Unexpected Drop-ins

The early morning hours have been very quiet, and it’s almost shift change when the dispatch tones for Attack One sound: “Attack One, respond on a motor vehicle crash on the interstate.” It’s a quick response in light traffic. As Attack One approaches the overpass above the freeway, crew members note a large amount of debris on the road next to the bridge wall. Bystanders point the rescuers to the interstate below, where they see a chilling sight:

“Dispatch, this is a tour bus that has crashed,” the Attack One officer reports. “It’s lying on its side on the interstate, heavily damaged. I will initiate command. Stand by for further information.”

Within seconds the terrible nature of this incident becomes apparent: This full-size tour bus has somehow gone off the overpass and landed on the freeway below. The officer begins to issue a crisp scene size-up and orders for response: “We have a multiple-casualty incident with multiple trapped patients. Please dispatch a entrapment response with heavy rescue and resources for at least 20 patients. There is a significant fuel spill, and the interstate is closed. We need someone to check the bridge above to see if there are victims up there also.”

The Attack One crew starts a flurry of activity, evaluating how stable the bus is, triaging the victims trapped in and around the bus, and attempting to estimate the number of persons who might need care. The officer finds an individual who has information that will help.

“Dispatch, the group on this bus consists of 35 persons, and we will prepare for that many patients. Command, we are well into triage, and we have multiple critical patients, with some who are trapped. We have a collection point for the walking wounded along the wall of the interstate. We will need ambulances and a bus for transport. We will also need the medical examiner.”

The battalion chief who has arrived on scene and assumed command is now busy organizing the scene’s many aspects. There will now be heavy rescue, control of a large fuel spill, management of scene fatalities, treatment of critical injuries and transport of a large number of patients.

The Attack One crew reassembles and is assigned to lead the triage operation. They must work their way along the length of the bus, both inside and outside. Most of the glass in the bus is broken out, the full load of diesel fuel has spilled, and several victims are trapped along the vehicle’s outer surfaces. There are several victims with fatal injuries, and the Attack One crew has to cover them and work on.

The crew triages 35 persons, with the results summarized in Figure 1. Three of the victims are trapped along the outside of the bus. Five will need immobilized and moved out of the bus. The rest of the victims are already outside the bus and have a variety of injuries. About half complain of head, neck or back pain and will need to be immobilized on backboards. The rest have injuries that will not require immobilization.

The Attack One officer communicates the triage report to command so ambulances can be organized by the transportation officer. There will also be a treatment officer who organizes care of victims who are trapped. Several of these will need airway management before they can be removed from the scene.

The Attack One officer also must arrange to have the victims with fatal injuries managed appropriately. As the red-, yellow- and green-triaged patients are moved off the scene, the next job for the Attack One crew is to completely survey the wreckage and bridge above to make sure no victims are missed. This job cannot be completed until a heavy wrecker lifts the bus upright and all compartments of the bus are examined.

Operations prioritizes the available fire, EMS and extrication resources. Patient transports are organized with multiple ambulances and a bus for those with minor injuries. The command team works the scene until all victim care is complete. A logistics operation is then established to manage the many roles the agency needs to fulfill. The PIO works with other information officers to establish a joint information center, which will coordinate information release from law enforcement, the hospitals, the medical examiner’s office and other organizations that ultimately will be involved.

Case Discussion

The Attack One crew organized this unexpected multiple-casualty incident into manageable sections, focusing on the initial rescue and triage needs to begin the operation.

The tour bus contained a group from a university in another state. The group leaders were all seriously injured. This created the need to coordinate a number of “recovery” operations until university authorities could arrive to assist. Local hospitals, relief agencies, the emergency management agency and many others would ultimately join to assist the victims, families and university authorities with their needs over the months before the final patient was released. There was also an outpouring of assistance from volunteers, a hotel, an airline and countless organizations to assist the victims.

That this incident involved an out-of-town university group made managing it more complicated than other multiple-casualty scenarios. University students travel without chaperones, “call trees” and single points of contact. In this incident most of the students were separated from their cell phones and computers, which made contact with their parents and families challenging. Social media is now a very important method of communication for this age group, but parents may not be linked in the same way. Access to digital communications is one of the best ways to help a young person connect with family in an emergency.

Electronic media plays a significant role in major incidents. Many victims’ parents reported they received much of their information from broadcast reports. Some received phone calls from their children. The parents who didn’t get contacts from their children became acutely aware of the lack of phone communications as they interacted with other parents.

With many of the victims’ family members arriving in the city in the next 18 hours with little information, it was necessary for local agencies to establish a central collection point. They did this at a local hotel that volunteered its services. This provided the victims a place to go as they were discharged from hospitals, and out-of-town family members a place to collect. Relief agencies established operations at the hotel to provide clothing and other items needed by the victims, and then a site for university operations and family support.

It was also beneficial to have airport and airline staff coordinate the arrival and management of parents and other family members flying in. Those arrivals were then transported to the hotel that served as the central point or, if necessary, to the hospitals where the victims were being treated.

The major recovery operations were completed over the next few days, but it was months before the last victim was released to finish rehabilitation at home.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.