Editor’s Note: New to this post? Catch up on the background of Standing Rock, where Dr. Glenn was volunteering as an EM physician, and mass gathering management by reading Doctoring at Standing Rock – Part 1.

Author’s Note: The 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. 

On the ground, felt like I was struggling to keep a mass gathering from snowballing into a full-out disaster. Leadership, medical staffing and credentialing, clinical standards of care, and supply chain all seemed vague, starting with my volunteer orientation on Saturday, December 3rd. I asked the man leading it, an ER nurse who had been at camp for several months, what triage method we would use if there were a mass causality incident. He wasn’t sure, but he didn’t want to use “military triage.” I wasn’t sure what that meant. Triage, the sorting of patients according to the severity of their injuries and the need for urgent surgery, is believed to be a concept developed by a military surgeon in Napoleon’s army. There are various methods that have been created, including START and SALT, and experts could debate all day about which one is better. In the end, the most important thing is that everyone responding to a single event be in agreement as to which method they are using. If they are not, confusion as to how to prioritize patient treatment can lead to increased conflict and worsened patient outcomes.

When the blizzard hit on Monday, December 5th, the same day that the veterans marched to the barricade, things only got worse. Although I had limited situational awareness because random people kept saying incorrect statements on the radio, it quickly became apparent that thousands of people weren’t adequately prepared for the winter storm. Unfortunately, they realized this as the snow made the roads impassable, preventing any kind of egress. It also prevented the Standing Rock EMS ambulances from reaching our camps, over an hour from the ED’s in Bismarck. Around this same time, a gastroenteritis illness broke out, but there was no flowing water, no way to isolate patients, and limited porta-poties (which also required a long walk through the snow to reach). That night, temperatures hovered around 0 degrees Fahrenheit. A handful of long-term volunteers (referred to as the “bottom-liners”) visited every car, tent, and tepee in camp, successfully moving people without proper gear into winterized yurts. Early the next morning, one of the tents housing veterans burned down. Luckily, nobody was hurt.

By Tuesday afternoon, the road conditions improved enough to get the most vulnerable out via a coordinated effort. Thousands of people were transported to the nearby community center and casino, believing that an indoor facility with central heating would be safer than camp. However, I doubt those facilities had the resources to handle this massive influx. Also departing was the mass of weekend volunteers and veterans who had arrived for the potential December 5th evacuation – myself included. Life at camp could finally go back to normal.

When I returned home, I described my experience to the disaster coordinators at my office. They agreed – we were very lucky that everyone made it out safely. They also noted that many of the issues I encountered are typical of almost all disasters. For example, during Katrina, there was no unified command when directing emergency response to the various flooded hospitals, so air evacuations were uncoordinated and inefficient. People dependent on ventilators to breathe were left behind in hospitals with no electricity to power them. There was no source of accurate information. Law enforcement heard that there were looters taking over Memorial Hospital, so a SWAT team rushed in. There were no looters, and they left as quickly as they had arrived, without providing any of the aid that employees and staff actually needed. At this same hospital, there was no agreed-upon method of triage, so staff decided that the healthiest patients should be evacuated first, and that any patients with a DNR should be evacuated last, including patients that did not have any life-threatening illness. This is in stark contrast to both SALT and START methods that recommend treating critically ill patients first and do not include DNR status in their algorithms. If these are such common problems in disasters, isn’t it likely that there are common solutions?

As I poured through the medical disaster literature, I read clear methods to prevent and correct many of the operational problems I had encountered. There are research studies, position papers, textbooks, and training programs that explain how to best manage mass gatherings and disasters, yet none of that information seemed to make it to North Dakota. I initially blamed this on two main things: disparate leadership and a lack of interagency coordination. The use of ICS, or a similar structure that fits more closely with existing native leadership, could have prevented much of the confusion regarding objectives and operations. But how can the goals of decolonized medicine reconcile with those of a unified response based on the structures developed by European wars and touted by the US Department of Homeland security?

As to the lack of coordination between Standing Rock EMS, Morton County EMS, law enforcement, public health, and local organizations, the highly politically charged environment and lack of a common operational language almost preclude such interactions. Unfortunately, this is almost a moot point; as neither side trusts each other, this conversation likely would never occur. How can there be a coordinated, unified command when the two sides ultimately have very different goals? The state wants to remove the protesters, and the protesters want to remove the state.

As someone just swooping in for a weekend, I don’t think I’ll even come close to understanding all the complexities of Standing Rock. Although I’m leaving with more questions that answers, I now wholeheartedly believe that the natural tendency of people facing disaster-like situations is to devolve into chaos, underscoring the necessity of involving disaster experts in the planning and operations of such events. With the increasingly divisive political environment that our country is entering, the issue of how to best provide care at loosely planned protests may become more common, as will the politicization of EMS. Therefore, it will become even more important for emergency medicine and EMS to focus on the goal of improving the health of our patients. Although we cannot remain completely apolitical, as the health of our communities is affected by legislation, we must not let our political differences sideline our mission.