All Abuzz

     Attack One responds to a report of a bee-sting incident involving several persons. The crew arrives at a construction site, where they are greeted by one of the workers. He tells them some coworkers accidentally struck a ground nest and were attacked by a large swarm of bees. Several are now unresponsive. He estimates five victims, with bees continuing to swarm the area.

     Establishing Command, Attack One calls for additional resources, including an engine and a total of three medics. The crew then dons bunker gear and takes two carbon dioxide fire extinguishers to assist in defending themselves from the bees.

     Walking to the back of the site, they find a number of people on the ground. It looks like a major trauma scene: One man is screaming and bleeding from an open ankle fracture; another is lying prone and unmoving on the ground, with no one else around him. The latter man is nearest the site of the nest, and an audible buzzing indicates the bees are still agitated. The rest of the victims are scattered around the worksite-it's going to require some effort just to determine the number of patients and their conditions.

     The Attack One crew recruits the initial worker who flagged them down to help organize the scene. He is asked to have victims collect at a site closer to the roadway, away from the bee area. As he gets started, the crew organizes its approach to the victims they know they have. The motionless victim nearest the bees needs to be rescued; the patient with the open fracture needs to be stabilized; and several other nearby victims also seem to be in distress. The crew yells to the motionless victim, who is able to respond to them by waving his hand.

     It is decided that two crew members will attempt to drag this victim from the area of the nest, and one will do triage of the other victims. They assemble their equipment at a point that appears to be as safe as possible, and get as many vials of epinephrine out of their drug bags as they can. They ask some workers to stretch out a tarp, find a few chairs, get as many bags of ice as can be located, and coopt a large ventilating fan being used on the site to move as much air across the treatment area as possible.

     The plan is to approach the victim under cover of discharge from the fire extinguishers, and use a sheet to drag him out to a safer area. The crew members snug their turnout gear as much as possible, then rush into the area and discharge the extinguishers in a direction away from the victim. As they approach him, he verbalizes that he's in too much pain and fear to move, but that he's conscious and able to breathe. The crew members stretch the sheet and begin to roll him onto it. As they do, they notice his clothing is buzzing. He has a number of bees in his clothing, continuing to attack him. The crew has to rapidly split the man's clothing with trauma scissors and gently discharge the extinguisher perpendicular to him to drive the insects off. Some have even gotten into his underwear. He has multiple sting sites. As rapidly as possible, they drag him away.

     The other crew member radios that he has five more sting victims, including the one with the open ankle fracture. That individual had jumped about 15 feet off the construction steel when he was attacked, sustaining the injury when he landed. He also has multiple sting wounds. Another victim is unresponsive with multiple stings and a thready pulse. The crew member also notes that man still has multiple bees in his clothing, and assistance will be needed to help him.

     Command has been turned over to the engine officer at the designated treatment area, and several medic units are now available to assist. The Attack One crew turns to assisting the rescue of the next person down. The two crew members who had pulled the first victim from harm's way grab another sheet and make their way to him. They then use the same technique to sweep the area with the extinguisher, use trauma scissors to split the victim's clothing, peel them away, and again chase off the bees with a discharge of carbon dioxide. The victim is rolled onto the sheet and dragged to the treatment area. He has several sting sites and poor perfusion of his skin, with some respiratory difficulty.

     The initial worker returns to say he's found another three victims in the area of the work site cleanup and toilet area, and one is "in bad shape." The Attack One crew runs across the work site to start on this group of patients. The worst-off young man had been close to the nest site, and was running toward the cleanup area to access his allergy medicine when he collapsed. Another two workers have several sting wounds, but are in no acute distress.

     The downed worker is unresponsive and has no palpable pulse. There is no buzzing noise in his clothing, but because of the experience with the other victims, his clothes are peeled off. Only one sting can be found-it's on his neck. His skin is not perfusing well; he's cold, clammy, and pale white. After tending to the other victims, the crew has only the vials of epinephrine with them, along with small syringes and needles. They elect to draw up the 1:1,000 concentration of epinephrine and administer it to the victim intramuscularly. A single dose of 0.5 cc is delivered into his thigh. The crew calls for a priority use of one of the available medic units, and for assistance with a complete medical bag, IV supplies and oxygen. After three minutes, they repeat another 0.5-cc dose of the epinephrine. As the medic crew arrives, the victim wakes up.

     The other two victims have 5-10 stings each and complain of pain and lightheadedness, but they have no respiratory or cardiovascular compromise. They are given some small bags of ice to place on their wounds, and are prioritized to be transported by a medic unit with other green victims.

     The victim in profound shock has now fully awakened, his vital signs stabilized. He states he had a prior allergy to stings and was trying to reach his epinephrine injector before he passed out. The intramuscular epinephrine had been effective in reversing his circulatory collapse, and he now needs only supportive care en route to the hospital.

     The original victim is a 22-year-old male who was attacked by the insects after he accidentally ran over their nest. As other workers attempted to grab him, the bees became more irritated and attacked the would-be rescuers. The swarm even found some workers up in the structure under construction, causing the one to jump and fracture his ankle. Two other workers were stung and were wheezing notably on arrival in the treatment area.

Transportation and Hospital Course
     A total of 10 victims are in need of treatment and transportation. Five medic units are ultimately needed. The patient with the open ankle fracture requires service from the regional trauma center, and one of his ill coworkers wants to accompany him there. The other patients are removed to other EDs. None require treatment beyond epinephrine, except for the ankle fracture. Those workers with wheezing are treated with subcutaneous epinephrine and nebulized albuterol.

Case Discussion
     It is good management practice to approach every scene with an open mind. This medical incident rapidly evolved into a multiple-casualty incident with an element of trauma.

     The antigen dose in bee stings does not correlate with the severity of the illness. Most fatal outcomes from stings occur with a single sting wound, and this incident illustrated that principle. The patient with the most profound and life-threatening reaction was the young man with the single wound. Those with many stings may have significant symptoms of pain, swelling and a late complex that includes fever, joint pain and nausea. But it is extremely uncommon for anaphylaxis to occur in a multiple-sting victim. In America, the emergence of more aggressive bee strains may result in more incidents in which multiple victims with many sting wounds, and even fatal outcomes, become more common.

     Incidents where a victim endures multiple stings and continually attacking insects can be stopped fairly quickly if the victim can jump into a body of water or a shower. This incident, however, occurred at a construction site, so water was not available. Lawn-maintenance crews often use blowers to ward off insects and other attackers. Animals react to loud noises, and an attack by a wild animal or dog may be aborted by pulling the rescue vehicle up close to the victim and activating the siren. Discharging a carbon dioxide fire extinguisher produces a cloud, a very cool spray and static electricity. This combination is generally potent enough to distract or repel insects and animals. Obviously, dry chemical extinguishers can be dangerous to injured humans, so these would not be a good choice.