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School Bus Crash Challenges Rural EMS Providers


On May 16, a school bus carrying 26 children and four adults was returning from a trip to a recreation center in Paducah, Ky., when it swerved off a rural, two-lane highway in Carlisle County and rolled over three times. Carlisle County is in western Kentucky, and the closest hospital is some 30 miles away. The school is located in the center of the county. Therefore, school buses must regularly travel narrow, rural roads to reach their destinations.

Carlisle County Ambulance operates three ambulances and provides service at the ALS level. So when Director Wayne Floyd, EMT-P, arrived on scene at the beginning of the incident, he called for mutual aid units from Ballard County, Hickman County and McCracken County and two helicopter units from Air Evac. He said the scene presented challenges, and his agency has learned some lessons from the incident, including dispatch procedures and the behavior of children.

The Incident
Initial calls for the incident were received at 1:57 p.m. The crash occurred about 8 miles from ambulance base. The first EMS providers arrived on scene about 11 minutes later. When the first providers arrived, they found the bus on its side approximately 30 feet down a ravine. Many children were sleeping on the bus when the crash occurred, and therefore became projectiles inside the rolling bus. However, when EMS first arrived, most of the children were already exiting the bus and were climbing up the hillside. The ground was still wet from a previous rain, making the climb treacherous for the children and rescuers.

The first EMT on scene set up triage, which was accomplished using the simple triage and rapid treatment (START) method. Most of the patients were ambulatory. Four people were still in the bus, including two adults who were injured and one who had stayed to help the others. There was also one child on the bus who was obviously deceased. One of the adults, who had a punctured lung, a lacerated liver and three spinal fractures, was transported by air to The Med in Memphis, Tenn. The other injured adult was transported by ground to Western Baptist Hospital in Paducah for evaluation of a head injury.

Challenges & Lessons Learned
One lesson learned involves dispatch procedures. Carlisle County communications had instituted a specific procedure to dispatch school bus related crashes. Rather than specifically say a call is for a “school bus crash,” they used the term “code yellow.” The idea was that most people listening to scanners wouldn’t know what a code yellow was. But the reality was that many quickly figured it out and came to see what was happening. Although it seemed like a good idea, the procedure is now under review.

Another lesson learned relates to the behavior of children in such incidents. Providers may mistakenly believe that young children will panic in such a situation or be too scared to follow directions. In this incident, the bus was filled with first and second graders. Floyd praised the children for how well they followed directions from EMS providers, and how calm they remained during the incident: They did exactly what they were told to do.

A major challenge was encountered when numerous parents showed up on the scene. Because it’s common for children to have cell phones, and since many schools use notification systems to alert parents to incidents, EMS should expect parents to arrive during operations and plan to manage them. EMS providers can’t allow parents to interfere with operations, but at same time, parents can create a significant problem if information isn’t shared with them.

In the case of the Carlisle County crash, EMS providers used parents on the scene to assist with little jobs, including caring for children who didn’t appear to be hurt. The parents were instructed to get each child’s name, date of birth, address and parents’ names. This not only kept the on-scene parents occupied, but it also allowed critical information to be obtained while at the same time freeing EMS providers from performing this task. Carlisle County Ambulance Service has asked school officials not to notify parents immediately when a school bus crash occurs. They’ve also asked that any aides, who always have a list of the parents’ names and their phone numbers, make contact with command personnel on the scene to provide them with the list rather than immediately start calling the parents.

Although they didn’t need to implement it, a procedure in Carlisle County’s MCI plan that Floyd mentioned organized patients in what they refer to as pods. The pod concept is to arrange the patients in a formation like the spokes of a wagon wheel with their heads toward the center. This allows one EMS provider to more easily manage six to eight patients and to monitor their airways and level of consciousness. Because Carlisle County has a limited number of EMS providers, and mutual aid is a long distance away, this helps to maximize the limited personnel resources. Carlisle County also has special IV poles that can be placed in the center of the wheel and that can support multiple IV fluid bags to supply IVs on the patients in the POD. While one EMS provider is assigned to each POD, others can move around to assist with patient care, such as obtaining vital signs and starting IVs. Other EMS agencies may be able to adopt this concept, but they should practice it during drills to ensure it can be accomplished smoothly at an actual incident.

Floyd mentioned one thing that he would have done differently: Use a staging area to better manage resources. He said incoming EMS units didn’t notify him as they were arriving. Since the crash was on a two-lane road, as EMS units showed up at the incident the scene quickly became congested. In retrospect, he said a staging area should have been established to better control incoming EMS vehicles.

Overall, the incident flowed smoothly. Of the 26 children on the bus, seven were triaged as red, 18 as yellow and one as black. Although most of the children were ambulatory, due to the mechanism of the crash and their ages, it was felt that it was better to upgrade their triage classifications (for more insight on triage, see A.J. Heightman’s commentary “Triage Is Easy” in the May 2011 issue of JEMS.) Three of the four adults were triaged red, and one was classified as yellow.

All patients were transported (two by air and the remainder by ground) within 37 minutes of the arrival of the first EMS providers. It was decided that all patients would be transported to a hospital for further evaluation. This is a prudent decision when so many young children are involved, since injuries may not present until some time after the incident. The patients transported by ground were transported to two hospitals in Paducah.

We must remember that rural EMS services often don’t have the luxury of dividing patients between multiple hospitals due to lengthy transport times. In this case, because most patients were transported primarily for further evaluation and observation, this didn’t overload the hospitals involved. To transport so many patients, Carlisle County Ambulance Service received assistance from ambulances from three other counties in the region.

The unfortunate fact is that many school bus crashes occur in rural regions due to the types of roads that exist in these areas. But as always, EMS agencies and providers should be ready to manage even these types of stressful and complex calls.


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