Disaster Close-up: What Top Docs Learned When It Happened to Them

“No plan survives contact with the enemy.”

–Field Marshal Helmuth von Moltke, Chief of the German Staff, 1857

I volunteered to summarize the MCI part of the Gathering of Eagles conference for EMS World for a number of reasons. As a leader and decision maker in unified command, I felt compelled to draw out salient points for the understanding and benefit of both my own organization and yours. As well, in a previous life half a decade ago and an ocean away, I was a Gold commander (the U.K. uses Gold, Silver and Bronze to express levels of command and control) for a number of incidents myself.

The Eagles’ opening track on multiple-casualty incidents brought out the best in the worst and covered a range of man-made and natural disasters on a grand and national scale. The medical director of the actual agency that dealt with the incident described the events that unfolded, how their agency responded and treated, and then, importantly, the results of after-action reviews, reports and analyses. As the sessions went on, some themes and lessons emerged.

Explosive Situations

It has only been a year since the nation reeled at the devastation wrought by two young men at the Boston Marathon. Boston EMS medical director Sophia Dyer, MD, began her focused 10 minutes on the moments of detonation and how the bombs, only 13 seconds apart, created a scene of indiscriminate killing and maiming. The onsite medical coverage consisted of both ALS and BLS resources alongside medical tents. The marathon, with its half-million spectators and 20,000 runners, had already attracted 600 patients into the medical tents before the explosion.

With a robust incident action plan (IAP) in place, employment of the Incident Command System (ICS) and calm, clear radio traffic, patients were rapidly distributed to 10 hospitals. Good command and control on the ground ensured that staging areas were controlled and that staff were tightly managed to prevent self-response into areas where efforts were not required.

The latter point is important to commanders. With an event such as the Boston bombing, while those involved are running out, first responders, invited or not, can be running in, so the need for control and precise allocation of tasks is critical. In Boston great levels of interoperability and familiarity between agencies made for easier management. Use of the same radio system and a joint MCI plan, along with standard triage tags, eliminated problems that may have occurred otherwise.

Only days after Boston, another event in West, TX, played out when a fertilizer storage facility exploded during a fire. Emily Kidd, MD, interim medical director for the San Antonio Fire Department, painted a picture of carnage in a small community where a nursing home was destroyed and 12 responders were killed, devastating the local first-response system. With initial reports that there were 600 injuries, mobilization of a medical task force and ambulance buses was essential. In the immediate aftermath of the explosion, the public were a key to success: More than half of the patients transported from the scene left in privately owned vehicles.

Kidd identified that familiarity breeds success. Getting to know the capabilities of, and working beforehand with, public health and emergency management teams in frequent drills and exercises breaks the ice before an event occurs. The team approach also allows plans to change rapidly with learning from other agencies and events.

Active Shooters and Fast Responders

Before the session moved on to the next tragedy, FBI medical director William P. Fabbri, MD, began with a definition of what an active shooter is:

An active shooter is an individual actively engaged in killing or attempting to kill people in a con?ned and populated area; in most cases, active shooters use ?rearms, and the indiscriminate method of their assault means victims are randomly if not accidentally selected.

Fabbri’s sobering statistics from the FBI’s analysis of such attackers have informed a sea change in tactics recently made by both law enforcement and responding medics. The FBI notes that 98% of incidents involve a single shooter, and 2% involve improvised explosives. The total length of such events averages 12 minutes, which means that when police arrive on scene, shooting may still be going on. Swift action is of paramount importance to both stopping the shooting and drawing fire away from civilians.

Evolving tactics require arriving police officers to immediately enter and engage the shooter, which places them in harm’s way and statistically provides a 1 in 3 chance of being injured. Fabbri noted that one major to-do for law enforcement is to get more fully engaged in NIMS/ICS, which may reduce the occasional terminology barriers that crop up.

The bottom line for the medic, however, is that if they’re first to arrive, they could be in the thick of it from the outset and must be trained and, more important, prepared to advance into the warm zone to receive, treat and evacuate casualties. Tactical medicine may exist to support SWAT, but the paradigm now pushes any medic forward to match the tempo of the counterassault, in the same way that active-shooter scenarios overall have turned the urban assault from a SWAT issue to a patrol one.

Much of the FBI’s wisdom is already incorporated in Philadelphia, and in his session “Tactical Moves: How Philly Firefighters Are Now Preparing for Fire Fights,” Philadelphia FD medical director Crawford Mechem, MD, highlighted some new tactics. FEMA’s active-shooter guidelines (www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf) should be understood by anyone likely to be involved. The EMS deployment into a cleared and secured area will occur rapidly, and use of rapid-assessment medical support (RAMS) teams should follow.

Training and equipment is also a key consideration, and within the Philadelphia system all medics have undergone special training that includes reinforcing treatment of penetrating-trauma injuries and learning and rehearsing tactical movements under the instruction of the police SWAT unit. Finally Mechem identified the additional equipment needed for such an event, including combat gauze, tourniquets, chest seals, body armor and helmets on all vehicles, based on the fact that any vehicle could end up providing immediate tactical support.

Hemorrhage Control

The Philadelphia story was reinforced by Kathryn H. Brinsfield, MD, acting chief medical officer for the Department of Homeland Security’s Office of Health Affairs, in her session, “Homeland Security Is Addressing Hometown Security.” Brinsfield presented a summary of the recent DHS stakeholders meeting. In addition to tactics, techniques and procedures, she identified again that medical and police responders do better by working together more frequently. A modern-day battlefield lesson is to get better and faster at hemorrhage control, which is the point of police having tourniquets. “No one,” Brinsfield said, “should die from bleeding out in this day and age.” 

Tourniquets and immediate wound care were also highlighted by Utah state medical director Peter P. Taillac, MD. His session, “An Evidence-Based Guideline for Prehospital Hemorrhage Control,” reported on the American College of Surgeons Committee on Trauma expert panel recommendations that all providers should use hemostatic agents in conjunction with direct pressure and wound packing. The latter could present a training task, as many in EMS may not be familiar with it. 

Air-to-Ground Disasters

Both man-made and natural events can provide first responders with cause for concern. In his session on take-home lessons from Oklahoma’s tornadoes, the top doc of EMSA in Tulsa and Oklahoma City, Jeffrey M. Goodloe, MD, summarized circumstances and solutions. With tornadoes on the ground and in the immediate aftermath, it was difficult to conduct scene assessments—debris, damage and casualties were spread far and wide. The use of airborne reconnaissance through news and military helicopters was a good way to inform the operational picture. 

Goodloe also raised a major lesson that’s often missed: Much training focuses on the early stages of an incident, zeroing in on response, rescue and evacuation. This can overlook post-event considerations and demobilization. The immediate aftermath may require huge resources over a long period to assist continuity of operations and general life.

It is often said that major events and mass gatherings are in fact preplanned disasters. Columbus medical director David P. Keseg, MD, provided an overview on handling the Ohio capital’s beloved Independence Day fireworks event. 

Keseg, as others had done, identified preparation and planning as the key to a successful event. Vehicle and crew location (as well as placement of bikes and boats) and preplanned extraction sites are important factors, along with a good understanding of weather and wind strength. Potential flashpoints such as the attendee exodus that occurs at the end of mass events can lead to casualties and occasionally violence.

Most EMS systems that serve airports have conducted training exercises involving a downed-aircraft scenario. That training was put into practice in San Francisco when Asiana Flight 214 landed short and crashed in 2013. San Francisco medical director Clement C. Yeh, MD, offered lessons from the incident.

Yeh highlighted the need for plans and practice, and again we heard communicating was problematic. Clinically, he noted there will always be a need to remove critical patients fast, but remain aware that those walking away may also have serious or critical injuries and need to be screened. I noted this lesson in particular; back in my day we deployed paramedic teams to railway stations outside of London to catch any patients who may have slipped away in the aftermath of the London Underground bombings. 

The dispersal of patients to hospitals should also be monitored (usually the function of medical control), and care must be taken to ensure no receiving facility is overloaded beyond its capacity to function. To do this is simply to transfer the MCI to another location. Yeh also commented on the one thing those dealing with a focused disaster or geographic emergency often overlook in the heat of the moment: that even in an MCI, normal daily business still occurs, and STEMIs, cardiac arrests, shootings and stabbings will still need attended to. Again this last lesson had a personal resonance: After the London bombings, staff fulfilling normal duties were disappointed to be supporting the general 9-9-9 system and not deployed to support the London Ambulance Service. Life and lifesaving go on, an excellent point drawn out by Yeh.

Rob Lawrence is chief operating officer of the Richmond Ambulance Authority. Before coming to the USA in 2008 to work with RAA, he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a member of the EMS World editorial advisory board.