Case Review: After the Storm

A sunny, humid afternoon is deteriorating rapidly. The area is now getting battered by high wind, and severe weather watches for the county have evolved into warnings. The station TV is on, the live radar looking ominously maroon, and the Attack One crew watches and waits for the tones to start. The winds begin to rattle the doors, followed by the pounding of hail on the roof of the equipment bay. 

It’s time to shelter in the station, and the crew makes its way to an interior room with cinderblock walls. They open up the radio scanner and listen as emergency traffic increases, first in the southwest part of the county, then moving up toward Attack One’s service area. Alarms give way to wires down, which become trees down, and then buildings damaged.

The Attack One crew leader recognizes this pattern of destruction and suggests the crew prepare for an evening of weather-related emergencies. As soon as they leave their shelter area, they will load up their apparatus with extra clothes, snacks, water and the multiple-casualty incident packs from the station. They will need two extra batteries for each radio and extra batteries for flashlights. They topped off the gasoline in the station’s emergency generator early in the afternoon, and have made sure all linens are cleaned, laundry completed and the vehicle fully stocked with medical equipment.

The power at the station soon fails, and the room where the crew is sheltering grows as dark as the skies outside. Before the hail stops, an ominous message comes from the officer assigned to the central communications center. Sounding the emergency tones for all agencies, the officer announces that “significant destruction” is occurring on a path through the county, and all units are to begin assessments of their response districts as soon as the weather clears.

The Attack One crew members exchange calls and text messages with their family members as they wait for the winds and hail to stop, and it appears all families are in good shape as the storm finally begins to move on. When the hail quits banging the roof, the crews all move toward the apparatus bay, manually open the doors and take in the relatively mild damage outside. There are piles of hail, a few downed trees and lots of blown debris, including what appears to be insulation material. The station is intact, but the parked vehicles outside are hail-dented. The sky to the north now has an awful green coloration as the storm line moves away.

The battalion chief for the area comes over the dispatch frequency to assign sectors for each crew in the area to assess. All crews are warned to stay away from live wires, be aware of street debris that could flatten tires, maintain accountability and report to him any significant structural damage. Attack One is assigned to contact the hospital and be prepared to serve as liaison with the emergency department.

The Attack One crew members load their vehicle and move toward their assigned sector. As they do, the paramedic contacts the emergency department. The lead physician there reports the hospital is intact, but power has failed and they are operating on generators. There are no casualties, the emergency department has been almost completely cleared of patients, and emergency staff has been asked to report back to the hospital. Hospital leaders are preparing for multiple casualties but have adequate staffing. Phone service is irregular, and the physician asks if they can be updated regularly by radio of damage in the community.

Suddenly, the county communications officer sets off the disaster tones and announces that the 9-1-1 center has received numerous calls regarding tornado damage in the area just east of Attack One’s station, and the center is moving into its emergency operations mode. The area is directly where Attack One was already assigned, so they proceed directly there, with an additional first alarm fire assignment of engines, ladder trucks, two ambulances and a battalion chief.

Tornado Zone

Attack One uses four major roads to outline its sector, and moves toward it along the path they think will have the fewest obstructions. They arrive quickly in the high-impact neighborhood, where a path of destruction begins along the five-lane road on which they enter. They complete a survey along the road and ask the other incoming units to survey the other three sides of the sector. Each unit reports its findings to the battalion chief.

The Attack One crew drives as far as they can before the road becomes impassable. They find trees and homes flattened, a number of injured persons, and the smell of fresh lumber and leaking natural gas. The crew leader relays these findings to the chief, and the chief assigns Attack One to triage damage and victims in the sector’s northern approach. Other units are similarly assigned to the western, eastern and southern approaches. The Attack One crew leader receives an additional assignment as triage coordinator for the entire sector and as liaison to the hospital until a formal medical branch can be activated.

The hospital is notified, and the ED physician reports that walk-in victims are beginning to arrive, and the hospital is activating its emergency operations plan for a multiple-casualty incident. Attack One notifies the communication center of that, and the department chief confirms it and announces the department is establishing its emergency operations center at headquarters.

The Attack One crew leader decides to keep the crew together and establish a casualty collection point at the entrance to the neighborhood, near their vehicle and where a home with an empty two-car garage can be used as a shelter. Vehicles can’t enter the neighborhood beyond that, so the Attack One crew leader meets with the lieutenant from the first-arriving fire engine and asks that the engine crew proceed on foot to do further surveillance and bring victims back to the collection point. If victims require care in the debris field, the Attack One crew will move in to assist.

The first-arriving ambulance is emptied of its stretcher and first aid gear, and the crews work together to treat the first found injuries. While the Attack One crew leader collects casualty information from all four approaches to the assigned section, the other crew members proceed with triage and treatment.

A few persons have lacerations, and many have debris in their eyes. One man is carried in with a broken lower leg, but he insists he only be splinted and left in the treatment area. “There are a lot worse-injured people back in the neighborhood,” he says.

The engine crew is finding some of these more seriously injured patients and requests several teams with equipment walk in to begin treatment. Some victims are still trapped in their homes. “Don’t worry about bringing backboards,” the lieutenant radios. “We’re moving people on doors that have been blown off houses.”

The Attack One crew leader assigns treatment crews to move in as close as possible, and carry necessary first aid equipment to begin treatment of the trapped patients. “Just take your trauma bags, pulse oximeters and simple splints,” he tells them. “Leave the big stuff here.”

The next two hours are a blur. The crews rescue victims and treat lacerations, broken bones and persons impaled with pieces of wood and other objects. Some of the victims were “tattooed,” having exposed areas of their body peppered with dirt and small pieces of insulation that can’t be rinsed or scrubbed away.

The worst-injured persons are being carried to the collection point by rescuers and neighbors using doors as backboards. One victim has been impaled with a piece of wood in the neck and needs an emergency airway. One has been thrown from her house and suffered a spine injury. Several have been impaled with pieces of wood in their chests and need decompressions.

Then the first of the chainsaw injuries arrives: a firefighter who lacerated his leg performing a rescue. Many persons ask for irrigation of their eyes due to flying debris. Mutual aid ambulances are arriving from departments around the area, organized into task groups assigned to each of the sectors by staff at the EOC. The Attack One crew leader and his aide ultimately collect and communicate information on 32 victims who are transported from their sector to the hospital (see Figure 1). Dozens of additional patients are treated on site but do not require transportation.

The Attack One crew prepares for an all-night operation searching each house in the neighborhood as rescue crews clear pathways into the area. The crew leader prepares them to manage the “ongoing incident casualty types,” including chainsaw injuries, eye injuries and carbon monoxide exposures.

The aide working with the Attack One crew leader serves as victim tracking leader, and tracks each victim by name, age and sex, sector of operation, triage class, transport medic unit, and hospital removed to. He requests each transport unit complete the necessary patient care reports, and on behalf of the “host” EMS agency, he will collect and track all scene documents and worksheets.

Case Discussion

The communications center officer, department chief and battalion chief all sequentially organized this widespread incident into manageable sectors, and activated appropriate emergency operations plans. Weather incidents are marked by large fields of operation, and tornado damage will restrict vehicle movement. Rescue operations need to occur quickly, and often are facilitated by bystanders and neighbors. Treatment is performed as environmental conditions permit, and it may take some time before sufficient transport units can be mobilized.

In this incident, the Attack One crew performed three critical duties:

• Recognizing a large incident and operating in the area they could access, relying on other fire-EMS units to find alternative approaches to the emergency ground, perform assessments and organize emergency operations. The Attack One crew then organized a casualty collection point and prepared for treatment and transportation.

• The Attack One officer organized communication with the local emergency department and allowed it to prepare hospital capability for the victims.

• The crew leader assigned an individual to perform the necessary victim tracking, which ultimately facilitates family reunification and investigation.