Victims by the Hundreds: EMS Response and Command

Aerial view of the Alfred P. Murrah Federal Building after bombing

BY GARY DAVIS

Fire Headquarters shook violently at 9:02 a.m. I looked up, and Special Operations Chief Mike Shannon was walking by my office. I asked, “What was that?” He replied, “I don`t know, but I think we`re gonna be needed.” I ran out into the parking lot where my car was parked and looked to the east from the office. It looked as though four or five blocks in the middle of downtown were one big pillar of smoke. Mike Weatherly, a light-duty firefighter working on some projects in my office, and I responded down NW 5th Street. We could see thick black smoke billowing out from the area of 5th and Harvey. I parked my car at NW 5th and Hudson, one block west of the Alfred P. Murrah Federal Building.

The Oklahoma City Bombing: Report and Analysis

As I reached the intersection of NW 5th and Harvey, I observed that a command post was being set up at NW 6th and Harvey. Debris was all over the streets, papers were coming down from the sky, and smoke was rolling out from the north side of 5th, filling the entire area. I could see fire on the north side for the entire block. Crews already were on the scene assisting the victims. Instead of entering the building, I proceeded to the command post so I could better coordinate the rescue effort with the medical transportation effort–many people were severely injured. Through the smoke, I could see the terrible destruction of the Murrah Building.

ESTABLISHING EMS COMMAND

I reported to District Chief Robert McMahon, the IC, and asked if he wanted me to set up EMS Command. He said yes. I established EMS Command and assumed the position of commander of this branch within the ICS structure, which included responsibility for all medical agencies and individuals in this integrated EMS response–OCFD, EMSA, mutual-aid ambulances, and civilian volunteers. The EMS branch of the OCFD ICS is comprised of four main groups: triage, treatment, transportation, and decontamination.

I met with the commander of the citywide transport company, EMSA, and discussed our plan/objectives. We needed to establish a primary triage, direct the scores of walking wounded to the triage area, bring the critical patients to that location, and start getting supplies to the site immediately. We established our objectives based on what little information we had at that time. These were clear-cut: treat and transport the injured as quickly as possible, procure the personnel and equipment resources to handle a large demand of patients, remove the dead to a temporary on-site morgue for proper handling by the coroner`s office, and establish the mechanisms for a possible long-term medical operation.

Almost immediately–before I even got to the command post–the radio communications were jammed. Personnel were coming to me and asking if they could assist me. I immediately delegated authority to them and assigned specific tasks, many of which involved acting as “runners” to obtain information. OCFD performs first responder/BLS citywide; 452 personnel are firefighter/EMTs.

Several ambulances from the four hospitals near the downtown area responded to the scene before dispatching even started. They were on standby or releasing patients when the blast occurred. At 9:03 a.m., the first wave of seven ambulances and two supervisor units responded to the scene from EMSA. Three or four mutual-aid ambulances also arrived very quickly. There were already at this time many patients in several pockets around the site.

At 9:11, we set up triage at NW 6th and Robinson, near the EMS command post, and directed the walking wounded there. We could not communicate with area hospitals at this time, so we dispatched police units to individual hospitals to obtain available patient capacity counts. Patient treatment and packaging already were underway. We set up an ambulance staging area at NW 10th and Robinson. Two “secondary” triage areas were established quickly in the incident, one at the plaza area near the south entrance of the Murrah Building and the other at NW 4th and Harvey. They were set up, primarily by civilian medical personnel, as a natural reaction to large numbers of victims migrating to those areas. We were aware of these areas at EMS Command and were able to provide a degree of coordination, particularly by directing several ambulances to these locations.

At about 9:15, I requested all BLS medical supplies and personal protection equipment–including rubber gloves; full biohazard protective suits, including booties, jumpsuit, hat, eye shields, goggles and face shields; and disinfectants–from our fire stations.

Near command, I set up personnel staging for OCFD, mutual-aid fire departments, and civilian medical personnel. I directed that civilian medical personnel be separated from fire department and EMSA personnel and assigned OCFD personnel to keep track of these people, grouping and assigning them by medical skills and specialties. I did the same with mutual-aid companies and OCFD personnel. Maintaining control of the manpower pool was important though in the earliest stages of this incident extremely difficult: Civilians tended to remain in staging for only about 10 minutes before their desire to help compelled them to the Murrah Building.

By 9:27, approximately 10 ambulances full of patients had been transported off the scene from the triage and treatment area at NW 6th and Robinson. Ambulances also had transported numerous patients from the secondary triage locations. Treatment and transport continued at a furious pace. At 10:05, the last patients were transported out of the primary triage area.

Hundreds of medical calls and reports came in during the first hours. We had numerous calls from adjacent occupancies. Many of these injured either made it on their own to the general location of the primary triage area or were already being taken by private vehicles to various hospitals.

Ambulances transported a total of 210 patients to area hospitals from the incident site. Out of the primary triage area, 85 patients were transported by ambulance and 25 patients by other means. Many victims were transported to health-care facilities by private vehicles; some even walked.

At 10:21, we moved the triage and treatment area one block south to NW 5th and Robinson. We moved the ambulance staging area three blocks south to NW 7th and Robinson.

At 10:30 the scene was evacuated in response to a bomb threat. The evacuation was emotionally and mentally draining on rescuers, some of whom came to me with very sad faces and stories of having to leave live victims in the building.

Once we returned to the Murrah Building, we had established greater accountability of personnel under EMS Command. We were able to assign tasks by organized groups. Fewer than 20 live victims were pulled from the building after the bomb scare, and for all but three, this was accomplished in short order. By 11:15, no more live victims were found, except for one–Brandi–who would be found much later.

At approximately 1 p.m., EMS Command was moved down to the building site and set up in an area adjacent to Rescue Command in an attached parking garage on the west side of the Murrah Building. We reassessed our supply and equipment needs, ordered necessary items from logistics, and organized the equipment accordingly. At this time, we also addressed our personnel and equipment decontamination procedures and established a system for disposing of biohazardous waste collected from the site.

With live victim discoveries coming at a slow pace, we deescalated all medical personnel not needed at the scene.

By 3 p.m., rescuers had extricated a 25-year-old female and a 21-year-old female. At this point, there were no known live victims in the Murrah Building.

At 3 p.m., we established a medical plan that provided for the potentiality of finding a pocket of victims or many injured rescuers. The transport company had deescalated its ambulances down to approximately eight on standby: Four were stationed at the site and the rest at an off-site field hospital set up by a D-MAT (this agency reported to the EMS Command post in the early afternoon). The on-scene ambulances were stationed at the east, south, and west sides of the Murrah Building–none were placed at the north side because of the lack of dependable egress from that area, busy with rescue operational components/equipment. Egress/ingress routes for these apparatus were specified. The Oklahoma City Police Department worked with us closely to ensure that all predetermined routes remained open.

Once the USAR teams came into place, late the first day, I remained in close contact with the medical team within each team. Each team had a doctor who worked 12-hour shifts; a doctor was always on duty. I made them aware of the medical plan, which was modified according to how the rescue effort was going. For example, the number of standby ambulances on the scene was adjusted according to the number of rescuers on the scene. If we had fewer rescuers, the number of ambulances was decreased. The minimum number of ambulances on the scene was two, the maximum four.

HEALTH AND SAFETY ISSUES

Part of my duties included on-site health and safety of rescuers–the “decon group” in our ICS. From the beginning of the incident, all rescue workers were directed to wear Latex gloves underneath their leather gloves. All personnel working in the building the first two days were disinfected head to toe and were directed to totally scrub their hands and wear HEPA (high efficiency particulate air) respirators in case the building presented some type of respiratory hazard. Two decon stations were established. They were staffed 24 hours a day with three to six personnel.

After our personnel deescalation on Day One, I put together a task force of four personnel to patrol the scene with biohazardous bags to start the process of collecting and removing biohazardous materials from the blast area. Once the bags were full, they were put in boxes and placed in the refrigerated trailer. These personnel also collected all the biohazardous materials at the two decon stations. As they made their rounds, they ensured that the stations had plenty of disinfectant solution in their systems. They also checked to see if the stations needed additional supplies or equipment.

Later into the incident, rescuers who had direct contact with the bodies or who put them in the body bags wore Tyvek® suits. The suits were disposed of and the workers were limitedly decontaminated. One of the innovations we made on the second day was using garden sprayers for disinfecting. They proved effective, especially for large areas; they also made it possible to decontaminate workers more quickly. A phenolic disinfectant solution diluted to a 200-to-1 ratio was used. We used a proportioner to premix the concentrate. These procedures were kept in place throughout the incident.

All facilities available for OCFD–decon, transport, medical care, and so on–were available to the FEMA USAR personnel working at the Murrah Building.

On Day Five, the Centers for Disease Control; the state health department; EMSA and OCFD Medical Director, Dr. Peter Maningas; and I toured the incident site. We established that all health safety standards–except those for sanitation of food and hand-washing facilities at the restrooms–were being met or exceeded. Decontamination of personnel became optional for workers not contaminated at the scene. Rescuers who had been contaminated were decontaminated and disinfected.

EMS Command was staffed 24 hours a day. I delegated one individual to brief rescuers in teams of 25 when they came from resources so they would be prepared when called into the building. All personnel were briefed on the biohazard and respiratory risks inside the building and were issued personal protection equipment. They were fit-tested for respirators and trained in their use and methods for detecting when the respirator was not functioning properly. The briefing took approximately 10 minutes.

Personnel from my staff served as liaisons to the medical examiner, remaining with the medical examiner at all times. The responsibilities included coordinating with rescuers when a victim was ready for retrieval and expediting the process of handing off a victim to the medical examiner`s office.

LESSONS LEARNED

One of the problems we faced before the bomb threat and evacuation was unaccountability for the many civilian medical personnel who had come to the scene in response to media requests and who were not following the ICS. Lack of perimeter control before the bomb scare made it possible for unassigned civilian medical personnel to leave staging and get through to the bomb site. Effective perimeter control was established after the evacuation, and a personnel accountability system was established.

Accountability is critical in mass-casualty incidents–not only for personnel safety but also for effectiveness in patient treatment. Escalate incidents slowly, if possible. The high blitz is very dangerous because span of control becomes very difficult to maintain. Personnel should be held in staging and used as necessary in accountable groups. Staged personnel should be grouped according to skill levels, and a member of each group should be delegated as the group supervisor.

When mass casualties are involved, call early for the needed medical equipment in anticipation of an extended incident.

Fire department managers should not get immersed in individual patient treatment during mass-casualty incidents. Looking back, it was hard for me to pass by the people who were bleeding, but it seemed the only thing to do, not knowing how many injured there were. Remember, however, your big-picture goals and tasks within the ICS–if you are treating patients, you`re not implementing command.

Set up lines of authority early. Tasks must be delegated. One person cannot take care of all tasks. Personnel were assigned to take full charge of areas within my command, such as triage, transportation, medical communications, and medical logistics.

All personnel must be briefed on operational hazards and risks. These should be posted in an area where they can be read by all. Prebriefings should be held for all personnel before they enter the immediate incident area.

A close working relationship with local law enforcement is needed to maintain egress/ingress ambulance routes. The Oklahoma City Police Department was invaluable to this end–without its efforts, we would have been in trouble. Keep streets clear for essential medical traffic.

The incident commander must be flexible and make changes in the operational plan as the incident dictates. This was evidenced in the strategic positioning of ambulances, moving the triage area forward, and so on.

The length of incidents of this type are a big challenge for fire department managers. Rotation of managers is an absolute necessity.

Operational meetings should be held as often as necessary. The entire incident command staff must know which direction the incident is taking. Meetings should start at the commander level and gravitate down to the operational commands.

Goals and objectives must be set and estimated time lines established. An action plan must be devised and followed. These goals and objectives should be posted for all personnel to see.

The potential for biohazards at this incident was great. During the course of the response, our concerns went from bloodborne and airborne diseases to various bacterial infections. Always begin your health and safety protocols at the highest appropriate level and deescalate as it is determined safe to do so (by competent medical authority). Establish personnel decon protocols for biohazardous risks as well as protocols for properly disposing of biohazardous waste. Failure to do so at an extended mass-casualty incident could result in major medical problems.

Assess all unknown personnel. Observe them as they perform their tasks and replace them if necessary. They must know what their specific tasks are and what is expected of them before they go on-site. There is no time to retrain personnel.

A Logistics liaison should be established to expedite resource procurement. The liaison should meet with the operations person, who would show the liaison exactly what a project entails. The liaison would order the supplies and equipment needed. Operations officers do not have the time to order each item and put the items together to create the project. If Logistics does not understand what is needed, Logistics should send a person over to Operations for a face-to-face meeting.

Medical Command should have personnel available when needed. There should be an action plan for pooling resources. The IC should know if and when additional resources will be needed.

Medical supplies should be ready to go and available for a mass-casualty incident.

Conserve equipment. Much equipment is used during an extended incident. As much equipment should be recycled (decontaminated) as possible. Do not let the rescuers carry equipment from the scene.

Monitor your decon site. During this incident, a volunteer donated a disinfectant to one of our decon sites. It was not properly marked, nor was it communicated to personnel exactly what the vessels contained. Instead of a diluted solution, disinfectant concentrate was used in the decon of three firefighters, who received first- and second-degree chemical burns. From that point on, I posted directives at all decon stations that only solution authorized by OCFD was to be used.

Training for specific tasks takes time. Personnel working on rotational shifts will help promote a better learning curve. Those going off shift should brief personnel on the next shift on the objectives that have been met and those that are to be accomplished on their shift.

Use a tape recorder to document the proceedings of the incident. In addition to providing documentation, this system will update your replacement on the next shift, saving the time that otherwise would be needed to exchange information. It will also be a useful learning tool after the incident.

Provide for an off-site local donations coordinator and storage area, apart from the incident logistics area. Logistics, however, should be kept up to date on the off-site inventory. Thousands of dollars worth of donated medical supplies were wasted in this incident.

Develop a disaster plan and practice it regularly. All agencies that will be involved in the incident–including hospitals and their emergency departments and all area emergency medical services, fire departments, and law enforcement agencies–should participate in the training.

Photo by Jim Argo/The Daily Oklahoman/Saba.

Rescuers move an injured patient from the Murrah Building to the triage area at 6th and Robinson. By 10 a.m., most live victims had been brought to triage areas and transported to area hospitals. (Photo by Penny Terpin James, IFPA.)

(Left) A view of the south side of the Murrah Building prior to the explosion. The integrity of the south stairwell remained after the blast, and numerous occupants fled this route to the plaza area shown. Civilian responders established a secondary triage area in this location (right). (Photos courtesy of Oklahoma City Fire Department.)

At about 1 p.m., EMS Command was moved closer to the site, occupying a small space in the Murrah Building`s west side garage. (Photo courtesy of Oklahoma City Fire Department.)

Decontamination of personnel and equipment fell under the jurisdiction of EMS Command. Shown here are two decon areas–at left, at NW 5th, across from the Water Resources Board Building and, at right, behind a church at NW 4th and Robinson–both within a short distance from operating personnel. (Photos courtesy of Oklahoma City Fire Department.)

AGNES “PINKY” WEBSTER worked on the south side of the YMCA Building, with a clear view of the Federal Building: The explosion shattered the windows, and the ceiling seemed to fall on me in slow motion. I heard the employees I supervised screaming. I moved from office to office checking to be sure everyone was out. I put my hand to my breast without looking down. I felt two pieces of glass protruding like knives out of stab wounds. I pulled them out and dropped them somewhere in the hall. I was the last person to leave the sixth floor.

RUSSELL BURKHALTER, captain, Oklahoma City Fire Department: Captain Fields and I went around to the south side of the building and crawled down into the rubble….There was a woman who was able to tell us that her name was Sheila. I don`t know how long we had been digging before Sheila said, “You are standing on my back!” She was not yet visible to us, so we could only determine the approximate location of her back by moving around in a circular pattern until her pain subsided. The hole we were creating was nearly four feet in diameter. Sheila told us that she was three months pregnant and feared for her child. That worried us, with the weight of all the debris and not knowing the extent of her injuries. Her hand became free and I held it for a moment to reassure her. We cleared her face and part of a shoulder and called for oxygen. Sheila began to lose consciousness. Outwardly, she had no real signs of visible injury, but she was covered with a heavy amount of dust and insulation fibers. We knew we had to hurry. We tried to lift her out of this big hole with our hands, but her left foot was trapped. I removed some of the trash and we pulled her free. She had a badly fractured left tibia and fibula. She was lifted out of this terrible place alive!

[Sheila Driver, a twenty-eight-year-old mother of one, with a child on the way, had been married only ten months. She was a customer in the credit union and had fallen three floors. She went into cardiac arrest in an ambulance and died.]

GARY DAVIS is a 23-year career firefighter with the Oklahoma City (OK) Fire Department. He advanced through the ranks to his current position of district chief, emergency medical services coordinator. He is a state-certified EMS instructor and a nationally registered emergency medical technician with defibrillator certification. In 1990, he served as chairman of the department`s defibrillator selection committee and developed its defibrillator program, implemented in 1991. He served as the EMS command chief during the bombing disaster, responsible for all medical and health-related activities.

Originally ran in Volume 148, Issue 10.