Mass Casualty Response

Mass Casualty Response

DISASTER MANAGEMENT

November 5, 1988, a rainy Saturday morning, proved to be a very unusual day for the Chesterfield County (VA) Fire Department and the Richmond metropolitan area. A simulated mass casualty incident was scheduled on this day at the Richmond International Airport in Henrico County, just north of Richmond. The drill was designed to test the Richmond metro area’s hospital notification and patient allocation procedures for mass casualty incidents. These procedures were developed from a statewide task force study.

As the drill began, the Chesterfield County Fire Department, located south of Richmond, experienced a real mass casualty incident of its own that tested the resources of the fire department and provided valuable training to everyone involved.

THE INCIDENT

The incident began at 1114 hours as Station 7 and the Manchester Rescue Squad were dispatched to a single vehicle accident on a major east-west highway that runs through Chesterfield County. Information relayed by fire alarm headquarters to the responding units reported that the vehicle was a daycare van loaded with children. This prompted the officer of Engine 73 to request an additional engine for EMS manpower. (The Chesterfield County Fire Department is not the primary provider of EMS in the county, but all career firefighters are trained to the EMT-A or EMT-D level. The fire department does provide nontransport EMS when the four volunteer rescue squads in the county are busy or unavailable, or for largescale incidents. In 1988, roughly onethird of the department’s 6,453 alarms were medical-assist calls.)

The temperature at the time of the incident was in the 60s and heavy rains with high wind gusts were passing through the area. Engine 102 was dispatched to assist with the accident but was diverted to assist a rescue squad with a cardiac arrest incident. At this time, Engine 22 was dispatched to the accident. The Manchester Rescue Squad was able to respond with four ambulances almost immediately, as they were conducting a drivers training exercise that morning.

At 1124 hours, members of Engine 73 arrived at the scene to find an extended-body van upright in the median strip with damage to the roof and sides. Seventeen injured passengers, adults and children, were sitting and lying around the area. They were family members of inmates of a nearby correctional facility, traveling from Richmond for a visit.

The lieutenant from Engine 73 assumed command of the incident and assigned his two firefighter/EMTs to triage the patients so that he could get a clearer picture of the incident. He then requested the status of Medflight, the regional paramedic helicopter, but was informed by fire alarm that it was grounded due to the weather. A triage of the patients revealed one fatality, five to six multisystem-trauma patients, and two trauma cardiac arrests; the remaining patients had various injuries that were not life-threatening. Upon arrival of Engine 76, a tanker from Station 7, a handline was stretched for safety and its personnel were assigned to assist the firefighter/EMTs in patient care.

Shortly after fire department arrival, units from the Manchester Rescue Squad arrived and began treating those seriously injured. Command designated a senior member of the rescue squad as the triage sector officer and assigned him to perform a more thorough triage of all patients and coordinate their treatment. At this time the battalion chief assumed command and assigned Engine 73’s lieutenant as transportation sector officer to coordinate the transportation of patients and the rescue loading area. Engine 53 was called for additional EMS manpower.

Command was notified of four additional patients located in another van on the side of the highway. Members of the next available incoming rescue unit were assigned to examine and treat these patients. As Engines 22 and 53 arrived at the scene, their personnel were directed to assist in setting up an EMS equipment pool and to initiate treatment of remaining patients.

The initial transporting rescue units advised the area hospitals of the situation in preparation for the patients who would soon be arriving. Fortunately, the closest hospital was conducting a training session for some of its doctors and nurses and had available more staff than usual. Some patients were transported to other area hospitals to prevent overloading any one hospital. The transportation sector officer recorded the rescue unit number, the number of patients carried, and the hospital to which they were transported. An additional battalion chief was assigned to document the scene and to coordinate the triage, treatment, and transportation sectors. As the incident stabilized, Engine 112 was called to provide backup EMS manpower and to assist in gathering EMS equipment and disposable waste at the scene.

In all, 20 patients were treated by fire and rescue personnel and transported to area hospitals. Two of the patients later died at the hospital. All patients were treated and transported within one hour and 45 minutes. Ten rescue units with 31 rescue personnel were utilized from three of the county rescue squads. Five fire department engines with 25 members were utilized. The incident was marked under control at 1400 hours. As a side note, Engine 102’s crew, which had been diverted to the cardiac arrest incident, rode to one of the hospitals on the ambulance and assisted the hospital staff in victim handling.

LESSONS LEARNED AND REINFORCED

This incident reinforced several important aspects of the Chesterfield Fire Department’s operations, as well as taught many new lessons that have been or will be implemented.

  1. This incident reinforced the value of using the Incident Command System at all incidents, not just fire situations. Sectoring major functional areas helped organize the incident and prevented overloading command.
  2. The county rescue squads and police department were unfamiliar with ICS operations and terminology. At mass casualty incidents personnel need to operate under one standard system and unified command. Training in the ICS is now being provided to the rescue squads in the county.
  3. There was some confusion among both fire and rescue personnel at the incident concerning who was in charge of certain sectors. At a large, multiagency operation, sector officers should be identified by visible means —vests, armbands, etc. —so that communication and coordination can be more easily maintained.
  4. One person must be designated to manage each of the major sectors: triage, treatment, and transportation. Coordination was made easier and communications simplified.
  5. This incident highlighted the need for mass casualty incident procedures and identified responsibilities within the fire department. The initial stages of the incident are critical to success. The fire department is developing mass casualty incident guidelines and outlining position responsibilities in ICS for future situations. The fire department adopted a triage procedure and is training all personnel in its use.No triage-tagging or patientmarking system was available on responding fire department apparatus at this incident. Command was hampered in assigning EMS resources as it was difficult to remember which patients were most critical. Also, treatment crews assigned to patients had to retriage them to establish treatment priorities. The fire department is now making small triage kits for all first-out apparatus, consisting of colored survey tape to prioritize patients.
  6. In the initial stages of a mass casualty incident there is a severe shortage of EMS personnel to treat patients. In this situation, command successfully utilized several civilian passersby to monitor the less critical patients and report changes in their condition to EMS personnel.
  7. A quick and accurate count of patients is important so that adequate fire and rescue resources can be called immediately. Additional fire and rescue resources should be called based on equipment and manpower need. Rescue units outside the county, but closer, could have been a consideration in this situation in lieu of in-county rescue squads. Also, fire units with extra manpower —five members instead of three—should be called to gain extra resources.
  8. Setting up critical stress debriefing sessions for personnel after such an incident is vital. The fire department has routinely done this after similar incidents for several years and it has continued to help maintain the well-being of our personnel.
  9. This incident required large amounts of EMS equipment and manpower. EMS equipment and manpower pools need to be established early in the operation. Consideration should be given to stockpiling EMS equipment for rapid transportation and use at mass casualty incidents.
  10. The fire department, rescue squads, and police department operate on an 800 MHz radio system. The system provides the capability for units to be grouped together for direct communications. This was done in the latter stages of the incident between fire and rescue at the command level. Operating on a common frequency or channel is very important in multiagency or department operations.
  11. The infrequency of this type of incident calls for increased practical training by the fire department in mass casualty incidents. Our department is developing training for personnel using the new mass casualty incident and triage procedures.
  12. This incident required separate staging areas for fire and rescue units. Rescue units must have quick access to the scene, easy patient loading, and quick exit from the scene. If a drivethrough setup is not available, rescue units should be backed in to facilitate faster patient loading and removal.
  13. Finally, as at any incident, command must be established at a distance from the scene. This positions the incident commander away from the confusion. Also, representatives from the other organizations involved need to be at the command post for coordination.

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