eye.”
But, he points out, if he were not aware of those limitations, it would be up to his colleagues to initiate the difficult conversation with him, and they would not have access to objective measures of his performance that could help them. “As was done in the airline industry, I believe there should be rigorous performance standards and special attention paid to older physicians in terms of skills and cognitive ability,” he said. “It would be a monumental undertaking in a specialty such as emergency medicine, where the need to think rapidly and to be able to multitask is so necessary. There should be ways of measuring that among older practitioners, and accommodating to the expected decline in ability to perform along certain lines.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. doi:10.1016/j.annemergmed.2011.07.003
REFERENCES 1. Stolley PD, Becker MH, Lasagna L, et al. The relationship between physician characteristics and prescribing
Reaping the Whirlwind Emergency Physician Recounts His Fateful Brush With Deadly Twister in Joplin, MO
By MARYN McKENNA Special Contributor to Annals News & Perspective
T
he day started like any routine Sunday. Kevin Kikta, DO, woke in the hotel room he occupies one third of every month, ate, showered, went to the gym, and drove to the start of his 4 PM shift as a locum tenens emergency physician. Volume , . : September
What he found when he got there made him think the day would continue to be routine. About 18 of the 24 beds were full, with a normal mix of patients: some injuries, an unstable angina, a psychiatric patient needing evaluation. As it turned out, the day would be anything but normal. It was May 22, 2011. Less than 2 hours into his shift, it struck: a category EF5 tornado, the deadliest in more than 50 years, which tore
2.
3.
4.
5.
6.
7.
8.
9.
appropriateness. Med Care. 1972;10:17-28. O’Neill L, Lanska DJ, Hartz A. Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy. Neurology. 2000;55: 773-781. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med. 2002;77(10 suppl):S1-6. Neumayer LA, Gawande AA, Wang J, et al. Proficiency of surgeons in inguinal hernia repair: effect of experience and age. Ann Surg. 2005;242:344-348; discussion 348-352. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142: 260-273. Weinberger SE, Duffy FD, Cassel CK. “Practice makes perfect”...or does it? Ann Intern Med. 2005;142:302-303. Goldberg R, Thomas H, Penner L. Issues of concern to emergency physicians in pre-retirement years: a survey. J Emerg Med. 2011;40:706-713. American College of Emergency Physicians. Considerations for emergency physicians in pre-retirement years. Available at: http://www.acep.org/ Content.aspx?id⫽45899&terms⫽aging% 20physician. Accessed April 19, 2011. American Board of Emergency Medicine. Longitudinal study of emergency physicians. Available at: http://www. abem.org/PUBLIC/portal/alias__ Rainbow/lang__en-US/tabID__3890/ DesktopDefault.aspx. Accessed April 18, 2011.
through Joplin, MO, and made a direct hit on his workplace, St. John’s Regional Medical Center.1 At 5:42 PM a security guard yelled to everyone, “Take cover! We are about to get hit by a tornado!” I ran with a pregnant RN, Shilo Cook... to the only place that I was familiar with in the hospital without windows, a small doctor’s office in the [emergency department] ED. Together, Shilo and I trembled and huddled under a desk. We heard a loud horrifying sound like a large locomotive ripping through the hospital. The whole hospital shook and vibrated as we heard glass shattering, light bulbs popping, walls collapsing, people screaming, the ceiling caving in above us, and water pipes breaking, showering water down on everything.2 Dr. Kikta is 40 years old, a New Jersey native who ended up in Missouri alAnnals of Emergency Medicine 17A
most by chance. His home ED is Trinitas Regional Medical Center in Elizabeth, NJ, not far from where he completed his residency in Newark— but he went to medical school at the Oklahoma State University College of Osteopathic Medicine, and 2 years ago, he bumped into a classmate from there. The classmate had become an ED director in Joplin. If Dr. Kikta was going to do locum work, his friend said, he owed it to himself to check the city out.
He went for a visit. He liked the place at once. “It’s a stellar running hospital,” he said. “My door-to-balloon times are 30 minutes—incredible. I felt extremely comfortable there.” He began commuting from New Jersey, where his father and girlfriend live, working 4 days on, a day off, and then 4 more. Then disaster struck, and time stood still.
45 LONG SECONDS
W
e could feel a tight pressure in our heads... . Then it was over. Just 45 seconds. 45 long seconds. We looked at each other, terrified, and thanked God that we were alive. We didn’t know, but hoped that it was safe enough to go back out to the ED, find the rest of the staff and patients, and assess our losses... . The floor was covered with about 3 inches of water, there was no power, 18A Annals of Emergency Medicine
not even backup generators, rendering it completely dark and eerie in the ED. The frightening aroma of gas leaking from the broken gas lines permeated the air.2 When they opened the door to the windowless room they had hidden in, Dr. Kikta and Ms. Cook thought they were the ED’s only survivors. The rubble was backlit by a narrow shaft of daylight; the ceiling panels had fallen and the wind had torn off part of the roof, exposing the ED to the sky. Then he heard screaming. Flashlight beams arrowed through the dust. He walked in a tight circle, groping for landmarks, trying to find his staff and patients. He heard a noise and looked up: Already, victims were limping and stumbling through the ambulance bay doors. Some of them were being pushed in wheelchairs that had blown into the parking lot. There was a man in his 20s gasping for breath: A shard of glass had pierced his back and collapsed one lung. There was no anesthetic anywhere; Dr. Kikta punched the thoracostomy tube in without it and was rewarded with a rush of air. An older man was in status asthmaticus; Dr. Kikta performed a rapid sequence intubation, holding a flashlight between his teeth. Nurses and physicians he had never seen before, refugees from elsewhere in the hospital, reached out to help him. Later, he would learn that ED staff had flung themselves on top of patients to protect them and that their desperately needed orthopedist was trapped in the operating room, unable to climb past the rubble. A child of approximately 3⫺4 years of age was crying; he had a large avulsion of skin to his neck and spine. The gaping wound revealed his cervical spine and upper thoracic spine bones. I could actually count his vertebrae with my fingers. This was a child, his whole life ahead of him, suffering life-threatening wounds in front of me, his eyes pleading me to help him... . We could not find any pediatric C-collars in the darkness, and water from the shattered main pipes was once again showering down upon all of us. We were able to get him immobilized with towels, and start an IV.2 There were no triage bracelets or toe tags; the staff marked the patients with masking tape, writing down any data they could extract from the wounded:
name, date of birth, town. There was no suction, no cardiac monitor, no pulse oximetry. With no electricity and no generator, there was no way to get into the automated medication cabinets, until they smashed open its glass front. “Every hospital I’ve ever worked in, we’ve done disaster drills: a bus turning over, an airplane crash,” Dr. Kikta said. “But you always have full power, you always have light, you always have every available resource. I’ve never done a disaster drill where you are the disaster. I’ve never gone chartless in my life.” Within minutes of the horrific event, local residents showed up in pickups and sport utility vehicles, all offering to help transport the wounded to other facilities, including Freeman, the trauma center literally across the street. Ironically, it had sustained only minimal damage and was functioning... . Within hours I estimated that over 100 EMS units showed up from various towns, counties and four different states. Considering the circumstances, their response time was miraculous. Roads were blocked with downed utility lines, smashed up cars in piles, and they still made it through.2 “We started looking at each other, saying, ‘We don’t have enough ambulances—we have to get these people out of here,’” Dr. Kikta said. “We had one guy, on a trach, alert, being bagged. We put him in the back of a pickup, put a guy in with him and said, ‘Here, squeeze this 15 times a minute.’” About midnight, Dr. Kikta went outside with some police officers. They had brought an update: A mobile surgical unit was triaging victims at Memorial Hall, an elegant 1920s stone building about 3 miles away. Dr. Kikta helped the police patrol the parking lot, searching flattened cars for survivors or bodies. Empty cars were spraypainted with an X: They had been checked. When there were corpses, the police added a number to indicate how many bodies were crushed within. Dr. Kikta looked for his own car. It was gone, sucked away by the wind, carrying the credit cards, identification, and cash he had stashed in the glove box to keep them out of the ED. The tornado had dropped a John Deere tractor and a crumpled helicopter in its place. Volume , . : September
I saw a man crushed under a large SUV, still alive, begging for help; another one was dead, impaled by a street sign through his chest . . . . We walked where flourishing neighborhoods once stood, astonished to see only the disastrous remains of flattened homes, body parts, and dead people everywhere. I saw a small dog just whimpering in circles over his master who was dead, unaware that his master would not ever play with him again. At one point we tended to a young woman who just stood crying over her dead mother who was crushed by her own home. The young woman covered her mother up with a blanket and then asked all of us, “What should I do?” We had no answer for her, but silence and tears.2 He worked until 4 AM, suturing lacerations and splinting open fractures. Sometime that night, his mother found him. She is an obstetrician-gynecologist in Tulsa and had driven 110 miles to get there, showing her identification to get past the police cordons. She had texted him after the tornado, asking if he was all right. With cell coverage gone, he had never gotten the message. She had seen the shots of the devastated hospital on television and feared he was dead. Dr. Kikta’s next shift was scheduled for the following afternoon, but his director told him to go home, wherever that might be for the time being. A few days later, he went to the Tulsa airport, explained to the
Volume , . : September
Transportation Security Administration officers why he had no identification to show them, submitted to a background check, and flew home to New Jersey. He returned to Joplin in mid-June.
“I want to go back,” he said just before leaving. “I want to be part of the rebuilding. The day that emergency room opens again, I want to watch the opening ceremony. I feel this created a lifetime bond.” For all of the injured who I treated, although I do not remember your names (nor would I expect you to remember mine) I will never forget your faces. I’m glad that I was able to make a difference and help in the best way that I knew how, and hopefully give some of you a chance at rebuilding your lives again. For those whom I was not able to get to or treat, I apologize wholeheartedly.
Thank you and God bless you, Mercy/St John’s, for providing incredible care in good times and even more so, in times of the unthinkable, and for all the training that enabled us to be a team and treat the people and save lives.2 This story is based on interviews with Dr. Kikta and on an essay he wrote immediately after the disaster that was posted to the Web page of Sisters of Mercy Health System. Used by permission. Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author have stated that no such relationships exist. doi:10.1016/j.annemergmed.2011.07.004
REFERENCES 1. Sulzberger AG, Stelter B. A rush to protect patients, then bloody chaos. New York Times. May 24, 2011:A1. Available at: http://www.nytimes.com/2011/05/24/us/ 24tornado.html. Accessed June 6, 2011. 2. Kikta K. 45 Seconds: memoirs of an ER doctor from May 22, 2011. May 25, 2011. Available at: http://www.mercy. net/joplin/stories-of-mercy/45-seconds. Accessed May 29, 2011.
Annals of Emergency Medicine 19A
But, he points out, if he were not aware of those limitations, it would be up to his colleagues to initiate the difficult conversation with him, and they would not have access to objective measures of his performance that could help them. “As was done in the airline industry, I believe there should be rigorous performance standards and special attention paid to older physicians in terms of skills and cognitive ability,” he said. “It would be a monumental undertaking in a specialty such as emergency medicine, where the need to think rapidly and to be able to multitask is so necessary. There should be ways of measuring that among older practitioners, and accommodating to the expected decline in ability to perform along certain lines.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. doi:10.1016/j.annemergmed.2011.07.003
REFERENCES 1. Stolley PD, Becker MH, Lasagna L, et al. The relationship between physician characteristics and prescribing
Reaping the Whirlwind Emergency Physician Recounts His Fateful Brush With Deadly Twister in Joplin, MO
By MARYN McKENNA Special Contributor to Annals News & Perspective
T
he day started like any routine Sunday. Kevin Kikta, DO, woke in the hotel room he occupies one third of every month, ate, showered, went to the gym, and drove to the start of his 4 PM shift as a locum tenens emergency physician. Volume , . : September
What he found when he got there made him think the day would continue to be routine. About 18 of the 24 beds were full, with a normal mix of patients: some injuries, an unstable angina, a psychiatric patient needing evaluation. As it turned out, the day would be anything but normal. It was May 22, 2011. Less than 2 hours into his shift, it struck: a category EF5 tornado, the deadliest in more than 50 years, which tore
2.
3.
4.
5.
6.
7.
8.
9.
appropriateness. Med Care. 1972;10:17-28. O’Neill L, Lanska DJ, Hartz A. Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy. Neurology. 2000;55: 773-781. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med. 2002;77(10 suppl):S1-6. Neumayer LA, Gawande AA, Wang J, et al. Proficiency of surgeons in inguinal hernia repair: effect of experience and age. Ann Surg. 2005;242:344-348; discussion 348-352. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142: 260-273. Weinberger SE, Duffy FD, Cassel CK. “Practice makes perfect”...or does it? Ann Intern Med. 2005;142:302-303. Goldberg R, Thomas H, Penner L. Issues of concern to emergency physicians in pre-retirement years: a survey. J Emerg Med. 2011;40:706-713. American College of Emergency Physicians. Considerations for emergency physicians in pre-retirement years. Available at: http://www.acep.org/ Content.aspx?id⫽45899&terms⫽aging% 20physician. Accessed April 19, 2011. American Board of Emergency Medicine. Longitudinal study of emergency physicians. Available at: http://www. abem.org/PUBLIC/portal/alias__ Rainbow/lang__en-US/tabID__3890/ DesktopDefault.aspx. Accessed April 18, 2011.
through Joplin, MO, and made a direct hit on his workplace, St. John’s Regional Medical Center.1 At 5:42 PM a security guard yelled to everyone, “Take cover! We are about to get hit by a tornado!” I ran with a pregnant RN, Shilo Cook... to the only place that I was familiar with in the hospital without windows, a small doctor’s office in the [emergency department] ED. Together, Shilo and I trembled and huddled under a desk. We heard a loud horrifying sound like a large locomotive ripping through the hospital. The whole hospital shook and vibrated as we heard glass shattering, light bulbs popping, walls collapsing, people screaming, the ceiling caving in above us, and water pipes breaking, showering water down on everything.2 Dr. Kikta is 40 years old, a New Jersey native who ended up in Missouri alAnnals of Emergency Medicine 17A
most by chance. His home ED is Trinitas Regional Medical Center in Elizabeth, NJ, not far from where he completed his residency in Newark— but he went to medical school at the Oklahoma State University College of Osteopathic Medicine, and 2 years ago, he bumped into a classmate from there. The classmate had become an ED director in Joplin. If Dr. Kikta was going to do locum work, his friend said, he owed it to himself to check the city out.
He went for a visit. He liked the place at once. “It’s a stellar running hospital,” he said. “My door-to-balloon times are 30 minutes—incredible. I felt extremely comfortable there.” He began commuting from New Jersey, where his father and girlfriend live, working 4 days on, a day off, and then 4 more. Then disaster struck, and time stood still.
45 LONG SECONDS
W
e could feel a tight pressure in our heads... . Then it was over. Just 45 seconds. 45 long seconds. We looked at each other, terrified, and thanked God that we were alive. We didn’t know, but hoped that it was safe enough to go back out to the ED, find the rest of the staff and patients, and assess our losses... . The floor was covered with about 3 inches of water, there was no power, 18A Annals of Emergency Medicine
not even backup generators, rendering it completely dark and eerie in the ED. The frightening aroma of gas leaking from the broken gas lines permeated the air.2 When they opened the door to the windowless room they had hidden in, Dr. Kikta and Ms. Cook thought they were the ED’s only survivors. The rubble was backlit by a narrow shaft of daylight; the ceiling panels had fallen and the wind had torn off part of the roof, exposing the ED to the sky. Then he heard screaming. Flashlight beams arrowed through the dust. He walked in a tight circle, groping for landmarks, trying to find his staff and patients. He heard a noise and looked up: Already, victims were limping and stumbling through the ambulance bay doors. Some of them were being pushed in wheelchairs that had blown into the parking lot. There was a man in his 20s gasping for breath: A shard of glass had pierced his back and collapsed one lung. There was no anesthetic anywhere; Dr. Kikta punched the thoracostomy tube in without it and was rewarded with a rush of air. An older man was in status asthmaticus; Dr. Kikta performed a rapid sequence intubation, holding a flashlight between his teeth. Nurses and physicians he had never seen before, refugees from elsewhere in the hospital, reached out to help him. Later, he would learn that ED staff had flung themselves on top of patients to protect them and that their desperately needed orthopedist was trapped in the operating room, unable to climb past the rubble. A child of approximately 3⫺4 years of age was crying; he had a large avulsion of skin to his neck and spine. The gaping wound revealed his cervical spine and upper thoracic spine bones. I could actually count his vertebrae with my fingers. This was a child, his whole life ahead of him, suffering life-threatening wounds in front of me, his eyes pleading me to help him... . We could not find any pediatric C-collars in the darkness, and water from the shattered main pipes was once again showering down upon all of us. We were able to get him immobilized with towels, and start an IV.2 There were no triage bracelets or toe tags; the staff marked the patients with masking tape, writing down any data they could extract from the wounded:
name, date of birth, town. There was no suction, no cardiac monitor, no pulse oximetry. With no electricity and no generator, there was no way to get into the automated medication cabinets, until they smashed open its glass front. “Every hospital I’ve ever worked in, we’ve done disaster drills: a bus turning over, an airplane crash,” Dr. Kikta said. “But you always have full power, you always have light, you always have every available resource. I’ve never done a disaster drill where you are the disaster. I’ve never gone chartless in my life.” Within minutes of the horrific event, local residents showed up in pickups and sport utility vehicles, all offering to help transport the wounded to other facilities, including Freeman, the trauma center literally across the street. Ironically, it had sustained only minimal damage and was functioning... . Within hours I estimated that over 100 EMS units showed up from various towns, counties and four different states. Considering the circumstances, their response time was miraculous. Roads were blocked with downed utility lines, smashed up cars in piles, and they still made it through.2 “We started looking at each other, saying, ‘We don’t have enough ambulances—we have to get these people out of here,’” Dr. Kikta said. “We had one guy, on a trach, alert, being bagged. We put him in the back of a pickup, put a guy in with him and said, ‘Here, squeeze this 15 times a minute.’” About midnight, Dr. Kikta went outside with some police officers. They had brought an update: A mobile surgical unit was triaging victims at Memorial Hall, an elegant 1920s stone building about 3 miles away. Dr. Kikta helped the police patrol the parking lot, searching flattened cars for survivors or bodies. Empty cars were spraypainted with an X: They had been checked. When there were corpses, the police added a number to indicate how many bodies were crushed within. Dr. Kikta looked for his own car. It was gone, sucked away by the wind, carrying the credit cards, identification, and cash he had stashed in the glove box to keep them out of the ED. The tornado had dropped a John Deere tractor and a crumpled helicopter in its place. Volume , . : September
I saw a man crushed under a large SUV, still alive, begging for help; another one was dead, impaled by a street sign through his chest . . . . We walked where flourishing neighborhoods once stood, astonished to see only the disastrous remains of flattened homes, body parts, and dead people everywhere. I saw a small dog just whimpering in circles over his master who was dead, unaware that his master would not ever play with him again. At one point we tended to a young woman who just stood crying over her dead mother who was crushed by her own home. The young woman covered her mother up with a blanket and then asked all of us, “What should I do?” We had no answer for her, but silence and tears.2 He worked until 4 AM, suturing lacerations and splinting open fractures. Sometime that night, his mother found him. She is an obstetrician-gynecologist in Tulsa and had driven 110 miles to get there, showing her identification to get past the police cordons. She had texted him after the tornado, asking if he was all right. With cell coverage gone, he had never gotten the message. She had seen the shots of the devastated hospital on television and feared he was dead. Dr. Kikta’s next shift was scheduled for the following afternoon, but his director told him to go home, wherever that might be for the time being. A few days later, he went to the Tulsa airport, explained to the
Volume , . : September
Transportation Security Administration officers why he had no identification to show them, submitted to a background check, and flew home to New Jersey. He returned to Joplin in mid-June.
“I want to go back,” he said just before leaving. “I want to be part of the rebuilding. The day that emergency room opens again, I want to watch the opening ceremony. I feel this created a lifetime bond.” For all of the injured who I treated, although I do not remember your names (nor would I expect you to remember mine) I will never forget your faces. I’m glad that I was able to make a difference and help in the best way that I knew how, and hopefully give some of you a chance at rebuilding your lives again. For those whom I was not able to get to or treat, I apologize wholeheartedly.
Thank you and God bless you, Mercy/St John’s, for providing incredible care in good times and even more so, in times of the unthinkable, and for all the training that enabled us to be a team and treat the people and save lives.2 This story is based on interviews with Dr. Kikta and on an essay he wrote immediately after the disaster that was posted to the Web page of Sisters of Mercy Health System. Used by permission. Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author have stated that no such relationships exist. doi:10.1016/j.annemergmed.2011.07.004
REFERENCES 1. Sulzberger AG, Stelter B. A rush to protect patients, then bloody chaos. New York Times. May 24, 2011:A1. Available at: http://www.nytimes.com/2011/05/24/us/ 24tornado.html. Accessed June 6, 2011. 2. Kikta K. 45 Seconds: memoirs of an ER doctor from May 22, 2011. May 25, 2011. Available at: http://www.mercy. net/joplin/stories-of-mercy/45-seconds. Accessed May 29, 2011.
Annals of Emergency Medicine 19A