On Monday, Oct. 2, 2006, at approximately 1000 hrs, an armed man entered the West Nickel Mines Amish School in Bart Township, Lancaster County, Pa. A traditional one-room school, Nickel Mines educated children from kindergarten through 8th grade. That morning the small building was occupied by 26 children, a teacher and two women who were visiting their children's school. What started out as a beautiful day would turn into a mass casualty incident (MCI) of unprecedented proportions in this peaceful Amish community, with EMS units confronted with multiple critically wounded children all at once.
The shooter, known to some of the children as a milk truck driver, entered the school with the intent to do harm. He came carrying guns, knives and restraints. After threatening the students, he released the boys and the female visitors. The teacher was also able to flee to a nearby farm to call authorities. Only one female student was able to escape when the boys were released. The assailant kept the remaining 10 young girls, between the ages of six and 13 in the school, barricading the doors and windows.
Quick EMS Response
At 1035 hrs, the initial 9-1-1 call was received at the Lancaster County-Wide Communications (LCWC) Center. The caller stated that a male had entered the school with a gun and had taken students hostage. A second 9-1-1 call reporting the same information was received at 1041 hrs.
The phone calls were immediately transferred to the Pennsylvania State Police (PSP) Harrisburg Communications Center and, per protocol, PSP troopers were dispatched from their Lancaster Station (Troop J). At 1045 hrs, PSP called LCWC to request EMS standby near the scene.
Christiana EMS and Bart Fire Company's Quick Response Service (QRS) were dispatched to the school for an emergent BLS response/"emotional problem." Troopers arrived at approximately 1050 hrs and set up a perimeter around the school. EMS units were advised to stage at a nearby farm. The troopers attempted to make contact with the assailant without success. Then, at 1055 hrs, the assailant called LCWC and said that he was going to start shooting if PSP troopers didn't move away from the school.
Bart QRS staged at the Nickel Mines Auction House at 1056 hrs, followed by Christiana EMS at 1102 hrs. Bart QRS requested Lancaster EMS Medic 6-12-10 (an ALS unit) and an air medical resource (SkyFlight Care) be dispatched to the staging area.
Approximately 30 seconds later, the gunman began shooting and continued doing so until PSP troopers entered the school, at which time he committed suicide. PSP reported that everyone inside the school had at least one gunshot wound.
The troopers rapidly secured the scene and waived EMS onto the school property. Staged BLS units confirmed scene security with PSP and proceeded into the schoolyard. On arrival, several PSP troopers carried patients out of the building. EMS crews began the initial triage of patients in the schoolyard as one of the QRS providers established EMS command.
EMS command requested four additional air medical units because of the school's rural location. Fire department personnel immediately secured a large field behind the school and set up multiple landing zones. Because of the significant number of patients, LCWC activated the county's MCI plan, dispatching a predetermined number of units for the level of the incident. This included 12 BLS ambulances, nine ALS units, five air medical units and one mass casualty response trailer (MCRT).
The initial interaction betweenEMS command and PSP was minimal as each hurried to implement their specific operational functions. Table 1 lists the patients encountered during the first three rounds of triage.
Unique Factors of the Amish Setting
As EMS resources arrived and the gravity of the incident became clear, several factors complicated the tasks of triage and treatment. These factors included patient age, sex and proximity, as well as the types of injuries inflicted.
All patients were in the narrow age range of six to 13 years old, and all patients were female. They were placed in close proximity to one another, and similarities in dress and hair (traditionally, Amish females wear their hair pulled into a small bun at the back of the head) made it difficult for EMS personnel to differentiate between the victims. Also, the emotional impact on the providers of dealing with multiple pediatric patients was evident.
The severity of injuries also complicated treatment. Multiple patients were critical, with similar wounds to the head. Many patients had a GCS score less than 6. Several patients presented with clenched jaw muscles due to their head injuries. Also, significant blood and emesis presented an ongoing factor in airway management. Therefore, airway management proved difficult for ground providers, who had to wait for flight crews capable of using paralytics to facilitate intubation.
The remote location of this incident (35 minutes by ground to the closest trauma center) also affected triage decisions. These multiple Priority 1 pediatric patients required specialized care that wasn't readily accessible.
However, the location wasn't beyond the reach of the media. Within minutes of the initial 9-1-1 dispatch, media converged on the scene. Camera crews were present on the ground and in the air, and multiple national television networks began broadcasting live coverage of the events. The overwhelming presence of media aircraft made it difficult and dangerous for air medical services to enter and exit the scene.
Once all of the young patients had been transported from the scene, it was clear that the identification process, although not an immediate factor forEMS, would create extreme difficulties for PSP and the patient's families. Some patients were flown directly to trauma centers outside of Lancaster County, while others, initially treated and transported by ground to the local trauma center at Lancaster General Hospital, were then transferred to pediatric trauma centers located elsewhere (see Table 2).
Patients were sent to Philadelphia, Reading and Hershey, Pa., and Christiana Hospital, Del. These transfers, in conjunction with the use of multiple out-of-county air medical services, resulted in the wide dispersion of patients to various receiving facilities. Further complicating the situation, the Amish typically do not carry any means of identification and several victims were unconscious on arrival at the hospital, making positive identification by parents essential.
Because each facility was more than an hour's drive from Bart Township, PSP initially arranged to fly the victims' families to the hospital locations in order to reunite the parents with their children. However, the religious beliefs of the Amish prohibit air travel, so another method of victim identification was needed. The receiving facilities and PSP decided to take digital photographs of the patients and fax the printouts to the command post at the Bart Township Fire Company. These photographs were then shown to the victim's families, who were able to identify each girl. But because of this complication, several families weren't able to locate their children until late into the evening of the first day. Arrangements were then made by the PSP to transport the affected families to their child's destination hospital by ground.
Immediately after all patients were transported, the Bart Township Fire Company became the central meeting point for providers, counselors, members of the community and agency representatives (FEMA, PSP, PEMA). For the next six days, this fire station served as the command post for all communications regarding the incident.
Media teams further complicated matters by their overwhelming presence at the scene awaiting news from hospital staff regarding the status of each victim and news of the upcoming funerals for the deceased.
Press conferences attended by international media brought more and more people to this rural fire station. During this time, the fire station coordinated the 24-hour security needs around the station and the four square miles surrounding the school, as well as the homes of the children. The fire station also assisted in the planning of the funerals.
The donations and public outpouring of support was unparalleled. Nearly 3,000 pieces of mail passed through Bart Township Fire Company each day. Members of the fire company served more than 900 meals and hosted several CISM debriefing sessions in the fire station for providers as well as members of the community. Coordination of all of these activities by this remote, volunteer fire department was now an ongoing, complex part of life.
Although the initial incident had changed the lives of all of those involved, no one had considered the magnitude and impact of the days that would follow. For the providers, volunteers and community, there was no escaping the tragedy. It was ever present and a point of discussion everywhere the providers went in the small community. In subsequent weeks, many providers took advantage of group debriefing sessions and others sought out and received professional counseling and support. The psychological impact on health-care providers proved to be an intense and ongoing consequence of their role in this event.
Five young girls survived the trauma they experienced that tragic morning. By Christmas 2007, all five had been discharged home to their families. Each now experiences varying levels of disability, but most have returned to school.
One of the biggest lessons we learned came from the families of the victims. The grace and forgiveness they have shown to the shooter and his family set an example for us all.
On the operational side, the benefit of having air medical assets, advanced MCI training and dispatch procedures, MCI trailers and unified command became apparent during this fast-moving MCI in a very rural area. The early dispatch and staging ofEMS personnel by the PSP officers on scene enabled care to be rendered immediately upon the removal of victims from the school.
The events of Oct. 2, 2006 indelibly touched the lives of all involved responders forever. Each individual practitioner has and will continue to process the events of that day and will continue to heal. Bonds have been forged that will never be broken between providers, the families and the victims. Some continue to visit and foster friendships within the Amish community.
Gregory Noll, CSP, CHMM, program manager of the South Central Pennsylvania Task Force (previously known as the Counter Terrorism Task Force), perhaps summed up the success of our MCI operation and the impact we had on the survival of our young victims when he said, "Some people spend an entire lifetime wondering if they made a difference to the world. The men and women [who] responded to the West Nickel Mines Amish School Shooting on Oct. 2, 2006, will never have that problem."
Rich Ressel, EMT/FF, serves with Bart Township Fire Company. Contact him at firstname.lastname@example.org.
Michael Reihart, DO, FACEP, is an emergency department physician at Lancaster (Pa.) General Hospital and the medical director for Regional EMS. Contact him at email@example.com.
Stephanie Brown, EMT-P, is the performance improvement supervisor for Lancaster EMS. Robert Hinkle, EMT-P, is a field supervisor at Lancaster EMS.
Steve "Mouse" Wireback, EMT, serves with Lancaster EMS.
Andrew Gilger, EMT-P, is the director of operations for Lancaster EMS. He has been involved in prehospital medicine since 1982. Contact him at firstname.lastname@example.org.