Knowing & Overcoming the Challenges of MCIs Involving Buses

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 A.J. Heightman, MPA, EMT-P | From the September 2013 Issue | Thursday, August 8, 2013

Photo Rick Sforza.

FEATURED IN MAJOR INCIDENTS

• Blacksburg Volunteer Rescue Squad Partners with Police to Create Rescue Task Force
• Understanding the NFPA 473 Improved Standard for EMS Hazmat Professionals
• Supporting Paradigm Change in EMS’ Operational Medical Response to Active Shooter Events
• Hit and Run at LAX Airport
• EMS Data Use in Integrating Mobile Healthcare, Mass Gatherings and MCIs
• The Importance of Scene Illumination at Mass-Casualty Incidents
• Improving the CDC’s National Field Triage Decision Scheme

        

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When an airplane crashes, it’s gruesome. The high-altitude impact results in few survivors, which can make this type of mass casualty incident (MCI) challenging for many first responders. But although these incidents are known for the horrific aftermath, bus crashes actually far outnumber plane crashes in the number of injured annually. Each year in the United States alone, 20,000 people are injured in bus crashes—12,000 of those injuries involve children.1
Bus Structures & Statistics

The Aircraft Record Office (ACRO), a non-government organization based in Geneva, reported 119 airplane crashes worldwide in 2012, compared to 144 school-bus crashes each day in the United States.1,2 This means there are more than 26,000 school-bus accidents in the U.S. annually, with more crashes happening in California than any other state.3
Every year in the U.S., 360 million people use bus transportation. There are 30,000 commercial buses and 450,000 school buses on the road each day. School buses transport more than 24 million students to and from school and school-related activities, completing more than 8.8 billion student trips per year. That makes buses the largest form of mass transit in the United States.4

Standard passenger buses can carry 55 passengers and a driver. But many buses, particularly double-decker buses operated by casinos and theme parks, can carry as many as 81 passengers—each with no law requiring riders to wear a seatbelt. Buses outweigh other automobiles and usually fare better in a collision because of the structural integrity from the window line down to the chassis frame—as long as the bus remains upright. The passengers are usually at a higher level above the bus frame, engine compartment and baggage area. But when a bus flips on its side or rolls over, the unbelted occupants inside are thrown around like the day’s catch being offloaded from a commercial fishing boat.

The reality is that passenger buses present one of the most challenging MCIs for emergency responders—particularly if they occur at night, in bad weather or in remote areas.

Learning from the Past
If you focus on one of the worst possible scenarios for a bus accident—a nighttime occurrence, a remote area with difficult access and egress, a language barrier, and multiple agencies involved—you will be able to overcome any logistical or geographic impediments to access, treatment and transportation in future crashes. I chose to focus on the bus accident that occurred in San Bernardino County, Calif., earlier this year because of its many complexities.

I was allowed the opportunity to sit in on the after-action review for this event and will present facts about the incident, the challenges presented to the responders and the amazing results produced by the well-trained agencies that responded. More importantly, I’ll present the outstanding actions taken by the responding personnel, lessons they learned at the incident and recommendations I have for bus-related MCI responses.

San Bernardino County Bus Crash
The San Bernardino County Bus Crash occurred on a Sunday evening, Feb. 3, 2013, around 6:30 p.m. on a rural two-lane highway (State Route 38) about 80 miles east of Los Angeles. The bus was packed with tired travelers returning to Tijuana, Mexico, after a day-trip to the resort town of Big Bear, Calif.

The tour bus was winding down the mountain road—State Route 38 meanders through the remote and rural San Bernardino National Forest—when it suddenly picked up speed. The driver shouted for passengers to call 9-1-1, reporting that the brakes had failed.

As passengers frantically tried to get a cellphone signal in the rural area, the bus careened downhill, rear-ended a Saturn sedan, swerved, flipped and slid on its passenger side. As the bus skidded down the roadway on its side, many passengers were ejected through the expansive side windows, only to be slid over by the bulk of the bus. A Ford pickup traveling in the oncoming lane around a curve then plowed into the bus, spinning it 180 degrees, righting it and tossing additional passengers out through the shattered windows. The bus traveled about a mile from the point where it struck the Saturn until it came to a stop.5

State Route 38 was littered with debris as the bus lay positioned sideways across both lanes with its front end crushed, its windows blown out and part of the roof peeled back like a tin can.

Responding to the Crash
Medic Engine 551 was the first fire unit on scene and gave the initial size-up. Battalion Chief (BC) Jim Topoleski from Redlands Fire Department, a nearby district, arrived as the first BC and assumed incident commander (IC) for the first 47 minutes of the call. When San Bernardino County Fire Dept. Battalion Chief Kathleen Opliger arrived on scene, there was a smooth transfer of command and she requested Topoleski remain at the command post to assist her. Overall, the call required the use of 44 pieces of apparatus and lasted 24 hours and 13 minutes. (See Table 1, p. 44.)

Initial arriving units found significant damage to the passenger side of the bus, plus debris, clothing, bodies, body parts and a large amount of blood surrounding the bus. Many survivors said they were thrown more than 20 feet.

There were 45 people aboard the bus, including the driver. Two other vehicles and their occupants were also involved in the crash. The incident killed eight people before EMS arrived and resulted in 37 injured patients, all of whom were transported. However, the initial scene report stated there were 20–30 patients and multiple people dead on arrival (DOA) because the horrific carnage, body parts and gruesomeness of the injuries they observed made it difficult for authorities to determine just how many had died.

Fast Calls & Hard Decisions
Staging: Because of the limited access, congestion and debris at the crash site, ICs established the staging area for ambulances at a nearby fire station. This was also the location where a well-lit, spacious, secure landing zone was established to handle multiple helicopters. American Medical Response (AMR) Operations Supervisor Nathan Groff and Operations Supervisor Gerry Gardner arrived on scene rapidly and reported to the IC for assignments. One of the AMR supervisors was assigned to and managed the designated staging area. This major decision, made early by scene commanders, prevented a log-jam of ambulances at the difficult-to-access scene.

Triage & Tarps: The first-arriving ALS engine crews established a medical branch and set up triage and treatment groups. Colored tarps were immediately deployed to identify patient collection areas by triage priority.

While triaging one critical male patient, the branch officer told the crew they had to make a hard decision and “either get him in an ambulance or declare him dead!” At the after-action review, one responder said he felt this was a perfect statement to be made at the moment. He explained that while he and others were trying to bag, package and treat the patient, the treatment group leader recognized the urgency and got them to make a rapid decision with the patient, who did survive.

As an added complication, the narrow road and bus position dictated that the triage area be positioned on one side of the bus and treatment tarps placed on the opposite side, out of sight from each other.

Different styles of triage tags were deployed by the various agencies on scene. Although the color codes for the triage categories were standardized, the documentation and transportation stubs were different, which led to confusion. After the incident—but before the after-action review occurred—officials from each agency agreed to standardize their tags and consider use of colored ribbons for initial triage in case of another MCI in the future. This is an example of positive pro-active, pre-critique action.

Light Sticks: Responders also noted that it was extremely difficult to see the triage tags and categories in the dark, making it tough to triage and move patients rapidly. In addition, many of the victims rolled over onto their tags, the wind blew tags under patients and several had their tags covered with a blanket or clothing. Until the area can be lit sufficiently, the use of chemical light sticks that correspond to each triage category may resolve this problem at major incidents that have to be managed in dark conditions.

Vests: Distinguishing group leaders in high-visibility vests was also noted in the after-action review as a way to combat nighttime conditions, stay organized despite separate triage and treatment locations, and identify leadership among responders, victims, walking wounded, and bystanders. The lack of vests worn early in the response caused confusion about who was in charge of each area. Although everyone on scene knew what needed to be accomplished, it would have been beneficial to have the key commanders identified on their arrival at scene to facilitate the process.

At the after-action review, fire service officials ordered extra vest sets to resolve this issue for future incidents. In addition, AMR, the county’s contracted ALS ambulance provider, also added scene vest kits and colored triage tarps to each supervisor vehicle. These are additional examples of positive after-action initiatives that will enhance future MCI operations.

Language Barrier & “Buddy Care”
Most of the bus occupants were from Mexico and didn’t speak English. Initially, there weren’t enough responding personnel to have a responder assigned to every patient. Firefighters removed the walking wounded from the bus and used several as interpreters and companions, telling them, “Stay with this person; stay with your friend. Talk to them and, if something changes, come find us.”

Search & Rescue Operations
Ladders were deployed rapidly to allow rescuers access to multiple areas of the mangled bus and as a means of rapid removal of patients and stretchers. Roof ladders—which have curved hooks on their top end—work well at bus incidents because the hooks will fit and hold over the bus window frames.

As rescue operations commenced, it was apparent that overall scene illumination was needed, so the first-in ladder company extended its aerial platform over the scene to provide light. This was a significant action that helped personnel find, assess, treat and move patients.

Fire crews fanned out in a coordinated search formation around the circumference of bus and debris areas to search for any victims who walked or were thrown from the rollover incident. They used their thermal imagers to detect any body heat emitted from unconscious or unresponsive victims hidden by the darkness of the brush and hilly terrain. If available, police helicopters equipped with forward looking infra-red (FLIR) systems can be used to detect heat from patients/bodies on the ground.

Supplies & MCI Trucks
Communications centers should automatically dispatch special MCI equipment caches and vehicles to confirmed MCIs with the responding EMS and fire units. Agencies with these assets and vehicles often forget to request them, or request them too late for them to be useful.

Although ambulances, ALS engines and AMR supervisors had a large amount of BLS and ALS supplies and equipment on scene with them, extra supplies—particularly lifting and moving devices, lighting, body bags and rehab supplies like food—would have been beneficial. The incident occurred on a Super Bowl Sunday before many of the responders had a chance to eat, and some crews were tied up on the assignment for nearly 10 hours without food or extra water. Scene managers agreed this could be resolved at future incidents by having extra supplies such as prepackaged meals and drinks sent to the scene much earlier.

An MCI trailer, equipped with scene vests and other MCI supplies, didn’t arrive at the scene because the vehicle assigned to tow it was already out on another incident and then diverted to the bus accident. It would have taken an extra 20 minutes to divert and pick up the trailer, so it never happened.

A large state-supplied medical support truck, equipped with enough BLS and ALS supplies to manage 50 patients, was also not sent to the scene. This vehicle and other MCI resource units have now been added to the automatic dispatch of resources to be sent immediately to scenes in the future.

Agencies should establish a system to have their MCI trucks and trailers (already hitched to a vehicle) taken to a scene by personnel who aren’t on the first wave of dispatched units. Suggestions include: available emergency agency personnel, members of a citizen emergency response team (CERT), a road crew supervisor, and a fire police officer or auxiliary police officer.

It is also beneficial to have a prearranged agreement and process in place to have school buses requested and sent to a scene to serve as temporary shelter or treatment areas for Priority 3 patients, and to transport Priority 3 and non-injured patients. This would free ambulances to transport higher-priority patients. 

The county protocol at the time of the bus crash allowed the use of one-piece backboard straps that were not pre-attached to the boards. Therefore, rescuers had plenty of backboards, but no straps pre-affixed to them. This can result in unnecessary delays, especially when the injured need to be rapidly extricated first over debris in a bus and then down ladders.

Communications & Helicopter Capabilities
Early notification to the hospitals that would be involved in the incident was helpful because of the time of day the crash happened—right at shift change. This allowed the EDs to hold staff, call in specialists and have “all hands on deck” to care for incoming critical patients.

The San Bernardino County Communications Center told all responding crew from within and outside the county to use “MED 7” for common radio communications with crews. However, several unit personnel on scene felt they didn’t have that frequency available to them because, in their radios, it was actually positioned as “MED 6.” It was the same frequency but, in the heat of the moment, no one realized.

It’s helpful if agencies position radio frequencies that have common and important functions with their neighboring communities. This can eliminate confusion when communicating on an incident. If this is not feasible, the communications center assigning frequencies must clearly report what the assigned frequency is: “This is San Bernardino’s MED 7 frequency.”

To ensure out-of-county ambulances all communicated on the assigned frequency, AMR supervisors at the fire station staging area handed out extra portable radios. This facilitated the dispatch and coordination of units at the staging area and crash site.
The ReddiNet system in operation throughout the San Bernardino region also worked extremely well at this incident, helping crews disperse patients to various facilities and not overwhelm resources. ReddiNet is a dedicated emergency medical communications network that facilitates information exchange among hospitals, EMS crews, dispatch centers, law enforcement, homeland security, public health officials and other health care agencies.

A physician from the only out-of-county ED/trauma center reported that his facility logged in to the ReddiNet system and submitted its availability to take three immediate patients and seven or eight delayed and minor patients. However, after that login, his facility received seven patients from the incident but didn’t receive advanced radio communication from the transporting units because they didn’t have EMS-to-hospital frequencies in the ambulances. This created staffing and patient assignment/distribution issues at that facility because of limited information and no advanced notice to get trauma teams, beds and resources ready.

Scene managers noted that, in the event common frequencies or direct communications aren’t available, crews should at least have their communications center notify the out-of-county receiving hospitals to give them advanced notification, patient triage priorities, primary injuries or conditions and ETA.

Mercy Air helicopter pilots involved in this incident were communicating with the news helicopters in the air the entire time. This helped the news helicopters back off or maintain a higher altitude throughout the incident if needed.
T

he flight crew was also monitoring three to five radio frequencies from different agencies, which gave them the ability to hear and synthesize a lot of scene communications and distinguish what units were talking with whom. This capability offers ground crews an extra safety net if there is an incident escalation or coordination question; the helicopter can serve as not only three sets of eyes in the sky, but also a remote communications center.

It’s important to note that during an MCI in a remote area with limited access and a limited number of ground ambulances, a medical helicopter—although normally thought of as an airborne ICU—can be used as an ambulance to transport patients to more distant hospitals to lessen the burden on the closest receiving hospitals. They can also transport extra supplies and personnel to incidents, recon for patients, access routes and serve as airborne radio repeaters.

The ICEMA Role
The Inland Counties Emergency Medical Agency (ICEMA), the regional EMS office that serves and provides support to the three counties involved in this incident, has a department operations center and had debated whether or not to open it. In hindsight, officials said they probably should have opened it because they could’ve had better face-to-face communications, ensured the disaster medical support unit was taken to the scene and helped coordinate additional resources for county-to-county coverage.

The closest out-of-county hospital didn’t receive any patients from this incident. The Department Operations Center could’ve detected this and assisted the transportation group with patient distribution to area hospitals.

Officials from the agencies involved in the bus accident reviewed the county’s MCI policy immediately after the incident to start correcting areas in need. And, although it’s not ICEMA’s role to go to a scene or send resources to an incident until the IC requests them, officials agreed that if the ICEMA was more involved during the incident, they might have been able to at least confirm‎ whether the DMSU was ordered, and suggest its dispatch to the IC.

As one of the rescuers responsible for the secondary triage of patients poignantly commented at the after-action review, “Just because they're covered in blood doesn't mean they're red-tagged.” There was a need for additional triage and tagging training. ICEMA and the involved EMS and fire agencies discussed how to standardized triage tags so all involved, including hospital staff, were familiar with the tags and tagging process and didn’t triage patients incorrectly at future incidents. To practice, the first Tuesday of every month has been deemed a triage tag day, which means all patients encountered on that Tuesday will be tagged with a triage tag regardless of the incident.

Conclusion
A total of 37 patients were transported from this complex, rural, bus-involved MCI—two of which died in the hospital, bringing the total number of fatalities to 10. Many of the rescuers were emotionally impacted by the horrific trauma they saw, but their agencies are working to reduce the stress left behind.

Despite the obstacles and complexities this incident presented, the ICs and crew were able to transport one patient from the scene every two minutes and 15 seconds. This measures the initial time of dispatch until the final patients were en route to assigned hospitals.

The bulk of the patients involved in this catastrophic bus accident were triaged, treated and transported to receiving hospitals within 87 minutes, an exceptional accomplishment for a major incident involving more than three dozen patients and eight fatalities in a dark, hard-to-access remote area.

They say practice makes perfect. This was the case in San Bernardino County four days after the bus accident, when former Los Angeles police officer Christopher Dorner, on the run for shooting and killing police officers and their families, was involved in a gun battle on the same road and hill as the bus crash. The attacks left four people dead, including three police officers, and left three police officers wounded.

The experience gained by responders involved in the nighttime bus accident proved valuable as they set up command, utilized mutual aid in an earlier and more coordinated manner, and established well-defined staging and treatment areas at that incident. jems

References
1. Bus Accidents in America. (n.d.) Los Angeles Personal Injury. Retrieved July 28, 2013, from www.ftpersonalinjurylawyers.com/blog/bus-accident-statistics-in-america.
2. Airplane accident rates per year. (n.d.) Aircraft Crashes Record Office. Retrieved on July 28, 2013, from www.baaaacro.com/Liste%20du%20nombre%20d%27accidents%20par%20annee.htm.
3. National Transportation Safety Board. Bus Crashworthiness Special Investigation Report (Publication PB99-917006 NTSB/SIR-99/04). Washington, DC: NTSB, 1999.
4. School Bus Accidents. Schwartz Zweben LLP. Retrieved July 28, 2013, from www.personalinjuryattorneynow.com/
practice-areas/school-bus-accidents.html.
5. Updated: 7 dead in tour bus crash in San Bernardino Co.; Driver says brakes failed (Photos, video, map). 89.3 KPCC. Retrieved July 28, 2013, from www.scpr.org/news/2013/02/04/35836/multiple-deaths-as-tour-bus-rolls-ove....

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