Anyone who’s been a part of EMS for a number of years has probably encountered a situation where they felt like it took forever for help to arrive. But even in those cases, help is usually just “up the road”—literally. But what about those EMS providers who don’t have an “up the road” to rely on? This past month, an MCI occurred on an actual island, so the local EMS providers had to use their training to the fullest to meet the challenges of managing this unexpected incident.
Shaw is a small island of about 5,000-acres in the San Juan Islands, about 80 miles northwest of Seattle. It has a year-round population of about 200 and features a small general store/post office at the ferry landing, a community center, community library and the oldest continuously operating school house in Washington State (120 years). No law enforcement agencies or paramedics, doctors or medical clinics are on the island. But the island does have some volunteer firefighters and seven volunteer EMTs, who staff an ambulance. Shaw also is home to Our Lady of the Rock, a Benedictine monastery and working farm. Several church groups from the mainland had been at the monastery for a week when the accident occurred.
The Shaw EMTs and fire department were called at 11:18 a.m. on Sunday, July 30, to a hay wagon accident at a location known to be on a very steep (5+-degree) gravel road. The initial report was that 50 people were involved and that the injuries ranged from an amputation to broken bones, lacerations and abrasions. Alex MacLeod was the first to arrive at the scene at about 11:25. Three firefighters were already on scene, but MacLeod was the first EMT. He took charge of medical operations.
MacLeod approached from the top of the hill and saw an upright hay wagon jack-knifed against a mid-size tractor. MacLeod saw two patients on the wagon, which was surrounded by other individuals, and several patients on the ground, who were being assisted by members of the group.
MacLeod identified the most obvious and serious injuries, prioritized the patients, and assigned EMTs to provide further care on their arrival. Because Shaw has no ALS capabilities, two airlift helicopters were requested to respond to a landing zone about two miles away. MacLeod then reassessed the other patients at the scene and found no other indications of significant trauma.
The two most seriously injured patients were treated, backboarded, transported to the helicopters, and were off the ground within 25 minutes. One patient with an amputated finger (which was located) and other unknown injuries went to the trauma center in Seattle. The other patient, who had a suspected femur fracture, went to St. Joseph’s hospital in Bellingham, a 13-minute flight to the northeast. A third patient, with a suspected ankle fracture, was airlifted by fixed-wing to the Bellingham hospital.
Because mutual aid would have to come from another island, it was not requested initially. However, once the most seriously injured patients were packaged and transported, it was determined they could use a paramedic's help in assessing the remaining 45 or so patients, who had been moved to the monastery. A paramedic and three EMTs from Orcas Island arrived at about 3:50 p.m. They began a methodical process of assessing each individual. No other injuries were discovered, but a complete record of the incident was created.
Shaw EMTs identified seven other patients whose injuries or suspected injuries were significant enough to warrant hospital examination. One patient began to display significant abdominal pain and was airlifted to the Bellingham hospital. After consulting with their medical control in Bellingham, Shaw EMTs determined the remaining six patients could be transported by Washington State Ferry to a hospital in Anacortes, about an hour trip to the southeast. The last of the injured patients were off the island by 4 p.m. This experience emphasizes the need to continually reassess patients at an MCI. Initial triage may not reveal any significant injuries, but as time progresses, latent signs and symptoms of a serious problem may become apparent.
In total, four Shaw EMTs responded to the incident, as did five firefighters and the fire chief, and later a paramedic and three other EMTs. The San Juan County Sheriff's Department sent deputies to the island to investigate the accident.
Challenges & Successes
The main challenge was the large number of patients and the small number of EMTs and firefighters on the island. EMS providers overcame those challenges through clear incident command, the good fortune that the number of serious injuries was relatively low, and the fact that all the individuals involved in the accident, including the injured, remained calm and helpful. Bystanders on the scene had even completed some initial treatment (bandages and wilderness splints).
Shaw EMTs have received training on MCI management, and this proved helpful. They’re used to the challenges of isolation and lack of on-site ALS. Because of the small EMS presence on the island, the firefighters were trained to perform several important medical procedures, such as performing C-spine stabilization, backboarding of patients, locating and retrieving items from the ambulance, and assisting with transporting patients and ensuring scene safety.
As this example shows, EMS agencies should consider what alternate sources for personnel are available in their area and plan ahead as to how these can be used at an MCI.
MacLeod noted that triage tags could have been handled differently. MCI training includes triaging patients as red, yellow or green, but they didn’t use any type of color-coded triage tags in this incident. Shaw EMTs plan on using tags at all future MCIs.
In conclusion, the success of an MCI can at times be measured by the response of those who were treated. Following the incident, the most seriously injured patient sent a “thank you” note to one of the providers expressing her gratitude. What better measure of success could the Shaw EMTs who managed this MCI ask for?