Patient Tracking At An MCI

     It's a busy Saturday morning, and the Attack One crew is finishing up its station rounds at a fire station adjacent to the interstate. The usual hum of traffic is suddenly interrupted by the profound and unmistakable sound of a truck crash. No need to wait for the phone call or a motorist to relay the news; the crew climbs aboard and heads for the interstate.

     As the crew approaches, traffic is backing up on the southbound on-ramp. Halfway up it, they recognize a column of smoke rising from the highway ahead. Several motorists are trying to back down the ramp, making access more difficult than usual. There's an obvious multiple-vehicle collision ahead, and at least one of the trucks has erupted in flames.

     The crew calls dispatch: "Please send a trap response to the southbound interstate for a multiple-vehicle collision with one vehicle on fire. It is likely to be a multiple-casualty incident, so please prepare for a request for additional medic units."

     The scene is chaos. A tractor-trailer loaded with junk metal has plowed into a number of stopped cars in a construction zone. The tractor portion of the truck is on fire on the median wall, and metal is scattered all over the road, along with three victims who have obviously been ejected from their vehicles. Bystanders can smell fuel from the vehicles that's sprayed across the road and are attempting to get other vehicles out of the area.

     The crew will need to divide functions. Priorities are establishing Command, planning logistics, triage and minimizing further hazards. Quick reports indicate approximately 12 victims on the scene, at least four with critical injuries. There are more victims too far down the highway to walk to. The truck tractor is completely ablaze, but the driver has been ejected, and there is no further hazardous cargo to consider. Fuel has spilled from other vehicles, but there is no other immediate ignition source. Two vehicles have trapped victims. The best entrance to the scene for emergency vehicles will be via the exit ramp from the next exit south. Traffic will not be moving on the freeway, so fire and EMS response is directed to access the scene from there. One EMS unit needs to check on a vehicle that was pushed way down the road after being struck.

     Each of these elements is communicated through dispatch, and the request is placed for a total of eight medics to initiate transportation (one for each of the critical patients, and one for each additional pair of victims). The four critical victims are prepared for rapid transport. Fire suppression is focused on the truck tractor and protecting the rest of the scene. Extrication crews are able to rapidly initiate removal of victims from the two vehicles with entrapments. The vehicle further southbound is an extended passenger van with 15 occupants, of whom five are injured. The van driver was struck by an object thrown from the back of the van, and was dazed enough that a passenger had to reach over to stop the van after it traveled about 800 yards from the impact site. Another three medic units will be needed to transport those victims.

     Victim conditions are summarized in Table 1

     The Command position is assumed by an arriving chief, and the Attack One crew is assigned to oversee triage. The initial triage estimate of victims proves correct, and includes one bystander who passed out on the roadway after seeing a young couple seriously injured from being ejected out the rear window of a large pickup truck. The truck driver responsible for the crash has been ejected from the cab of his truck, and witnesses report he may have been unconscious as he plowed at full speed into the stopped traffic on the highway. He is found under the wheels of one of the other trucks he struck; fortunately that truck stopped before running him over.

     The ABCDE Approach
Using the ABCDE approach to patients presenting for triage:
Airway: Assess for patency, swelling or bleeding that will compromise the patient in a short time.
Breathing: Assess for signs of respiratory distress, wheezing, chest wall injury and unusually high or low breathing rates.
Circulation: Assess for perfusion by level of consciousness, pulse oximetry reading, capillary refill, diaphoretic skin, pulse, blood pressure.
Disability: Determine responsiveness, looking for injury to brain or spinal cord.
Exposure of Other Major Problems: Significant pain, wounds, inhalation of dangerous substances, limb-threatening wounds.

Treatment and Transport
     The weather conditions are warm and sunny, so victims can be packaged, removed from vehicles and treated on the highway surface until transport units arrive. A treatment sector is organized, and victims are placed in that area as they are removed from their vehicles. An experienced EMT oversees the transport sector, and four hospitals are contacted to receive patients. Trauma centers will each get two of the most critical victims, and others in the pickup truck from which the young couple was ejected will be removed to the same hospital as their companions.

     Five people require removal from the extended van; all are members of a college group coming home from a hiking event. They will also be removed to the same hospital. Other victims removed from the same vehicles are kept together and taken to a trauma center and another hospital.

     Transport sector personnel track each victim by name, vehicle of origin, triage class, transport medic unit and hospital destination. A one-page worksheet is used for that purpose, with copies made for the police agency managing the incident, the fire agency and the transport agency. For complete incident documentation, case review and risk management purposes, it is often necessary for the "host" EMS agency to collect and track all scene documents, patient care reports and worksheets. This is a follow-up job for the EMS leadership team.

Case Discussion
     The Attack One crew organized this complicated incident into manageable sections, focusing on the needs of the worst-injured patients and using ABCDE assessment. Fire and extrication operations had to occur quickly. Treatment could be performed as environmental conditions permitted and sufficient transport units could be mobilized.

     The transport sector performed two critical duties:

• Finding available hospital capacity for the victims, and assigning victims for removal in a way to keep families and groups together, without overwhelming any single hospital.
• Performing the necessary documentation of victim tracking, facilitating the work of law enforcement investigators and family members calling the communications center looking for loved ones.

     The tracking function allowed the members of the college group to be kept together. These individuals, needing evaluation for head, back and neck pain and lacerations, ultimately needed to organize transportation back to school. Fortunately, none sustained serious injury, but their van was disabled in the crash and was not drivable. The other 10 members of the group could be taken by nonemergency vehicles to the same hospital where their injured friends were being cared for.

Learning Point
     Tracking patients and papers in multiple-victim incidents is difficult. For complete documentation, case review and risk-management purposes, it will be necessary to track all scene documents, patient care reports and worksheets. EMS command officers will be accountable for those functions.

Customer Service
     Many fire and EMS agencies have developed customer service programs to address the needs of victims after the original scene work and assist in recovery functions. The customer service element becomes a priority after the original emergency is managed. In multiple-casualty incidents, a necessary element is the accurate tracking of patients and subsequent matching of loved ones with victims. This is greatly facilitated if families and groups can be removed to the same hospital. This is not an option in some multiple-casualty incidents, when care may be compromised by taking patients to hospitals without the capacity to manage their needs. But this option should be considered when possible.

     Tracking patient transport destinations is a responsibility of the scene. Typically assigned to a single individual, it allows collection of patient names, triage conditions (and perhaps major injuries or illnesses), transport agencies and units, transport destinations and approximate times of transport. This function may be delegated to several individuals if there is an unusually large number of victims or they are being processed at distant sites, but at some point all the information needs to be assembled at a single point. Typically Incident Command is that site. Command can then determine a way to make that list available should it be needed.

     A common scenario is an incident at a school that involves multiple students and hospitals. Though such an incident may have minor medical complications, parents will have a great deal of concern and a need to find their children quickly. Command may logically decide that a school phone number be used to release information to concerned parents and direct them to the correct hospitals to find their children (or inform them if their children weren't transported to hospitals). The transport list would then be copied to the school system for use in matching children with parents/guardians.

     It should be noted that these disclosures are not a violation of patient-confidentiality laws, in particular HIPAA.

     Customer service also includes caring for individuals who might be left "standing in the street." In this incident, the 10 uninjured members of the travel group were not left with their disabled van-they were taken to the hospital where the others were to be treated. There, they could be comfortably accommodated in a waiting area, given access to phones to contact parents, fed and matched with appropriate transportation to get home.

     We will cover other valuable aspects of customer service in future columns.

Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugust@emory.edu.

Jim Augustine is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.