Editor’s Note: This is the first in a two part series by Dr. Melody Glenn on her experience as a physician at Standing Rock.

Author’s Note: This topic of this post is controversial.  Although I tried to be as factual as possible, due to the politically charged nature of the event, it was difficult to verify all of the information I heard and interpreted. Therefore, the content is just my opinion and based on limited experience. Any interactions I describe should not be taken as a complete reflection of the situation on the ground. The goal is to create a dialog about the nature of EMS and medical care in such scenarios. 

After arranging transport (a pickup truck, a good Samaritan, and a nurse) for a sick 30-year-old-woman to get to the Emergency Department in Bismarck, North Dakota, I start the half-hour trek through the snow and ice back to our satellite clinic. It’s Sunday, December 4th, and I’m volunteering as an emergency and disaster medicine physician at Standing Rock. When I finally make it back to the medical tent, one of the few places with heating (albeit by a small space heater powered by a generator) I find a man standing in the middle, intently changing all of the stations on my 4 walkie-talkies.

“Umm, can I help you?” I ask. When he turns to look at me, I realize that we met yesterday; he is the self-proclaimed “expert” in disaster management who rattled off various international conflicts that he supposedly attended. Just like many of the other volunteers at Standing Rock, he shows no credentials or proof of his identity.

“Yeah, you have all of the stations wrong. I’m fixing them.”

“Actually, they are on the right stations. Security is using channels 8, 11, 12 – they can’t agree on just one channel – and main medical is on the other radio.”

He scoffs, “Who told you that?”

“Amanda, the nurse in charge here,” I respond.

“Well, actually, we need to have a meeting to discuss that; that’s all going to be changing. Call all the other medics in. And you, you need to leave! The elders have said that everyone affiliated with UCSF needs to leave.”

Instead, I call in Amanda. She calls in a native leader from the Medic and Healer council. The Radio-Changer-Guy calls in a native man who is supposedly in charge of our campsite. And they all disagree about who is the boss and what we should do. I can’t believe this is happening. First, we couldn’t get any medical volunteers to stick around for more than five minutes before leaving to see the action at the “front lines.” Then, we had to deal with sorting boxes upon boxes of useless medical donations that people kept dropping off, including dozens of ice packs – useless in the 20 degree weather – that we threw into the giant trash heap that continued to stack higher and higher. Now, I’m in the middle of a mutiny in the medical tent, which happens to be occurring at the same time as the U.S. Army Corps of Engineers announcement that they have denied the easement required to build the Dakota Access Pipeline. Instead of celebrating, we’re delving deeper into the chaos. I start to question whether I made the right decision in coming here.

The events leading up to my involvement require some historical background. Since April, there have been protesters (who prefer the term “water protectors”) camping out by the Cannonball River in opposition to the Dakota Access Pipeline, particularly in terms of its negotiations with the Standing Rock Sioux. A patchwork of medical clinics popped up, and the Medic and Healer Council was formed to direct medical care for the water protectors. In late October, law enforcement set up a permanent barricade on Highway 1806, the main road between camp and Bismarck, dividing the proposed drilling site and the protester camps. Reportedly, ambulances had been turned away, increasing their travel time to the emergency department from 50 to 70 minutes (even longer during winter road conditions). North Dakota Governor Dalrymple also requested additional law enforcement personnel from nearby communities through existing mutual aid agreements. On November 20th, a group of protesters marched to the barricade, and were met with water cannons, tear gas, and rubber bullets.

On November 25th, the U.S. Army Corps of Engineers said that by December 5th, all protesters must leave “Corps-managed land,” which is the land to the North of the Cannonball River where the largest protester camp, Oceti Sakowin, was located. For decades, it has been contested as to who owns this land – the federal government or the Standing Rock Sioux. In response to the mandatory evacuation, about 15,000 activists, including 2,000 veterans, said they would come to Standing Rock around December 5th to show their support. On November 28th, North Dakota Governor Dalrymple issued an Executive Order further mandating that all protesters leave camp, and discouraging emergency service (EMS) from serving the area. I was surprised that instead of invoking mutual aid agreements to obtain more EMS for the influx of people, he was taking the approach of withdrawing medical care.

However, it seems like Morton County EMS’s de facto involvement at camp ended before this official declaration.  Currently, the water protectors are using Standing Rock EMS as their sole EMS provider. Unfortunately, they only have two ambulances, and the rest of the Standing Rock Sioux reservation also needs them.

As a physician working in EMS, I suffered some cognitive dissonance from the idea of EMS as a politicized entity. I am used to the belief that paramedics and ambulances provide emergency care to everyone who needs it. In the United States, most, if not all, states and counties prohibit medics from refusing to treat those who request emergency services. Where I work in San Francisco, ambulances are often involved with political protests, helping anyone injured – whether they are protesters or police. Nonetheless, protesters may affiliate EMS with law enforcement, as it is true that EMS is used to partnering with police and fire more than they are used to partnering with protesters. Part of this is because they share a common operational language. They are operating under similar regulations and local government. They use similar radio frequencies, triage methods, and leadership structures, namely, the incident command system (ICS).

ICS developed in the 1970’s in response to the difficulties that emergency responders from different agencies faced when trying to work together to fight large California wildfires. ICS is a management system that can be used for a small event, such as a minor house fire, or a large event, such as a train derailment with hundreds of casualties. Personnel are organized into assignment areas (operations, logistics, planning, or finance) with clear reporting relationships. For example, the charge nurse of the ER would only ask the medical branch director for more normal saline and more personnel (instead of ordering it directly from medical supply or staffing) and would only work with him/her when discussing the issues of inpatient beds or problematic transfers. The medical branch director would report to the operations section chief, who then reports to the command staff. This concept is defined as “unity of command,” and helps make sure that the organization is all moving together in the same direction. ICS has been promoted nationally through the Department of Homeland Security and by its incorporation into a number of consensus standards issued by government and non-governmental agencies, including OSHA and FEMA. The incident command system was not being used at Standing Rock, perhaps because they aspired to use a native leadership structure that better supported their goal of decolonized medicine.

Practicing decolonized medicine was a major objective of the Medic and Healer Council, who did not want volunteers going to “save the Indians,” but rather, to serve. In the orientation packet, Linda Black Elk, an ethnobotanist on the Council, asked medical volunteers to prioritize the use of local medicinal plants in their treatments and defer to the hierarchy of native leaders. Decolonized medicine requires recognizing the effect that generations of trauma caused by colonial expansion, genocide, and cultural assimilation can have on the health of American Indians, and using a more holistic approach – based on an indigenous worldview — to healing.

In anticipation of the massive influx of protesters around December 5th, a forecasted winter storm, and the potential for a mass casualty incident if law enforcement forcibly removed people from Oceti Sakowin camp (which had the majority of the winterized structures), the Standing Rock Medic and Healer Council requested additional medical personnel. As an emergency medicine physician completing an EMS and disaster medicine fellowship, I thought I would have something to offer. Mass gathering and disaster medicine often falls in the wheelhouse of emergency medicine, as emergency physicians are uniquely suited to both planning the medical infrastructure and providing the clinical care.

On the ground, felt like I was struggling to keep a mass gathering from snowballing into a full-out disaster.

Join me for Part 2, where I describe the rest of my experience and question the role that EMS can play in political demonstrations and protests.