Mass-Casualty MVA

On April 16, 2014, at 1859, Virginia Beach (VA) Fire, EMS, and Police were dispatched to a reported motor vehicle crash at 563 Sandbridge Road. The two-lane rural road is five blocks from Sandbridge Beach and is heavily traveled by beachgoers and residents who live in the cottage community. The narrow road has tidal spillways and ditches on both sides, with power poles in the easement.

(1) The crash scene with the sedan in the ditch and placement of Ladder 21 and the front bumper-mounted hydraulic tools. (Photos by Kirk Kellerhalls, VBFD Multimedia Bureau.)
(1) The crash scene with the sedan in the ditch and placement of Ladder 21 and the front bumper-mounted hydraulic tools. (Photos by Kirk Kellerhalls, VBFD Multimedia Bureau.)

The 911 call takers were inundated with reports of the crash. A call taker documented these comments: “The complainant is trying not to get close because he doesn’t want his children seeing what is going on.” Another documented a bystander’s concerns as fire and EMS were responding: “It is bad. There are people bending over the car in the ditch. They are trying to extract patients from the vehicle. Possible fatality. This is a rollover. Four subjects are unconscious; unknown if they are breathing.”

The Scene

Engine 17 arrived on the scene with four firefighters within three minutes of being dispatched. The captain reported one child ejected and possibly four patients in cardiac arrest. He then upgraded the incident to a “mass casualty,” confirming multiple patients were pinned in the vehicle and that a car was on its side in the ditch.

Further assessment revealed that two vehicles were involved in the crash with an unknown number of patients. Two patients were outside of a full-size Toyota pickup truck, and an unknown number of advanced life support (ALS) patients, all nonresponsive, were in or ejected from a Nissan Sentra. The captain established command and requested air ambulance support because of the number of critical patients and the distance of the crash from a hospital or trauma center. Nightingale Air Ambulance was on a flight, so no air ambulance support was available. This information was important, as multiple ground ambulances were needed to handle the multiple casualties. Two patients were identified as green (delayed) and an unknown number as red (immediate/critical).

Engine 17’s crew was logistically overwhelmed with the number of critical patients. The officer was in command and gathering information from bystanders. The operator placed a hoseline on the ground and shuttled medical equipment, including backboards, a cardiac monitor, an IV box, a drug box, and immobilization equipment, across the ditch to the two firefighters who were triaging and treating patients.

The firefighters conducted rapid trauma assessments of the patients they were able to access. With extrication equipment and transport ambulances en route, the two firefighters treated one child who was ejected and in cardiac arrest and another child who was unconscious, unresponsive, and severely injured. That patient was pulled through the back window of the sedan.

(2) The sedan after extrication was completed by Ladder 21’s and Rescue 1’s crews.
(2) The sedan after extrication was completed by Ladder 21’s and Rescue 1’s crews.

The district chief arrived and assumed command. A first-alarm medical was declared. This allowed a predefined number of additional fire and EMS resources to be added to the incident. Battalion 4 arrived and was assigned as operations section chief. Ladder 21 arrived next with extrication equipment. The Ladder 21 officer assumed the role of extrication group supervisor. The operator deployed hydraulic extrication equipment that was mounted on the front bumper and preplumbed to hydraulic pumps. Spreaders, cutters, and rams were placed on the roadway while the firefighter in Ladder 21’s jump seat and a firefighter on Engine 17 stabilized the small four-door Sentra with wood step chocks and cribbing. The Engine 17 firefighters were now able to reach in the sedan’s rear window and start removing additional patients while the ladder company and Rescue 1 firefighters started to cut and pry the roof and doors. With the extrication ongoing, the crews quickly realized this incident was even more horrific than they originally thought. Not only were all the patients pinned in the sedan critically injured, but six of the seven in the vehicle were children.

As they made access to one patient, underneath that child was another child. They continued to cut and remove metal, removing one child after another after another. Crews from Engine 17, Ladder 21, Engine 5, and Engine 21 were overwhelmed with five more critical patients. Four of the seven patients removed from the Nissan Sentra were in traumatic cardiac arrest. The other three were unconscious, unresponsive, and critically injured.

No one from the Nissan Sentra was able to communicate with firefighters or EMS providers. No one knew how many were in the car or their ages or identities. Police, bystanders, and additional responding fire crews searched the woods and ditch for additional patients. EMS supervisors arrived and integrated into the command post; they became medical group supervisors, coordinating patient triage, treatment, and transportation. Additional tactical channels were established to separate rescue operations and medical communications. As the ground ambulances arrived, paramedic firefighters from Engine 21 and Engine 5 boarded the ambulances and worked with paramedics from Virginia Beach EMS to transport the critical patients to the trauma center.

The Numbers

Because of the number of critical patients and the distance of the crash scene from additionally responding ambulances, the medical group supervisors decided to send two patients per ambulance on two of the first-arriving ambulances. Once members completed extrication, completed the search of the area for additional ejected patients, and sent all critically injured patients for transport, the two basic life support (BLS) patients from the pickup truck were transported. All critically injured children were extricated and en route to the hospital within 29 minutes of Engine 17’s arrival. Within 43 minutes of Engine 17’s arrival, all critically injured children were at the trauma center.

In all, eight patients were initially transported to two area hospitals. One patient was deceased at the scene; five were transported to Sentara Virginia Beach General Hospital; three were transported to Sentara Princess Anne Hospital.

(3) The crash scene and the pickup truck involved in the crash.
(3) The crash scene and the pickup truck involved in the crash.

The area hospitals were instrumental in the outcome of this mass-casualty incident (MCI). Sentara Virginia Beach General was the lead hospital and the closest trauma center. The medical group supervisor notified Virginia Beach General early in the incident, and the hospital’s supervisors made provisions to hold the off-going emergency department staff since the incident occurred at the hospital’s scheduled shift change. The trauma team was notified early, and staff was prepared for the patients’ arrival.

Five critically injured children arrived at the trauma center within four minutes of each other; even with additional staff, the trauma center was overwhelmed. Two children arrived at 1940 hours, one at 1942 hours, and two more at 1944 hours. Two children were transferred to the Pediatric Intensive Care Unit (ICU) at the Children’s Hospital of the King’s Daughters, and two were transferred to Sentara Norfolk General’s ICU. Three patients were diverted to Sentara Princess Anne Hospital because of the overload at the trauma center. One of the three went into traumatic cardiac arrest while en route; the other two patients were BLS.

The emergency services resources required to handle an MCI with this many critical patients included the following: Virginia Beach EMS sent four ambulances, three paramedic zone cars, and five supervisors. Navy-Regional Mid Atlantic sent a supervisor, one engine, and two ambulances. Virginia Beach Fire Department sent four supervisors, three engines, two ladders, one heavy rescue, and a safety officer. Virginia Beach Police sent multiple officers and the crash fatality investigation team. The hospitals all worked in harmony to coordinate receiving these patients. It was also noteworthy that when an MCI like this occurs, the emergency departments are still receiving and caring for their “normal” patient loads, which include other trauma and medical patients. They were able to provide not only for the patients in the crash but also for the patients already in their emergency departments or being delivered by ambulances from the region.

The Lessons

Although four people died, there are many successes worth noting.

  1. The scene size-up by the first-arriving fire officer set the tone for the other responding units by declaring an MCI and requesting additional equipment early in the incident. When incident scenes are remote from the center of a city, additional responding apparatus and responders, and the trauma center and other hospitals, call early for additional resources.
  2. By establishing command and relaying to the responding resources the complexity of the incident, Engine 17’s crew was able to concentrate on caring for the injured, knowing help was coming. Also, once command was transferred and section chiefs and group supervisors were established, the incident could be managed and coordinated with a defined span of control.
  3. Because of excellent training and equipment, the responders were able to stabilize the vehicle and extricate the critical patients quickly. From the arrival of the ladder company until all patients were extricated took 10 minutes. This cannot occur unless properly trained and equipped responders are in the proper assignments. At this incident, the officers, firefighters, medics, and supervisors were trained, equipped, and experienced to handle a significant incident.
  4. Notify area hospitals early when dealing with an MCI. This allows the lead hospital time to coordinate between the incident responders bringing the injured to the trauma center and the other area hospitals. This coordination resulted in three critically injured children surviving. The trauma center was well prepared and was able to receive five critical patients within four minutes while still managing a busy emergency department, but they had to divert three patients to another area hospital because of the surge.
  5. When no one in the vehicle has identification or can speak to responders, responders must search the area around the crash scene to identify additional patients or casualties. Until you can confirm that everyone is accounted for, continue to search the area and use all available resources, like police and bystanders, until enough emergency responders can be directed to the search.
  6. Request additional tactical or working radio channels to separate the radio traffic of the rescue/extrication operations from the medical communications. Essentially, operations should be on one tactical channel and medical groups should be on another tactical channel.
  7. Have BLS and ALS equipment on fire apparatus to supplement the ambulances. When an MCI occurs, the BLS and ALS equipment on the ambulances will not be sufficient to handle the number of patients. Likewise, the amount of BLS or ALS equipment on the fire apparatus, coupled with the number of firefighters, cannot handle an MCI. For this reason, multiple fire apparatus and multiple ambulances must work in concert to triage, treat, and transport the patients.
  8. Institute a first-alarm medical response package for an MCI. This will allow for predetermined resources and notifications to occur with one request, preventing the need to piecemeal fire and EMS resources.
  9. Use mutual-aid or automatic-aid resources to supplement the response to an MCI, especially if the resources are close to the scene. NAS Oceana Dam Neck Annex, called Dam Neck Base, is just north of the crash scene. With the road closed from the crash and rescue efforts, all assist city resources had to come from the west. Navy Region Mid-Atlantic’s Dam Neck Fire Department provided two ambulances, an engine, and a battalion chief from the east. The Virginia Beach Fire Department and Navy Region Mid Atlantic have established automatic-aid agreements that allow for the Navy’s apparatus to come off base and supplement the city’s response. For this scene, the resources integrated seamlessly, and the citizens involved in the crash were better served because of the automatic-aid agreement.

MICHAEL J. BARAKEY, EFO/CFO, is a district chief with the Virginia Beach (VA) Fire Department, where he is assigned to Administration. He is a PEER assessor for the Commission on Fire Accreditation International (CFAI) and is the department’s accreditation manager. Previously, he was assigned to Personnel and Development, Operations, and Training. He is a hazmat specialist, an instructor III, a nationally registered paramedic, and a neonatal/pediatric critical care paramedic for the Children’s Hospital of the King’s Daughters in Norfolk, Virginia. Barakey is a plans team manager for the VA-TF2 US&R team and has a master’s degree in public administration from Old Dominion University in Norfolk, Virginia. He is an FDIC classroom instructor.

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The First 10 Minutes: A Best Practices Approach to Motor Vehicle Crash Response
Best Practices of Vehicle Rescue: The First 15 Minutes of a Motor Vehicle Collision

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