On Sept. 11, 2010, at approximately 2:30 a.m., a double-decker MegaBus strayed from its route and slammed into a low-clearance railroad bridge that crosses the Onondaga Lake Parkway in Syracuse, N.Y. The crash killed four passengers and injured 24 others. Special Operations Manager for Central New York Rural/Metro, Butch Hoffmann, provided some interesting insights about the mass casualty incident (MCI).
Although the incident occurred in an area normally serviced by Rural/Metro, an ambulance from Greater Baldwinsville Ambulance Corps (GBAC) was en route from a hospital to its station when it came across the crash just moments after it occurred. The first EMS providers saw a MegaBus on its side, pinned up against the bridge abutment. Outside the bus, approximately 15 patients were walking around, and two victims were deceased. At this point, it was unknown how many additional patients were still onboard the bus.
Rural/Metro initially dispatched an ambulance and a supervisor to the incident. The first fire response was from Liverpool Fire Department. The Rural/Metro supervisor and ambulance arrived on scene at the same time, but prior to the first fire units. An EMS command structure was established by the supervisor, which included assigning triage, treatment and transportation unit leaders. The supervisor also declared a Level III MCI, which alerted Rural/Metro’s communications center that the incident involved more than 10 patients. Dispatchers upgraded the response to include one ambulance for every two patients, with the addition of a supervisor’s unit.
Level III protocol automatically dispatches Rural/Metro’s MCI supply trailer, pulled by a converted ambulance, which also serves also as a communications and rehab vehicle. Additionally, the county 9-1-1 center was notified to provide for move-ups as needed because Syracuse’s resources were being depleted. The local aeromedical service was alerted, and Upstate Medical Center (UMC), which serves as the resource hospital, was also notified. UMC hospital instructed the scene transportation units regarding which hospitals to transport patients to.
Triage was initiated using the Simple Triage and Rapid Treatment (START) triage system. The first group of patients triaged were those who were already outside of the bus. Within the first 10 minutes, EMS providers had triaged 15 patients—two of whom were identified as priority patients. The remaining patients coming off the bus were triaged after they were extricated by the fire department. Of the 24 total patients, seven were triaged as red, eight as yellow and nine as green.
Early in the operation, a treatment area was established and all “walking wounded” were moved to this area. Around the same time, Dan Smith, the Rural/Metro supervisor who was overseeing EMS operations, decided to begin transporting the critical patients who were already outside the bus. The majority of the remaining patients that came off the bus were tagged as red or yellow and were transported as soon as they were extricated.
Transportation unit operations were also organized quickly. The transportation unit leader maintained contact with UMC in order to ascertain where to send patients transported by ambulance. Additionally, a bus was provided by CENTRO (the local public bus company) to serve as a holding area for the green patients until ambulances arrived to transport them. Due to the number of resources available, it was decided to transport green patients in ambulances rather than buses. It took approximately one hour for all the patients to be transported to hospital.
Although a staging area was designated, the formal area wasn’t needed because arriving units were moved to the scene to provide transport. All responding EMS units were told to approach the scene from the south for easy access and egress from the incident. This accomplished many of the same goals as staging because scene clutter was avoided. It also provided clearer access to the area’s hospitals.
As scene operations progressed, five emergency physicians responded to the incident. One of the physicians was already working in the emergency department (ED) at St. Joseph’s Hospital in Syracuse and left to come to the scene. The physicians assisted with clearing C-spines and providing medical care. They also made pronouncements of the remaining deceased victims who were on the bus but hadn’t been extricated.
Although many providers commented on how successfully the MCI was managed, as with all incidents, there were some challenges. One of these challenges (and one that is very common throughout the country) related to Rural/Metro’s inability to communicate with county personnel. They’re currently in the process of changing radio operations so all agencies can communicate freely in the future. There was also some initial difficulty faced in determining the exact number of patients onboard the bus and the extent of their injuries due to limited access to the wreckage.
It’s interesting to note that an EMS unit literally happened upon this MCI. In MCI management classes, we are often taught that MCI standard operating guidelines and management concepts need to be understood by all EMS providers, not just officers or supervisory personnel. This MCI emphasizes the importance of this point; an EMS provider should be prepared to start organizing the scene of an MCI and move from the role of patient-care provider to incident manager.
A second interesting aspect of this MCI was that several emergency physicians responded directly to the incident. This was indeed fortunate, because doctors can provide on-site medical control and advanced emergency medical procedures that go beyond what ALS personnel can do. In this case, physicians were able to clear C-spines in the field. In MCIs, this can allow some patients to be placed in (or transported sitting in) buses, as opposed to being transported supine on backboards in ambulances. However, this might not work well in all areas. For example, EMS communities that establish such teams must consider whether there are enough in-hospital resources to enable medical personnel to go out to a scene while ensuring that patients arriving at hospitals are adequately treated.
Although Rural/Metro served as the lead agency and responded with four vehicles and their MCI trailer, numerous other agencies contributed to the success of the incident. North Area Volunteer Ambulance Corps responded with two ambulances, Northern Onondaga Volunteer Ambulance sent one ambulance, an ambulance from GBAC was the initial unit on the scene, and another ambulance was provided by TLC Medical Transportation Services. Fire and rescue support was provided by the Liverpool Fire Department, Moyers Corners Fire Department, Mattydale Fire Department, North Syracuse Fire Department and Syracuse Fire Department. The strong working relationship between all the agencies and their concerted team effort contributed to the successful operations at this incident.