COMMON PERSONS / UNCOMMON VALOR

45 Seconds:  Memoirs of an ER Doctor from May 22, 2011.

My name is Dr. Kevin Kikta, and I was one of two emergency room doctors who were on duty at St. John's Regional Medical Center in Joplin, MO on Sunday May 22, 2011. 
You never know that it will be the most important day of your life until the day is over.  The day started like any other day for me: waking up, eating, going to the gym, showering, and going to my 4:00 pm ER shift.  As I drove to the hospital I mentally prepared for my shift as I always do, but nothing could ever have prepared me for what was going to happen on this shift.  Things were normal for the first hour and half.  At approximately 5:30 pm we received a warning that a tornado had been spotted. . Although I work in Joplin and went to medical school in Oklahoma, I live in New Jersey, and I have never seen or been in a tornado.  I learned that a "code gray" was being called.  We were to start bringing patients to safer spots within the ED and hospital.

At 5: 42pm 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, while others scattered to various places, to the only place that I was familiar with in the hospital without windows, a small doctor's office in the ED. Together, Shilo and I tremored 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.  We suffered this in complete darkness, unaware of anyone else's status, worried, scared. We could feel a tight pressure in our heads as the tornado annihilated the hospital and the surrounding area.  The whole process took about 45 seconds, but seemed like eternity. The hospital had just taken a direct hit from a category EF-4 tornado.

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 loses.

"Like a bomb went off."  That's the only way that I can describe what we saw next.  Patients were coming into the ED in droves.  It was absolute, utter chaos.  They were limping, bleeding, crying, terrified, with debris and glass sticking out of them, just thankful to be alive.  The floor was covered with about 3 inches of water; there was no power, not even backup generators, rendering it completely dark and eerie in the ED.  The frightening aroma of methane gas leaking from the broken gas lines permeated the air; we knew, but did not dare mention aloud, what that meant.  I redoubled my pace.
We had to use flashlights to direct ourselves to the crying and wounded.  Where did all the flashlights come from?  I'll never know, but immediately, and thankfully, my years of training in emergency procedures kicked in.  There was no power, but our mental generators, were up and running, and on high test adrenaline.  We had no cell phone service in the first hour, so we were not even able to call for help and backup in the ED.

I remember a patient in his early 20's gasping for breath, telling me that he was going to die.  After a quick exam, I removed the large shard of glass from his back, made the clinical diagnosis of a pneumothorax (collapsed lung) and gathered supplies from wherever I could locate them to insert a thoracostomy tube in him.  He was a trooper; I'll never forget his courage.  He allowed me to do this without any local anesthetic since none could be found. With his life threatening injuries I knew he was running out of time, and it had to be done.  Quickly.  Imagine my relief when I heard a big rush of air, and breath sounds again; fortunately, I was able to get him transported out. I immediately moved on to the next patient, .an asthmatic in status asthmaticus.  We didn't even have the option of trying a nebulizer treatment or steroids, but I was able to get him intubated using a flashlight that I held in my mouth.  A small 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. Fortunately, we were able to get him immobilized with towels, and start an IV with fluids and pain meds before shipping him out.  We felt paralyzed and helpless ourselves.  I didn't even know a lot of the RN's I was working with.  They were from departments scattered all over the hospital. It didn't matter.  We worked as a team, determined to save lives.  There were no specialists available -- my orthopedist was trapped in the OR.  We were it, and we knew we had to get patients out of the hospital as quickly as possible.  As we were shuffling them out, the fire department showed up and helped us to evacuate.  Together we worked furiously; motivated by the knowledge and fear that the methane leaks could cause the hospital could blow up at any minute.

Things were no better outside of the ED. 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.  Wounded people were walking, staggering, all over, dazed and shocked.  All around us was chaos, reminding me of scenes in a war movie, or newsreels from bombings in Bagdad.  Except this was right in front of me and it had happened in just 45 seconds.  My own car was blown away.  Gone.  Seemingly evaporated.  We searched within a half mile radius later that night, but never found the car, only the littered, crumpled remains of former cars, and a John Deere tractor that had blown in from miles away.

Tragedy has a way of revealing human goodness.  As I worked, surrounded by devastation and suffering, I realized I was not alone.  The people of the community of Joplin were absolutely incredible.  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 (although I'm sure overwhelmed).  I carried on, grateful for the help of the community.  At one point I had placed a conscious intubated patient in the back of a pickup truck with someone, a layman, for transport. The patient was self- ventilating himself, and I gave instructions to someone with absolutely no medical knowledge on how to bag the patient until they got to Freeman.

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.

We continued to carry patients out of the hospital on anything that we could find: sheets, stretchers, broken doors, mattresses, wheelchairs-anything that could be used as a transport mechanism.
As I finished up what I could do at St John's, I walked with two RN's, Shilo Cook and Julie Vandorn, to a makeshift MASH center that was being set up miles away at Memorial Hall.  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.
By this time news crews and photographers were starting to swarm around, and we were able to get a ride to Memorial Hall from another RN.  The chaos was slightly more controlled at Memorial Hall.  I was relieved to see many of my colleagues, doctors from every specialty, helping out.  It was amazing to be able to see life again.  It was also amazing to see how fast workers mobilized to set up this MASH unit under the circumstances. Supplies, food, drink, generators, exam tables, all were there-except pharmaceutical pain meds. I sutured multiple lacerations, and splinted many fractures, including some open with bone exposed, and then intubated another patient with severe COPD, slightly better controlled conditions this time, but still less than optimal.
But we really needed pain meds.  I managed to go back to the St John's with another physician, pharmacist, and a sheriff's officer. Luckily, security let us in to a highly guarded pharmacy to bring back a garbage bucket sized supply of pain meds.

At about midnight I walked around the parking lot of St. John's with local law enforcement officers looking for anyone who might be alive or trapped in crushed cars.  They spray painted "X"s on the fortunate vehicles that had been searched without finding anyone inside. The unfortunate vehicles wore "X's" and sprayed-on numerals, indicating the  number of  dead inside,  crushed in their cars, cars  which now resembled flattened  recycled aluminum cans the tornado had crumpled  in her iron hands,  an EF4 tornado, one of the worst in history, whipping through this quiet town with demonic strength.  I continued back to Memorial hall into the early morning hours until my ER colleagues told me it was time for me to go home.  I was completely exhausted.  I had seen enough of my first tornado. 
How can one describe these indescribable scenes of destruction?  The next day I saw news coverage of this horrible, deadly tornado.  It was excellent coverage, and Mike Bettes from the Weather Channel did a great job, but there is nothing that pictures and video can depict compared to seeing it in person. That video will play forever in my mind.

I would like to express my sincerest gratitude to everyone involved in helping during this nightmarish disaster.  My fellow doctors, RN's, techs, and all of the staff from St. John's.  I have worked at St John's for approximately 2 years, and I have always been proud to say that I was a physician at St John's in Joplin, MO.  The smart, selfless and immediate response of the professionals and the community during this catastrophe proves to me that St John's and the surrounding community are special.  I am beyond proud

To the members of this  community, the  health care workers from states away,  and especially Freeman Medical Center, I commend everyone on unselfishly coming together and giving 110% the way that you all did, even in your own time of need. St John's Medical Center is gone, but her spirit and goodness lives on in each of you.
EMS, you should be proud of yourselves.  You were all excellent, and did a great job despite incredible difficulties and against all odds
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 whole heartedly.
Last, but not least, thank you, and God Bless you, Mercy/St John 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. 

Sincerely,
Kevin J. Kikta, DO
Department of Emergency Medicine
Mercy/St John's Regional Medical Center, Joplin, MO
 

                                Land of the Lawless

When the Law Does Not Pay

I do not think in California there is much law these days. We are regressing to the days of my grandfather's stories. He used to relate to me a wild Central Valley circa 1900, when the sheriff was a day away. A neighbor down the road is now openly violating county zoning regulations by simply moving in immobile Winnebago's and creating a sort of ad hoc mobile home park - with jerry-rigged electricity, sewage, and water. "Restaurants" pop up around my farm along the side of the road, exempt from state and local inspection, apparently by parking a canteen, plopping down some plastic chairs, an awning, a porta-potty, a hose - and, presto, we have an eatery, with signs no less.

There are no dumping laws enforced in rural California: stopping the guy who throws out his garbage and a sofa is a money-loser; finding the guy in the Mercedes who uses his cell phone is a money-winner.

Yet most state lawlessness out here is predicated on priorities of enforcement and driven by public employee unions who see us the people in terms of "fees" and "fines" to feed their salaries, perhaps in the way the Thanksgiving chef eyes the roasting turkey amid hungry mouths.

AWOL in Washington.

The new lawlessness at the federal level, however, is far more serious, because it is predicated on "social justice": those deemed "in need" shall be exempt from the law; those "not in need" shall not.

The War Powers Resolution, like it or not, is the law of the land. It requires the president to notify Congress within 48 hours of committing armed forces to military action. Without an authorization of the use of military force or a declaration of war, the military cannot remain in combat abroad. That's why George W. Bush went to Congress to authorize the Afghanistan and Iraq wars. During the heated rhetoric over the Iranian missile controversy, presidential and vice-presidential candidates Obama and Biden both expressed support for the resolution - apparently outraged that Bush might unilaterally bomb Iran without notifying a Senator like themselves.

So when we recently passed the 60-day limit after the initial and continual use of armed forces in Libya, why did not Obama seek permission from Congress?

Here the question is not the usual Obama hypocrisy that has seen him demagogue and damn Guantanamo, preventative detention, tribunals, renditions, the Patriot Act (just signed by a former critic via computerized autopen from the UK no less), and Predators - only to expand or embrace them all. Rather, the problem is a question of legality itself.

Is the War Powers Resolution the law of the land or not? Or are we to assume a progressive president is complying with both UN resolutions and an Arab League mandate, and therefore, as the good internationalist and Nobel laureate, sees no reason to consult, as American law requires, his own elected U.S. Congress - the latter a more suspect and reactionary body that does not enjoy the moral stature of the UN or the Arab League?

This disregard reminds us of the shake-down of BP, when the administration more or less declared by fiat that the demonized corporation had to cough up a $20 billion contingency clean-up fund - reminiscent of someone in the classical Athenian ekklesia or late 18th-century French assembly going after the better off by mere proclamation.

In that regard, an administration is sworn to uphold the established law; why, then, was the Defense of Marriage Act arbitrarily rendered null and void without legislative appeal, simply because it was considered illegal by those now with executive power? Can President Obama and Attorney General Holder de facto declare a law unconstitutional and then not enforce it? Could a renegade conservative counterpart likewise declare Roe vs. Wade unconstitutional, and go after abortionists because it deemed them too liberal?

Or perhaps a better example is the bailout to Chrysler that was contingent upon reversing the contractual order of creditors, putting union members and retirees, contrary to law, to the front of the line, and those who held Chrysler debt to the rear. Was the logic something like the following spread-the-wealth notion: Bondholders are wealthier anyway and so have enough money already; union members - and Democratic stalwarts - actually do the work, and so have a moral claim to the money that trumps the superfluous legal right of the wealthy and powerful?

Or we might ponder the administrative decision by bureaucratic decree to stop a company like Boeing from opening a new airline production line in South Carolina, purportedly because it is a red, right-to-work state. Again, the logic is that companies cannot open factories where they wish, since they have moral obligations that must stand above a mere legal notion of freedom of commerce and association.

Do we remember the voter intimidation case dropped against the Black Panthers - on the supposition that, given the history of the poll tax and Jim Crow voter discrimination, a little minor pushback is small potatoes?

Then we come to federal immigration law, or rather the deliberate effort to undermine it - in a fashion that goes well beyond the neglect of the law shown by previous administrations. The Obama administration is going to court, along with Mexico, to sue the state of Arizona that is trying to find ways to bolster a federal law that the administration will not enforce.

But it gets worse: the Obama administration tries to subvert states that wish to follow its own laws, but ignores cities that deliberately flaunt them by declaring themselves "sanctuary cities." And consider entire states like California, whose Assembly just passed its own version of the "Dream Act" to provide millions in state funds to support illegal aliens at the state-run colleges and universities (at a time when the state is $15 billion short in balancing its annual budget, and, due to such a shortage of funds, must release 40,000 prisoners because of an inability to comply with a court order addressing overcrowding).

By now we know the accustomed logic. Demonize those who would seek to obey the law (e.g., they wish to arrest kids on their way to ice cream, they want alligators and moats in the Rio Grande, they are "enemies" that Latinos should "punish," they have already "basically"

finished their fence) and apotheosize those who break it (e.g., no mention of the 20,000-30,000 illegal alien felons in the California penal system).

A Slippery Slope

I find all this quite frightening for a variety of reasons. Once the moral high ground is claimed, and then legality is constructed as some sort of reactionary impediment in the way of egalitarian "fairness."

The process works geometrically: each time the federal government rules by fiat instead of following the law - for reasons of humanitarianism abroad, ecological responsibility, worker fairness, gay rights, or empathy for the alien - it becomes a little bolder the next time.

The Left simply disregards its former purported role as guardians of constitutional law, and grows quiet, again on the apparent logic that the rare progressive presidency is simply too precious a commodity to endanger by maintaining any consistent criticism in the manner it once went after the Bush administration.

Imagine the reaction of the New York Times, NPR, or a Senator Obama had a President Palin decided to bomb Iran off and on for 70 days without congressional consultation, or had she decided to throw open the U.S. border to any from Europe who could fly in, or had she violated union contracts to favor junior Wall Street creditors, or had she demanded that an Al Gore organization plop down several million in a contingency fund for the damage it had done oil workers by obstructing efforts of companies to gain oil leases.

Where does this end, this effort by Ivy League lawyers and civil libertarians to substitute supposedly enlightened progressivism for purported reactionary law? We easily and rightly condemn the crime when the Right tries to overthrow legality in the cases of a Franco, Hitler, Greek colonels, or Pinochet, who are easily identified as autocrats and dictators openly subverting constitutional government.

But the assault from the Left is more insidious, given that the miscreants do it in self-declared high-minded fashion for "us." I think here of the frightening trial of Socrates in ancient Athens, the ascendency of the Jacobins during the French Revolution, or Hugo Chavez's thuggery in Venezuela - not coups as much as overdue punishment of "them."

Without the law, there is nothing.

Victor Davis Hanson - May 30, 2011

 Classes forming now for 2012