Suburban Plane Crash

What a beautiful holiday! Christmas has been cold but clear, and the staff had a noontime celebration for the families of the crew on duty. There are still a few family members saying good-bye when the station tone drops and the dispatcher announces a response for a plane crash.

This must be a drill, or a false call, or a mishap with a radio-control airplane someone got for Christmas! The crew members exchange guesses. The area is far from any airport, the call is in a residential neighborhood, the sun is shining brightly, and it is Christmas day!

But as they move toward the apparatus in the station, the dispatcher follows up with details: A small plane is down in the front yard of a residence, there is a small fire, and people are trapped.

Attack One is first on scene and finds a congested site. A small aircraft sits upright on its belly in the front yard of a house on a narrow residential street. It has obviously hit several cars, then slid against a tree. Its wings have been sheared off, and the body of the four-seat plane has been severely damaged and buckled near the middle of the passenger cabin. There is no obvious fire. Numerous people surround the aircraft, attempting to help the injured.

The Attack One crew officer quickly notes one thing missing from the scene: There is no smell of aircraft fuel.

“Dispatch, Attack One on the scene with a small aircraft that is upright in a yard. It appears we have patients trapped and will need to continue a full aircraft response.”

The crew pulls far ahead of the wreck and begins the process of assessing the scene and addressing hazards. They find an additional hazard in an electric wire that has been sheared off and now lies in the roadway. A police officer is immediately assigned to protect that area. One of the EMTs arrives at the plane and finds a patient unconscious in the front, another out of the plane, and two children in the rear who are trapped.

The Attack One crew leader contacts the dispatch office and en route battalion chief, advising there are four victims, two of them trapped in the wreckage. Additional ambulances are dispatched.

The patient out of the wreckage is a woman who says the man in the front is her husband and the children are theirs. She says they ran out of fuel, and there were no areas where they could safely land. She has burns on her hands but is not interested in treatment at this point because of concern for her family members.

The man in the front of the airplane is approximately 40 and regains consciousness as the crew enters the plane. He complains of chest pain and shortness of breath. He is not trapped. Behind him are two children, a 12-year-old girl with fractured lower legs trapped under the seats and a 10-year-old boy with upper-extremity injuries. Both young people appear to be in significant pain, and the paramedic is asked to provide pain treatment as rapidly as possible. In an ironic twist, both of the children are covered by brightly wrapped Christmas presents, part of the family’s plan to attend a party at the end of their trip.

The full set of response vehicles arrives, and the battalion chief assumes command, releasing the paramedic to focus on patient care and serve as treatment officer. A paramedic from another arriving ambulance is assigned to be the EMS officer and oversee transportation. The heavy-rescue vehicle is given the prime location beside the aircraft, and its crew brings extrication tools promptly to the crash site.

The first-arriving engine has established a safety fire line and brought multiple fire extinguishers. One of its members is trained in aircraft fire rescue and is able to immediately find and disable the aircraft’s electrical system and fuel lines. With that there are no fire hazards present. That firefighter is also most familiar with the extrication tools that will be most useful and where the most important stabilization points will be to effect a safe rescue.

The aircraft’s body is stabilized with cribbing material. Only one rescuer can fit in the craft, and that’s an EMT from the Attack One crew. She prepares the man for removal as the paramedic readies to treat the young patients in the back, who will require a more time-consuming effort. The mother maintains her position near the back of the aircraft, calming the children. She has been given dressings for her hands but refuses any other care and won’t back away from the plane.

The paramedic quickly assesses both children and recognizes that their injuries appear limited to their extremities. The girl has multiple leg fractures but can talk with the crew. The young man has a dislocated elbow and broken arm, and part of the wreckage is pinning him in place. The paramedic believes both will benefit from pain medication, so he prepares and delivers a dose of fentanyl to each through their nose. This intranasal route is safe, rapid and available despite the fact that both are still trapped in the wreckage.

The extrication equipment is now in place and begins to tear into the sides of the craft. The former airport firefighter provides direction for cuts that will not compromise the overall integrity of the aircraft. The extrication officer has determined that removing the young girl first will be most efficient, and the paramedic agrees, considering her injuries are potentially more severe. But any movement of the craft and seats causes her to be uncomfortable. As her father is removed from the front of the aircraft, it creates a little more room for the crews to begin to release her. Her legs are soon freed, and she is safely lifted out.

The young boy is the final victim, and he is on the side of the craft that is up against a tree. Once his sister is extricated, it is possible to access him and stabilize his upper body. His mother remains at his side throughout the process, but once he is free and placed on the stretcher, she finally sits down and allows a full assessment of her injuries.

Outside the airplane, neither child is found to have evidence of any more significant harm. Each is assigned to an ambulance to be transported to the regional children’s hospital. As the crews discuss this, the mother states she’ll be accompanying them.

This is the first point where the Attack One paramedic can sit the woman on a stretcher and perform a full evaluation. She has sustained burns to both of her hands, which she says occurred when she put out a small fire near her husband’s legs. She has likely sustained a wrist fracture and a chest wall injury from her seat belt. Her blood pressure is 90/60. The paramedic strongly suggests she should be immobilized on the stretcher and transported to the same trauma center as her husband. He moves her onto the stretcher and is able to get the straps in place before the woman firmly decides that she will not be going to the adult hospital. She removes the immobilizing straps, rises off the stretcher and makes her way to one of the ambulances carrying her children.

The paramedic again attempts to persuade the mother to be treated, but her mind is set on accompanying her children. She says she will seek care once the children are stable, and she will ask other family members to go to the hospital where her husband has been taken to keep her up to date on his injuries.

Command is completing the emergency scene responsibilities, arranging safe operations to remove the wreckage, restore power to the neighborhood and deal with the media. The EMS officer reports that the mother has refused transportation, but the other victims have been removed safely to appropriate hospitals.

Emergency Department and Hospital Care

The father and children are fully assessed on arrival at their trauma centers. The father has the most significant injuries, including a collapsed lung from the impact. He recovers rapidly. The children have significant bony injuries, and the daughter’s lower-extremity injuries require the longest in-hospital care. The mother accompanies her children to the children’s hospital and, after their injuries are stabilized, consents to be evaluated and treated there. She also recovers completely.

The cause of the crash is determined to be a fueling error; the plane lost power in an area where no airports or safe landing points could be reached.

Case Discussion

The Attack One crew organized this unexpected incident into manageable sections, focusing on the needs of the victims, scene safety and extrication priorities.

Small aircraft accidents are far more common than commercial aircraft incidents. As small aircraft (fixed-wing and rotor) become more complex and crashes become more survivable, all EMS providers should be prepared for these incidents.

The Federal Aviation Administration (FAA) has prepared a document titled First Responder Safety at a Small Aircraft or Helicopter Accident, available at www.faa.gov/aircraft/gen_av/first_responders/. This training and response program will help all public safety personnel prepare for safe management of aircraft incidents. This is necessary because of the incredible changes in the materials from which aircraft are manufactured, the evolution of propulsion systems, and the potential hazards of the safety systems deployed in small craft. For example, modern small fixed-wing airplanes may have a parachute safety system that floats a disabled aircraft to the ground. This and other safety equipment may require special management procedures in the event of an incident.

In this incident, the crash occurred in a completely unexpected area and with a survivable impact. The multiple-casualty incident was managed using principles of a standard automobile crash, but with extrication procedures unique to an aircraft. The timeliness of care was enhanced by immediate pain control in the trapped patients, and the concerns of the mother were addressed in as professional a manner as possible under the circumstances.

Triage, Treatment, and Transportation

The triage of the four patients in this incident followed straightforward ABCDE principles. But the perfusion status of the mother was hard to evaluate, and her transportation status was complicated by her concern for her children. This is a relatively common problem faced by EMS providers when a family incident occurs and there are significant injuries to both children and their parents or responsible adults.

The differentiation of adult and pediatric trauma centers in many metropolitan areas can result in transportation conflicts for both families and EMS providers. There is tremendous advantage to having EMS providers prepared with explanations for patients regarding the appropriate, but different, hospitals that manage adult and pediatric emergencies. They need to be able to quickly explain why families may be split up to optimize care.

Treatment priorities in trauma always begin with management of airway, breathing, circulation and disability. But pain management has been elevated to a higher priority in many acutely injured patients because it allows more rapid extrication and better patient outcomes. It also may significantly reduce stress in providers. In war zones rapid pain management has been shown to reduce long-term stress response, and this is likely to occur in civilian patients as well. In this incident, rapid pain management allowed the siblings trapped in the aircraft to tolerate a dual extrication operation.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.