Several recent bus accidents that presented dozens of injured passengers to first arriving EMS and Fire Rescue responders points out the need for advance preparation and a systematic approach to bus accident EMS and MCI management.
A.J. Heightman, MPA, EMT-P, Elsevier Public Safety editorial director and a mass casualty incident management instructor offers the following tips and “to-do” suggestions for emergency response and communications agencies:
1. Remember that resources are often limited: In the early phases of an incident, resources are taxed significantly early in the operation, and needed to set-up and operate multiple command and control operations. So it is critical that you have a system-wide, county-wide, MCI dispatch process in place to dispatch “waves” of resources (EMS, Fire & Law Enforcement) to MCIs as necessary and as early as possible
Level 1 (less than 10 surviving patients involved): Dispatch at least 10 EMS units, a 1st Alarm fire response, and 3 police units and supervisors for each agency;
Level 2 (10-25 surviving patients involved): Dispatch at least 20 EMS units, a 2nd Alarm fire response, and 5 police units and supervisors for each agency;
Level 3 (more than 25 surviving patients involved): Dispatch at least 30 EMS units, a 3rd Alarm fire response, and 7 police units and supervisors for each agency;
2. “Declare” the incident and request resources: The first unit (police, fire or EMS) to realize that “their butt is being bit by the alligators of chaos”, should “declare it” a major incident to their communications center, declare “Command” and institute the Incident Command System (ICS), identify their “Command Post” (exact) location, provide a brief scene report and advise the comm center of the best approach route for apparatus and possible “staging” areas (streets, parking lots or roadway shoulders that would be optimal for ambulances to be lined-up/staged at the scene).
3. Gain control of the scene early: Assign someone to position (Stage) arriving apparatus on their arrival in an organized and specific manner so they can perform their duties early and not get boxed in and “trapped” on scene by other arriving emergency vehicles, command officers, news medic or personal vehicles.
4. Make sure responders “know the bus:”
- Train your personnel of the nuances of bus construction and operation so the scene can be made safe early and crews can access, treat and remove victims rapidly and efficiently.
- Make them aware of the exterior engine shut-down switch location;
- The location of the exterior button to open the right front door;
- How to “chock” bus wheels with wood cribbing, a spare tire, an AED (just kidding!) or solid, non-harzardous debris available at the scene.
- How to open all bus windows;
- How to secure (rig) windows in an open position to extricate and transfer patients out the side windows when appropriate. (Tip: A rope can be tethered around a window, thrown over the top of the bus and secured to a fixed location on the opposite side to hold the window open. “Propping” windows open with pike poles, etc can become a hazard if bumped during backboard or patient transfer, causing the propped window to drop.
- Teach your crews to use the pre-set distance of all bus seats to their advantage. A backboard can be place across the top of three seat pairings and held steady with accompanying straps (secured through backboard strap holes and wrapped around seatbacks). Equipment such as lights and emergency kits can be conveniently position out of the way, or patients can be lifted onto the secured board from their position on the floor or in between seats.
5. Address patient triage, placement and distribution:
- Make sure all personnel (including dispatch center personnel) are familiar with the triage tags that will be used at the scene as well as the way patients will be tagged, the tags and patient information will be logged in, patients selected and distributed evenly and by condition/category, and reported (by on scene EMS-to-receiving hospital radio transmission, or through communications center relay from transportation Officer to each receiving hospital by phone, intercom, internet or radio links.
- Establish Color-coded Triage and Treatment Areas: Red, Yellow, Green and Black tarps (the best, most visible way), color-coded cyalume light sticks, traffic cones, double-sided signs, or lights should be deployed early to enable the coordinated placement by Triage Tagged color code (RED = Priority 1; YELLOW = Priority 2; GREEN = Priority 3; BLACK (to be placed away from others in a secured area) = Priority 4 [Dead))
6. Take care of your personnel:
- Ensure a Safety Officer is designated and vigilant for hazards at the scene (mark and secure debris, ensure traffic control is in operation and functioning effectively, traffic warning systems are activated, bystanders are directed away from the scene and not allowed to intermingle or become inappropriately involved at the scene.
- The Command Post should request that a REHAB (Personnel rehabilitation) Area is established early and positioned in a convenient but safe area at the incident scene. The goal of this area is to periodically log in all on scene emergency personnel; check their medical status (performed by EMS); cool all responders’ body temperature down (or warm them up in frigid weather or night-time conditions); rehydrate them with appropriate fluids; allow responders to get 10-20 minutes rest after periods of strenuous activity or during prolonged operations.
- Request Critical Incident Stress Management (CISM), Crisis Response Teams or other department counsellors, as necessary, to address the stress and emotional needs of responders after unusual or extremely tragic incidents such as the critical injury or death of a responder, multiple fatalities, significant injuries or deaths involving infants or small children.