Mass Casualty Incident Management: Part 11

In September 1994, a small aircraft crashed into an elementary school in New Fairfield, CT, causing an explosion and fire that injured 15 students and drew emergency resources from many surrounding communities. EMTs and paramedics had to work around hazards, including spilled fuel and plane wreckage, in order to triage, treat and transport injured children and adults. While it attracted the amount of attention you might expect from such an incident, fortunately it was only a training exercise. Such an incident requires career and volunteer agencies from different branches of emergency services to work together to care for more sick and injured patients than any one agency is capable of individually.

Only weeks later, at 3:50 p.m. on November 8, planning and preparation became reality. Three buses packed with middle school children on their way home collided in a chain reaction crash. The majority of the patients were terrified children with lacerations, and neck and back injuries. Several adults (including one pregnant bus driver) complained of more serious injuries, including chest pain and shortness of breath. These 111 victims provided a real-life challenge for the New Fairfield Volunteer Fire Department and surrounding agencies.

Within moments, Fire Chief Peter Benzinger took over as incident commander and called for emergency resources from neighboring communities to assist, following the protocol of the regional mass casualty incident training the agencies had recently worked on together. As the first arriving paramedics began triage inside the buses, I was assigned to establish the treatment area and began to assemble resources to assist with the extrication of students.

Shortly after police, fire and EMS were dispatched, the school system began notifying parents about the incident via telephone call-back. This resulted in the sudden arrival of almost as many parents as patients, many of whom pushed past emergency providers just as the fire department was beginning to coordinate the scene and account for the injured children.

Thirty-six patients of various priorities were transported by individual ambulances. The remaining 75 patients (all lowest priority) assembled on additional school buses for transport to the local emergency department. Closely coordinated by the transport officer, this enabled responders to provide a secure location, well away from the emergency scene, where parents could pick up their children and, should they wish, seek additional medical evaluation.

This is the kind of incident that can be encountered by any agency, in any town across North America. “I was very proud of how it went,” says Benzinger in a recent interview. At the time only in his third year as chief, Benzinger had pushed hard for integration of the incident command system and close operations with mutual aid agencies. “I’m glad the training paid off.”

So what lessons from our MCI series can be seen in this commonly uncommon mass casualty incident?

1. Train for the MCI you’re likely to get in your area: New Fairfield’s exercise involved a plane crash (there is a small, nearby airport) into a school (of which there are many). While not identical, the training helped prepare responders to deal with large numbers of injured children during the real incident.
2. Identifying the MCI: New Fairfield’s response was expedited by a written MCI threshold that helped them avoid the temptation to say, “Let’s just see how many people are really hurt before we go and call an MCI.”
3. Different agencies, one approach: An important aspect of the plane-crash exercise was all area agencies were invited and involved from the beginning. This allowed problems to arise and be addressed before the real-life incident occurred.
4. First due: The first arriving units gave an immediate size-up, initiating the MCI early. The first arriving paramedic was then able to hand-off incident command to Chief Benzinger, allowing the paramedic to focus on the next medical priority.
5. Triage: Performing primary triage on the buses, establishing exactly what resources would be needed.
6. Treatment: While the patients in this case did not require complex treatment, it highlights how each MCI officer position is about more than just tagging and bandaging patients. An open parking lot was chosen as the treatment area, allowing easy access in for triage and out to transport. However, this easy access also allowed parents to swarm the area, disrupting care and accountability for the children in the treatment area.
7. Transport: In this case transport was simplified by the decision to send all patients to a single hospital, which is unusual for most MCIs. While the large number of patients had a significant impact on regular emergency department care, the ED remained operational and allowed “one-stop-shopping” for parents to reunite with and receive care for their children.
8. Staging: Here again, because of recent training most responding units understood the importance of responding to, and remaining at, a collection area off-scene until specifically needed.
9. After action: A week after the bus crash an after action review was held, which incorporated all key stakeholders and the local media. While it could have just been an excuse for back-patting, real difficulties encountered during the incident were discussed, along with ways to improve the system. As a result, changes were made by local police, fire, EMS and the school system to better protect the community those entities serve.

While calls like this may not happen every day in your jurisdiction, they do occur on a regular basis all across North America. They highlight the need for all emergency responders to learn from the lessons of the past in order to prepare for the incidents of the future.

An emergency responder for more than 20 years with career and volunteer fire departments, public and private emergency medical services and hospital-based healthcare, Rom Duckworth is an internationally recognized subject matter expert, fire officer, paramedic and educator. He is currently a career fire lieutenant, EMS coordinator and an American Heart Association national faculty member.