Skating to Patients
It had snowed all afternoon, but nothing much happened -- just a few illness calls. Big, wet flakes that melted on the road surfaces but turned the grass a nice shade of white. At about 1600 hours the sky cleared, the sun came out, and the temperature began to drop as the cold front came in. The Attack One crew is watching a beautiful sunset from the station as the Saturday evening meal is prepared.
As darkness falls, though, the station scanner starts to chirp. Crash, fall, crash, fall, more crashes. The local helicopter service is requested for the first crash dispatched, in the service area just east of Attack One's district. What is going on? Dinner is being pulled out when the tones for Attack One come through the radio: "Attack One, respond on a multiple-vehicle collision with a trap." The site is a bridge about two blocks from the station.
As Attack One approaches, a police officer waves it to a stop. "Don't even try to drive on the bridge," he says. "It's solid ice, and you won't be able to stop. Leave the vehicle here, and walk along the railing to hold on."
The police officer's car is a short distance away, where he slid into the railing himself. There isn't a car on the bridge that's sitting straight in a lane. Three are crashed on the middle of the bridge. One minor trap, although the vehicles are heavily damaged. The young woman has multiple leg fractures, but is able to talk with the crew. Four other people are injured, but seat belts and passive restraint systems have prevented serious injuries. The most verbal patient is a young man screaming in pain from a badly dislocated elbow. He wasn't in one of the cars that wrecked, but was walking from his vehicle to help when he fell and injured his arm.
The difficult issue: Basically, no one can stand safely on the bridge without holding on to something. The Attack One crew essentially "skates" their way to the vehicles and victims. They slide their equipment on the ice to avoid having to carry it. The ice has formed from the melting of the afternoon snow and an instant freeze when the sun set. It's "black ice," the slick, almost-invisible coating that's always so dangerous. The bridge is covered with it, although the surface streets between the station and bridge are almost completely clear. The drivers involved in the accident, like the first-arriving police officer, had no idea what was happening on the road until they were sliding out of control.
The rescue unit arrives but can't make it safely onto the bridge. Extrication equipment has to be pushed to the vehicles. And the police officer has more bad news: There will be no salt trucks for at least an hour. The road crews had no idea problems were coming, and had not prepared people or vehicles. Then dispatch relays another downer: There are so many accidents and falls, only two transport ambulances in the entire mutual aid region can be found to respond. And the accident reports keep coming in.
The scene is manageable. The victims are relatively stable, and no fire risks are present. Extrication will be complete in about five minutes. One of the Attack One crew members has triaged the other patients and arranged appropriate packaging while the transport units are en route. Another has had everyone on the bridge either sit down or hold on to something to avoid more injuries.
But the radio is crackling: "Bridge Command, can you please speak with CareFlight?" This is the helicopter service that was dispatched to the previous accident the crew was listening to at the station.
"CareFlight to Command, can you please update me on your patients?"
Command gives a brief description of the scene and patients.
"CareFlight to Command. We are at the other scene. Our victims are much more seriously injured and are still being extricated. Can you remove your patients to a Level 3 trauma center south of your location? The Level 1 trauma center is almost overwhelmed with patients, and we're going to have six more with serious or critical injuries to take there."
The next voice on the radio is the chief: "Command, every department in the region is out on accidents or falls, and all the region's hospitals are getting a lot of patients transported. Two ambulances and a fire engine have slid off roads, and the on-duty chief needs to manage those vehicles and personnel. Road salting crews won't be out for hours. Would you please coordinate work with the hospitals, helicopter and other EMS services?"
Then dispatch chimes in: "Dispatch to Command. We have two more reported accidents, uncertain on injuries. Can you clear and respond?"
The chief inserts himself quickly: "Dispatch, send two fire engines to those calls, and leave Attack One to manage the multiple incidents and hospital responses. We need to initiate our Major Incident Plan and open an Emergency Operations Center. Attack One, manage the victims from all incidents and work with the hospitals. And our Public Information Officer is not available, so you need to manage that also."
Managing the Incident
The Attack One crew completes duties at the bridge incident, and will now need to divide functions to manage the multiple issues brought about by the icing conditions. They must establish Command, plan hospital coordination, triage the patients from the many incidents, and minimize further hazards. There are three individuals to assist Command. One will act as the PIO. One will oversee logistics. One will lead operations.
Command contacts dispatch to assess regional conditions. There are more than 100 accidents on the roadways, and another 10 calls for persons injured in falls. All ambulances are now busy, and essentially all fire, rescue and law enforcement vehicles are also tied up. The air ambulance service has called for additional helicopters, as the sky is completely clear. All five regional hospitals have received victims. The media is calling for reports.
The critical challenges are slowing the number of accidents and falls, and distributing rescuers and patients as efficiently as possible. The media offers the capability to address the public most quickly. Although no precipitation is falling from the sky, the conditions on certain roads, sidewalks and parking lots are as dangerous as can be. The PIO will call together the local stations for a crisis briefing. He quickly prepares a news release that notifies all local media outlets of the crisis situation outside. It asks the community to either stay inside or use extreme caution when walking or driving. The television stations are asked to run a "crawl" across screens warning of the unexpected dangers of black ice on walking and driving surfaces. Based on the 100-plus accidents, the regional Emergency Management Agency is asked to release information through the Emergency Broadcast System. The PIO also notifies school systems (for Saturday evening sports events), hospitals, malls and churches regarding the dangerous conditions.
Logistics is assigned responsibility for coordinating victim triage, hospital resources, air ambulances and notification of road safety and law enforcement resources. A mutual aid group with fire and EMS resources is organized from south of the area and brought in to fill stations. Each of the regional hospitals has full emergency departments. There is one Level 1 trauma center, still receiving the worst injuries, now with all available operating teams working. There are two Level 3 trauma centers that have received seriously injured patients from several of the accidents. All five hospitals are managing both patients that arrived by EMS and as walk-ins injured in falls or less-severe auto accidents. A quick count by the hospitals finds that about 200 victims of the icy conditions have been seen already. The air ambulance service will be removing the next sets of seriously injured patients to the Level 1 trauma center 60 miles to the south, which has not been affected by the road conditions and has surgical teams prepared. A patient injury grid is prepared for Command (see Figure 1). Dispatch has brought an additional dispatcher into the communications center, and that individual will assist transport units in determining which ED can receive the next victims. All ambulances are aware of the need to make quick, safe transports and return to service.
Law enforcement and road safety crews are now fully activated, although the salt trucks are slow getting out because of the unexpected conditions. Law enforcement has prepared a priority list of dangerous roads to be addressed.
Operations is prioritizing the available fire, EMS, air ambulance and extrication resources. Mutual aid companies are being mixed into responses. The air ambulance resources are available, and at this point air transport is the safest avenue for critical patients. Personnel on all vehicles are advised to wear whatever shoes give them the best traction on ice. Patients from icy scenes are to be slid safely along the ground rather than carried. Patient transports are organized through the communications center.
The Command team functions at high level for about three hours. At that point public notification has been successful and traffic has been reduced; roads are salted; fire and EMS units are available; and only a trickle of calls typical for a Saturday night is being managed. The hospitals' status has improved, and each is capable of receiving the normal volumes. Mutual aid resources are thanked and released.
Attack One returns to the station to begin the documentation process. The acting PIO prepares for live broadcasts for the 11 p.m. news, which will take place at one of the hospitals. He prepares a message to thank the media for broadcasting the messages that prevented more injuries and possibly saved lives. Thanks also go to the safety crews, mutual aid group and hospitals that collaborated to handle the unexpected surge.
Learning Point
Some areas have weather conditions that can lead to simultaneous multiple-victim incidents. Public safety leaders, including fire, EMS and law enforcement, must work with the media (the fourth member of the public safety team) to minimize the threats to public health. Managing the incidents may be very difficult, with shortages of resources and great difficulty in prioritizing needs. Incident and victim tracking may be difficult and require efforts to supplement dispatching resources. Multiple incidents occurring in rapid succession, particularly when road conditions are bad, may be among the most challenging situations for EMS leaders to manage. The work of the Public Information Officer with the local media may be lifesaving in these events.
Case Discussion
The Attack One crew organized this unexpected incident into manageable sections, focusing on the needs of the community's hospitals and rescue and safety resources.
Jim Augustine, MD, FACEP, is the medical director for a number of fire services in the Atlanta area, including Atlanta Fire Rescue, which includes operations at Hartsfield-Jackson Atlanta International Airport. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He has served since 1981 as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.
