Mass Casualty Incidents

Responders from the Berkeley Balcony Collapse Reflect on Incident Challenges

Issue 5 and Volume 41.

Shortly after midenight on June 16, 2015, a cantilevered balcony on an apartment complex in the 2000 block of Kittredge St. in Berkeley, Calif., collapsed, crashing to the pavement along with a group of residents and guests attending a party in the affected apartment. Located just a few short blocks away, the Berkeley Fire Department Engine 2 captain heard the dispatch:“Engine 2, Medic 2, for a medical emergency, 2020 Kittredge St. Reporting party advising that one of the balconies broke, and at least 10 people fell from the second or third floor.”

The captain was familiar with the address. As he stepped onto the engine, he thought it would be one of the interior balconies. He knew there were bushes at the bottom of those, and falls would be at least somewhat protected.

He keyed his radio, asking dispatch to repeat what they knew so far. Dispatch replied they had nothing further, but had dispatched police to investigate as well. Thinking of both the structural integrity of the scene, as well as the potential for patients, he requested Truck 2 and the next due ambulance to join in the response.

The incident was close, and there wasn’t much update from dispatch en route. As the engine and ambulance turned the corner, the captain noticed multiple police cars already on scene but couldn’t see what was going on. The block was dark and there were a lot of people moving around, but there were no real signs of structural collapse or injury. The units continued to roll into the block and, as they stopped in front of the address, the captain looked out the apparatus window and took a quick scene size-up.

The closer he got, the more he realized this wasn’t going to be an ordinary incident. The balcony had fallen from the fifth floor. To his left, there were bodies-some moving, many not. Residents had run downstairs and were traversed throughout the debris, complicating the scene size-up.

Some were holding their friends, some were turned away shocked and upset. Police were scattered throughout the scene, trying to establish some semblance of order.

The seasoned fire captain hadn’t been prepared to be visually hit with the scope of this incident so suddenly. He’d expected to roll into it and gather the information as they took the block, as they often do; slowly building the scene as his crew arrived. Instead, the initial scene will be burned in his memory forever. He remembers almost every part of it, including the make and model of the cars parked in front of the building.

EMS responds to Berkeley balcony collapse

Police officers gather at the scene of the fifth-floor apartment balcony collapse.

TRIAGE & TRANSPORT

The captain stepped off the rig with the crew, wanting to go to work. A senior officer with 29 years of experience, he was torn initially on this particular event, knowing that he had to step back, take command and build the incident. It was hard for him having to step back and manage, and let his crews go to work.

His firefighter and driver, both paramedics, joined with one of the paramedics on the first due ambulance, Medic 2, to initiate triage.

The second paramedic met the engine captain and took on the role of medical group supervisor. She immediately notified the Alameda County communications center that this incident qualified as a mass casualty incident (MCI), and began polling local hospitals for bed availability.

Medic 3 had been added to the assignment before units were on scene, but the incident commander (IC) realized immediately that additional ambulances were going to be needed. He requested five more ambulances, which meant mutual aid from neighboring ambulance provider Paramedics Plus. The IC also requested and was assigned an additional two ALS engine companies to provide personnel and ALS care. Shortly after, IC was transferred seamlessly to the first arriving battalion chief, who kept the engine captain with him in the command post for command continuity.

Perhaps the most challenging aspect of the MCI was the acuity of the incident. All patients were either tagged “immediate” or “deceased,” except for one who was tagged “delayed,” but was upgraded soon after.

Additionally, all patients were closely situated; in many cases, they were on top of one another. Although this made it relatively easy to distinguish patients from bystanders, each patient was suffering from multisystem trauma due to the distance of the fall and the fact that many victims landed on top of each other.

Injuries included severe airway compromise, closed head injuries with resulting increased intracranial pressure symptoms, and high probabilities of internal hemorrhage. This made early treatment especially difficult, as each “immediate” patient required far more intervention than a single responder could provide.

Multiple police officers, all with first responder training, were on scene early. As additional ALS resources were added, the training of the police officers was invaluable in assisting with the care and management of many victims. The police also did an exceptional and early job of crowd control.

Early responders found it especially helpful to have officers available, and would task them out to simple duties, such as holding manual in-line stabilization, rolling vomiting patients to keep airways clear, or movement of patients from the triage area.

It was also fortunate that many of the mutual aid ambulances arrived on scene rapidly due to their geographic location at the time of the incident; two happened to be clearing from the local hospital and were able to immediately respond. In addition, a field supervisor for Paramedics Plus heard the request and responded as well.

Early into the incident, the resources needed outweighed availability. However, as treatment, triage and transportation were established and ambulances began to arrive, the flow of patients moved rapidly. In fact, staging was never implemented because the scene moved so swiftly that arriving ambulances were almost immediately given patients and sent to area hospitals.

On arrival, a vehicle path/pattern had already been established due to early arriving units staged properly-out of the way. The engineer from the first arriving engine was tasked to serve as the transport leader, and as ambulances arrived, patients were transferred to them rapidly based on triage acuity.

Fire department personnel teamed up with ambulance teams to make sure there were two paramedics in the back of each ambulance, and, as the ambulances departed the scene, the field supervisor would confirm their assigned destination, providing an additional check to the transport leader’s assignments.

The patients were transported to three different trauma centers: Highland Hospital in Oakland, Calif.; Eden Medical Center in Castro Valley, Calif.; and John Muir Medical Center in Walnut Creek, Calif. The last of the seven transported patients left the scene 27 minutes after the first 9-1-1 call was received.

DEBRIEFING & AFTER-ACTION

Early debriefing for the responders started 12 hours after the event. The debriefing was multifaceted, multilayered and comprehensive because all of the survivors and all but one of the fatalities were Irish nationals traveling to the United States on student visas, making the diplomatic response a unique aftermath the fire department was unaccustomed to.

Personnel were debriefed on the incident as a whole and made aware of these additional diplomatic concerns, but most of the responders were already aware of the international ties: Irish newspapers, well into their workday across the Atlantic, were calling the firehouses through the early morning hours.

Diplomatic responses were handled by the department and city administration, which included using the public safety headquarters as a gathering place for family and friends of the victims, many of whom were arriving from overseas. Department administration also provided personnel to assist in shuttling family members around on their arrival, provide support at gatherings, and assist wherever and whenever possible. This relationship continued for months, culminating with the arrival of the president of Ireland four months after the incident to meet both the responders and the American families.

Secondary and tertiary critical incident stress debriefing (CISD) sessions were hosted by local fire departments with specialized training. These sessions were spaced out intentionally so that crews were assigned while on duty and responders had personal time to process their reactions between sessions.

A formal after-action and incident debriefing was held separately to discuss tactics and resources. As a result of this incident, management from each department reexamined and researched future/additional psychological support teams. They sought to understand how responders are affected and what type of agency support provides the most comprehensive response to support their staff.

EMS responds to Berkeley balcony collapse

All patients were either tagged “immediate” or “deceased,” but the flow of patients moved rapidly. The incident left six dead and seven injured.

LESSONS LEARNED

Early debriefing provided a number of key takeaways. First and foremost, the early IC could have simplified his responsibilities on scene by using single-point resource ordering of predesignated quantities. For instance, instead of ordering an additional two engine companies, he could have asked for a first alarm assignment, leaving the dispatch center to handle the composition of the response apparatus.

On scene, the responding supervisor from the ambulance company should’ve been more closely tied into a unified command with the IC. Although there’s radio interoperability between the agencies, better interagency management on scene would likely have minimized duplicating efforts, such as destination confirmation.

The department had recently issued new MCI bags to each apparatus. These bags had colored tape to assist with the visual identification of patient priorities. However, it was difficult to identify the tape on such a dimly lit scene, especially if the patient was wearing dark clothing. The color of the tape was also hard to distinguish.

Specific strengths included a strong network of dedicated staff who were assigned early and aggressively. The tenacity of the responders and the interagency cooperation of each responding agency made this MCI response remarkably efficient and productive. Although the concentrated loss of life of younger students made the scene and aftermath especially difficult, many of the responders shared how proud they were of the speed, weight and professionalism of the response, and felt the diplomatic efforts of local agency officials in the aftermath continued that response in a way that left them proud.

In the days after the incident, some of the greatest lessons came from the around-the-clock administrative teams that provided support to families and diplomats, and responded to media requests. The city, which prides itself in a coordinated community response to high-acuity incidents, was caught between the apparently modest size of the MCI and the unanticipated national attention from extenuating circumstances.

The team assigned to handle the political and media challenges that continued for days after the event felt that an early activation of the Emergency Operations Center, along with training to prepare staff for their roles in high-profile incidents, would’ve been helpful.

An early unified command between agencies such as Fire, police, mental health, public works and the Irish Consulate would have helped minimize the duplication of efforts and maximized the efficiency of assigned staff. The staff that evaluated the response felt strongly that early coordination and direction would have aided incoming families and diplomats, many traveling from overseas, in their efforts to glean information and resources from a highly politicized scene.

As is often the lesson in operations, order resources early, create an IC structure to accommodate them and worry about canceling later.

CONCLUSION

Berkeley Assistant Fire Chief David Brannigan, while accepting an award given to the first responders for their efforts, remarked that this event was a nightmare for many people, both victims and rescuers. He asked those in the room to not sit back on their laurels of having “tried their best.” He told the audience:

“The young souls who suffered that night deserve to have their memories honored by improving what we do … so that the next victims will see an even faster, more efficient, more effective level of care. What I’m getting at is a challenge. A challenge that everyone who ‘adapts and overcomes’ in tough situations should push their leadership to have policies that make sense; to train to a higher standard; to look back at our responses and not just note what could have been better, but actually make it better.”

The responding agencies have taken Brannigan’s words to heart. There have been active efforts to improve radio interoperability, simplify hospital polling and clear up hospitals’ understanding of their role in an MCI, and continuing MCI drills to improve the speed and weight of response.

As always, MCIs continue to be challenging, imperfect events that strain resources and capabilities, and test the resolve of responders. The department’s transparent, flexible stance on looking for ways to improve its operational capacity has improved communication flow, hospital cooperation and responder efficacy.