If EMS Ran the Show

There’s a very human tendency to think we could always do better. And not just us as a species, but as individuals, too. Specifically, when things go wrong—and sometimes even when they don’t—a common refrain is, “If I were in charge …”

Well, what if EMS were in charge? Would the way we deliver care be any different? Better?

That idea has effectively been put into practice in the middle of the Nevada desert—and no, that’s not the start of a joke. For the past three years medical care at the annual Burning Man festival, located smack dab in the heart of Nevada’s Black Rock Desert, has been administered primarily by EMS providers from Humboldt General Hospital EMS Rescue out of Winnemucca, NV, led by its director Pat Songer, ASM, EMT-P. Medical direction comes from Bryan Bledsoe, DO, FACEP, FAAEM, professor and director of EMS Fellowship, Department of Emergency Medicine, University of Nevada School of Medicine and medical director of MedicWest Ambulance.

First, some background. Burning Man literally springs up once a year out of nothing, 122 miles from Reno, NV, in the middle of a dry lake bed. “Black Rock City,” as it’s dubbed, is built from scratch each time in a matter of days, and one week later the tens of thousands of revelers depart, leaving virtually no trace. During that week Black Rock City becomes Nevada’s third largest city, boasting a population of 68,000 in 2012 in an area approximately 8–9 miles across. Nothing can be bought or sold during the festival, with the exception of ice, and what results is an exceedingly utopian community based on the Ten Principles.

In the middle of all this is a first class EMS system, offering free, high quality healthcare. This year alone medical staff at Burning Man treated about 3,500 people over the course of the week.

So, how do they do it?

Sound Preparation

Burning Man itself may only last a week, but planning for the event is year round, says Louis Mendiola, BS, EMT-II, wellness coordinator for Humboldt General Hospital. He says one of the major challenges that go into that planning relates to recruiting, hiring and credentialing the nearly 400 Burning Man employees who will help oversee care.

“Establishing EMS for Burning Man is no easy task,” Mendiola explains. “The austere environment, remote location (no existing infrastructure) and the large population present a number of challenges. HGH relies heavily on the dedication of members of the Burning Man Leadership Team to ensure the operations rolls out seamlessly. HGH has organized a team of some of the nation’s best EMS leaders from a number of different backgrounds and areas of expertise. HGH strives to continually find ways to improve the operation by creating systems that improve patient care and system wide readiness. The willingness to incorporate EMS leaders from such diverse backgrounds has equated to an operation that is truly ‘high performance.’”

Additionally, supplies are tracked and par levels are set depending on the day of the event. The goal being to never run out of supplies but make it to day seven of the event without a huge surplus, according to Mendiola. “This is challenging but technology like Operative IQ helps in tracking usage and supply availability.”

Also, a comprehensive protocol and procedure manual was developed, says Mendiola. This manual is key in dictating the care provided by all levels of providers. “Additionally our operation is based on the value of teamwork. Physicians look to field providers for help in addressing certain complaints and physicians often provide field responders education in a congenial fashion.”

“Instead of approaching Burning Man like any other mass event, we looked at the geographic distance to civilization and healthcare facilities, the environment, the attendee type, and decided to take a more global direction,” explains Bledsoe. “Instead of just placing ambulances and first aid stations everywhere we decided we would develop an integrated emergency healthcare system that ranged from first aiders to board-certified emergency physicians. We specifically wanted to use paramedics in an expanded role because they are already accustomed to the austere environment, independent thought, and the general mindset of the event medical and EMS leaders. As emergency physicians we saw the capability to safely expand their scope of practice to meet the needs of Burning Man.”

Excellent Patient Care

Because the providers on-site at Burning Man are quite literally the only care for miles, patient care needs to be robust and all-encompassing. The care provided ranges from minor to major and during the entire event there is at least one physician level provided and one medical director on call (usually via radio), says Mendiola.

“As with a typical ER, most patients are first seen by a triage nurse or tech, who decides which of the four pods the patient is best suited for,” Mendiola states. The actual structure is comprised of four inflatable disaster-type hospitals and a large wooden triage structure that serves as the entry way. More impervious mod spaces are used for x-ray, a suturing suite and command offices.

“We operate a fully functional emergency department, with facilities for minor care, emergency care and extended care,” adds Bledsoe. “We have x-ray, ultrasound and lab capabilities. While we rely heavily on emergency medicine residents and fellows, a Nevada-licensed medical director is within the hospital or nearby at all times (with a radio). We reduce fractures and dislocations, repair lacerations, manage drug overdoses (including mechanical ventilation), use deep and moderate sedation, and treat multiple common medical conditions. On the last Saturday of the event, the day they burn the man, we become one of the busiest, if not the busiest, emergency department in the United States. We will exceed the volume of patients we see daily at UMC in Las Vegas (a big, busy public hospital) by over 40% (more than 600 patients on the last Saturday). We have a large formulary/pharmacy of prescription and non-prescription drugs to treat the attendees at the event. And all medical care is provided without costs to the attendees, keeping with the prevailing spirit of the Burning Man event.”

Notes Mendiola, eight ALS ambulances are staffed and deployed with at least one ALS level provider. One EMS operations chief oversees ambulance observation and one incident commander is available 24/7. An airway team/critical intervention team is also available to assist with advanced procedures.

The patients the EMS providers and medical staff see during Burning Man are quite diverse, encompassing all ages (though relatively few are children) and all walks of society.

“The population is generally healthy and chronic conditions are less common,” Mendiola says. “Unlike a regular healthcare system there are typically fewer patients with secondary gain issues, like drug seeking, doc shopping, or who are indigent.”

But the perception of risk is highly distorted on playa (the desert). “The culture equates to risky behavior, which subsequently means more injuries,” explains Mendiola.

“We see a lot of lacerations and fractures, eye problems, skin problems, female urinary tract infections, dehydration and similar conditions,” says Bledsoe. “Although many people think Burning Man is a drug fest that’s far from the truth. In 2011, only 2.5% of the patients we saw were drug or alcohol-related. The Burning Man systems actually take care of most substance abuse problems in a separate facility, referred to as the sanctuary. We help them with medical issues, if present, and have sent some of our psychiatry residents over to the sanctuary to help.

“We treat all comers,” Bledsoe continues. “Sometimes all they want is a medical opinion, a band-aid or an over-the-counter medication. All patients who present are assessed and triaged to the appropriate level of provider (e.g., EMT, community paramedic, nurse, physician). There are certain things we don’t get into unless absolutely necessary. We don’t do sexual assault exams and female pelvic exams. We did treat some pregnancy-related issues but had ultrasound available. High-risk issues and problems are immediately handled by the most senior personnel. For example, we had a patient go into labor at 36 weeks. I personally assumed her care, did a quick OB ultrasound, checked her cervix to ensure she could safely make the trip to Reno, contacted her OB/GYN and the labor and delivery department in Reno, and safely sent her to the hospital by ground ambulance.

“The difference between Burning Man and other big events,” adds Bledsoe, “is that we can’t simply say, ‘That’s all we can do here. We’re going to send you to the hospital.’ The closest hospitals are 150 miles away and sending an ambulance to the hospital can take 6–7 hours to go and return as the event enters the weekend. We try and do as much as we can on site. If a patent needs more detailed care, imaging (e.g., CT, MRI), or hospital admission we send them to Reno or Sacramento. Some can go by private vehicle. We pride ourselves on minimizing transports off the desert. People plan for this event all year, spend a great deal of money to attend, and want to stay through the final ‘burn.’ The people are quite nice and thankful. Pat (Songer) always receives nice letters from patients who compliment the medical care at Burning Man and even go on to say that they feel that medical care at Burning Man is a model for healthcare in general.”

The Lessons for Permanent EMS Systems

A unique event like Burning Man requires a unique take on EMS and additional medical care. But the things that work for the Burning Man model of care don’t just have to be limited to the desert for one week a year.

“I think what I have learned from Burning Man—and I have been in EMS and healthcare for almost 40 years—is that the current healthcare system is broken,” says Bledsoe. “At Burning Man we have looked beyond the constraints of conventional thought and protocol and tried to develop a healthcare system that is truly integrated from the first responders to the physicians. We have taken down numerous barriers between healthcare providers and eliminated turf battles. We try to ensure the patient gets to the level of provider most capable of managing their problem—and that is not always a physician.”

That sentiment is backed up by Mendiola. “Our system has demonstrated that paramedics and other levels of EMS providers can effectively serve as physician extenders, helping to deliver appropriate care in a much more sustainable manner—while still being physician led.”

“My residents and medical students love their Burning Man experience,” Bledsoe adds. “They provide high-quality, oftentimes challenging, quality healthcare in an austere environment without worries about insurance or social status—all for free. They aren’t overly concerned with charting, electronic healthcare records, medical liability and so on. They just take care of people in a manner that they hoped for when they applied to medical school. A good but unplanned benefit from the Burning Man experience was that all providers developed mutual respect for the other types of providers with whom they worked. We have graduated three groups of emergency medicine residents from the University of Nevada and other programs who now have a new-found respect for EMTs and paramedics and, in turn, the EMTs and paramedics now better understand the capabilities of the emergency physicians and the 11–12 year journey it takes to become an emergency physician.”