A “C.A.R.E.E.R.” CHALLANGE
BY WILLIAM SHOULDIS
The radio message was urgent: “56th Street Command from Medical Group…the patient`s condition is deteriorating. A field amputation is necessary.” After a short pause: ” Medical Group from 56th Street Command…prepare to start the surgical procedure once authorized by the on-duty doctor at base hospital.”
It is often stated that decisions made in the seconds and minutes following a major incident can make a profound difference in the ultimate outcome. As a chief officer for more than eight years, I understand that quick decisions can have a long-term impact on the lives of the emergency responders and citizens of a community. Few study materials can adequately prepare a fire officer for making the kind of decision that members of the Philadelphia (PA) Fire Department had to make beneath the CSX railroad bridge at 56th Street.
It had been a hot summer along the entire East Coast. A heat wave extended over the Northeast for 18 straight days. The high humidity made life sticky. The weather on Friday, August 25, 1995, was a slight improvement; but by midmorning, a hot, extended, and sticky situation arose that challenged an experienced squad of firefighters and paramedics.
INCIDENT SCENE: INITIAL ACTION
At 1037 hours, 911 calls reporting a motor vehicle crash into the support column of a railroad bridge flooded the dispatch center. Units were dispatched immediately, and the first members to arrive on scene found a large, city-operated Crane Carrier trash truck that had tried to drive under a railroad bridge. Unfortunately, the roof of the 11-foot, six-inch trash truck was too high for the posted nine-foot, 10-inch underpass clearance. The impact of the crash tilted the trash truck on its right side. The truck went out of control and smashed into a support pillar. It was partially wedged against the underside of the bridge, precariously balanced on only two right rear wheels and less than halfway on its side.
The first-due company set up an operational system by calling a heavy rescue company for help and asking for additional medical assistance.
Command was established as the engine company`s crew stretched a 134-inch water line. The crew used the hose stream to divert the diesel fuel leaking from a 60-gallon saddlebag tank from a sew er intake. In addition, the crew redirected traffic on the busy roadway and halted traffic on the CSX railroad.
STABILIZING THE CRASH VEHICLE
The ladder crew took steps to prevent the truck from rolling or sliding farther on the sloped terrain. Although there were numerous natural anchor points, their rope was not strong enough to tie off the compactor trash truck. Instead, the crew placed wedges behind the rear wheel and built a two-foot crib bed of oak blocks under the left front tire, which was off the pavement. The blocks were neatly stacked in perpendicular layers to create a stable box with a single contact point. A second, much higher platform was constructed and strategically placed at an appropriate support point under the truck`s frame rail. This field-assembled crib provided pivotal support and helped distribute the weight of the 44,000-pound vehicle.
As time passed, air began leaking from the passenger-side tires. The vehicle settled, and the wedges around these load-bearing tires became firmly secured. Additional shims were needed to fill the air spaces and gaps that appeared above the cribbing. Later, a “come-along” cable was wrapped around the truck, affixed to a solid anchor point to prevent horizonal movement. Also, three nine-foot-long railroad tie sections were cut and placed against the passenger side of the truck to prevent a sudden vertical shift.
STABILIZING AND EXTRICATING VICTIMS
The paramedics started medical care for the driver, who was helped from behind the steering wheel. A second paramedic entered the crushed cab and did a primary scan and immobilized the two trapped passengers. The medic immediately realized that both victims were perilously pinned and required a complex extrication because of the massive entanglement. The medical group gathered the necessary supplies to provide oxygen and intravenous fluid replacement.
Arriving as the district chief, and after an initial 360-degree survey of the scene, I noted that a workable plan had been implemented in the circular work zones. After assuming command, I assigned a seasoned department member as the incident scene safety officer, defined operating corridors, and used a tactical worksheet to keep track of operating forces.
Since the vehicle was stabilized, patient care was in progress, proper pneumatic equipment was staged, and access corridors were controlled, the focus shifted to a team-based approach for the passengers` disentanglement. The medical group was working inside the crushed cab and under the front of the truck. The extrication group approached from the side doors with hand-held and hydraulic-powered tools. Because of the heavy-gauge steel used in the truck`s bumper assembly and frame, progress was surprisingly slow. Even when using a powerful spreader to compress the rocker panel, there was little room to insert a small ram. Dashboard displacement was impossible because the front of the cab was embedded in the the railroad bridge`s steel pillar. The extrication team used two sets of cutters to remove the truck`s A-post and access valuable space. Using specialized tools to make small cuts, the crew relocated pieces of mangled metal. After a protracted time, enough debris was dislodged to expose the lower leg of one of the passengers. Regrettably, the limb was impaled on the front fire wall of the vehicle.
ON-SITE AMPUTATION
After numerous attempts to remove the jagged metal penetrating the leg like a pair of Chinese handcuffs and since the time was approaching the “Golden Hour,” a request was made to Philadelphia`s Base Hospital for proper authorization to perform a delicate field amputation. When permission was granted, the grim assignment was started. The initial step was to apply a tourniquet just above the knee. Then a careful surgical cut was made below the knee. Once the flesh, muscle, and crushed bone were removed, the critically injured passenger was pried from an access panel on the side of the twisted wreckage and placed on a spine board with a MAST (military antishock trousers) suit.
Both patients and the shattered leg were quickly transported to a hospital trauma center, which had been placed on a full medical alert. Unfortunately, an orthopedic surgeon could not reattach the severed limb.
During the incident`s restoration and recovery phase, several responding members noted that despite the many hours of preincident planning, days of extrication training, and years of experience, we encountered many unanticipated variables. Important considerations and emergency contacts simply slipped through the cracks. The real world of vehicle rescue is much more than casual “chock and cut.” Often, it is a combination of innovation, interpretation, and gut-feeling judgment. Today, I still believe what is needed during emergency response is an organized way of taking the classroom and drill-field information and using it to plan, evaluate, and take meaningful action.
MAKING C.A.R.E.E.R. MOVES
After reviewing many articles on extrication, speaking with certified Pennsylvania state vehicle rescue instructors, and combining the lessons learned at the 56th Street incident, I found an approach that may help public safety providers at a “C.A.R.E.E.R.”-challenging crash site.
C–Coordination. Coordinate efforts to produce the most effective results. Standard operating procedures, basic vehicle rescue tools, and training levels may differ throughout the fire service, but the incident priority of life safety does not. Cutting or prying tasks cannot begin until firefighter accountability, vehicle stabilization, and patient immobilization have been completed.
A–Appointments. A safety officer should be assigned to focus on the single issue of personnel protection. Firefighters, paramedics, and members of outside agencies can get caught up in the tension-filled operation and become blind to the numerous surface, overhead, and vibration hazards.
R–Responsibilities. Duties must be clearly defined. Roles will be interdependent. Responders should never reach or work under an unstable load until it is shored or cribbed. The rescue plan must be well-communicated to all personnel so they can work toward a common goal without wasting time. Anticipate reasonable delays when dealing with the rare event. Regional planning should include provisions for requesting heavy equipment, tow trucks, special suppression agents, along with a notification list for other community-operated services and major railroads.
E–Extended operations. Since such incidents can be physically and mentally taxing to working crews, expect to rotate crews. Equipment and medical supplies should be brought to a staging site for immediate use.
E–Egos and Emotions. Expressed criticism is warranted at the emergency scene only when safe standards are ignored. Employee assistance programs and critical incident stress debriefing can confront humanitarian issues in a positive and proactive manner.
R–Reflection. Reviewing routine and nonroutine incidents is necessary for growth and development within any profession. Regulations that mandate a postincident analysis will improve the readiness of an organization by involving workers in the review of “real-life” experiences. According to the National Highway Safety Administration, more than two million people per year are injured on America`s highways. Yet, extrication training may receive little backing because it is not federally mandated as is hazardous materials or confined space entry training. State support varies greatly, often leaving it up to local lawmakers to allocate adequate funding. Even the National Fire Protection Association (NFPA), which governs most industry standards, doesn`t have a single document or technical committee in this specific area. Consequently, many frontline responders are lacking in up-to-date policies, knowledge of widely tested procedures, and state-of-the-art equipment.
HAVE A PLAN
It is human nature to want to take immediate action and offer assistance at an accident scene. Naturally, there is a great sense of urgency to do something to free the trapped victims. However, it is essential for the incident commander to channel this energy into a common effort.
The safety of many individuals–the public as well as the emergency responders–depends on our technical skills and ability to communicate internally with other emergency responders and externally with organizations that can supply needed resources. Regardless of the scenario, the emphasis constantly must be on following proper procedures to manage the scene safely and obtaining accurate information to be tactically correct in our decision-making process. Having a system will help. Without a doubt, a systems approach did save two sanitation department workers` lives beneath the CSX bridge in Philadelphia. Daily training and personal commitment will ensure that your system will be ready for your career challenge. n
WILLIAM SHOULDIS is a battalion chief and a 23-year veteran of the Philadephia (PA) Fire Department. A certified fire protection specialist, he is an adjunct instructor at the National Fire Academy in both resident and field programs, teaching courses in fireground operations, health and safety, and fire prevention. An editorial advisory board member of Fire Engineering, Shouldis has a bachelor`s degree in fire service administration and a master`s degree in public safety.
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Photo by Tony Marra.
