Major Incidents, Mass Casualty Incidents

Fire in Senior Apartments High-Rise Requires Coordinated Multi-Agency Response

Issue 9 and Volume 40.

Learning Objectives
>>Large senior apartments and assisted living facilities should have an up-todate roster of residents, with emergency contact information for multiple family members.
>>An updated list of medications and pharmacy/doctor contact information should be available for all residents. Family members or friends who don’t live with the residents should also have a copy.
>>Have residents keep one week’s worth of essential pills in their purses or a “go bag” in their rooms.
>>Have residents write essential contact information and place it in their purse or “go bag”—especially because cell phones may not work or be locked when rescuers find them.
>>Ensure residents know to quickly grab essential items—purse, wallet, medication list, cell phone and charger—when fire alarms go off.
>>Have resident make a “drop zone” for such items in each room/apartment so they don’t lose or forget essential items when they exit.
>>Check for working smoke detectors and have local fire department do routine safety inspections.
>>Ensure all agencies and hospitals practice, drill and improve processes before an incident occurs to avoid patient logging and tracking problems when a major, high-patient-volume incident occurs.

“In my 30 years of firefighting, I’ve never pulled up to a fire and seen so many people hanging out of windows and balconies.” This is how San Antonio Fire Chief Charles N. Hood described the cold December morning scene at the Wedgwood Senior Apartments in Castle Hills, Texas.

The fire alarm began to ring at the senior living facility at approximately 6:10 a.m. on Dec. 28, 2014. Unfortunately, it was a sound that many of the elderly residents in the highrise had grown complacent to over the years and many failed to immediately respond.

Castle Hills Fire Department (CHFD) Engine 1 (E1) and Ladder 1 (L1) were the first to respond to the alarm with a four-person crew at approximately 6:12 a.m. for report of a “smoke alarm activation.”

CHFD Captain Harold DeHart was the officer in charge and requested a first alarm, which initiated automatic aid from the Balcones Heights and Shavano Park Fire Departments. Fortunately, CHFD personnel had responded to the facility in the past and knew its occupancy, building construction and layout, and stairway, elevator, and standpipe logistics.

Fire and smoke damage on the third floor, where the fire originated. Photo courtesy SAFD

 

Structure Anatomy

The Wedgwood Senior Apartments, constructed in 1962 with Type 1 fire-resistive construction, sits just inside the Castle Hills city limits near the north side of San Antonio. The 11-story, Y-shaped building houses 297 apartments and serves as an independent living facility catering to adults over the age of 55. Many of the facility’s elderly residents are mobility impaired and/or suffer from chronic ailments associated with their age.

Sprinklers are located only on the sublevel floor, leaving all of the occupied living space from the first floor to the eleventh floor without sprinkler system protection.

The building itself is comprised of a central core with three distinctive wings extending outward. Each wing has an enclosed stairway that’s vented to the exterior.

The building’s elevator bank is located in the central core of the building along with an enclosed stairway. Standpipes are located at the end of each wing with no standpipe in the center stairway.

Alamo Heights and San Antonio Fire Department ladder companies rescued residents via aerial ladders on the alpha side of the building. Photo courtesy SAFD

 

Apparatus Arrival & Actions

CHFD E1 and L1 arrived on scene three minutes later and saw light smoke coming from the building, prompting DeHart to request a second alarm, notifying CHFD Fire Chief Jerry Riedel and all CHFD off-duty personnel.

Responders from CHFD E1 and L1 entered the building through the main lobby and went up the center stairwell. The lobby and center stairwell were clear of smoke, but when the fire crews opened the stairwell door to the third floor, they were met with heavy smoke that had banked down to approximately 12 inches off the floor.

Crews immediately reported this to incident command and began removing residents from the third floor. The fire appeared to be located in room 302.

Units arrived from Olmos Park, Alamo Heights, Balcones Heights, Shavano Park, Bexar-Bulverde, Leon Valley and ultimately the San Antonio Fire Department (SAFD), the last agency contacted for assistance at approximately 6:24 a.m. The SAFD initially responded with four engine companies, two ladder trucks, one platform truck, one medic unit, one medic officer and a battalion chief (BC). At this point, a hose line was attached to the standpipe in one of the stairwells and a connection was established from CHFD E1 to the fire department connection on that wing.

Unified Command

SAFD BC Walter Yates arrived on scene at 6:40 a.m. and called for a unified command. The following divisions/groups/sectors were established:

  • Base of operations (lobby);
  • Occupant services (conference room near lobby);
  • Medical (SAFD ambulance bus);
  • Division 1 (first floor);
  • Division 2 (second floor);
  • Division 3 attack group (third floor);
  • Attack group supervisor;
  • Division 4 (fourth floor); and
  • Divisions 5–11 (fifth floor & up).

SAFD units staged on their arrival at the Wedgwood facility until they were given assignments. Once unified command was established with CHFD, the building manager as well as a representative from Acadian Ambulance Services, a private ambulance company contracted by the city of Castle Hills, responded to the incident command post located in the parking lot.

Initial Rescue Operations

SAFD Engine 28 was assigned lobby command and used firefighter manual override to recall both elevators to the ground floor. Alamo Heights Fire Department (AHFD) and SAFD ladder companies were tasked with rescuing residents via aerial ladders on the alpha side of the building.

An AHFD ladder truck and SAFD Ladder 17 set up on the alpha side of the structure and began rescuing occupants from the third floor where the fire originated. Some occupants on the third floor were outside of their apartments, standing precariously on a small outside ledge. Others were rescued from inside their third floor apartments and brought down aerial ladders as well as stairwells.

SAFD Aerial Platform (AP) 32 set up on the delta side of the building and evacuated occupants from the 11th floor. Excellent apparatus placement and familiarity with the apparatus allowed this 100-foot platform to be operated at its maximum capabilities in order to facilitate rescues from the top floor of the building.

SAFD units Engine 17 and Engine 31 were assigned to assist CHFD units with the fire attack on the third floor. The SAFD fire shift commander’s incident command technician (ICT) was assigned occupant services, which was located in the lobby.

Three additional SAFD BCs were requested at 7:08 a.m. The division 3 attack group reported no water pressure on their attack line and was able to find safe refuge in the apartment unit opposite from the room of origin. The ICT for BC Yates was assigned to water supply and worked with Balcones Heights Fire Department to establish a supply line.

Medical Operations

Rescue, firefighting and care of the sick and injured ran simultaneously. Multiple patients evacuated from the building required medical evaluation and care.

Many would consider this a mass casualty incident (MCI), but this was different from a typical MCI. It was mostly a mass evacuation, assessment, shelter and relocation incident.

Although there weren’t a significant number of injuries at the scene, managing, assessing, logging and relocating hundreds of infirm residents is a logistical challenge and demanding on manpower and vehicle resources, particularly on a cold winter morning.

“The SAFD has an MCI plan, and while triage, treatment and transport did take place, this was not your typical MCI,” said SAFD Fire Chief Robert Mikel. “This was essentially a large-scale occupant services mission that included the sheltering and care of an aged and at-risk population who didn’t necessarily require transport to a hospital or immediate medical care.”

Although this incident didn’t fit the typical MCI operation, many MCI principles still applied, so it was handled in a similar fashion by fire and EMS units. Initial triage was performed by fire crews and Acadian Ambulance personnel. A structured medical sector was quickly established, clarifying span of control. San Antonio EMS and Acadian worked together to transport the sick and injured from the scene.

Evacuated occupants were brought to SAFD’s ambulance bus for triage, treatment and transport decisions. Photo courtesy San Antonio Express News/Cynthia Esparza

As rescue efforts proceeded, occupants were brought to the lobby, which was extremely cold, breezy and chaotic. Therefore, those requiring medical assistance were brought to SAFD’s ambulance bus for triage, treatment and transport decisions. This kept patients from suffering exposure complications that could’ve resulted from the inclement weather.

An additional complication that had to be addressed early was a steady stream of family members arriving on scene looking for their loved ones. The concerned relatives were at first diverted to the medics and lieutenants with their questions and concerns, which tied up valuable resources. Therefore, police officers were requested to secure the scene and assist in management of foot traffic. Relatives were later directed to the shelter/relocation center once it was established.

Patients presented to the medical sector in controlled waves, and while triage tags were initially used for identification, it was soon realized that the tagging of all evacuated residents wasn’t necessary. Instead, SAFD personnel assigned to the transportation sector to keep a written record of patients who were transported via ambulance and those who were transported by family members.

Charting was difficult early in the incident due to the fact that residents were removed from their apartments without any form of identification. Some were disoriented or confused, and those requiring immediate transport due to their conditions were therefore logged as “Jane/John Doe.”



 

Rescuers placed an “X” on the door after going in and searching the room completely. Photo courtesy SAFD

Medical personnel and members of the Southwest Texas Regional Advisory Council (STRAC) were instrumental in identification and accountability of those patients during the days following the fire.

Sadly, there were five DOAs on scene. EMS transports included one patient in cardiac arrest and 18 residents with smoke inhalation. Many others presented to EMS personnel, traumatized by the incident, exhausted and with high levels of anxiety.

All but one of the patients transported survived. A 71-year-old female passed away two days after admission but it was determined by the Bexar County medical examiner that the fire didn’t play a role in her death.

Hospital destinations were made with assistance from the SAFD communications division. Dispatchers contacted San Antonio Military Medical Center (SAMMC), Northeast Baptist, Methodist, and University Hospital to determine the number of patients each could accommodate and the transportation officer evenly distributed patients to the facilities to avoid overloading any one facility.

It should be noted that some residents arrived at the hospitals by private vehicles. It’s important for the medical group to notify hospitals early into an incident of this nature so they aren’t surprised when patients begin to arrive on their own or in civilian vehicles.

Additional Resources

As the incident progressed, additional resources were required and were requested by the incident commander. To enhance communication capabilities, additional radio channels were used. Mutual aid channels 8–11 were assigned to operations, medical, logistics and rescue, respectively. (The rescue channel was made available but not used.)

Additional equipment and personnel were also requested through a second alarm response. BCs 1, 6 and 7 were assigned to search and rescue covering all 11 divisions. BC 4 was assigned to set up the command bus and subsequently assist unified command with fire ground operations as the support officer. These additional resources allowed the incident commander to increase and strengthen control of the fire scene.

Under Control

The main body of the fire, on the third floor (division 3) of the building, was soon put under control. BC 1 reported that his assigned companies weren’t present on the fourth floor (division 4) and that smoke conditions were increasing. The fire companies not present were trading out their self-contained breathing apparatus bottles after executing rescues from their assigned division and were being rotated through rehab, so fresh companies were sent to replace them. They located a small fire that had extended upward from the floor of origin and used a house line from a nearby hose cabinet to extinguish the extended flames.

In order to safely affect rescues from divisions 6–11, engineers from the lobby (base of operations) were assigned to pressurize the stairwells. BC 6 ensured roof access was open. Numerous occupants were trapped on the 11th floor (division 11) with smoke conditions increasing. An attempt to use the elevators failed and they would remain inaccessible for the duration of the incident. Instead, occupants were moved to a large balcony area outside the penthouse and were evacuated, in pairs, using SAFD AP32.

As on-scene resources were depleted, a third alarm was requested at 8:07 a.m. Fire companies from all of the involved agencies were rotated into the existing division and group assignments to continue rescue operations. This manpower was also used to conduct a thorough and systematic secondary search of the entire building.

A rehab sector and officer were also established because of the multiple rescues and evacuations underway in addition to firefighting operations. Bexar County Emergency Scene Rehab—a local volunteer organization—SAFD and a Schertz Fire Rescue ambulance bus were assigned to that sector. All three agencies worked well together to support the large number of fire suppression, police and EMS personnel on scene.

Media Briefings

The incident drew great attention from local, national and international media. Information dissemination was coordinated by SAFD Public Information Officer (PIO) Christian Bove. Through the PIO, unified command relayed information to Castle Hills officials, the jurisdictional entity.

A short joint press conference was held onsite in a designated media area to relay information about the actions taken during the incident as well as what would occur in the following days. Chief Hood, Chief Reidel and Castle Hills City Manager Diane Pfeil addressed the media and answered questions about the incident.

The media was also provided with details concerning a shelter being established at nearby Churchill High School. Family and friends of Wedgwood residents were directed to go to the shelter in order to reunite. Bexar-Bulverde Volunteer Fire Department PIO Ken Jarvis was assigned to the shelter to handle any onsite media requests.

Conclusion

Although six lives were tragically lost, the outcome could have been much worse without the coordinated efforts of every agency involved in this incident. It was a perfect storm: a high-rise structure of unusual construction and without a sprinkler system, inhabited by an elderly, mobility-impaired population and located in a small municipality, thus requiring the assistance of several outside agencies unfamiliar with the structure.

“This event re-emphasizes the need for regional mutual aid. This was something that was well beyond our capabilities as a small department and the help from our neighboring departments was crucial,” Riedel said.

More than 50 people were rescued from the 11-story high-rise that morning without the use of elevators, and, even with approximately 150 firefighters on scene from multiple fire departments, the majority of whom were on the tail end of a 24-hour shift, not a single firefighter or EMS injury was reported.

 

 

Sidebar: Medical Director’s Actions & Perspective

David A. Miramontes, MD, FACEP, NREMT, medical director for San Antonio Fire Department (SAFD), responded to the Wedgwood Senior Apartments fire and was primarily involved at the temporary shelter at Churchill High School where Emergency Medical Task Force (EMTF) members from Southwest Texas Regional Advisory Council (STRAC), San Antonio Fire Department (SAFD) and Acadian Ambulance assisted local authorities from Castle Hills, Bexar County and the American Red Cross.

Evacuated seniors were bused from the fire scene using several buses from VIA Metropolitan Transit to a rapidly set up shelter in a cafeteria in order to meet the needs of these fragile displaced seniors. “During the height of the chaos, I met a 99-years young resident who brought a smile to my face with her calm demeanor and smile,” said Miramontes.

EMTF administrative staff assisted local authorities with patient tracking using WebEOC incident management software with area hospitals and facilitated interagency communications to account for all the residents thought to be at the Wedgwood facility at the time of the fire. This management of the list of residents also assisted with identification of the dead and those who were transported to area hospitals.

The displaced residents were fed, warmed and, for those who were medically fragile, assessed and monitored by Texas EMTF members from STRAC and Acadian Ambulance.

When setting up an evacuation center for residents of a senior center, you have to be prepared to have an average of three relatives arrive for each resident.

The occupant services division at the fire scene was able to quickly search all rooms except for those on the third floor and retrieved medications and belongings that were in plain sight during a quick search of each apartment.

When personnel entered each apartment, they placed medications in a bag labeled with the corresponding room number. Crews then collected medication bags from each floor and packed them in large 55-gallon bags, one bag for each floor. These were then delivered to the shelter.

A large percentage of the residents were able to receive most of their medication containers. The rest of the collected medications were delivered to residents at their hotels and the remainder were distributed by the Castle Hills Police Department to those who sought shelter with friends and family.

Insulin and medications not collected, or those damaged by smoke/heat, had to be replaced. H-E-B Pharmacy sent an emergency cache of mission-critical medications from their pharmacy located near the fire scene and enabled EMTF nurses and SAFD paramedics to begin treatment of patients for pain, diabetes and hypertension at the shelter. Most residents hadn’t taken morning medications or insulin and, as such, hypertension and hyperglycemia issues were becoming apparent.

Missing or damaged medications such as insulin, metformin, hypertension medications, and oxygen/nebulizer delivery needs were addressed by Miramontes writing over 100 prescriptions.

Medications collected from each floor were packed into large 55-gallon bags, one bag for each floor. These were then delivered to the shelter. Photo courtesy San Antonio Express News/Matthew Busch

Because the incident occurred between Christmas and New Year’s, many primary physician offices were closed, complicating the medication recovery efforts. A pharmacy representative from long-term care pharmacy company Legends Pharmacy responded to the shelter and facilitated procurement of some medication refills and delivery of needed medication replacements to nearby hotels.

Further complicating matters, many residents didn’t have a medication list, used mail-order pharmacies or didn’t have refills available. The EMTF staff tried to reconcile medication lists and assist with the re-ordering of medications.

H-E-B, Walgreens and CVS pharmacies in the area stepped up to the task and helped make these displaced residents a little less stressed by having needed medications replaced despite residents not having insurance cards, money or credit cards.

Though frustrated with some delays and confusion, over 60 residents were placed in temporary shelter in five area hotels by 6:00 p.m. the day of the fire with the help of the American Red Cross.

In less than 24 hours after the fire, the SAFD responded to a 9-1-1 call for one of the displaced residents at her hotel. She had suffered cardiac arrest and succumbed to complications of pre-existing health problems most probably exacerbated by the fire.

Upon review of this case, the SAFD Office of the Medical Director, command staff and STRAC engaged local officials and began making “house calls,” checking on the displaced residents with an EMTF strike team, two SAFD paramedic units and two EMS officers.

These teams assessed displaced residents, did medication reconciliation, and provided primary healthcare services in the five hotels for six days following the fire. During this time, multiple prescriptions were written, medication doses were titrated, and needed supplies and medications were obtained with the assistance of the American Red Cross and local pharmacies.

In addition, multiple patients had to be transported during these visits for conditions such as severe hyperglycemia, influenza, dehydration and exacerbation of mental illness. One resident became suicidal and homicidal and needed urgent hospitalization. This resident was suffering from post-traumatic stress disorder and survivor’s guilt. He reported that, in order to escape the fire, he had to physically walk over one of the deceased residents whom he knew very well.

Numerous patients with depression and anxiety decompensated with the stress of the fire and their displacement from their homes and routines. Medications were replaced, counseling was facilitated and these patients were monitored for suicidal ideation.

The diabetic patients were having issues controlling their blood glucose levels due to the higher carbohydrate diets provided in the hotels and by local agencies. Provisions were therefore made for healthier, lower carbohydrate catered meals, and patient education was continued.

On day seven after the fire, patient care was transferred to BCFS Health and Human Services and they assumed assessment and case management of the displaced residents.

All residents had to eventually relocate to other accommodations and their salvageable belongings were packed up and moved from the fire scene by the building managers four months after the fire.

The team effort by all the stakeholders helped make this tragic situation more tolerable and helped transition the Wedgwood residents to new apartments or assisted living homes.

Learn more from David A. Miramontes as he presents an in-depth lecture on this challenging MCI at the EMS Today Conference & Exposition, Feb. 25–27, in Baltimore, Md. EMSToday.com