On the morning of Feb. 23, 2011, vehicles traveling into downtown St. Louis encountered unexpected but significant icy conditions on I-64, which led to a chain reaction crash. Thirty-one vehicles, including several tractor trailers and five fire and EMS vehicles, were involved in the crash that shut down the highway, creating a challenge for responding emergency personnel. By the time the incident concluded, 21 people were transported to the hospital, one with critical injuries received when he was pinned between two cars. We reviewed this incident with EMS Supervisor Bob Geigle of St. Louis Fire & EMS to learn a little more about how we can use their experience to improve our preparedness.
The fire and EMS crews in the initial responding vehicles that were involved in the crash were uninjured, so they were able to commence operations. Multiple vehicles were packed into a small area between concrete lane dividers, which affected the rescuers’ ability to access injured patients and position ambulances and fire apparatus close to the crash.
St. Louis uses the simple triage and rapid treatment (START) system to perform triage. As the first-on-scene EMS providers started assessing the situation, they found six of the occupants of various vehicles complaining of minor injuries. These patients were triaged as green. They also encountered one red patient who was critically injured and trapped between cars in a triangular area measuring about 4 x 5 feet. This patient was initially treated by the Medic 2 crew, which was one of the ambulances also damaged in the crash. Interestingly, the patient counts escalated during the incident, as minor injuries were noted by the civilians who experienced the original surge of adrenaline when the cold weather conditions warmed up.
St. Louis Fire & EMS has guidelines that call for the use of the Incident Command System (ICS) and assigning key command positions to supervise the medical operations. Personnel were assigned to supervise triage, treatment and transportation units. Command personnel began requesting additional resources and addressing the issue of ingress and egress for responding emergency vehicles. Let’s look at some of the ways they met the various challenges.
Due to the hazardous road conditions, an alternate route had to be determined to allow responding emergency vehicles, including transport units, to access the scene. EMS Supervisor Geigle decided to use the adjacent opposite direction lanes to accomplish this. He notified the communications center to advise all responding units of these instructions. Although it sounds simple, complications arise when command overlooks delivering simple instructions to incoming units.
There were more than 40 people involved in the crash. Due to the cold weather, a major concern was cold injury to those with other physical injuries and those who weren’t complaining of injuries. So command requested that a metro bus respond to the scene to hold the uninjured and provide a warm environment for them. The bus offered a way to remove the uninjured from the danger zone and for providers to periodically re-evaluate patients. Command knew, however, that the bus could have a lengthy response time, so they initially used some of the ambulances already on scene.
A system is already in place in St. Louis that allows the EMS Communications Center to conduct a hospital capability roll call via a computer network. The initial patient capabilities of the two major trauma centers in the metropolitan area were ascertained. Barnes Hospital advised they could accept 10 red, 15 yellow and no green patients. St. Louis University Hospital advised they could accept 10 red, 10 yellow and 20 green patients. Because each hospital initially provided such a high capability count, and due to the inclement weather conditions, command decided to send all 21 patients (20 greens and one red) to only these two hospitals.
We can learn two important lessons from this experience. First, when the local communications center can be used to ascertain hospital capability—and especially when this can be done electronically—scene personnel can better use their time to organize and manage the scene. Also, although we often encourage sending the patients at a mass casualty incident (MCI) to a number of hospitals, consider using less hospitals when closer hospitals volunteer to accept a larger number of patients. This is especially useful in making ambulances available faster.
As was mentioned, some responding emergency vehicles fell victim to the icy road conditions. This presents an interesting challenge in MCIs during inclement weather and highlights the need to have all EMS providers trained in the basic concepts of incident command at MCIs. If an EMS agency relies only on certain providers to serve in command positions but those providers can’t reach the scene in a reasonable amount of time, agencies should be able to move others into the needed roles. Geigle noted how important it is to know the strengths and weaknesses of your personnel so they can be effectively assigned to positions. For example, he assigned the positions of the EMS ICS structure based on the strengths of the provider rather than rank. Triage and transport personnel were EMTs, while treatment was assigned to a paramedic.
Doubling Up Duties
An additional success related to the use of the ICS at this event involved the combining of certain duties. Due to the number of patients and their conditions, there was no need for a separate triage and transportation unit leader, so the two positions were assigned to one individual. This allowed for more efficient use of command personnel. At this incident, it was easy for a single person to triage the patients, assign them to an ambulance and advise the EMS providers which hospital to transport to.
The short arrival time of additional ambulances allowed patients already on backboards to be directly loaded into the units. The names of the patients and their destination were recorded, and the ambulances could leave with minimal delay. The lesson here is that we shouldn’t make the incident too complex. Good use of ICS means understanding how large, or how small, the command structure should be to maintain efficient operations without the structure becoming unwieldy.
An interesting resource that was made available, but that wasn’t used, was an on-scene doctor. Geigle received a call on the scene from their Assistant Medical Director, Dr. Scott Gilmore, who informed him that if needed, he had a trauma resident ready to respond to the scene. Washington University physicians have their own response vehicle. It’s equipped with the basic tools needed to complete emergency amputations and provide care for extended entrapment situations. During protracted operations and special events, the Washington University physicians have volunteered their time and do ride-alongs with EMS as part of their emergency physician training.
Although they didn’t have to take advantage of the offer this time, the situation certainly had the potential for needing such a service. On-scene assistance can be invaluable, but arrangements must be in place in advance (including pre-designated methods for getting the physician to the scene) in order to take full advantage of this specialized resource.
We sometimes make the mistake of thinking we’ll have enough equipment and resources when an MCI occurs in an urban area. But we never want to underestimate that in some cases, the cause of the incident (such as in this case, the ice), can significantly affect our ability to respond, or these conditions can limit who arrives at the incident. We must have back-up plans in place, and all our EMS providers must be able to operate in different roles.