Keep the Kids Together

     A beautiful May morning is unfolding as Attack One changes over crews at 0700 hours. House duties for the day look light---it's a great opportunity to have breakfast outside and enjoy a spectacular morning.

     Then the dispatch frequency crackles with a call for a motor vehicle accident. The location is familiar: a curve on the main north/south state route through the area where the two-lane road twists through some rolling hills. This site is a frequent accident location during night hours and in icy conditions, but neither applies this morning.

     As Attack One crests the hill from the north, a horrible scene is unfolding. Traffic is stopped, the road is full of children, and a school bus lies on its side in the field adjacent to the road. Adult bystanders quickly guide the crew to the rear of the bus, where a young lady is trapped. Approximately 15 children are lying or sitting in the roadway, removed from the bus by the bystanders.

     A quick scene survey finds a small amount of leaking fuel, but no electrical or fire exposures. Traffic is stopped on the road. Only one patient is trapped in the bus. The bus driver is able to communicate that 16 children of various ages were on the bus when it rolled off the road. With the driver, this means 17 victims. Bystanders have calmed the 15 children in the roadway, and the scene is eerily quiet.

     The Attack One crew members force their way into the back of the bus and find a 17-year-old student wrapped around the rear seat in an awkward position. She stirs as the crew arrives, her discomfort resulting in piercing cries for help. The quiet scene now becomes painful, as the trapped young lady has suffered a major back injury.

Scene Management
     As other resources arrive, the three Ts of multiple-casualty incident management are initiated: Triage is assigned to two paramedics from the engine crew-one in the bus and the other on the roadway. The Attack One crew assumes responsibility for the Transport Sector. When the next medic unit arrives, its crew is assigned the Treatment Sector. Triage identifies 17 victims, with one classified red (the entrapped victim, who has a serious spinal column/spinal cord injury), eight tagged yellow, and eight green. The crew working in the bus requests a helicopter for transport of the trapped girl. They estimate that the anticipated extrication time of about 20 minutes will match the arrival time of the helicopter.

     The Treatment Sector can only be organized where the children are already located: in the roadway. No other locations further from the scene can accommodate them. Unfortunately, this location is within hearing distance of the wreckage, and the badly injured girl being extricated is in severe pain. Her cries become upsetting to the other children, especially the younger ones. The bus had picked up children from kindergarten through high-school ages for a private academy. A number of the victims are siblings. Treatment Sector personnel have organized the siblings to stay together, so as parents arrive, they can match the children with the adults, and allow all of them to console each other as the extrication is carefully completed.

Focus on the Transportation Function
     Transport operations will require coordination unique to this incident.

     The two-lane road, now filled with victims, bystanders, rescue vehicles and law enforcement, has no flow-through for transport vehicles. Command has assigned responsibility for helicopter landing zone operations to the Transport Sector, and the only available safe landing area is just adjacent to the roadway on the south side. The Attack One crew divides their roles to have one member oversee destination and medic assignments and one document patient and transportation information. The critical patient will require transport in the helicopter to a trauma center. The other 16 victims will need spinal immobilization and transport to other local hospitals. Transport Sector personnel request nine transport vehicles from Command, allowing one vehicle for contingency in case the helicopter has any delay or difficulty. Command acknowledges the request and reports that mutual-aid medics will be arriving from agencies to the north and south of the scene.

     The Attack crew now huddles to organize the transport operation. The 16 victims are a mixture of ages. The Treatment Sector has initiated a useful process for matching older/younger children and siblings. Parents will be well-served if siblings are treated at the same hospital. The worst-injured girl has no siblings, so no other victims will go to the trauma center.

     Four hospitals are relatively equidistant from the scene, two to the north and two to the south. Incoming medic units are arriving in almost equal numbers from the north and south. It's impossible to cross over the accident scene, so the crew hypothesizes that medics from the north can transport to the northern EDs, and those from the south to the southern ones. If the children are from homes north and south of the scene, it might be possible to match the victims to areas that might be more convenient for their parents. It is also a priority to match older and younger children in the medic rigs to provide some extra measure of comfort while en route to the ED.

     The Attack crew asks the bus driver for assistance in locating where the children were picked up. By coincidence, about half are from each side of the accident scene, so the designating member assigns north-end children to north-end medics for removal to north-end hospitals, and likewise for the south. The other crew member then completes the transport worksheet that records victims' names, ages, triage classes, removing medics and hospitals.

     As mutual-aid medics arrive from either direction, immobilization equipment is removed for packaging, and victims are loaded for transport. Short scene times are desirable to allow the children to move quickly away from the stressful incident.

     Command has initiated communication with the school system to find a site to establish a phone center for parents. Police work to locate the parents of the most seriously injured girl; when they do, they ask them to proceed directly to the trauma center. The school system has an office and phone number available for the notification function. As the media arrive at the scene, reporters are briefed on the nature of the incident and given the contact phone number to broadcast for parents concerned that their children might be on the bus. When the Attack crew member assigned to do patient removal documentation completes the worksheet, a copy is passed to Command, and another hand-carried to school authorities.

Victim Assessments
     First Patient: A 17-year-old female who has severe back pain. She is obviously twisted around the seat in the bus. She had been unconscious for a few minutes, then awoke and was crying and repetitively asking questions. On exam, she has no respiratory compromise and no abdominal pain. She is unable to feel or move her legs.
     Patients 2-9: The bus driver, a female of 40, with lacerations and head and shoulder injuries; seven children, ages 6-17, with a variety of lacerations, contusions, and head and neck pain.
     Patients 10-17: Eight victims, ages 10-16, with a variety of contusions and neck pain.

Organizing Patient Assessment
     Many fire and EMS organizations use triage systems that result in patients being numbered in sequential fashion. The Emergency Assessment box represents the results of that triage process here. The crews triaged 17 patients, and categorized them by compromise of the ABCDE body systems.

Discussion
     The Attack One crew was aware that other multiple-casualty incidents in the region had been successfully managed by recognizing family needs and, where possible, transporting members of the same family to the same emergency department. Customer service training given to department personnel had also stressed that element of service.

     The scene became much more difficult to manage when the badly injured patient developed the characteristic cry of the head-injured teenager. Emergency workers can generally recognize the screams of a mid-teens patient who has suffered a moderate head injury and some period of loss of consciousness. Those patients typically will repeat questions, request their parents and vocalize loudly when they are in pain. It is difficult, if not impossible, to medicate those patients in the prehospital setting. Such victims require a patient rescuer to calm and quiet the scene.

     This unfortunate young lady also had a painful injury and required meticulous extrication from around the seat supports in the rear of the bus. Her cries of pain could not be controlled, and the other victims could not be moved far enough away to shield their ears, so a difficult scene ensued when other children started to cry as well. Siblings in communication with each other can be the most effective way of providing comfort, especially for the youngest children--that was done in this case. For young children without siblings present, older children and rescuers or bystanders filled the role of comforter. This stressful aspect of the incident could only be resolved when the critically injured patient was removed in the helicopter, and the other victims were placed in arriving medic units and removed to hospitals.

     The school system provided the communication center for parents needing information about which children were injured. This is a useful process for emergency personnel to utilize, as schools often have available phone systems and call takers, as well as parent and guardian names, and personnel who can definitively tell worried parents of children not involved in the emergency that their children are safe at the school.

     In this incident, victims required comfort and care at the scene, then a coordinated approach to transportation and communication to the parents. The critically injured victim needed transport to a trauma center. The other victims were removed to four other emergency departments that would provide excellent care for their lesser injuries and were convenient to parents. The additional step of transporting family members to the same ED, when possible and appropriate, allows the family to regroup and begin the recovery process. When possible, rescuers should apply this management principle in multiple-casualty incidents.