Major Incidents, Mass Casualty Incidents, Operations, Rescue & Vehicle Extrication

Many Factors Contribute to the Successful Management of a Mass Casualty Incident

Issue 9 and Volume 37.

When you think of a mass casualty incident (MCI), you often think of a plane crash, bus accident or other incident that thrusts a large number of victims on responders and tests the resources of an EMS system. However, multiple-patient incidents that have complicating factors occur throughout the world every day. These “MCI multipliers” tax the resources of an EMS system or inhibit the response, access or egress to a scene.

When MCI multipliers exist or occur during an incident, a small MCI can be just as challenging to manage as a large one, so it’s important that incident managers—and EMS, fire and law enforcement personnel—recognize these factors and take them into account when developing their action plans and managing a scene that involves one or more multipliers (see Table below).

But if you plan ahead and recognize MCI multipliers when you encounter them, you can request any necessary additional or specialized resources. You can also engage in important communications with supervisors, communications centers, hospitals and regional medical resource centers to stay ahead of the chaos.

This article profiles an incident that occurred in the Los Angeles County Fire Department’s (LACoFD) service area. On Tuesday, June 26, 2012, this well-drilled, high-call-volume EMS system with numerous resources and personnel was presented with a small MCI that involved several MCI multipliers.

The first multiplier was the location of the incident: a heavily traveled section of the Antelope Valley (14) Freeway that traverses a mountainous, remote area in northeastern Los Angeles County near Agua Dulce south of Lancaster. It’s a section of the highway that’s notorious to responders for frequent accidents.

The incident involved just 17 people, two of whom were triaged as critical, but it presented situations and obstacles that made the incident commander’s work just as hard as an MCI involving 100 patients.

The Incident Unfolds
The incident started around 9:40 a.m. on the southbound side of the “14” freeway, in an area where there’s a steep, downhill, right-hand bend on the highway. Debris that fell from an unidentified vehicle caused traffic to strike it, which led to a sudden backup on the freeway. A tractor trailer rig full of stone and dirt then rounded the bend at normal speed and collided with stopped vehicles.

In an instant, a chain reaction began, causing the tractor trailer and 18 other vehicles to pile up in what a Los Angeles Times reporter described as “bizarre roadside sculptures.” Another multiplier was traffic halted on the southbound side of the freeway and subsequent lane closures that caused a backup for miles. The LACoFD dispatch center initially dispatched crews on a “traffic collision, person trapped” assignment.

That assignment sent ALS Squad 131, Engine 107, paramedic assessment Engine 81, Quint 104 and Battalion Chief (BC) 22 and an American Medical Response (AMR) ambulance. But subsequent reports and MCI multipliers soon escalated the incident to a higher-level response.

In a stroke of good luck, a Bowers Ambulance Service ambulance, not a normal response unit for the area, was on another assignment and happened on the crash scene within two minutes of the pileup. They reported to LACoFD dispatch that there were at least six vehicles involved and two patients trapped, one underneath a pile of vehicles (another multiplier). Another ambulance from MedResponse Ambulance Inc., also traveling on the freeway, also stopped at the scene and was integrated into the operation.

Early Command Decisions
When BC 22 Greg Hisel arrived on scene, he immediately established formal incident command (IC) from a position in the northbound lane/center divider, where he could be easily identified and located, and had a maximum view of the incident.

Hisel says that his first observation after assessing the scene was that the big rig wasn’t able to stop in time and “ran through the stopped vehicles like a ping pong ball.”

California Highway Patrol (CHP) officers were already on scene and had shut down the No. 1 northbound lane and all southbound lanes. The IC confirmed with the Bowers crew and CHP officers that there were eight patients, two of whom were entrapped in a vehicle under the pile.
Hisel knew he shouldn’t delay requesting additional resources. So he requested that two additional ambulances be sent to the scene by AMR, the contracted LACoFD ambulance provider.

Because of the tractor trailer involvement and the fact that multiple vehicles were mangled on top of each other, with the potential for fuel leaks and other hazardous materials involved (more multipliers), the IC requested a hazardous materials (hazmat) response. That request resulted in the dispatch of Hazmat Task Force 129 that brought Hazmat Engine 129 and a specialized hazmat vehicle to the scene.

Initial Search & Assessment
For a more complete search and tally of involved people and patients, the IC assigned Paramedic Assessment Engine 81, commanded by Captain Frank McCarthy, to perform a search of the scene and all involved vehicles. He also assigned Engine 81 to start triage operations and requested the closet LACoFD air squad be placed on standby.

As a standard procedure, Hisel ordered one engine to position protector hose lines and dry chemical extinguishers on both sides of the incident. Engine 107’s crew, commanded by Captain Steve Bartram, was assigned to establish a medical group.

A duty safety officer, Captain Doug LaCount, ensured that proper safety gear was in use and all safety aspects were considered and managed. LaCount also doubled as the scene public information officer and briefed the media.

Incident Escalation
When advised by Engine 81 that 17 patients were involved, with two of them entrapped, Hisel asked dispatchers to upgrade the call to a “major” incident. This escalated the unit response to three engines, two trucks, two paramedic squads, urban search and rescue (USAR) Task Force 130 (seven personnel who respond in a special tractor trailer) and Squad 130, a two-person USAR Rescue Tender. He also requested the dispatch of a heavy rescue vehicle equipped with a crane.

As another stroke of luck, LACoFD USAR 130, en route to a training exercise, happened to be on the southbound 14 freeway and arrived on the scene rapidly. They went to work immediately, cribbing and shoring vehicles with air shores and other stabilization equipment not normally carried on ladder companies, quints or engines. Quint 104, led by Captain Chad Hunter, was designated as the extrication group, and oversaw the extrication of both patients in conjunction with the USAR team.

When AMR supervisor David Ellis arrived on scene, he was assigned the role of transportation coordinator and immediately requested five additional ambulances. With the southbound side of the freeway completely shut down, the IC and CHP command officer approved several northbound units to have access the scene via the southbound lanes (another multiplier).

Access was difficult because of the road closure, so Ellis requested five additional ambulances from the Santa Clarita area because he knew access from that direction would be more efficient.

Ellis had to have incoming units, approaching from both directions, stage in separate areas, with non-transport LACoFD ALS and USAR squad units positioned in a separate area. The first-arriving ALS squad (131) was assigned to established contact with the LA County Medical Alert Center to provide a scene report, alert local hospitals of the incident and request bed availability.

Triage & Treatment
Most of the injured were walking wounded victims who extricated themselves and walked up to the established triage area located along the shade side of the highway along the face of a cliff. This can be another multiplier: EMT/firefighters were initially confronted with five to seven walking wounded and Priority 3 patients complaining of neck and back pain. In the initial stages of triage, the EMTs applied C-collars and positioned patients in a safe patient collection area on the shady side of the highway until triage was completed and additional treatment personnel arrived on scene.

Once assessed, the patients deemed to be in need of complete immobilization were fully immobilized and moved in priority order to ambulances by the transportation coordinator. The Medical Alert Center assisted the transportation group supervisor via his assigned radio officer (from ALS Squad 131) in assigning patient to the most appropriate hospital and ensuring an even distribution of patients. Because the size of the incident was within the scope of normal operations for the crews on the scene, triage tags weren’t used. Instead, the crews used their regular EMS reports, which feature a special section on the back of each report for multiple-patient incidents.

The patients at this incident were all triaged, treated and transported from the scene in less than an hour despite the geographic and physical obstacles presented by the remote area of the highway. They were evenly distributed to four area hospitals: Antelope Valley Hospital in Lancaster, Palmdale Regional Medical Center in Palmdale, Henry Mayo Newhall Memorial Hospital in Newhall and Providence Holy Cross Medical Center in Mission Hills.

Lessons Learned
As with any incident of this nature, crews debriefed and conducted an “after action” review. Some of the key lessons learned include the following:

1. The benefits of joint training with contracted and mutual aid ambulance services and their familiarity of critical MCI operational and command practices;

2. The importance of early search and rescue process and designation/use of a safety officer;

3. The benefits of joint command and use of frequent, concise scene reports;

4. The need to request extra resources and specialized teams early;

5. The importance of knowing the distance to nearby exits/access points;

6. Presentation of vehicle access, approach and staging information to units, particularly when major traffic backups or blocked roadways are involved;

7. The need to use tarps or flags to identify the location of the triage and treatment areas for walking wounded and rescuers bringing supplies or patients to them;

8. The potential need to dispatch a tanker or water tender in the event a significant water supply is needed in a remote area;

9. The benefit of dispatching heavy rescue and/or USAR resources early into an incident to capitalize on their technical skills, specialized tools and shoring supplies; and

10. The need to deploy scene ID vests whenever a scene escalates or mutual aid resources are involved, so command responsibilities are clearly visible and crews can identify key personnel and their locations.

Table 1: Multipliers that Affect MCIs
1. Physical location & access/egress complications.
2. Number of access points & distance between exits on a highway.
3. Location, speed & density of traffic.
4. Weather or roadway conditions.
5. Time of day.
6. Staffing levels.
7. Massive debris field.
8. Other simultaneous incidents that drain available resources.
9. Location of specialty teams & resources.
10. Ambulances unfamiliar with a district’s MCI operational procedures.
11. Ambulances from another system arriving on scene, or self-dispatching.
12. Hospital backlogs, closures or lack of resources or capabilities.
13. Communication coverage gaps or inability to communicate with mutual response resources.
14. Failure to establish incident command, divisions or groups early enough.
15. Lack of scene vests or identification of triage, treatment or transportation areas.
16. Late or improper access directions or staging instruction to incoming units.
17. Complicating factors, such as ongoing crashes, gunfire or explosions.