Mass Casualty Incidents

Duck vs. Bus Complex MCI on Seattle’s Aurora Bridge

Issue 11 and Volume 41.

The clinical excellence of the Seattle Fire Department (SFD) EMS and Medic One system is known worldwide, with highly structured protocols and procedures that are practiced and meticulously followed with great results by well-trained and disciplined personnel.

But what many don’t know is that this exceptional discipline, practice, and command and control permeates the department’s fire, rescue and mass casualty incident (MCI) operations.

I wrote about several of these aspects in a 1998 article about a massive tandem bus MCI that occurred after a rider shot and killed the bus driver while the bus was crossing Seattle’s Aurora Bridge. In that incident, the bus crashed into several cars, catapulted off the bridge into an apartment building and broke apart as it hit the ground below, injuring 52 passengers.

So when I learned that a large DUKW—a six-wheel-drive amphibious vehicle used by the U.S. military in World War II and retrofitted to serve as a land/water tourist attraction—crashed into the side of a charter bus on the Aurora Bridge, I decided to go to Seattle to get the inside story on this horrific incident.

What follows is a detailed, time-sequential account of the extraordinarily well-executed MCI operation handled primarily by SFD and their contracted ambulance transportation partner, American Medical Response (AMR).

You’ll learn how a disciplined approach to incident command (IC), role awareness and proper use of resources enabled SFD to have units on scene in less than two minutes, start triage and put a transportation corridor in place in just 2.5 minutes after arrival, extricate all patients in 31 minutes, have all initial Red priority patients transported in 19 minutes, and all 51 patients (12 Red, 11 Yellow, 28 Green) transported in 1 hour and 45 minutes.

bus crash MCI incident synopsis

Dispatch & Scene Size-Up

11:12 a.m. (Calls received at dispatch)

On Thursday, Sept. 24, 2015, at 11:12 a.m., the Seattle Fire Alarm Center (FAC) received multiple calls reporting that a “Ride the Duck” tour vehicle had collided with a charter bus on the Aurora Bridge, which rises 167 feet above Lake Union. Motorists and bystanders on the bridge reported that multiple people were in need of assistance.

At 11:13 a.m., two separate incidents were dispatched to 3700 Aurora Avenue North. The first was a motor vehicle incident freeway (MVIF) response that included Engines 20 and 8, and Aid Car 5.

The second response was an MCI. The MCI-assigned companies were: Engines 18, 21, 22, 34 and 41; Ladders 1 and 10; Battalions 4 and 6; Medic Units 16, 18 and 44; MCI-1; Aid Car 14; Deputy 1; Safety 2; Staff 10; and Air 9.

The FAC then notified Engine 8 that the incident had been upgraded to an MCI and reported that multiple people were reported ejected. The FAC also added SFD’s Technical Rescue Team, Ladder 7, Aid Car 14 and Rescue 1 to the response.

The incident location was a cantilever and truss bridge built in 1932 that spans the west end of Seattle’s Lake Union and is 70 feet wide, 2,945 feet long and 167 feet above the water. Officially dubbed the George Washington Memorial Bridge, it connects State Route 99 with the city’s Queen Anne and Fremont sections.1

The posted speed limit on the six-lane bridge is 40 mph with no center barrier between the three northbound and three southbound lanes.

The charter bus involved was carrying 48 international students and staff from North Seattle College to downtown Seattle for a new student orientation. It was being followed by a second bus. Many of the students didn’t speak English, which would present a unique obstacle during assessment and triage.

The massive Ride the Duck amphibious tour vehicle was approximately 8.5 feet wide, 31 feet long and weighted 15 tons.2 Neither the bus nor the Duck had seatbelts available to their passengers. Two other personal vehicles were also involved in the collision.

While en route, Lt. John Fisk, the on-duty citywide medical services officer (MSO) riding on Medic 44, called Harborview Medical Center (HMC), the region’s Level 1 trauma center and Medic One’s physician command hospital, to notify them there was a report of a major incident on the bridge.

Every Seattle Medic Unit and MSO carries an MCI bag that holds the EMS/MCI vests, command flow charts and forms, as well as color-coded triage tape and patient tagging strips that are assigned to key positions for deployment on scene.

SFD has a unique deployment system that uses BLS engines and ladders staffed by SFD firefighter/EMTs as “aid units” and BLS ambulances staffed by SFD EMTs as “aid cars,” with AMR handling BLS transportation needs. One SFD aid unit or aid car responds on all BLS calls as a first response resource. Despite responding to incidents in an ambulance, aid cars don’t routinely transport patients. Instead, an AMR ambulance is requested so that SFD assets return to service available for other responses.

On ALS cases, the SFD Medic One ALS unit transports—with assistance from SFD personnel if necessary—and AMR isn’t dispatched.

Because of the nature of this incident, Medic 45—SFD Medical Services Administrator (MSA) Craig Aman—riding with Fisk-immediately contacted AMR and requested six ambulances be dispatched. AMR has 20 ambulances assigned to the Seattle corridor: two for each of the five SFD battalions. Therefore, they were immediately able to dedicate multiple BLS ambulance units as well as divert several interfacility critical care ambulances to the incident.

Figure 1:
bus crash MCI layout of responding units

11:15 a.m. (Two minutes after dispatch)

Apparatus from Battalions 4 and 6 were first to arrive on scene, having responded from a station just north of the bridge. The full extent of the incident wasn’t clear from their northern vantage point, but at least 10 victims could be observed on the roadway.

Battalion Chief Tamalyn Nigretto (Battalion 6) conveyed this information to the FAC and directed Battalion 4 crews to conduct further size up.

Battalion 4 notified the FAC that all responding units would likely have to approach the incident from the north end of the bridge due to heavy traffic conditions on the southbound side. The FAC then directed all incoming units to approach the incident from the north.

Battalion 4 personnel soon found an increasing number of victims and evidence of severe impact between the two large vehicles, with at least 12–15 victims lying on the ground surrounded by personal belongings ejected from the vehicles upon impact.

bus crash MCI DUCk vehicle
Exterior and interior of the World War II-era amphibious “DUCK.”
Photo A.J. Heightman

During the collision, the high structural integrity bow of the former military landing craft tore a large hole in the bus, killing and critically injuring occupants on the bus. Numerous victims remained in both vehicles. Battalion 4 initially estimated there might be as many as 40 critical victims involved due to the size and weight of the vehicles and the T-bone mechanism of injury.

Upon hearing the radio report of 10 patients on the ground, Fisk contacted the on-duty HMC trauma doctor to confirm this was a major incident and report a large number of patients would need to be transported. As the only Level 1 trauma center serving Alaska, Idaho, Montana and Washington, HBC’s ED is often filled near capacity.

Fisk requested that HMC’s Disaster Medical Control Center (DMCC) be established. The DMCC acts as the coordination center between on-scene transportation resources and the region’s EDs.

bus crash MCI
Lt. John Fisk diagrams ideal transportation corridor and loading zone. Photo A.J. Heightman

The DMCC uses the Northwest Healthcare Response Network to check resource availability and ensure proper and even patient distribution in one coordinated system. The system, operated in a quiet, controlled location at HMC, is manned by a nurse coordinator, an attending physician and Seattle Medical Director Michael Sayre, MD, and/or Associate Medical Director Andrew McCoy, MD.

This early notification of the DMCC gave ED staff time to organize their current patient load and prepare for the large and immediate influx of critically injured patients, preventing costly time delays and providing for faster lifesaving interventions.

11:16 a.m. (Three minutes after dispatch)

Nigretto established IC on her arrival and assigned Battalion 4 the role of rescue group supervisor (RGS).

Engine 9 arrived and Nigretto directed the crew to recon the scene and get a patient count. The RGS recognized a significant amount of vehicle fluid on the ground and requested that Engine 9 also deploy a precautionary hose line to protect against any fire potential.

Engine 18 arrived shortly after Engine 9 and was assigned by the RGS to secure a transportation corridor. RGS also notified command that “The corridor will have to be accessed from the north, and [ambulances routed] back to the north.”

The driver and officer from Engine 18 set up traffic cones on the north end of the bridge directed incoming units where to park in order to keep the transportation corridor clear. They cleared remaining civilian traffic with the assistance of Seattle Police and maintained tight control of the entrance and exit.

The remaining two crew members from Engine 18 proceeded to the accident scene to assist with patient care.

bus crash MCI
Capt. Craig Aman was the north transportation leader. Photo A.J. Heightman

Initial Triage

11:18 a.m. (Five minutes after dispatch)

IC received reports that there was a patient trapped between the bus and the Duck. Nigretto radioed, “First-in truck, announce your arrival and you will be assigned rescue group. And you will be focusing on the patient pinned between the Duck and the bus.”

Engine 9 crews completed their recon of the bus and notified IC that there were approximately 12 patients on the bus. The rapid reconnaissance of the first arriving engine company provided the IC the information needed to request additional resources early.

After Engine 9’s report from inside the bus, IC updated the FAC: “Let’s start stacking up some AMRs … Medic 16 from Aurora Command, you’ll be our Medical Group Supervisor (MGS).”

The IC also advised Fisk to request additional Seattle Medic One units and possibly mutual aid. The FAC heard this request and dispatched Medic 10, 28 and 31.

Medic 16—the first Medic One unit on scene—arrived and split their crew. Officer Carl Gordon, EMT-P, established the medical group per department protocol and served as the initial MGS overseeing triage, treatment and transport functions.3

The Medic 16 driver established the treatment team leader position. Medic 16 parked north of the crash in order to establish a treatment area directly behind their unit, which Gordon then announced on the radio.

Medic 18 arrived and also split their crew. The Medic 18 driver staffed the treatment area to begin treating the growing number of patients, while the Medic 18 officer, Pat Kyles, EMT-P, established the Triage Team Leader position.

In Seattle, all firefighters are trained to perform rapid “sick/not sick” triage and affix color-coded triage ribbons to patients to identify their priority and facilitate rapid removal to the appropriate colored tarp for re-triage and treatment.

Paramedics don’t perform initial triage so they can work at the treatment tarps and deliver the earliest interventions to patients in critical need and re-triage as necessary.

The triage personnel directed all patients on the bus who could walk to disembark. At most MCIs, the vast majority of patients are Green priority. But, due to the weight of the vehicles involved and the impact speed and angle, triage personnel were confronted with a significant number of head injuries and multiple systems traumas. The decision was made to intubate the critical head injury patients to protect their airways.

bus crash MCI dispatch
The Harborview Medical Center Disaster Medical Control Center includes communication capabilities and linkage used to check resource availability and ensure proper and even patient distribution. Photos A.J. Heightman

Engine 9, along with additional arriving SFD companies, simultaneously began removing Red and Yellow priority patients from the bus.

Because all of the victims were contained in and around the bus and Duck, they could each be rapidly extricated to the treatment tarps after passing by Kyles, who positioned himself on the flat front area of the Duck, in front of the windshield. This vantage point gave Kyles a clear view into the bus to direct patient removal operations, and Kyles opted not to spend time affixing colored tape to each victim in order to save time getting patients to the color-coded tarps and ALS-level care.

11:21 a.m. (Eight minutes after SFD dispatch)

The AMR units began arriving four minutes after being dispatched because they were already assigned to the Seattle area and on the road, deployed.

MCI-1, SFD’s well-stocked specialty MCI unit, arrived on scene and positioned the apparatus directly adjacent to the patient treatment area. This unit contains 112 backboards, 20 ALS treatment kits, and assorted medical equipment used to manage an MCI scene and care for over 100 patients. (See sidebar, “The Perfect MCI Resources.”)

The crew deployed red and yellow tarps inside the treatment area, designating separate areas for Red and Yellow priority patients. Personnel staged the rest of the MCI equipment by the treatment area, including their cache of backboards.

Command received further reports of Red and Yellow patients and requested four additional SFD BLS resources from the FAC. Engine 36 and Ladders 6, 8 and 9 were immediately dispatched. The MGS also requested two additional medic units. The FAC acknowledged the requests for additional units and notified IC that they currently had five SFD medic units assigned and would work on getting two mutual aid medic units. FAC then requested two medic units from the Shoreline Fire Department.

Engine 2 arrived on the south side of the incident and found civilians struggling to turn their cars around and exit the area. The Engine 2 officer assigned the Engine 2 driver to clear traffic from the area and sent Engine 2’s other two firefighters (Engine 2 Team Bravo) to assist in patient care at the bus. The Engine 2 officer then disconnected the bus batteries and began to gather the Green priority patients near the treatment area.

After his arrival on scene and a face-to-face meeting with Gordon, Fisk assumed the role of MGS, with a quick, smooth transfer of command. He then directed Aman to assume the transportation team l role and assigned Gordon to Treatment Team Leader.

bus crash MCI extrication
Aerial view of extrication. Photo courtesy KOMO

11:23 a.m. (10 minutes after dispatch)

The RGS updated IC that there were currently eight critical (Red priority) patients still on the bus, with four entrapped. The RGS requested that IC send all available resources to help remove these Red patients from the bus.

Ladder 4 arrived on scene and parked close to the bus, providing easy access to their tools, and prepared their extrication equipment to rescue the trapped victims.

By the time the equipment was set up, Ladder 1 and 7 and Aid 14 had arrived to assist Ladder 4. The Ladder 4 officer climbed to the front of the Duck, beside the triage coordinator, Battalion Chief Amy Bannister, in order to better direct extrication efforts.After pointing out striped tag/deceased patients, Bannister ordered the removal of the remaining surviving patients from the bus.

Ladders 4, 1 and 7 then cut away seats to access patients and placed ladders along the bus and the Duck for patient removal. Ladder 4 and Aid 14 worked initially to cut away the sides and seats to provide for patient access. Ladder slides were used to efficiently lower victims.

AMR Chief EMS Officer Greg Sim (AMR S1), and AMR EMS Supervisor Steve Enich (AMR S3) were departing a large active shooter/MCI tabletop exercise at the University of Washington Police Department when the MCI call was dispatched. They approached the scene at the south side of the bridge per SFD direction and arrived on scene at 11:25 a.m., just 12 minutes after the 11:13 a.m. MCI dispatch.

Upon arrival, Sim collaborated with Fisk and Aman to determine the Transportation Corridor. It was determined that the corridor would be from the north approach of the bridge. Seattle Police Department officers secured the area to provide clear ambulance passage.

Enich and Sim worked together to communicate with Fisk to ensure patients were tagged and transported.

bus crash MCI
Battalion Chief Tamalyn Nigretto was the incident commander. Photo courtesy Seattle Fire Department

11:28 a.m. (15 minutes after dispatch)

SFD Deputy 1 arrived on scene and assumed command from Nigretto, reassigning her to operations section chief. The RGS soon reported to operations, “We’re doing a small amount of cutting, but no one is trapped at this time.”

The RGS and Ladder 4 officer were helping to guide the rescue efforts, but little direction was needed because as soon as the rescue personnel completed one task, they immediately moved on to the next.

The priority for the crews was the extraction of the remaining Red priority patients and their transfer, along with Yellow priority patients to the treatment area.

Other firefighters assisted paramedics in the treatment area as they intubated patients, started IVs and dressed major wounds. All medic units and MCI-1 carry a supply of i-gel supraglottic airways as an important airway asset when needed. However, all of the patients requiring airway control were intubated on the first pass with no problems.

The Engine 2 officer, recognizing that Green priority patients can occasionally deteriorate into Yellow and/or Red priority patients, redirected several firefighters to the Green patient area to re-examine each Green priority patient to ensure they weren’t exhibiting injuries that needed more immediate attention.

The FAC then notified IC that two additional SFD medic units had just cleared a special dignitary protection detail and were responding along with the two Shoreline Fire Department medic units.

bus crash MCI
AMR Chief EMS Officer Greg Sim. Photo courtesy AMR Seattle

11:32 a.m. (19 minutes after dispatch)

As Red priority patients were being prepared for transport, Fisk contacted the DMCC with the following report: “We have a bus vs. a Duck with multiple patients. At this time, we have two confirmed DOA, approximately nine Red patients, and about 15 Yellow patients.”

The DMCC replied that they understood MCI protocols had been instituted, and that they were standing by for further information. DMCC also established that HMC was prepared to take all of the intubated patients (currently eight patients), and that the Yellow patients would be directed to other hospitals. HMC was notified that Red patients would be transported by BLS AMR units to allow SFD paramedics to stay on scene and continue to provide treatment to the remaining patients.

Effective & Efficient Transportation Groups

11:35 a.m. (22 minutes after dispatch)

The RGS received an updated count of current patients and updated operations: “We have two striped [deceased] patients on the bus. We’re bringing the last person off the bus. We have approximately a dozen Red patients, approximately a dozen to 15 Yellow patients, and about 20 Green walking wounded … But that is approximate.”

One minute later, the RGS also reported that four Yellow patients remained on the Duck.

A second SFD MSO, Michael Barokas, along with Tunnel Rescue Captain J.M. Havner, arrived on-scene after returning from the active shooter/MCI tabletop drill. This provided a fortuitous extra wave of key personnel.

bus crash MCI triage
The Red and Yellow priority patient treatment areas. Photo courtesy KOMO

Barokas consulted with the MGS and then established a second (south) transport branch and corridor because police had cleared that end of the bridge of all remaining traffic. Both north and south transport communicated with the DMCC on SFD Channel 8 to coordinate patient destinations.

At 11:37 a.m., Sim requested three additional ambulances and had them also approach from the north. With SFD rescue personnel extricating numerous patients, it was determined at 11:45 a.m. that six more ambulances were needed. Those additional AMR assets began arriving on scene four minutes later, at 11:49 a.m., and began transporting additional patients eight minutes later.

Each transportation group consisted of a transportation leader, radio operator, a “banding officer” tasked with placing a uniquely numbered band on each patient for tracking at the scene and throughout the hospital system, and a firefighter/assistant who removed and handed a numbered sticker from the tracking band to the charting/tracking officer, who then affixed it on the standardized tracking form.

When contacted by each transportation group with the patient’s injuries and priority, the DMCC would assign the patient to a hospital and the patient would then be placed in an awaiting AMR ambulance for immediate transport to that assigned hospital.

The first AMR transport ambulance was loaded and en route to HMC at 11:46 a.m., within 20 minutes of their arrival on scene.

The first six patients transported by AMR were all Red priority patients who had received ALS care and, per medical control agreement, were transported by EMTs trained to manage intubated patients and those with IVs established. All were taken to HMC, which was less than 15 minutes from the scene.

11:47 a.m. (34 minutes after dispatch)

The RGS radioed operations as the last patients were removed from the hazard area. “We have the final patient off the Duck. We have all patients off and into the triage area.All Red patients are on their way to transport.”

All nine Red priority patients (eight of them intubated) were rapidly processed through the transportation corridors and transported by AMR ambulances to HMC. Barokas and Aman then requested destinations for the Yellow priority patients. The DMCC stated that each of the area hospitals had been told to each expect to receive three to four Yellow priority patients.

Two of the Red priority patients who were extricated from the bus succumbed and were pronounced in the treatment area despite emergency interventions. They were covered with blankets and moved to a controlled and protected area away from the treatment tarps.

bus crash MCI
Lt. Michael Barokas acted as the south transportation leader. Photo A.J. Heightman

11:49 a.m. (36 minutes after dispatch)

The RGS reported that they were working on transporting the Yellow priority patients and needed a plan for transporting the Green priority patients.

Operations initially requested a Metro Bus, but that plan was later revised and the department’s medical ambulance bus (MAB-1) was dispatched to assist the Green priority team leader (Engine 2’s officer).

Additional AMR units arrived on scene and the first Yellow patients began to be transported from the scene by both transportation branches. Each transportation branch contacted the DMCC separately as they had units ready for transport, gave the age and general condition of their patient(s) and were assigned destination hospitals.

At 11:57, two additional AMR ambulances were requested. They arrived 11 minutes later and began transporting six minutes later.

11:58 a.m. (45 minutes after dispatch)

The RGS updated operations that there were eight Yellow priority patients and one final Red priority patient in the treatment area—a Yellow priority patient who had been upgraded.

At 12:01 p.m., two more AMR ambulances were requested and began arriving on scene eight minutes later.

12:05 p.m. (52 minutes after dispatch)

The final three patients, initially triaged as Yellow, were upgraded to Red and assigned to SFD Medic units for transport to HMC.

At 12:14 p.m., six more AMR units were requested and AMR transport liaison duties were transferred to Enich as Sim was added to the unified command briefing. Those six units began arriving on scene four minutes later.

Once Sim was brought into the unified command structure, he was asked to provide a list of units and number of patients transported from the scene. At that time, AMR had 34 units that had been involved and had transported 32 patients from the scene.

bus crash MCI
MSO Lt. Michael Barokas (white shirt) moves to set up the transportation corridor early in the incident.
AP Photo Ted S. Warren

12:16 p.m. (One hour, three minutes after dispatch)

Medic 81 broke down two blocks from HMC while en route with an intubated patient. The FAC dispatched Engine 5 to assist, and, with the help of all the Engine 5 crew, the patient was pushed uphill for four blocks to the HMC ED.

At 12:20, four more AMR units were requested and arrived on scene nine minutes later. MAB-1 arrived on-scene and the Green priority patients were assisted on board to keep them comfortable while they waited for transportation resources. At that time, two Yellow priority patients were still waiting for transport.

12:28 p.m. (One hour 15 minutes after dispatch)

The RGS radioed operations that the last Yellow priority patient was being loaded for transport and that all patients were out of the treatment area. The RGS also notified operations that crews had performed a complete secondary search of the area and no further patients had been found.

12:42 p.m. (One hour 29 minutes after dispatch)

Five additional AMR ambulances were requested. However, as patient transport needs slowed, several of those ambulances were held in staging and transported patients as needed as the scene wound down.

With all but the last of the Green priority patients transported, south transport and the DMCC reconciled their records, performed a “hot wash” review and agreed that 44 patients had been transported to eight area hospitals.

12:53 p.m. (One hour 40 minutes after dispatch)

The remaining seven low-acuity patients, still waiting to be transported from the scene, were taken via MAB-1 to Northwest Hospital at the end of the incident with a single transport, with the permission of the DMCC.

bus crash MCI patients transported

Conclusion

The SFD crews immediately recognized the need to implement the MCI plan. They executed the plan in a manner that resulted in the rapid triage, treatment and transportation of patients to area hospitals.

The crews were able to extricate all 51 patients in under 32 minutes and transport the critically injured patients away from the scene in less than 20 minutes.

Only one patient, initially transported as a Yellow priority patient, required an eventual inter-facility transport to HMC to undergo surgery. All of the other Yellow priority patients were treated and released from the hospitals where they were transported.

There were five fatalities as a result of the incident: four pronounced at the scene and one of the Red priority patients transported to HMC was pronounced at the hospital.

Unified command facilitated coordination between affected agencies throughout this incident and allowed for the dissemination of accurate information to the City Joint Information Center and Emergency Operations Center. It also allowed for the smooth transition of command from fire to police and finally to the Department of Transportation.

Incident Commander Nigretto credited the success of the SFD MCI operations by stating, “The key to the Seattle system is that all personnel understand their role in each position. Our template is always in place and we have well-trained personnel who can execute each role when an MCI occurs.”

References

1. Long P. (March 14, 2003.) Seattle’s George Washington Memorial Bridge (Aurora Bridge) is dedicated on February 22, 1932. HistoryLink.org. Retrieved Sept. 20, 2016, from www.historylink.org/File/5418.

2. DUKW specifications. (2012.) Advanced Amphibious Design. Retrieved Sept. 20, 2016, from www.aad.us.com/Eng/product/DUKW_specs.html.

3. Operating Guideline 5014 Multiple Casualty Incident [procedure]. Seattle Fire Department: Sept. 10, 2015.


After-Action Observations

1. Triage flagging tape wasn’t used.

Analysis: Color-coded triage flagging tape, normally used to color-code (red, yellow, green, and black/white striped) and prioritize patients, wasn’t used during the early stages of this incident. This resulted in some patients being triaged multiple times prior to being removed and some confusion about the triage category of several patients.

2. The red and yellow treatment areas were right next to each other.

Analysis: Space on the bridge was limited due to apparatus parked on the bridge deck, so the Red and Yellow tarps were placed next to each other. The close proximity of the tarps/treatment areas caused confusion about patients at the perimeter of the areas. It was agreed that the treatment areas should be in close proximity, but not overlap, if space allows.

3. Transportation located too far from the treatment areas.

The two transportation team leaders were located a long distance from the treatment team leader, which caused some confusion for members carrying patients to the two separate transportation corridors.

Analysis: SFD personnel were carrying patients to two transportation corridors without clear coordination through a direct chain of command. This caused some delays and rerouting of patients. Each treatment area should have one transportation team leader working in coordination with the treatment team leader. Larger incidents require that the transportation team leader delegate tasks by designating a DMCC coordinator, a patient loading coordinator, a tracking aide, and/or an ambulance staging manager. The transportation team leader filled all of these roles at this incident. AMR’s primary request was for more rapid declaration and control of ingress/egress routes because ambulances that initially approached from the south (the side of the bridge with more rapid access to Harborview Medical Center) were hampered by traffic.

4. Some patients had to be carried a long distance to the transportation corridor.

Analysis: SFD Operating Guidelines state: In most cases, ambulance staff should be directed to stay with their apparatus while patients are brought to the transportation area. Some staff left their units to retrieve patients from the treatment area. In addition, many patients were carried over an extended distance on backboards. This was exceptionally tiring for firefighters and the increased effort created a higher risk of injury and fatigue. If the transportation corridor is remote from the treatment area, it may be beneficial to bring stretcher to staging areas closer to the treatment area.

5. MCI command sheets were available, but not utilized at this incident.

Analysis: MCI-specific command sheets, created for use during complicated MCIs to simplify decision-making and remind units of key components needed to establish an organized MCI scene, weren’t utilized. The expectation is that they’ll be utilized at SFD incidents in the future to better organize action plans and facilitate a smoother transition from company officer incident commanders to later-arriving chief officers when they assume an established command.

6. Supervision of worried well (uninjured, Green priority patients) could have been better.

A group of approximately 25 Green priority patients from the chartered bus were medically evaluated by SFD personnel and assigned to the Green patient area. After medical evaluation determined they didn’t need to be transported to a medical facility, they were then escorted by law enforcement to a Metro bus on the north end of the bridge. These patients were left unattended for 40 minutes while patients in need of treatment or transport were treated and transported. These Green patients needed no further medical attention and believed they had been released, so they left the scene. It was reported that they walked to Woodland Park Zoo and were subsequently transported back to North Seattle Community College by privately operated vehicles.

Analysis: Although the initial action to relocate the Green patients was effective, dedicated personnel assigned to Green patients shouldn’t be redirected until the Green patients are moved definitively to area hospitals or handed over to alternate agencies as coordinated by unified command.