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Medical Mass Casualty: Lessons Learned from the Deadliest Human Smuggling Incident in U.S. History
In late June 2022, responders from the San Antonio Fire Department (SAFD) in Texas responded to the deadliest human smuggling incident in U.S. history.
Fifty-three migrants would eventually lose their lives. However, for a fortunate few, swift actions by SAFD to triage, evacuate, and treat patients meant survival.
What Happened
At approximately 1750 on June 27, a call was received for a body found near a road. An engine was dispatched for a possible DOA. As they responded, the calltaker began receiving information that more bodies were in a tractor-trailer. The arriving engine crew discovered the reports accurate, finding patients barely clinging to life.
The call was upgraded to a mass casualty incident (MCI), triggering a local and regional process that seamlessly allocated resources and notified emergency departments and stakeholders.
Working in sweltering temperatures above 100 degrees, the triage team sifted through bodies piled on one another. In total, they located 16 patients suffering from heat stroke, unconscious or semi-conscious, breathing but critically ill.
Patients were preloaded on backboards or ManSACs, and as medic units arrived, they were quickly transferred to the ambulance, with some units taking two patients. Command added drivers and extra EMTs from staging for medical support in the back for ambulances carrying two critical patients. During transport, paramedics worked on active cooling techniques, cold fluids, airway management, and cardiac monitoring. A transport coordinator assigned destinations for the transporting units so the city's emergency departments would not be overloaded.
All "red" patients were off the scene in less than 30 minutes, at which time the scene transitioned to secondary triage. An EMS physician arrived on the scene and assisted crews with confirming the dead, reducing responding assets and transitioning to a broad-area search, looking for survivors that might have tried to escape, and managing a mass fatality incident. Only one other patient was found and immediately treated for suspected heat stroke, and it was later discovered that he was the tractor-trailer driver.
What We Learned
Despite the loss of life, many successes and lessons were learned from this incident. First was the success of triage. The first arriving engine crew discovered a gruesome scene but effectively and efficiently sorted through the patients.
Only one patient was found to have responded to voice; all others were altered. On initial evaluation, the acting engine officer requested a specific number of resources based on his initial assessment.
From this estimate, the battalion chief initiated a predefined MCI plan through fire dispatch and the Southeast Texas Regional Advisory Council (STRAC). Within minutes crews located ten patients tagged red due to being unresponsive. Two minutes later, that count was increased to 12; ultimately, 16 patients were discovered and transported.
Communication
Communication tends to be the downfall of most complex incidents. However, this incident was different. The initial engine officer took command and effectively communicated needs and gave regular conditions, actions, and needs (CAN) reports to inform decision-makers of resource needs.
As the scene progressed, a transport officer was assigned with transport units to a separate channel to control load balancing of patients to emergency departments across the city while interfacing with MEDCOM.
Coordinated Transport
Coordinated transport led to an efficient process of getting patients to definitive care. In any EMS response, the phase that contributes most to the time to definitive care is the on-scene time. Several factors contributed to limiting the scene time for this incident.
First, a previously defined system for communication with area hospitals for MCIs had been established via STRAC, designated by the State of Texas for coordination of trauma and emergency care. MEDCOM, managed by STRAC, was integral in providing bed availability via mobile data terminals, allowing the incident commander, triage officer, or transport officer to make transport decisions to spread critical patients across multiple hospitals.
Access to the scene was an important consideration. Early on, incident command established a one-way transport corridor that allowed medic units to approach the scene in the same direction and leave with immediate access to the highway, thereby reducing the need to turn around, back up, or backtrack. Additionally, support vehicles were instructed to approach from opposite directions, leaving an open corridor.
Taking a page from previously trained rescue task force (RTF) tactics, backboards and ManSACs were brought to the scene. Viable patients were loaded, and as the medic unit arrived on the scene, the back doors were opened and patients were handed into the unit, making for a smooth transition from triage to transport. The medic unit was off the scene and headed to the assigned hospital moments after arriving on scene. The time from the initial call to the last patient transported off the scene, excluding the alleged driver, was 30 minutes.
Secondary Triage and Search
After all the "red" patients were found, the scene transitioned into a secondary triage. Due to the numerous apparent fatalities, concerns arose that a viable patient might be hidden among the pile of bodies.
By this time, an EMS physician was on the scene and able to assist with confirming deaths. Most patients had signs of apparent death, but several patients were found that did not. Cardiac monitoring was used to verify asystole, and the doctor pronounced them. Once the triage officer and EMS physician concluded that all additional patients were deceased, the incident commander was informed, and other resource needs were reduced.
Another consideration, given the scene’s context, was that additional patients might be in the surrounding woods and fields. Fire crews used thermal imaging cameras (TICs) to search the area. One patient was located and removed from the scene. He was later identified as the alleged driver of the vehicle.
Responder support services were ordered early to include a rehab bus, a canteen unit with water, food, and supplies, and toilets for the large volume of fire, EMS, police, state, and federal law enforcement agents on the scene. In addition, logistic support needs such as lighting, a command bus, and communications were identified for the medical examiner, and plans for processing the crime scene were implemented by federal law enforcement agencies who took over the crime scene.
Responder Well-Being
As the incident transitioned from an MCI to a mass fatality event, the sheer volume of the loss of life became apparent. No water, ventilation, or other amenities were provided to the migrants; all they had was what they had brought.
Bodies piled on top of each other harken images of war and other disaster-related mass fatality events. Prayer cards and bibles carried by the migrants that were found scattered around the scene impacted some responders.
For those involved, what would be a once-in-a-lifetime event, combined with its sights, sounds, and smells, led to many opportunities for stress-related triggering. It was important that, at this point, efforts were made to start caring for the responders.
First, everyone’s basic needs, hydration, caloric intake, removal from the heat, and distance from the actual scene were priorities. Like any other harmful substance, time and distance shielding help reduce the possibility of a stress reaction to such a horrific scene. Responders were removed from these traumatizing scenes as early as possible and returned to their “safe space” back at the engine house and around the kitchen table.
Key responding units were taken out of service and allowed to decompress with their crews. Peer support and incident debriefing were provided, while stress response resources were put into motion for crews involved in the scene requiring additional assistance for weeks after the event.
‘We Are Not OK’
Finally, it’s essential for leadership and those in key positions to acknowledge that scenes such as this are not typical to see or experience. This is a once-in-a-career incident, and it is OK to be affected.
San Antonio Fire Chief Charles Hood and San Antonio Fire Medical Director Dave Miramontes made it a point to say “We are not OK” when asked how the incident affected them. This allowed the providers and others to acknowledge that even seasoned leaders were affected and that even they needed peer support as well. It is understandable to feel hopeless and angry with the situation.
However, those who responded can take solace in knowing they did everything for those involved. Many lessons were learned and future responses will be improved and will work just as seamlessly, if not more.
The issue of human smuggling will cause future events, and we can only hope these lessons learned will help others in their time of exceptional need.
Bryan Everitt, MD, NRP, FAAEM, is associate medical director for the San Antonio Fire Dept.
Ramon Casanova, LP, is assistant chief for the San Antonio Fire Dept.
Michael Stringfellow, LP, is assistant chief for the San Antonio Fire Dept.
David Miramontes, MD, FACEP, is EMS medical director for the San Antonio Fire Dept.
Comments
Thank you for this educational piece showing how well a mass incident can go when everyone is versed in mass incidents and resources are in place to allow personnel to use their training! The countless hours of research, planning, training and resource acquisition by all have certainly paid off here. Training saves lives!
—Wendy Carton