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Behind the scenes at Burning Man

Rampart is the cornerstone of a sophisticated emergency medical system with cutting-edge goals that mirror some of the leading ideas in healthcare reform, community paramedicine and mobile integrated healthcare

I first heard about Burning Man from one of the smartest people I know: Dr. David Warner, a neuroscientist and self-described “hippy doctor” who has done groundbreaking work for DARPA (Defense Advanced Research Projects Agency). He used Burning Man as a test field for new types of communications in remote, hostile environments.

Then last year, Troy Hagen, CEO of Care Ambulance in Southern California, recounted what it was like working as a medic and supervisor at Burning Man. Like Warner, he was smitten. What he talked about was so revolutionary that we decided to dedicate a large portion of this issue to the topic. Troy arranged for editor Jenifer Goodwin to attend this year’s event, getting an inside look at how healthcare can be provided by a contingent of practitioners. We hope you enjoy the report as much as we did.

Every August during Burning Man, a weeklong art fest-rave-campout, Black Rock City rises up from a dry lakebed in the Nevada desert, 115 miles north of Reno. This year, 68,000 people made the pilgrimage in RVs and cars brimming with tents, food, costumes and pyrotechnic paraphernalia, temporarily turning Black Rock into the state’s third largest city.

For Burning Man attendees—“Burners,” in local parlance—the event is about participating in a community where self-expression rules, where nothing can be bought or sold (other than ice and coffee) and, surprisingly, where there’s no litter. The reigning philosophy is “leave no trace,” so there’s no need for trashcans.

For the community of EMTs, paramedics, nurses, medical students and physicians who converge on the site every year to provide emergency response and urgent care, Burning Man is their own form of utopia: healthcare with no billing and no bureaucracy and in which medical providers from EMTs to ED docs work side by side, unencumbered by many of the confines of typical hospital systems.

Since 2011, Burning Man, the organization, has contracted with Humboldt General Hospital in Winnemucca, Nev., to staff and equip Rampart Urgent Care, a field hospital that offers X-rays, ultrasounds, a hand-held head scanner, lab tests and a pharmacy. The single-room wooden structure is painted hot-pink and yellow; the walls of the waiting room are scrawled with random thoughts and thank-yous from patients. The hospital’s 40 beds are located in adjoining tents.

But don’t let the dust on the floor fool you. Rampart is the cornerstone of a sophisticated emergency medical system with cutting-edge goals that mirror some of the leading ideas in healthcare reform, community paramedicine and mobile integrated healthcare. At Rampart, when possible, patients are treated on site to avoid transports to Reno hospitals. EMTs, medics and nurses are empowered to practice medicine to the fullest ability their licensing and credentialing allow.

And with an average 22 minutes from check-in to discharge for urgent care patients, Rampart staff strive to minimize wait times and maximize patient satisfaction. Oh, yeah, and their patients get it all for free with the price of admission. Tickets to Burning Man cost $380, which the organization uses to fund medical care and other emergency response.

“If you would have asked me five years ago if I’d be out here doing this, I’d have told you, ‘You’re crazy. That’s just some weird art festival,’” says Bryan Bledsoe, D.O., a clinical professor of emergency medicine at the University of Nevada School of Medicine, who is in his third year as Rampart’s medical director. “It gives medical students and medics the opportunity to come out here and do real medicine, not coding and charting and worrying about bills. It’s high-quality medicine, without the bureaucracy.”

Treating the walking wounded

When you combine scorching temperatures, high elevation, dust storms, and copious amounts of alcohol and psychotropic drugs, there’s plenty for the medical team—which this year also includes an X-ray technician and a pharmacist—to do. Twenty-four hours a day, Rampart’s waiting room is buzzing with the walking wounded. This year, they treated 3,031 people—an average of 433 a day—for problems such as dehydration, burns, eye and urinary tract infections, broken bones and gashes, as well as mishaps more specific to the festival: a twisted ankle from jousting, facial burns from fire blowing.

By way of comparison, New York City’s Montefiore Medical Center is the second busiest ED in the nation, according to Modern Healthcare figures. The ED treats 294,000 patients annually, or about 800 a day. But Montefiore has hundreds of beds and a full complement of medical staff on duty at any given time, along with some of the world’s most sophisticated equipment. At Burning Man, 32 EMTs, medics, nurses and so on staff Rampart during the busiest times. “They learn austere medicine,” Bledsoe says of the medical residents he brings with him each year. “They learn to make diagnoses without a CT scan. It forces them to rely on their physical exam.”

With the nearest regional hospital either a $6,500, two-hour drive or a $26,000 helicopter ride away, medical staff are responsible for more than they would be off the playa. At Rampart, physicians don’t see every urgent care patient; instead, EMTs or paramedics are, for example, tasked with deciding if a patient needs an X-ray. X-rays are read by ED physicians, not radiologists.

And it was paramedics who handled many of the 125 suture cases done this year. (Only facial wounds or complex gashes are handled by physicians and referred off site.) Paramedics and nurses also treat and discharge patients suffering from dehydration; they are allowed to leave once they pass the “pee test” and their labs come back OK.

“They are empowered to use their clinical skills and to move patients through. If a patient comes in with a simple scrape, a physician doesn’t need to discharge that patient; an EMT-basic can do it. If you have dehydration, you can be discharged by a paramedic or a nurse,” says Pat Songer, director of EMS for Humboldt General and on-site incident commander. “We don’t need to send them to Reno on an ambulance to rule out a fracture. It can be done right here.”

The system works so well that this year, only 32 patients had illnesses or injuries serious enough that they needed transport. That included a fire blower’s facial burns. “Out here, you can’t just load and go and say, ‘It’s not our problem anymore,’” says Joseph Pred, who as operations chief for emergency services is one of Burning Man’s approximately 50 year-round employees.

Back at camp ...

On the playa, Burners organize themselves into hundreds of theme camps—some risqué, others civic-minded, others just funny. The Moon Cheese camp gives away late-night grilled cheese sandwiches. The Alternative Energy Zone Village is dedicated to the many uses of solar power. Burners can pick up free condoms at Safer Sex Camp or check out an interactive spaceship diorama at Barbarella Bootcamp. Other camps offer cocktails, foot rubs, fondue served by Burners wearing nothing but aprons or piano music. Burners can also attend dozens of participatory events—on making pasties (you read that right), or learning Michael Jackson’s Thriller dance, or finding the goddess within. One group even promises to grant temporary one-week divorces, presumably to ensure that married Burners really can do as they please during the week.

While at Burning Man, Burners are asked to abide by 10 principles, which include radical inclusion, gifting instead of commerce, self-reliance and communal effort. Burners take their self-expression seriously: The costumes are a cross between a circus and a strip club—lots of blue hair, garter belts, thigh-high platform boots and suits made of LED lights—although plenty dispense with clothes altogether … except for shoes.

For even when there isn’t a bona-fide dust storm, the playa dust leaves the city shrouded in an other-worldly, chalky haze. The dust is highly alkaline, leading to a well-known Burning Man affliction: the dreaded “playa foot,” when the skin on the feet crack. So even the nearly nude keep their boots on.

With no cars permitted in the main camp area, Burners pedal around on beach cruisers decked out in LEDs or ride on “mutant vehicles”—buses and camping trailers elaborately disguised to resemble pirate ships, yachts or lobsters, in keeping with the nautical, dry lake bed theme. Entertainment includes all-night raves and plenty of performance art—a tightrope walker high above the desert floor traversing a flaming rope as a homemade drone buzzes around his head; guys in heat-protective silver suits doing Dance, Dance Revolution. Every time they miss a step, a flame shoots up at them.

On Thursday night, the burns start. Many of the large, wooden art installations commissioned by Burning Man will never leave the playa. Instead, they’re ritualistically torched. The burns build to their apex on the weekend. On Saturday night, The Man—a 42-foot LED-lit stick figure perched atop a wooden spaceship—goes up in flames. On Sunday, there’s the torching of the Temple, a pyramid-shaped, geodesic structure where Burners come to grieve. Considered the spiritual center of Burning Man, the Temple is where Burners who have lost loved ones during the past year come to pray, meditate and weep. They leave behind letters and photographs and write messages to their loved ones using Sharpies tucked into the crevices of the structure. “The other burns are big parties,” Pred says. “But when the Temple burns, you can hear a pin drop.”

A city like no other

Though it exists for only one week a year, Black Rock organizes its city services and emergency response much like other municipalities. “The party is the glamorous distraction,” Pred says. “When you look at the underpinnings, you’re talking about a city—a very unusual city.”

There’s an airport, a department of public works and a DMV (Department of Mutant Vehicles). While most large festivals are plugged into local emergency services, Burning Man has its own. There’s an emergency dispatch center, staffed by three dispatchers and a supervisor housed in two trailers just outside the main camp. This year, dispatchers handled about 1,600 calls for service, up from 1,462 in 2012.

Fire protection—a critical service with all of the burns, fire breathing and pyrotechnics—is provided by Burning Man’s own fire department, made up mostly of firefighters who volunteer to work the event. Law enforcement is handled by Bureau of Land Management rangers or the Pershing County Sheriff’s Burning Man substation. There are also mental health services, whose experts are dispatched to retrieve people having drug-induced or other mental health crises. They’re taken to a place called The Sanctuary for monitoring.

With no cell phone service on the playa, 911 calls come in via 1,500 radios given to paid staff; Black Rock Rangers, volunteers who patrol the city (often in kilts); and Black Rock Emergency Services, another group of volunteers with at least EMT-level training who roam the city in quick response vehicles—ATVs equipped with stretchers—and handle BLS responses.

The sick and injured can walk into two first aid stations, which handle minor injuries. For more serious problems, patients can get transported by one of seven ALS ambulances supplied by Humboldt General Hospital. An eighth ambulance, used mainly for lengthy transports to Reno, is supplied by the North Lyon Fire Protection District.

On the playa, response times are closely watched. This year, quick response vehicles averaged a 3:03 response. ALS ambulances are expected to meet an 8:59 response time; this year, they averaged 7:07. Even though the main camp and festival is only 3 to 4 miles wide, getting to patients isn’t always easy. The speed limit is 5 mph. Dust storms compromise visibility. And landmarks are constantly changing. “Someone might say, ‘They’re near the dragon art car.’ Well, there might be four dragon art cars,” Pred says.

Over the years, Burning Man has been studied by everyone from the military, which was interested in how they handled communications and field medical care in an austere environment; to sociologists, anthropologists and disaster medicine experts interested in the similarities of Burning Man to large religious gatherings, the power of community expectation, and what lessons Burning Man might hold for aid workers setting up refugee camps—could values such as cooperation and community make the experience less miserable for the displaced?

“I often refer to Burning Man as a ‘recreational’ disaster,” Pred says. “Where else in the world do you have people who voluntarily displace themselves and set up a temporary city?”

Amid the spectacle, Rampart Urgent Care, a hot pink beacon with a red cross on the roof, is ready to help when things go awry. Which they do, with regularity.

A day at Rampart

As I drive to the playa on Friday morning, the air is thick with smoke from the Rim Fire raging near Yosemite National Park. For days, the wind has blown due east, leaving Carson City and Reno choking in a brown haze. Air quality on the playa, never known to be particularly good, is actually much better, thanks to a recent rain shower and relatively calm winds.

Upon arrival at the greeter’s gate, first time Burners—“virgins”—are greeted by a mostly topless welcoming party and invited to roll in the dust and bang a gong. Even rookie Burning Man medical staff are asked to get dirty—and many do. “It’s part of the culture, and we try to establish that we’re part of the community and here to take care of them,” Songer says.

While peak attendance usually hits Friday, this year, the crowds arrived early. By Tuesday night, the playa was already at capacity, and paramedics had responded to one of the most serious injuries they’d see that week: a 20-something woman who suffered a C-5 spinal fracture while jumping on a trampoline. They stabilized her spine, Bledsoe says. Then an ambulance transported her off the playa into the nearby town of Gerlach, pop. 206, where a medical helicopter landed on the high school field to airlift her out.

At Rampart, the volume of patients continued to pick up through the week. The field hospital is divided into four treatment zones. In rehab—a cool, dimly lit room with 18 beds—dehydrated Burners lie listless, getting rehydrated. Next to rehab are the 12 beds belonging to urgent care, where patients get stitches and broken bones splinted. The ED has two beds reserved for the most serious cases. Outside, a trailer holds the X-ray machine and a private exam room for gynecological issues.

Long-term care is in the final tent, where patients who have OD’ed or are having drug-induced reactions are treated and monitored. (Extremely agitated patients get taken to The Sanctuary.) Despite Burning Man’s anything-goes reputation, they treated only 52 people this year for drug-related issues and 23 for alcohol intoxication. (That’s not to say, however, that there aren’t plenty of substances being passed around at the festival. GHB, a depressant, seemed to be especially prevalent this year, medical staff report.)

Command staff during Burning Man included Songer and Jay Wittwer, battalion chief for North Las Vegas Fire, as deputy incident commander. Duty commanders included Matt Womble, a paramedic and hospital consultant from North Carolina; Troy Hagen, CEO of Care Ambulance in Orange, Calif.; and Chris Montera, assistant CEO for Eagle County Health Service District in Colorado.

While working Burning Man, medical staff are housed in RVs and fed in communal tents by a company that prepares food for firefighters on the line at wildfires. Though working the event can be grueling, the camaraderie is unbeatable, staffers say. So is the clinical experience—for everyone from residents to EMTs. “This is true integrated healthcare, with doctors, nurses and EMS working side by side,” Hagen says. “This is what healthcare would look like if EMS ran it.”

Another element of the Burning Man ethos is gratitude, and that gets shared with Rampart staff. As Bledsoe cruises around in a golf cart, Burners wave, offer a spray of water or a cocktail (which medical professionals are advised not to accept, even when off-duty, since they never can be sure what’s in it), or insist he take one of the homemade trinkets they use to barter with.

“It’s the best healthcare experience I’ve had in a long time,” Montera says. “I’ve never gotten so many thank-yous and hugs. I just love it.”

By 8 p.m. on Friday night, it’s standing room only in the waiting room. Patients limp in on the arms of friends or are wheeled in by responders. A woman is given a scrip for antibiotics to treat her strep throat. Another is treated for an eye infection. In rehab, several are treated for dehydration. In urgent care, a woman who twisted her ankle while jousting winces as medical staff splint her leg.

At about 9 p.m., a fuse blows on the generator, plunging the hospital briefly into darkness until the backup generators blink on. Maintenance staff run to the generators to see what went wrong.

And still, the patients keep coming. Bledsoe consults with his fellow physicians over an X-ray of a possible broken collarbone. A young man comes in with blood dripping off his hand down the front of his pants. Some crazy Burning Man stunt? “I got into a fight with a tuna can,” he says, ruefully.

For R.N. Anne Robinson-Montera, her favorite patient of the week was a pregnant woman who came in, spotting and terrified. It was her third baby, and she hadn’t yet seen an ob-gyn. With the ultrasound, Robinson-Montera was able to show the woman her baby fluttering in the womb and listen to its heartbeat. “She said if it was a girl she was going to name her Playa,” Robinson-Montera says. “I told her if it was a boy she should name him Dusty.”

Produced in partnership with NEMSMA, Paramedic Chief: Best Practices for the Progressive EMS Leader provides the latest research and most relevant leadership advice to EMS managers and executives. From emerging trends to analysis and insight, practical case studies to leadership development advice, Paramedic Chief is packed with useful, valuable ideas you simply can’t get anywhere else.
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