The Response of Virginia Task Force 1: A Medical Perspective
BY CRAIG DeATLEY, PA-C, EMT-P; ANTHONY G. MACINTYRE, M.D.; DEWEY H. PERKS, EMT-P; and JOSEPH A. BARBERA, M.D., FACEP
Early on April 23, 1995, FEMA placed the USAR Task Force from the Fairfax County (VA) Fire and Rescue Department–Virginia Task Force 1 (VA TF-1)–on alert. During the preactivation time period, telephone calls were made to federal representatives in Oklahoma City to gather predeployment information. Valuable information about work conditions, rescue operations, environmental hazards, and locally available support services was obtained by the time team members began meeting at the designated mobilization center. At 5:30 a.m., the team was activated.
The VA TF-1 medical team consists of a cadre of 14 Fairfield County paramedics (designated as medical specialists) and six emergency physicians from The George Washington University Medical Center and the INOVA Health Care System Hospitals (designated as medical team managers). The responding task force medical team consists of two physicians and four paramedics.
During the preceding 18 months, this combined group of clinicians had been regularly training to ensure their clinical skills and decision making met the challenges posed by confined-space rescue and austere surroundings. Practices were held in rubble piles and in dog labs to allow the paramedics and physicians to develop the competence, confidence, and teamwork needed to perform optimally during a deployment. Time had also been spent organizing the extensive medical cache that had been assembled to treat at least 10 critical, 15 moderately critical, and 25 minimally injured patients, as well as meet the emergency and primary care health needs of task force members and support personnel. Team members also had begun to learn basic aspects of veterinary medicine, since they also were responsible for providing medical care to the team`s search dogs.
As part of the mobilization procedures, the medical team arrived earlier than most of the other members to get checked in and to set up the medical surveillance station all task force members would be required to go through as part of the check-in. All team members completed preliminary medical paperwork, had their vital signs taken, and were given a brief examination to ensure they were fit for the deployment.
Priority medical items were pulled from the medical cache before loading them onto the truck. These items included medic and physician`s packs and monitor/defibrillators. Their immediate availability helped to ensure that an in-flight emergency could be effectively dealt with by the medical team. All task force members were provided a hot breakfast and a light lunch prior to departure for Oklahoma City. Reminders about the importance of good hygiene, hydration, and CISD were given to task force personnel at the medical check-in station.
Prior to departing for the airport, the entire task force was given a formal briefing by the task force leader. Following the briefing, members boarded buses for the 30-minute ride to Andrews Air Force Base. A member of the medical team was aboard each bus in case of medical need, a contingency approach used to cover all activities throughout the deployment. On arriving at Andrews, the task force moved to an assigned hangar, where the entire equipment cache was palletized to fit the AC-141-Starlifter military cargo plane. The medical component met after this activity to discuss operational plans to be used during the deployment. Once aboard the plane, the medical team members and packs were interspersed throughout the plane to be prepared to provide immediate care, if needed.
The flight to Tinker Air Force Base was uneventful. Task force members were encouraged to rest and sleep, particularly since data obtained at the Medical Check-In Station revealed that 85 percent of the team had slept less than three hours the night before. The excitement of the deployment, however, coupled with in-flight noise and small group discussions, kept most people awake during the three-hour flight.
Once on the ground, the task force was taken by bus to the Myriad Convention Center in downtown Oklahoma City, which served as the base of operations (BOO). Upon our arrival, sleeping quarters were established in the upper mezzanine level. The medical cache was organized at one end of the convention center floor (the Metro Dade (FL) Task Force was already set up at the opposite end), and the two-bed hospital/walk-in clinic was set up adjacent to the rest of the team cache. This location, along with the manner in which the medical center was set up, proved to be increasingly important as the deployment went on. What started out to be just a place to come for pre- and post-work surveillance monitoring eventually became a social center, while at the same time the location at which we handled an average of at least 10 patient complaints a day.
DURING THE DEPLOYMENT
Work shifts. Normally, the 56 members would be divided into two 12-hour work groups, thus allowing for 24 hours of continuous work activity by each FEMA USAR Task Force. However, FEMA revised the work plan for Oklahoma City. Each response team stayed intact with all 56 members working the same 12-hour shift together. For the majority of the deployment, VA TF-1. I worked the night shift, 7 p.m. to 7 a.m., along with the Metro Dade Task Force.
Medical screening. Before being bused down to the forward base camp to begin work each day, the task force members were given a brief examination by the medical team, which included vital signs and a quick set of health history questions such as “How did you sleep?” and “Do you have any eye, ear, or throat problems?” This information was recorded sequentially on each person`s medical record. Exclusionary criteria had been established, but no one was found to have vital signs or health complaints that precluded their being allowed to work.
Briefing. At the task force leader`s briefing, given before the start of each shift, team members were given reminders about proper safety practices, good hygiene, and the importance of hydration. The medical team manager also shared any noteworthy information he had learned by attending the twice-daily briefings from the FEMA IST medical officer. At these meetings, each of the medical team managers met to discuss the health and safety issues affecting their teams and to address matters of mutual importance.
Supplies. Before going to the work site (incident location), the entire task force met at a forward base of operations approximately two blocks from the Murrah Building. Selected equipment, including some medical items, were stored at this site to prevent the unnecessary ferrying of equipment back and forth to the base camp, 10 blocks away. Each medical team member was given his assignment for the shift. We double-checked to make sure our medical cache was properly stocked.
This incident provided the first real test for the recently designed physician and medic vests the medical team wore. The vests were overlaid with six pouches to carry such items as patient assessment equipment, soft-tissue injury supplies, advanced airway equipment, IV supplies, and necessary drugs. Although the vests looked cumbersome and weighed more than 30 pounds, they were very well-designed and proved to be quite practical. When not being worn, they were kept at designated spots at the work site for rapid access by the medical team when needed.
A central stock of additional medical equipment and supplies was established in a covered treatment area set up by the medical team in front of the Murrah Building.
Once the work shift was complete, the equipment was returned to the forward base camp for storage in a secured area.
Work crews. A medical specialist was assigned to work with each of the four rescue squads. The medical team manager and assistant team manager each supervised the activities of two medical specialists. This approach in which the medical specialist is part of the rescue squad proved to be very effective and will be used again in future deployments.
Once at the work site, each rescue squad was assigned a specific task (or tasks) and work area. The medical specialists monitored their rescue squad members closely during rescue activities, watching for signs of fatigue, stress, illness, or injury; they also assisted with body removal. A squad member exhibiting problems was treated at the work location or was sent to the treatment area, where the medical specialist and physician staff provided definitive care. If a task force member had to be evacuated for more definitive care, the initial assessment was made at the scene, and a medical team member accompanied the task force member to the hospital. Transport was provided by Oklahoma City EMS personnel, who were on-site 24 hours a day.
Safety. Shifts were usually organized so that every team member received a minimum of two small on-site rest periods built around an hour-long rotation to the rehabilitation sector at the forward base camp. During the extended break, the American Red Cross served a hot meal, and personnel could stretch out on nearby cots. On an hourly basis, during search and rescue activity periods, the message, “All Virginia Task Force I members, it`s time to hydrate,” was announced over the task force radio. The message was taken lightly at first by some members, but in time they came to see the importance of stopping work hourly to drink water from a canteen, or bottled water provided by local vendors, to avoid dehydration and fatigue. By week`s end, all personnel were “believers” to the point that, in a restaurant the night before the task force left and on the plane home, the announcement was still jokingly being made. Because personnel were working in a dangerous area, the medical team members constantly watched for signs of fatigue that, if not caught immediately, could lead to accidents causing injury or death. Medical team members also supported the work being done by the safety officer and held frequent conversations with the structural engineer who also was part of the task force.
Nature of medical complaints. Following the bus ride back to the convention center, all task force members were medically rechecked and their medical needs were tended to by the medical staff. As the deployment progressed, visits to the clinic for minor medical problems and requests for help to relieve sore and tired muscles increased. Ibuprofen was the most commonly dispensed drug from the minipharmacy that was part of the medical cache. Diphenhydramine (Benadryl®) was the second most often used medication; it was administered not for allergies but to help tired task force members to fall asleep.
Fortunately, the injuries suffered by VA TF-1 were relatively minor. Only three members required evaluation beyond the technical capabilities of the task force medical team. Three eye injuries required specialized equipment (slit-lamp examination) to rule out serious injury or to identify fine particulate matter that had become embedded in the cornea or eyelid. Only one team member sustained an injury requiring suturing. The repair was performed at the base camp clinic with supplies from the medical cache.
The majority of medical complaints involved upper-respiratory symptoms. The bomb site was heavily laden with a very fine dust containing a variety of agents, such as cement or granite; and, despite the proper use of a wide variety of protective masks, more than one-third of the team members developed problems related to inhalation exposure. Nasal congestion and sore throat were the two most common complaints. Three of the team members were treated with empiric antibiotics; the others were treated aggressively with decongestants, hydration, and throat lozenges.
Virtually no gastrointestinal or urinary complaints were treated during the deployment of VA TF-1. Only one team member required IV hydration, and that occurred on the way home–the result of fatigue and celebrating the pending return to family and friends.
Search dogs. The search dogs also fared reasonably well during the deployment. None of the four VA TF-1 dogs failed to perform when called on, despite not having the reward of finding any live bodies. Like their human counterparts, they also hydrated regularly, ate well, and received daily washing at the “Dog Decon Center” at the end of each work shift. While the VA TF-1 canines experienced no significant injuries, other task forces` search dogs experienced lacerations, eye foreign bodies, and other minor problems. They were addressed by USAR medical personnel and local veterinarians.
Due to the nature of the disaster, we found no live victims. The gruesome task of removing the bodies discovered by our team frequently was done by medical team members in conjunction with the Medical Examiner`s Office. Tyvek® suits and protective gloves were generally worn to prevent contamination. There had been concern about the potential psychological effects of the terrible smell associated with decaying bodies, but this fear was not realized by the Virginia Task Force, in part because of the cool night-time weather conditions and the respiratory protection worn by team personnel. The use of Vicks® inside of the nose and the periodic dropping of wintergreen inside the mask also proved helpful in avoiding what could have been a very debilitating problem.
Documentation. As with everyday EMS, documentation was another important aspect of the medical team role. Besides recording each task force member`s vital signs and history twice daily, patient records were kept on every clinic visit. The drugs dispensed from the pharmacy were also recorded on an inventory sheet. These records were all tabulated and reorganized upon returning home and became part of each person`s department medical record as well as part of the archived records of this deployment.
Clearly, everyone on the team was affected emotionally by what they had seen and heard. On a normal workday, rescue personnel stay with a job until it is completed, and we have become accustomed to “saving lives.” Since there were no live victims to be found, recovering bodies became an important goal, which was reinforced by the gratitude shown by the local population. On more than one occasion during the Oklahoma incident, our team would discover a buried body and begin to disentangle it from the surrounding debris, only to have the work shift end…and we would have to allow another team to complete the assignment. While not openly discussed initially, it became increasingly evident that this was an important mental health issue that must be more proactively addressed in future deployments.
Two of the medical team members were peer debriefers on Fairfax County`s CISD team. They were paying particular attention to identifying signs of CIS in their colleagues. A defusing session, using outside debriefers, was held on our third day in Oklahoma City but was poorly attended by task force personnel. As time proceeded, informal conversations among team members increased and they more openly discussed their feelings. These discussions frequently took place at the clinic or during meals at the base camp. Limited sleep each day and a change in everyone`s normal circadian rhythm, coupled with not finding anyone alive, contributed significantly to people`s feeling tired.
However, the repeated expressions of kindness and hospitality shown to the team by the citizens of Oklahoma City and the State of Oklahoma helped to bolster members` perception of the importance of our role there–if not to save lives, then to help recover those who had been killed so that their families and the communities could begin to recover from this tragedy.
Preparing to leave. By the seventh day on-site, the team was ready to return home. At the end of the final work shift, team pictures were taken and gifts from the team were given to several local people with whom we had worked closely. Gifts were given to the crane operators with whom we had developed a close comraderie and to some of the men and women who had cooked our meals and run the “support services” at the convention center. Sharing time and, at the end, presenting small tokens of our appreciation (T-shirts and caps) were other important outlets for dealing successfully with the stress we had encountered.
AFTER RETURNING HOME
The medical surveillance and concern about the mental health of team members continued after arriving home. Immediately on returning home, people who were taking prescription medications were provided with filled prescriptions, thanks to assistance from a local hospital pharmacy. Within five days after returning, a CISD was held for all team members and their families. Peer debriefers from the department along with psychologists from the county`s mental health unit conducted the well-received six-hour session. The families and team members were separated into two groups and given the opportunity to share their feelings. They were also instructed on effective coping strategies. All also were offered individual assistance for coping with lingering effects of this critical incident. Fairfax County-employed personnel were given three days off before returning to their scheduled shift work. For the volunteers on the team, additional absence from their full-time jobs was not really a viable option. Many of them returned to work the day following their return home.
During the first week home, medical team personnel contacted all members to check their physical and mental health. Those with identified medical problems received additional follow-up calls over the following weeks. Several team members` complaints prompted visits to their personal physicians. Working with the Department Health and Safety branch, appropriate specialty physician referrals were given when indicated.
Chief among the problems evaluated were lingering upper-respiratory inflammation or infections, including sore throats and sinusitis. They occurred despite the fact that team members used respiratory protection at the work site. Interestingly, two cases of vocal cord polyps, believed to be secondary to exposure to concrete and granite dust, were diagnosed and required prolonged treatment regimens. Due to the hazard exposures team members encountered, each person was asked to complete the department`s standard hazard exposure form, which became part of personnel`s individual department health files. In an effort to determine other important individual health data related to the Oklahoma City incident and to be better prepared for the next deployment, each team member also completed a health survey developed by the medical team. This form uncovered very useful information (still being tabulated) and will be used in future deployments to help medical team members monitor each person`s health problems and needs more effectively.
For the six members of the medical component of the Fairfax County Fire and Rescue Department, Virginia Task Force 1, the eight-day experience in Oklahoma City was physically taxing, emotionally draining, and yet immensely gratifying. The contributions made by the medical team proved essential to the entire task force`s meeting its mission objectives and returning home safely. Medical team members proved to themselves and their colleagues that they were a vital part of this urban research and rescue team concept and that the hours of hard work, planning, and training they had done before Oklahoma City were worth it. They knew their job, and they were able to perform it well. n
Dr. Bruce Cummings, of the Los Angeles County (CA) Task Force, discusses preventive health measures and recognition of symptoms of stress during a daily task-force briefing. These regularly scheduled educational intervention sessions were essential for maintaining responders` physical and mental well-being.
Virginia Task Force-1 medical team members move medical supplies into place at the start of a work cycle. A central stock of additional medical equipment and supplies was stored in a covered treatment area in front of the Murrah Building. The blue physician and medical vest being worn by the team members is overlaid with six pouches for carrying items such as patient assessment equipment, soft-tissue injury supplies, advanced airway equipment, IV supplies, and drugs. This was the first real test for the vest, which proved to be quite practical. When not being worn, the vests were dropped into designated spots at the work site for rapid access by the medical team. (Photos by authors.)
Medical personnel working within the structure wore the same protective gear as other rescue personnel.
A USAR medical specialist performs an eye wash on a task force member. (Photo courtesy of California OES Fire & Rescue.)
n CRAIG DeATLEY, PA-C, EMT-P, is director of the EMS program (B.S. degree) at The George Washington University and associate professor of emergency medicine. He is an EMS captain, a flight paramedic, and the assistant medical director for the Fairfax County Police Helicopter Division. He responded to Oklahoma City as a member of Virginia Task Force-1 medical team.
n ANTHONY G. MACINTYRE, M.D., is chief resident in emergency at The George Washington University. Prior to medical school, he was a practicing EMT. He responded to Oklahoma City as a member of VA Task Force-1`s medical team.
n DEWEY H. PERKS, EMT-P, is a captain and 23-year veteran of the Fairfax County (VA) Fire and Rescue Department. He was instrumental in the development and organization of the medical team and medical cache of VA Task Force-1. He responded to Oklahoma City as a member of VA-1`s medical team.
n JOSEPH A. BARBERA, M.D., FACEP, is an assistant professor of emergency medicine at The George Washington University and director of disaster medicine programs for the Ronald Reagan Institute of Emergency Medicine. He was the medical working group leader during the development of the FEMA Urban Search and Rescue Response System. Dr. Barbera is a member of VA Task Force-1. He responded to Oklahoma as the initial medical support officer for the FEMA Incident Support Team, the group that helped manage the FEMA USAR resources and their integration into the local response effort.