You arrive on scene at a mass casualty incident (MCI) on a dark interstate highway at 2 a.m. There are more than 30 cars and tractor-trailers involved in the chain reaction collision that occurred not only in the dark but also in dense fog.
You assume command, establish a command post and assign a triage group leader and personnel from multiple agencies to begin to triage, assess and treat patients. After just 45 minutes, your transportation group reports it’s distributed 39 patients (10 Priority 1/red tag patients, 13 Priority 2/yellow tag patients and 16 Priority 3/green tag patients) to your trauma centers and local hospitals.
You feel good because you think you’ve cleared the most critical patients from the scene. But suddenly, nine additional critical (Priority 1) patients are brought to the Priority 1 (red tarp) triage/patient collection area, including three Priority 2 and 3 patients who have now been reclassified to Priority 1. In addition, a firefighter is brought to the yellow tarp with a severely dislocated right knee and a fractured pelvis.
You wonder how this could happen. You thought you had the scene under control. Why didn’t you see this coming? That’s the key word: SEE! You can’t treat what you can’t see!
The post-incident action review reveals that once the scene was properly illuminated, several victims initially hidden by darkness were identified. Two victims in dark-colored clothing were found on the dark floorboard areas of their vehicles, and two more were found curled up and “blended” into crumbled, multi-colored and multi-shaped wreckage just 150 feet from the triage area.
Two additional unconscious patients were found in the brush in a ravine just off the interstate by firefighters who deployed their thermal imaging cameras to scan the dark areas on each side of the highway.
The firefighter with the dislocated knee and fractured pelvis sustained those injuries when he fell 30 feet down an embankment next to the highway in a dark area that didn’t have lighting, a guardrail or scene tape to alert him of the hazard.
In addition, three patients in the initially poorly illuminated Yellow and Green treatment tarps were found to have critical injuries that weren’t properly seen and assessed during the initial triage, assessment and treatment process. During reassessment on the now well-illuminated tarps, providers discover:
1. A patient with cyanosis and retroperitoneal bruising not seen during “dark assessment.” The patient was found to have sustained significant kidney damage and bleeding from blunt force impact to their lower back region.
2. A patient with a flail chest. The patient was determined to be in acute respiratory distress, with paradoxical respirations indicative of a flail chest, and bulging neck veins, indicative of circulatory compromise.
3. A patient with a small penetrating injury to the right side, below the hip, obscured by clothing and the darkness. There was a one-liter “pool” of blood that wasn’t detected until the patient was reassessed in a properly lit manner. He was also pale, diaphoretic and exhibited a 90/60 BP. The EMS provider who initially assessed him reported at the after-action review that he didn’t initially take a BP or see the patient’s abnormal skin presentations because he didn’t have adequate lighting to see and observe the patient or the BP gauge.
Officials at the after-action review of this incident agreed that most, if not all, of the patients and injuries would have been detected earlier, and the injury to the firefighter likely prevented, if the scene had been illuminated better and sooner—an important lesson learned for them, and you.
Ten Lighting Tips
Scene illumination is an often-neglected aspect at emergency scenes, whether medical calls or cardiac arrests that must be managed in a dark bedroom or accidents and MCIs that occur on a dark stretch of highway.
As illustrated earlier, early and adequate scene lighting is a critical aspect of scene management. It allows incident commanders and emergency personnel to safely move around the scene, find all involved patients, and properly triage, assess and treat their injuries.
Equip your vehicles and personnel with fixed and portable lighting and use the following 10 tips to optimize your scene operations at dark or low-light scenes:
1. Early into an incident, have arriving crews use vehicle headlights, spotlights and fixed scene lights to illuminate the scene.
2. Add “Start scene illumination ASAP” as an early action item on all your incident command checklists.
3. Put compact multi-LED lights in all vehicles and emergency response kits so they are immediately available to your crew at scenes and patient locations.
4. Add fixed lighting to the front, rear and side of all emergency vehicles so you can illuminate 360 degrees around each vehicle in dark environments.
5. Add chemical or battery-operated light sticks to incident and MCI management kits. They can be used to identify triage categories on patients and vehicles as well as illuminate incident commander vests or helmets at large scenes and “announce” their role/position. Examples: Blue for EMS command; orange for safety officers; red for triage and treatment group leaders as well as Priority 1 treatment areas; yellow for Priority 2 treatment group leaders and treatment areas; and green for transportation and staging group leaders as well as Priority 3 treatment areas.
6. Work with Fire and dispatch agencies to have aerial ladders respond to all major incidents and MCIs and deploy lighting from the top of the ladder or aerial platforms and mid-ladder levels.
7. Equip fire units and helicopters with thermal imagers and put them into operation at nighttime incidents to detect the body heat of victims who have been ejected from vehicles or have wandered away from the central area of a major incident.
8. Use medical helicopters to patrol the scene before ground lights are in operation, using their powerful search lights to locate victims and hazards. (But request that they do so from a high altitude to limit noise that can interfere with ground operations.)
9. Assign personnel with portable lights to light the way for stretchers being moved to awaiting ambulances.
10. Request crews to turn off unneccessary emergency lights that can impair ground visibility.