Sidetracked

The incident started modestly: The initial dispatch was for an address in an apartment complex, a report of “smoke in the area.”
The first-arriving fire engine found light smoke in the front of the building, but proceeded to the rear and found moderate smoke and a victim clinging to an outside balcony, screaming for help. Their size-up: “Engine 1 on the scene with a two-story occupied multi-unit apartment, approximately 200 by 30, with moderate smoke on the C side and a victim on a balcony.”
The radio waves begin to fill with chatter as more engines arrive:
“Engine 2 on side A of the building. We have a victim at the top of the second story. Initiating rescue.”
“Engine 3 on side C, assisting with rescue.”
“Medic 1 on the scene. Command, where would you like us?”
The battalion chief who will manage the incident organizes initial resources for both EMS and firefighting operations: “Command to Engine 1, what is the condition of your victim? Medic 1, proceed to side C, where there is a known victim, and assist Engine 1.”
When Attack One arrives, it positions itself on the A side of the building, along with multiple fire units. The Attack One crew leader, a paramedic, has listened to the early radio traffic and is prepared to oversee triage. There are dozens of persons now outside the building, and at least one patient lying in the front. This appears to be the individual rescued by Engine 2, and there is no time to delay care. He is a very large male, approximately 60, in respiratory distress, with soot in his mouth.
The Attack One crew leader focuses on both the current victim and the ongoing radio traffic. There are more victims, and they are being removed from the building in the front and back. With triage responsibility, the Attack One leader now has to make rapid crew deployment decisions so the Medical Sector can be organized appropriately, no matter how many patients or which side of the building they’re on. He contacts Command, announcing he will be Triage Sector, and assigns one of his EMTs as Side C Triage and another as Side A Triage. They are to report back to him, and he will coordinate ambulances for transport.
Until more resources arrive, the Attack One paramedic will need to deliver care to the victim on side A while overseeing the triage functions occurring on both side A and side C. His EMT on side C reports the victim there is not injured or burned but has significant difficulty breathing, so will be classified as red and treated and transported promptly by the crew on Medic 1.
“Triage to Side A Triage,” the paramedic tells them. “Collect information for me on that victim, then establish a triage area in your area. We will send necessary equipment to you.”
Simultaneously he leads care on the man pulled down the steps and out the front of the burning apartment. This victim weighs approximately 450 lbs. and is conscious enough to let the team know he wants to sit up to be able to breathe. He has burns on his face and is coughing up sputum with soot in it. He is not apparently injured or burned in any other way. When they apply the CO-oximeter to him, his oxygen saturation is 88%, his carbon monoxide level 25%. But the paramedic knows his airway is at risk, so he organizes a crew to pull him away from the building and initiate therapy until the next-arriving ambulance can provide transport. The patient is pulled back to a safe area near Engine 2 and supported in an upright position as the paramedic starts a nebulizer treatment with supplemental oxygen.
“Triage to Command, we need a transport ambulance for the victim on side A, critical patient. Requesting two more medic units beyond that, one to perform triage and treatment on side A and one on side C. We will have two areas for triage and use areas adjacent to them for incident rehab.”
As the additional ambulances move in, two more victims are found, and all hands keep working on what is now a two-alarm fire with four known victims. The Attack One paramedic is setting up the triage and incident rehabilitation areas and watching the respiratory-distress patient, who is still waiting for his ambulance to arrive. The paramedic notes the man’s respiratory effort is increasing and mental status is lagging, so it’s time to intubate him. He tells the patient what’s going to occur, but the man doesn’t respond. The paramedic keeps the patient supported sitting upright, and he is oxygenated with humidified oxygen and a bag-valve mask until the paramedic inserts the endotracheal tube through his mouth and into his trachea. Standing over the man, he confirms tube placement with a carbon dioxide monitor, then sets up the patient for further oxygen therapy. The ambulance that will transport him arrives, and he is loaded up on the stretcher, still in an upright position, and sent to the regional burn center.
The paramedic is already moving ahead, assisting the other Attack One EMT in triaging the next patients brought into the triage area on Side A. The first of those is a resident of one of the other apartments who has passed out during the evacuation and has an ongoing pulse rate of about 40 beats a minute. The EMT has this patient on supplemental oxygen.
The paramedic has communicated with the Side C Triage EMT, and the next patient in that area has burned hands from trying to extinguish the fire. His airway is not burned, and he is in no respiratory distress, so the EMT has assigned him to the yellow category.
“Triage to Command, those next two medic units will be committed to transporting another two patients, one red and one yellow. Request another two medic units to the scene for treatment and rehab operations,” the paramedic reports.
Command replies that those resources will be dispatched and announces the fire is proceeding to a third alarm. With that, another two ambulances are requested, so that one ambulance on each side can be responsible for treatment, and one committed to rehab operations. Triage is to maintain that unit level until the fire operation is completed.
Triage operations are located in safe areas on the A and C sides of the operation, and the rehab operations are placed nearby. These remain in place for the five hours of the fire operation, and the Attack One crew stays to provide leadership in both areas, with the Attack One paramedic ultimately designated as EMS Sector, with Triage A, Triage C, Rehab A and Rehab C officers responsible to him. He designates a record-keeping officer to collect all patient information and prepare reports for Command, and collect all rehab-area reports.
Another victim is injured during the next half hour when a firefighter sustains burns to his wrist and face. He requires transportation to the hospital for treatment.
Case Discussion
The crews in this incident initiated resuscitation in addition to the rescue of victims. The Triage Sector was organized using ABCDE assessment (see sidebar on page 10). The burn patient was removed to the regional burn center. The other patients were removed to the closest hospitals. The red-category patients were all admitted to the hospitals to which they were transported.
There are triage priorities for patients at fire incidents. These are important medical assessment needs for victims of burns and inhalation of combustion products. Scene safety includes the responsibility to protect from further exposure to fire or smoke and quench any continued burning process. In general, burn deaths are related to the risk of infection, and that is determined by the size and thickness of the burn, incident-related trauma (e.g., jumping out a window), age and associated medical problems. Burns associated with significant inhalation are also a greater life threat.
Early treatment involves efforts to reduce burn size and depth, manage the airway, treat any associated trauma, protect the thermal status of the patient (i.e., don’t let the victim chill), protect the wounds from sources of infection and provide pain control. After those are managed the next efforts are to gain intravenous access and, within the first few hours, begin the fluid resuscitation needed by these patients.
Geographic Organization of Complicated Incident Sites
The incident management in this case demonstrates the use of letter designations to refer to building sides. It is dangerous to use front/back or north/south/east/west in many operations, as those designations may be unclear.
Instead many fire/EMS agencies utilize the A-B-C-D system as a way to denote the side of an operation. This dates to the original FIRESCOPE (Firefighting Resources of Southern California Organized for Potential Emergencies) system released to the fire-rescue service in 1972 (www.firescope.org).
Phoenix Fire Chief Alan Brunacini’s Fireground Command System was released at about the same time and adopted by the National Fire Protection Association (NFPA). Brunacini designated the sides of a building north, south, east and west, because the city of Phoenix was historically laid out by the compass. But the compass designators proved too difficult in many jurisdictions, so the letter designations were far more usable.
Today public safety organizations reference the National Incident Management System (NIMS) as the basis of dividing up an incident site or building to keep response resources oriented. In recent years, responders to active-shooter incidents have minimized confusion by using the same A-B-C-D process. The basic training material can be found in NIMS 100 or the updated Brunacini Blue Card program (www.bshifter.com).
The use of incident management site designations routinely occurs at fire scenes. They may also be used at complex incidents like active shooters, explosions, gas leaks, hazmat incidents, plane crashes and derailments. Where multiple-casualty incidents are being managed along with another emergency, it may be practical to designate multiple triage, treatment and rehabilitation areas. Those may be identified with the A-B-C-D system in a similar manner. EMS leaders will want to use the same designations that are being used to manage the incident, as occurred in the case.
James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. He spent 32 years as a firefighter and EMT. Contact him at jaugustine@emp.com.