Ariz. Bus Crash Presents Unique Challenge for Providers - Major Incidents - @

Ariz. Bus Crash Presents Unique Challenge for Providers

Language barrier complicates care



Daniel Mack, NREMT-P | | Tuesday, July 27, 2010

Communications has long been the buzzword in the EMS world. It’s been almost 10 years since 9/11, and we’re still hearing about issues with radio interoperability. But although radios tend to be what initially comes to mind when we say the word “communications,” there’s obviously more involved than just our ability to communicate over the airwaves. In this column, we’ll examine a communications issue that can significantly impact your MCI operations and discuss strategies to overcome that issue with minimal budgetary concerns.

Bus Crash
At approximately 5:20 a.m. on March. 5, Gila River’s EMS, fire and police departments responded to a highway crash involving a tour bus with 22 people on board. The bus left the highway and rolled, ejecting a number of patients from the vehicle. The crash also triggered a second crash involving a pickup and a sedan. Due to these incidents, 17 patients were transported by ground or air ambulance, six were listed in critical condition, and there were six fatalities. Gila River EMS and fire units were assisted at the scene by eight other agencies.

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What makes this incident unique was the additional challenge the departments faced that affected the triage and treatment operations. First on scene was a Gila River EMS paramedic team of Kenny Leslie and Jeff Thomas who saw a significantly damaged bus with five or six people outside it. Initiating the Simple Triage and Rapid Treatment (START) triage system, they instructed those who could to walk over to the ambulance. Kenny noticed the patients were having difficulty understanding the English instructions. Among the injured was 11-year-old Oscar Rodriguez, who did speak English. He was asked by the paramedics to repeat their previous instructions in Spanish, after which patients started moving.

At that time, Rodriguez had no medical complaints, but he did say he was cold. So, after assisting the paramedics with their initial triage operations, he was moved to the ambulance’s captain chair and given a blanket. Around that time, more emergency responders were arriving (some of whom spoke Spanish), and they began extrication operations to remove seriously injured and entrapped patients from the bus.

Kenny moved into the ambulance, and patients were rotated in to receive more extensive medical assessments. During assessment, he requested that the patients point to their injury. When the patients spoke, Rodriguez translated. This sped up the evaluation process.

This mass casualty incident (MCI) occurred near the northern border of Mexico, so it may seem surprising that so few providers spoke Spanish. However, this MCI proves how a language barrier can hinder MCI operations.

Your Backyard
Perhaps you’re thinking to yourself, “This couldn’t happen in my community.” But, consider history. In January 1990, Avianca flight 52 was en route from Bogota, Columbia to New York’s JFK airport when it ran out of fuel and crashed in Long Island, N.Y. There were 85 survivors and 73 fatalities. The majority of the passengers spoke Spanish. The members of the EMS agencies within the area of the crash weren’t accustomed to dealing with a large number of Spanish-speaking patients. This incident underscores the possibility we all face on a daily basis. Each day tour buses laden with foreign visitors traverse U.S. roads. Although some of the passengers may speak English, there’s no guarantee they’ll be in a position to assist.

Problem Solving
Such incidents can present numerous challenges related to our MCI management strategies. For example, as was the case in Gila River, traditional global sorting methods—START and SALT—don’t work if the injured can’t understand the instructions. It’s also difficult, if not impossible, to do a thorough assessment in the treatment area if we can’t communicate.

There are a number of lessons to be learned from the Gila River and Avianca incidents. Many of these lessons relate to our being prepared not only for an MCI but also for EMS incidents that may occur on a daily basis involving a single or limited number of patients who speak a foreign language.

First, ambulances should carry interpreting tools. There are numerous aids available. Mosby’s Communimed: Multilingual Patient Assessment Manual presents 46 medical questions translated into 20 of the most common languages. The EMS provider simply needs to point to the question in English, and the patient can then read the question in their native language on the right-hand page. The “Emegency Medical Information Translator” (EMIT) from AMEC is a two-sided sheet that looks like an EMS report. It presents medical questions in Spanish with English subtitles. A patient or family member can simply check a “yes” or “no” box or the EMS provider can point to the questions that need to be answered. Kwikpoint produces pictograph-style, visual medical communicators. Using pictures and symbols, EMS providers can obtain basic medical information regardless of the language a patient speaks. And, many other publishers, such as Jones and Bartlett, Mavro and Lippincott, Williams & Wilkins, also produce various Spanish language medical references for EMS providers. An Internet search will reveal a variety of resources.

Next, you should utilize local resources. Are there bilingual emergency workers in the area? One would think there wouldn’t be a lack of bilingual rescuers in Arizona, but in the Gila River incident, Spanish-speaking EMS providers weren’t among the first to arrive on scene. You should have a list of EMS providers who speak different languages and can be requested to respond should their skills be helpful.

Another way to bridge the communication gap is to use telephone-accessible interpreting services to assist medical personnel when foreign language patients are encountered. The advantage of such a system is that interpreters familiar with medical issues are available for almost every language. The disadvantage is that passing a phone back and forth between the EMS provider and the patient can be challenging. Also, these services do cost money, and some require the EMS agency pay a monthly fee to join the network.

The fourth lesson learned relates to hospitals. EMS providers should notify hospitals early if they need to have interpreters present in the emergency department. Keep in mind that this may not be an easy task if multiple hospitals will be receiving patients from the MCI. This issue should be discussed beforehand in disaster planning meetings with hospitals to ensure that interpreting services will be available when needed.

Language barriers present unique challenges both at MCIs and on a daily basis, but with the proper preplanning and preparation, it may not seem like a barrier at all.

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Related Topics: Major Incidents, Mass Casualty Incidents, MCI planning, Gila River EMS, Dan Mack, Arizona bus crash

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Daniel Mack, NREMT-Pis assistant chief of Miami Township Fire & EMS, Cincinnati, and a member of the Cincinnati area UASI group and Hamilton County USAR Team. He can be contacted at


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