Reno 9-1-1: The September Air Race Response

The September air show disaster in Reno was the third-deadliest in U.S. history, killing 11 people, including the pilot of the plane that crashed into a spectator area. At least 69 more were hurt. But the Regional Emergency Medical Services Authority (REMSA), which provides EMS services to Reno and surrounding Washoe County, was largely acclaimed afterward for its performance in assisting the injured. Impressively, REMSA providers and their various helping hands triaged, treated and cleared 54 patients from the scene—25 of them critical—in just 62 minutes.

Following the service’s final debriefing on the incident in October, Director of EMS Kevin Romero talked to EMS World about what went into the successful response. Here are some key aspects:

• Preparation—An event with as large a potential for catastrophe as an air race requires intense, detailed planning and training. REMSA has been working the Reno air races (officially the National Championship Air Races and Air Show) for 20 years, and for the last 15 has exercised a mass-casualty preplan built around the possibility of a plane into the grandstands.

On the day of the crash, it had around 25 EMS personnel at the event, located in a grandstand clinic and mobile via four ALS ambulances (two dedicated to crash units) and four ALS-equipped Polaris Rangers. Standby resources were available based on a local special-events algorithm that evaluates an event’s risk factors (venue, weather, presence of alcohol, etc.). Plans were drawn up for getting resources in and casualties out if something went awry.

“Obviously, the air races are a high-risk event, with upwards of 80,000 people there on the final day,” says Romero. “It’s probably the largest number of spectators in a condensed area that we deal with. It’s an outdoor event and has a lot of environmental factors—it can get very hot out there on the tarmac, which can cause medical problems, and it’s not uncommon for us to see 400 or more patients over that five days. That’s pretty common and what we plan for.”

There’s also training—a lot of it. In May REMSA participated in a full-scale multiagency aircraft disaster exercise called Broken Wing, which presented more than 200 mock patients at Reno-Tahoe International Airport. In July it ran a pre-air race tabletop imagining a crash into the crowd. And on the day of the crash in September, it had done a small exercise with its personnel and other medical workers to discuss the response to potential incidents.

• Resources—When the crash happened, responders were able to activate needed resources quickly. REMSA routinely keeps an extra 20 ambulances stocked and ready to roll, and when it put out a call for off-duty personnel, it had them staffed and moving in 30 minutes.

“We’d always wondered how successful we’d be with an all-call, and we were very successful,” says Romero. “We think it’s that every TV and radio station cut in and had a ticker explaining that an airplane had gone into a spectator area at the air races. It hit the media very quickly, and I think that, on top of the page that went out, was key to getting off-duty personnel in.”

Mass-casualty buses were in place in a matter of minutes, and a mutual aid plan summoned help from surrounding counties. Patients were distributed among destination facilities in such a way that none were overloaded. At the communication center, the onslaught of media calls was funneled to a dedicated line so as not to interfere with the response.

And, interestingly, the rest of the community seemed to almost pause in the event’s immediate aftermath.

• Public cooperation—“One of the most interesting things was that the normal 9-1-1 system kind of shut down,” says Romero. “The community knew what was going on and was seeing everything on TV as it unfolded, and the 9-1-1 calls really came to a halt. That’s a lot different that many other multicasualty incidents, where people really inundate the system. We expected things to blow up, essentially, and that didn’t happen. Our 9-1-1 system kind of shut down, and that helped the EMS providers concentrate on the crash incident.”

Citizens pitched in at the scene as well, bringing the wounded to help and even carrying litters. Many were from within the public safety and healthcare communities, but others were lay rescuers who jumped in to assist.

• Employee assistance—The crash was marked by a large number of critical patients and blast-type injuries (“like an IED exploded,” says Romero), and leaders knew it would be tough on responders. They sent crews straight from the scene to employee assistance/stress management resources, using multiple CISM teams. That process started immediately and continued into October.

Debriefing/Lessons Learned

One thing REMSA learned: Carry more tourniquets. Though they’re stocked on every ambulance and used regularly, they ran dry at the crash scene.

“I can honestly say I never expected to come out of a debrief where people were screaming for more tourniquets,” says Romero. “That was very unusual. We’ve used them before, but never in the quantities we used in this incident. We literally ran out and were using other means, like belts and things like that.”

Another lesson involved triage. The first patients were loaded and removed even as ICS was being set up, with instructions for crews to tag them en route and call their information back to the transport coordinator. Once underway, though, crews realized their triage kits were under the bench seats, and inaccessible beneath patients in full spinal precautions. “Now we’ve looked at moving our triage kits to be more accessible,” says Romero.

Dissecting REMSA’s response was made easier by the abundance of video from the scene. Citizens with cell phones and ubiquitous surveillance cameras can now help preserve important response details for review, and agencies may wish to consider their own video capabilities at such scenes. “It’s really let us take a close look at where we set up treatment zones, how triage was done, and the ingress and egress of patients,” Romero says. “It’s helped us scrutinize our response.”

Take-Home Point

The biggest lesson to REMSA’s performance is the one its leaders went in knowing: For an event like this, you can’t be prepared enough.

They’d imagined a worst-case scenario that injured thousands. They’d practiced for that and knew what resources they’d need and where to get them. They’d worked out details with their fellow responders.

“The preplanning has to be across the board: police, fire and EMS,” says Romero. “We even had National Guard people there. Get all of them involved, because the fact is, if something big happens, you’re going to utilize every single one of them. We did, and that was with only 54 patients.

“That’s really the most important thing: to preplan and have something in place. Then don’t just do it once a year. Go over it with your first responders every single day of the event. Bring them in early and pay the overtime. Move vehicles and equipment into place and get people familiar with where things are. It has to be deployable, quickly and readily and easily. For us, that made a big difference.”

John Erich is an associate editor for EMS World.