Not for Oneself but for All

Lessons Learned in Disaster Medicine

When a 7.8 magnitude earthquake struck Nepal in the spring of 2015, survivors faced shock and fear in isolated villages throughout the Himalayas. Disaster aid arrived from around the world, including Michael Karch (M’95, R’02) and the International Medical Corps. He and his emergency response team helicoptered from village to village, assessing needs, treating patients, and putting communities literally “on the map” for additional aid and supplies.

When they landed near the small mountain town of Laprak, an elderly woman approached them about her husband who had suffered a stroke, and was now paralyzed and injured. He was fifteen minutes down the hill, she explained.

The aid workers had a limited window of time before they had to helicopter back to their camp, likely not enough time for a search and rescue. Disaster medicine is full of split-second decisions like this, when pragmatism and humanity might be at odds. But Karch and a team member, a volunteer EMT, decided they would try to find and help this man.

They ran down the hill, dodging rubble and the ravages of the earthquake. About an hour later, they found the elderly man. He was paralyzed and in need of immediate medical care to survive. The one caveat: they’d have to carry him back up the mountain.

Karch and his colleague took turns lifting the patient over their shoulders, fireman-style, carrying him 50 paces, and then trading off. In the midst of this crisis and grueling physical work, Karch admits to asking himself how they would make it out—and in fact, could they.

Then something miraculous happened. One by one, young men and boys from the village started arriving. They saw that their elderly neighbor now had hope, and they wanted to help.

“First there were two guys helping us,” Karch recalls. “And then four guys, and pretty soon a stretcher showed up. We no longer had to carry him on our shoulders.”

The larger team of locals and international volunteers eventually arrived at the helicopter, helping load the injured man on so he could be transported to medical care. By giving one man a chance, Karch and his team helped to mobilize an entire village at a time otherwise marked by trauma and despair. Their aid and example inspired a community to push through the disaster into hope and resilience.

Karch calls this the “force multiplier” effect—an essential part of disaster medicine. Through his work in disaster medicine, he seeks to not only help communities prepare for crisis before it happens and cope with its immediate trauma, but also to help affected communities build capabilities to strengthen and rebuild after relief teams exit.

“When you’re a team leader in a mass casualty event,” he says, “you forfeit your right to get caught up in the emotion, fatigue, or starvation of the circumstances. If your team sees you getting tired or overtaken by emotions, they will, too— because they’re scared. It’s hard to put into words how scary such an environment is, especially when there are aftershocks or gas explosions or terrorist attacks.”

He seeks to empower through example. “The force multiplier effect of the team leader is huge—the team leader can dictate how poorly or well a team functions. And then the team itself has a force multiplier effect on the village or city it’s treating. The community carries their energy forward.”

By demonstrating a path forward past trauma, the force multiplier effect sets off a ripple of hope and action. While helping the victims of a mass casualty situation is most immediately about basic physical and medical needs, it also has psychological, emotional, and spiritual elements. Karch finds that the most powerful way to attend to these needs of an affected community is leading through example. By providing support and demonstrating that there is reason for hope, he seeks to provide an example that is both instructive and inspiring—an example that can jumpstart a community and region’s resilience and recovery.

Karch’s brand of hope is a bold hope—but also grounded and pragmatic.

The Georgetown Ethic

Karch attends a victim of the 2015 earthquakeKarch attends a victim of the 2015 earthquake in Laprak, Nepal. The paralyzed man will need to be carried back up the mountain to receive care.

After college, when applying to medical school, he also knew that he wanted to attend Georgetown University School of Medicine. “It was always number one on my list,” he recalls, noting Georgetown’s ethic of cura personalis—treating the whole person “mind, body, and soul,” caring for those at the margins, putting others before yourself, and training rigorously. “The four years of med school were the best four years of my life, without question.”

He relished the training. “Every day, we were taught to do the right thing,” he says. In times of emergency and split-second decision-making, this sense of integrity helps propel him forward.

The principles and ethics taught at Georgetown go beyond professional life, he says. His formation in medical school and residency helped him become both the physician and the person he is today. By being educated as a whole person, he learned to care for others in the entirety of their beings—body, mind, and soul. Karch points out that this is about “not just the patient, but also your small community, your family, your spouse, your children—it goes on and on. That’s the ethic of Georgetown and it’s carried me into my practice.

“It can be easy to get caught up in the selfishness of modern society, but when you are given this base ethic as you’re being formed, it’s a stronghold you can always go back to.”

After graduation, Karch completed a surgical intern year in Southern California at Loma Linda University Medical Center, and then returned to Georgetown for a residency in orthopaedic surgery. He looks back on this time fondly, noting the program’s caliber and the impact of the mentorship he received, “not just in medicine but in life too.”

One such mentor, John N. Delahay (M’69, R’74), serves at Georgetown as the Peter Cyrus and Rose Dignan Rizzo Professor in the department of orthopaedic surgery and pediatrics, vice chair of the department of orthopaedic surgery, and program director of orthopaedic surgery training. He recalls Karch’s compassion and energy in all he pursues, along with his excellent surgical technique.

“He is a pioneer in developing protocols used today, creating structure in the delivery of healthcare in these completely chaotic settings.”

Karch’s classmate, Joseph McQuade (M’95), similarly recalls Karch’s drive and hard work in medical school. He calls Karch someone who makes those around him better through his example, and someone who brought this tenacity to his free time.

While students, the two friends ran the JFK 50-mile ultramarathon in Maryland. McQuade recalls arriving at the race on a cold, dark morning. While he had second thoughts, they didn’t linger long. He remembers thinking, “It’s Karch. Karch got us out here—let’s just do the best we can.” He laughs, adding, “I never ran harder in my whole life.”

Karch has since gone on to run 53 marathons, six Iron Man Triathlons, and two Badwaters, a 135-mile footrace through Death Valley.

School of Medicine Dean for Medical Education Ray Mitchell encourages Georgetown students to cultivate a mindful state of being, understanding their comfort zones, talents, and interests. “And sometimes part of reflection and formation is to journey up to your own limits,” he adds.

Karch, he says, exemplifies this principle.

An Inflection Point

While Karch always knew he’d become a surgeon, he never considered disaster medicine until the seventh year of his residency at Georgetown. Specifically, on September 11, 2001. For Karch, the date became an inflection point, both for himself personally and for disaster medicine.

As he walked through the hospital hallways with his team around 9 a.m. that morning, he wondered why everyone was glued to the television. Shortly after that, he heard the massive explosion of the plane hitting the Pentagon, just a few miles down the Potomac.

This is when it all changed—not just for him but for the field of disaster medicine. (He recounts this moment firsthand in a reflection.)

Karch wanted to go where he could have the biggest impact, so later that day he took a train to New York and volunteered at Ground Zero. Thinking himself well prepared to help, after a grueling 48 hours at the disaster site, he realized that there was a lot he wished he knew going in. Not typically provided in medical schools and residency programs, training for mass casualty situations would unfortunately need to be an increasing priority.

In the years that followed, as doctors and medical professionals returned from Afghanistan and Iraq, they brought reports of treating patients in mass casualty situations. The nature and pace of combat in these wars proved to be different than previous conflicts—and faster. As a result, it demanded new approaches to combat care and treatment, breeding innovation in mass casualty medicine. For example, a one-handed tourniquet was invented, allowing a soldier to selfapply it. Battlefield dressing technology improved, reducing significant blood loss, and pain management options advanced. Such innovations and adaptations, Karch says, impacted a generation of surgeons and physicians.

Karch spent the next decade educating himself in mass casualty medicine, drawing largely from the expertise of his military colleagues. He also participated in Tactical Combat Casualty Care (TCCC) and combat extremity surgery courses led by the military. He wanted to take the lessons learned in combat situations and apply them to civilian mass casualty events—an approach that would make him a pioneer in the field.

He continued his official surgical training after Georgetown through a fellowship in sports medicine and trauma at the Taos Orthopaedic Institute in New Mexico, and the study of advanced and masters AO trauma techniques in both the United States and Europe. He became a team physician for the United States ski and snowboard team, and eventually set up practice as an orthopaedic surgeon at Mammoth Hospital in Mammoth Lakes, a small mountain town near Yosemite National Park in central California.

In the remote town, Karch quickly noted the community’s vulnerability in the event of a disaster such as an earthquake. To prepare Mammoth Lakes to take care of itself should crisis strike, he developed a course to train both medical and nonmedical professionals in the protocols and best practices for a civilian mass casualty event. He applied many of the military’s lessons to civilian scenarios. The successful program grew into the annual International Disaster and Austere Medicine Course, offered in Mammoth Lakes to medical professionals from around the world.

Growing from this program, the Mammoth Medical Missions (MMM) is a nonprofit organization providing general medical and healthcare relief and education to underserved rural and mountain communities around the world. It also deploys emergency response teams to mass casualty events.

Military as Model

Karch helps with the 2015 Nepal earthquakeIn Nepal, locals work alongside International Medical Corps volunteers to help hoist the earthquake victim into the helicopter for transport to medical care.

In November 2013, Karch and a group of 15 MMM volunteers were on their way to Los Angeles International Airport for a routine medical mission in Chiapas, Mexico, when plans changed. They learned that Super Typhoon Haiyan— the strongest recorded tropical cyclone ever to hit land—had struck the Philippines. Karch and his team discussed the situation.

“We asked: where is the greatest need for us and our supplies?” Karch recalls.

They decided to reroute.

When they arrived in the Philippines, they learned of Tanauan, a town about 15 miles south of Tacloban that had been devastated. They went directly there and found chaos—no power, no running water, extreme medical needs, and another storm moving through. With the exception of the basic supplies they brought, their entire setup was ad hoc. They turned the town hall into a field hospital and rationed their supplies.

Over the course of four days, hundreds of patients were triaged and treated. Babies were born, some via C-section, and 157 surgeries were conducted—most on the town mayor’s desk, which had been converted into an operating table.

Frequently in disaster situations, whether natural or manmade, large aid organizations such as the Red Cross or Doctors Without Borders can’t mobilize to arrive until 72 to 100 hours after the first mass casualty event. But by studying military medical tactics, Karch had developed a model for closing this gap between disaster and the provision of medical care: the immediate deployment of small, nimble teams.

“Knowledge gained in wartime medicine can be directly applied to the civilian mass casualty setting,” explains Karch. “The statistic and treatment principles are the same.”

During the Gulf War in the 1990s, the military developed a new forward surgical team (FST) concept. The old mobile Army surgical hospital (MASH) unit, designed for Korea and Vietnam, was not suited to this kind of military operation with a fast-moving front. Combat teams needed a way to conduct surgery and provide care that was lighter and quicker than the 200,000-pound MASH unit. The FST was designed for rapid transit, with capabilities to perform lifesaving, damage-control surgeries.

Karch decided to apply this model to civilian mass casualty situations. He and MMM developed the civilian mobile forward surgical team (CMFST) and put it to work for the first time in the Philippines. As a result, they provided life-saving medical care in those first critical days before larger aid organizations could arrive.

The CMFST model is now employed in mass casualty events around the world.

Preparing for Disaster

Karch has learned from his experiences in the field—and he wants his story to beget others’ stories of crises met and lives saved.

How does a medical professional prepare for mass casualties?

First, hospital systems need to be ready to receive large numbers of trauma patients all at once. “Have we preemptively thought about this problem and told our workers the simple things—where to show up, who to report to—so that our response can be organized and not add to the chaos?” asks Karch.

Preemptive thought also applies to triage, he says. How will medical teams agree to triage victims and categorize them as needing care now, in 15 minutes, or in two hours?

He believes it’s also important for all physicians to have a basic technical skill set for mass casualty medicine. While general surgery, orthopaedic surgery, emergency medicine, and anesthesia might be especially well-suited to disaster scenarios, Karch believes that every physician should be able to treat gunshot, explosion, and crush victims, for instance —all who may be arriving nonstop.

“In disaster medicine, you have to be able to practice outside your comfort zone,” he says. “Disaster medicine forces us back to where we should be as physicians: on some level, we should be able to take care of the whole body. In disaster medicine, there are no specialists. So it’s good to have a refresher on general medicine, on the things we learned in medical school.” With recent mass casualty events around the world, he adds, “This is where medicine is going to need to go—to evolve into—in the next decade.”

What’s Next?

Karch’s next chapter includes spending more time with his wife Kim, a pediatrician, and their children, ages 8, 10, and 12. Two years ago, they bought Sweet Meadow Farms in the Shenandoah Valley of central Virginia. All family members work on the 200-acre operation, where they raise grass-fed, organic beef cattle, goats, and mixed poultry. Nearby farm-to-table restaurants in Lexington, Virginia, are their clients.

While the family is now based at the farm, Karch still spends about 10 days per month performing surgeries in Mammoth Lakes. He is also co-inventor of innovative surgical tools, and co-founder of Smart Medical Devices, Inc. His main focus now, however, is teaching—specifically, providing trainings in mass casualty medicine to physicians and medical students.

A primary vehicle for his teaching is Mammoth Medical Missions’ International Disaster and Austere Medicine Course, a mix of didactic training and hands-on simulations geared toward preparing trainees to think under fire.

By replicating the myriad stressors at play in a real disaster situation, the result is chaos. On the ground, such chaos may last for days at a time. But, as McQuade notes, one of the most important skills Karch teaches is being able to establish some order. “He teaches you to think under fire and focus on one thing at a time.”

Karch recognizes his strengths in high-stress, disaster situations, and is committed to the role he can play to meet the patients where they are, even when the setting is remote or dangerous, or both. “There’s a strong spiritual element to this work. I believe that my purpose on earth is to help people.”

This belief is reflected in the phrase he calls his North Star during trying times: Non sibi sed omnibus. “Not for oneself but for all.” In 2015, when he, his colleague, and villagers from Laprak, Nepal, were carrying the paralyzed elderly man to safety—and when the physical and mental challenge felt like too much—this phrase, like a mantra, centered him and pushed him onward.

“That’s what drives me. If things are getting tough physically, mentally, emotionally, I just say, hey, someone’s got it worse than I do. Anyone who’s in medicine believes on some level that they have some given talents and some learned talents. The combination of the two puts them in a position where they can reach down and pull people up. It’s these talents and learned skills that are valuable and you don’t want to abuse. When things get tough, Non sibi keeps me going and helps me push forward.”

By Kate Potterfield (C’04)