EMS Treatment and Transport
BY MARK ROBISON
Ninety seconds after the explosion, EMSA had seven ambulances and two supervisor units staffed with 24 medical personnel (paramedics and EMTs) on the way to the site. Treatment of victims began within three minutes. The first seven ambulances were designated strictly as treatment units; this ensured that there would be enough personnel to begin immediate triage and treatment. (In a typical response, the operational plan would be one ambulance for treatment, one ambulance for transport.) No one had to wait for treatment.
Within 15 minutes, a second wave of 34 EMSA ambulances (for transport only) arrived to begin transport, beginning with the critically injured. Between 9:02 and 10 a.m., 56 ambulances were operating on the scene, performing triage and providing treatment or transporting. This number included mutual-aid units–within 15 minutes, 22 mutual-aid ambulance services from throughout Oklahoma and even from Texas were en route to the incident site. Some had started out even before EMSA had requested them. Some communities sent their only ambulance to assist.
One hundred forty-six EMSA employees responded to the bombing site. Our first-in units responded with six personnel to well above the normal staffing level of one paramedic and one EMT. Some of these additional crew members quickly “broke ranks,” gravitated to the Alfred P. Murrah Federal Building, and joined in the search and rescue operations–an undesirable consequence driven by the magnitude of the incident. Fortunately, these actions did not hamper our ability to fulfill our primary mission.
An integrated command structure was established within six minutes. EMSA worked within the framework of OCFD EMS Command as an operational division. EMSA Medical Command established five sections: Triage, Treatment, Transportation, Staging, and Communications. A medical command liaison was assigned to the interagency command post, facilitating integration of state, federal, and other local agencies into the medical command system.
The triage and treatment area was at 6th and Robinson. Our initial strategy was to send all patients to this location. That could not be done: Secondary triage areas already were being set up at 4th and Harvey and near the south entrance of the Murrah Building, in response to the large number of victims and the migration patterns of the walking wounded.
Early in the incident, the emergency operations center issued the teletyped appeal: “All medical personnel to the scene.” [Editor`s note: There is some disagreement as to whether this request was made through emergency response channels or via television broadcast; it may actually have been made through both channels.] Many volunteer medical personnel with varied specialties came to the scene. The response made achieving control and accountability a challenge, but it was also beneficial. The volunteers were incorporated into the medical sector and did what they were asked to do. Those without assignments were staged across the street from the medical command post in a parking lot and organized according to medical discipline.
By 10 a.m., less than one hour into the incident, the medical section had transported 210 patients to area hospitals. (Hundreds of victims arrived at hospitals and doctors` offices by other means. A hospital was within walking distance of the Murrah Building. Many patients were driven to health-care facilities by private citizens and friends. One man made several trips from the scene to hospitals, transporting victims in his Corvette.)
D-MAT (Disaster Management and Assistance Team), a statewide organization of medical doctors, was notified at 9:40 a.m. They arrived at 1400 hours and established a field hospital in a vacant warehouse. They prepared for major surgery, but, as the incident evolved, it became apparent this service would not be needed.
At 10 a.m., it was reported that 200 or 300 more people were trapped in the Murrah Building. OCFD believed there would be a second wave of patients “very quickly,” and EMSA maintained its response level. Shortly after the majority of patients were transported from primary triage, the EMS command post and triage area were moved up to 5th and Robinson. At 10:30, in response to the first bomb scare, we moved command/triage to 5th and Broadway. After the second bomb threat, we relocated to 5th and Oklahoma.
By about 1 p.m., after rescue commanders had an opportunity to fully assess the situation in the Murrah Building, it was realized that we were facing a long-term operation and extricating the remaining occupants in all likelihood would be a slow, painful process. At 1 p.m., the mutual-aid ambulances were released. Primary triage was dissolved at 1:15 p.m.; four ambulances were staged at the Murrah Building and five at the field hospital. This remained our response level throughout Day One.
The response to the bombing did not affect normal 911 operations. Between 9 a.m. and noon on April 19, only seven requests for services were received (and the people were very apologetic)–normally, there would have been about 30 calls. Four ambulances were dedicated to serving the rest of the community; normally, there would be five. Regular service to unaffected communities was maintained.
INJURIES
Because of an abundance of transport vehicles and emergency medical personnel poised for rapid response at the outset of the incident and the nature of the injuries, very little treatment above the BLS level was provided at the triage/treatment areas. During the course of the incident, we treated 49 red (go right now) patients, 25 yellow (can wait up to an hour) patients, and 141 green (not serious) patients. Triage/treatment never had to deal with more than about five critical patients at one time. Basically, it was a START (simple triage and rapid transport) response.
Many of the injuries involved lacerations. Although the majority were small lacerations to the face, there were some major ones as well, including the laceration of one victim`s carotid artery, necessitating the transfusion of six pints of blood. Many injuries required only simple treatment–apply pressure, bandage, and go–but there were numerous blunt, crushing injuries as well, such as a pneumothorax, from a file cabinet that was blown into a victim`s chest. About eight people were intubated on the scene; very few IVs were administered.
Medical personnel were alert to the potential for crush-syndrome injuries but, in general, this would not become a major factor in this medical response because (1) firefighters/rescuers pulled most live trapped victims out of the debris within the first hour of the operation, and these victims were loaded quickly into ambulances where they would receive IVs as required; and (2) for the most part, in the few cases of extended entrapment, the degree of entrapment precluded immediate intubation. Of course, these victims were intubated at the first opportunity.
Only one EMS worker was injured. He received a three-inch laceration in a rescue operation; it required stitches.
COMMUNICATIONS
Initially, the bombing disabled seven-digit phone lines and cell phones. Three avenues of communication–the common statewide hospital frequency, 911, and portable radios–still were available to Medical Command and field personnel. Portable radios were installed for communications. Within 10 minutes, the EMS communications center designated an EMS dispatch coordinator; a transport dispatch coordinator (to maintain contact with hospitals to determine the number of available beds and so on); and a disaster dispatch coordinator. The system worked well. There was very little nonessential portable radio traffic on sector communications. Within 30 minutes, Southwestern Bell had put up its additional antenna and provided essential personnel with cell phones with special computer programs that allowed these phones to get through the otherwise jammed telephone system.
PRIMARY LESSONS LEARNED
Ensure that command personnel receive interagency disaster management training. The EMI course in Emmitsburg, Maryland, attended by city agency officers was invaluable.
Set a minimum number of disaster response training hours (classroom and field training) for all personnel. EMSA has devoted a lot of time to disaster management, and this showed in the response to the bombing. In a crisis, you fall back on your training.
Make sure command staff personnel know what state and federal resources are available in a disaster and how to get them quickly and efficiently.
Develop standards for mass-casualty response. EMSA has developed its own standard, but each organization is different. Be sure to address the following:
— resources needed (think ahead–for example, we had 50 backboards in reserve);
— training for field personnel–you cannot perform effectively at high-stress incidents without an organizational commitment to ongoing training for front-line personnel; and
— large-scale disaster training, including agency tabletop drills and communitywide interagency exercises.
Develop a CISD program that integrates state and federal responders. Most people who responded to the bombing needed it.
Establish a program whereby various agencies on the scene can communicate on a common radio frequency. When necessary, use runners.
Nonfirefighter EMS personnel must understand the importance of performing the job they are trained to do and reduce the likelihood of injury while performing a job for which they are not trained. Restraint and focus are essential in a disaster of this scope.
Designate/rotate the least possible number of personnel to serve as liaisons to the command post for continuity. Ensure that these personnel understand the role of the liaison.
Establish working relationships with mutual-aid EMS agencies.
Train on START methodology.
Develop a mobile (literally) command and triage/treatment organization; response to terrorist incidents may require it.
Establish the medical command post and triage area outside the collapse zone.
Prepare your organization for an influx of volunteer EMS personnel at a mass-casualty incident. Establish protocols for ensuring span of control and accountability.
Ensure that contingency communications protocols are in place. n
DR. CARL SPENGLER, emergency-room physician, University Hospital: Some people brought out a little girl who was still breathing. Nurses were preparing IVs. The crowd was screaming for the doctors to work on the child. I finally yelled for everybody to shut up. As I assessed the little girl, it was obvious she had catastrophic head and chest injuries…there was nothing left to save. I told a paramedic to get a blanket, wrap the child, and do nothing. People screamed, “You bastard.” I stepped back and said, “Let her die.” Another physician also stood up and said, “She`s dead already.” As I walked off, several of the people continued to curse me. That`s the nature of triage: In an emergency situation, you concentrate on the ones you can save and sacrifice the ones who are beyond help. It can be very tough, but it saves lives.
From the book In Their Name, edited by Clive Irving, Project Recovery OKC. Copyright © 1995. Reprinted with the permission of Random House, Inc.
EMSA
EMSA is a city-appointed trust that contracts out ambulance services. It has 150 employees. Staffing consists of one paramedic and one EMT per ambulance. Normally, EMSA receives approximately 150 service requests for per day. Normal response is five ambulances available per shift, with several apparatus on standby/available at all times.
HEATHER TAYLOR, college student majoring in basic emergency medical technology, who arrived early at the scene with Dr. Carl Spengler: While I was putting them [the gloves] on, I looked up and saw a man walking on what was was left of the third floor. I told Dr. Spengler that we needed to get him down because he was missing his right arm….As the firemen were bringing out the wounded, I tagged the first child dead. I heard someone tell me there was once a day care on the second floor. After that, I found myself making a temporary morgue–some call it “the church.” A priest had arrived, and he followed right behind me, praying for the lost ones. The firemen were bringing out so many dead. As soon as I would take one child, another child was laid next to it. I remember one man, a bystander who was helping me, said, “Why all the children, why?” I just watched him cry.
From the book In Their Name, edited by Clive Irving, Project Recovery OKC. Copyright © 1995. Reprinted with the permission of Random House, Inc.
MARK ROBISON is quality improvement manager for American Medical Response/ EMSA. He has been in the emergency medical services field for 10 years and has been a paramedic for nine years. He was a paramedic on the second-in ambulance unit at the Oklahoma City Bombing and performed an integral role in establishing primary triage and the field hospital for the incident.
