The first mass casualty incident I commanded was sloppy. I was an EMS Supervisor in a district that included a section of Interstate 95 known as “The Slab.”  It was 05:44 AM when units were dispatched for a bus-van collision on the northbound lanes. The first arriving engine company reported occupants trapped in the back of a 16 passenger van.

In that era, a battalion chief was not dispatched on motor vehicle accidents or mass patient events. This crash would be handled by the engine officer and EMS Supervisor. With four trapped and 1 dead in the passenger van, we called for an additional heavy rescue company, 5 additional ambulances, and a second EMS Supervisor.

The reality was cruel. The paramedic ambulance officer I tasked with getting a patient count said that he could not come up with an accurate number, estimated that 65 were involved.

The Operations Division Chief arrived and asked who the Transportation Officer was … oops … no one was assigned. The second EMS Supervisor, who would usually be assigned to Treatment and Transport, was assigned to the Extrication Sector at the van. The Chief said, “Mike, I am not hearing sirens.” The Chief was right, There was no Transportation Sector supervisor to get the ambulances on their way.

Get Enough Command-level Supervisors On The Incident

Assistant Chief Stephen Kries presented a seminar after Phoenix’s year-long recovery process from the Bret Tarver 2001 Southwest Supermarket LODD. Flying back from the January 2003 “Change in The Fire Service Symposium” in Phoenix I wrote up my notes and shared them.

The recovery process also looked at the utilization of company and command officers on the fireground. A company officer core competency is to command a fire company. A core chief officer competency is to command fire companies. It is a function of the fire department hierarchical structure, not of personality.

For example, a captain filling-in as a battalion chief does a better job as a West Sector officer than she would have if she was commanding Engine 2 AND in charge of West Sector. At the sector level of the incident management system, company officers are required to wear two hats. There are too many levels of tasks.

Phoenix suggests that it would be more effective to send more command officers to a fire event to function as sector and division commanders and allow the company officers to command their companies. It is a waste of talent and experience to allow command officers to stay in their fire stations while a low-frequency, high risk event like a structure fire is occurring in the city.

Keeping task-level fire crews intact under their supervisor as well as keeping ambulance transport crews intact – or assuring that every ambulance has a chauffeur – are important takeaways.

Get Trauma Patients to the Best Medical Destination

We are good at keeping those capable of surviving alive once we arrive. What happens once we leave the incident scene remains a work-in-progress. The issue is the distribution of trauma patients to the appropriate facility. An LAFD train derailment in 2005 and the 2013 Boston Marathon bombing provide two examples.

Representing six area trauma centers that cared for the injured, the Boston review credits the work of first responders and healthcare providers for the 100% survival rate for any patient that arrived at a trauma center. Field triage only tagged 50% of patients arriving at trauma centers and patients in extremis were unevenly distributed among the six area trauma centers, where one level 1 center received none of these patients.

A 2008 Los Angeles train derailment showed an improved distribution of trauma patients using lessons learned and new techniques after analysis of the 2005 incident.

Improving this metric will require more coordination with the emergency departments,  physicians providing medical oversite to the department as well as the 9-1-1 telecommuters.

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Kries, S: Rapid Intervention Isn’t Rapid. Fire Engineering. 156(12): 2003

Ward, M: Rapid Intervention Reality. thewatchdesk.com: 2003  [scroll down the post to see this article]

Heightman AJ, Mohlenbrok S, Eckstein M: “Disaster on the rails.” Journal of Emergency Medical Services. 30(4):46–67, 2005.

Boston Marathon bombings: An after-action review. J Trauma Acute Care Surg. 2014;77(3):501–503. 

Eckstein, M: “Trauma at the Tunnel.” Journal of Emergency Medical Services. 34(4): 2009

Featured image: 2005 treatment/transport area at Los Angeles train crash.

Elements, identifiers, and sequence of events may be altered in “war stories” to protect the innocent or work better as an example