CHAPTER KEY WORDS
- Active shooter
- Mass casualty incident
It is Friday night, and the high school football game is between 2 long-standing rivals. The game 1 year ago ended on a controversial call, and the home team is seeking to avenge the loss. The student section is exceptionally boisterous, and the stadium is full. As the teams line up for the opening kickoff, a railing in front of the student section gives way, and 20 to 25 students fall approximately 8 feet onto the turf in a tangled mass of humanity.
The ambulance crew on the scene consists of 2 paramedics and 1 emergency medical technician (EMT) in the opposite corner of the field. The crew immediately grabs the equipment and runs toward the incident. The senior medic takes command while the second medic and the EMT start to triage the students for injuries. The commander contacts county dispatch, reports the incident, and requests a second service medic unit plus the on-duty supervisor. Dispatch is also informed that after determining the total number of injuries, a county mass casualty incident (MCI) may be declared. This declaration would bring a third ambulance from the home service, plus 5 additional ambulances from mutual aid companies.
Several off-duty ambulance personnel and nurses come from the stands to assist the crew, and the school principal is also on the scene to gather the names of all the students who fell for risk-management purposes. A total of 22 students fell, and although there were many bumps and bruises, only 2 need transport to a hospital: 1 for an arm fracture, and the other for a laceration requiring sutures. The staff on the scene manages all minor injuries while the second ambulance transports both students to the hospital. Parents are contacted for all students, although many are already there. After all are treated and released to a parent or responsible adult, the members of the crew thank all who helped and return to their position for the game. The referee had stopped the kickoff when he observed the incident and had sent both teams to the sidelines until the issue was resolved. The total delay was approximately 20 minutes, and neither coach complained.
The school emergency action plan (EAP) for this venue did not anticipate the possibility of a railing collapse, but the response was well-managed because of the strength of the local emergency medical services (EMS) agency. Had additional off-duty personnel and nurses not responded from the stands, the athletic trainers from both teams would have been pressed into service and assisted the on-site EMS crew. The game had been delayed, and athletic trainers can handle the soft tissue injuries seen in this incident. Also, the referee had stopped the game and sent the teams to the sidelines. The incident commander had not recognized this until the referee contacted him and indicated that EMS personnel were to take their time and handle the incident thoroughly. The game would not start until the event was resolved, and the referee did not care how long that took. The EAP was updated afterwards to allow for an MCI.
Chapter 1 of this book examined the EAP and how it is developed specific to the venue and in conjunction with local EMS personnel. The chapter takes a strategic approach and considers how to prepare for handling serious injuries and events that will require external resources. Chapter 2 examines the issue from a tactical approach and deals with handling events with multiple patients who will require multiple external resources for mitigation.
An MCI is any event that produces more patients than local EMS can handle. In some resource-strapped communities, this could be a motor vehicle crash with 2 patients, whereas in large urban areas, EMS can handle 50 patients without calling for mutual aid assistance. Although MCIs can be either natural or man-made, the following basic tenets of MCI management apply:
- determine the nature of the incident and its impact on injury profile,
- ascertain the number of injured,
- provide initial treatment,
- notify hospitals of the event,
- package and transport the injured,
- clean up, and
Natural MCIs (Figure 2-1) include hurricanes, tornadoes, floods, and fires, whereas man-made MCIs deal with violence from shootings, stabbings, and bombings. Any of these events can impact athletic venues, and the athletic trainer may be the first health care professional on the scene. Starting the triage process and determining the total number of patients will provide invaluable assistance to responding public safety agencies. If the athletic trainer is to fulfill this role, it must be in conjunction with local agencies and described in the EAP. The athletic trainer must be readily identified as a first responder and have the appropriate equipment for initial management of severe bleeding. Damage from natural MCIs is so widespread that schools usually are closed, and athletic events are suspended. This chapter will mostly examine response to man-made MCIs.
Triage means to sort and is a technique used to determine the number and severity of injuries. The art of triage has been developed by military medicine in battlefield conditions and has significantly reduced battlefield mortalities. Triage is a dynamic process and should be repeated frequently throughout the event, as patient conditions may deteriorate. Many systems are used throughout the country, and the athletic trainer should use the same system used by local EMS. Any triage system divides patients into 4 categories: minor (green), delayed (yellow), immediate (red), and expectant (black).
Minor patients are considered walking wounded and can be transported en masse after all other patients are handled. Delayed patients have injuries that require significant medical treatment, but a slight delay will not cause their condition to worsen. Immediate patients have life- or limb-threatening injuries that require rapid transport. Expectant patients are those with injuries either incompatible with life or so severe that death is imminent and almost certain. Expending limited resources treating these patients may result in delaying treatment and transport of immediate patients and result in the death of many instead of just one. This is a difficult decision and requires unique characteristics in the triage officer.
A commonly used system is the Simple Triage and Rapid Transport (START), which was developed in California by the Newport Beach Fire Department in conjunction with Hoag Hospital (Figure 2-2). Although no system is perfect, START has the advantage of simplicity and concentrates on respiratory status, perfusion, and level of consciousness. Triage tags are attached to each patient, indicating status and providing treatment and transport information to responders. Again, there is no perfect triage tag, and unless EMS either uses or trains with the tags on a continuous basis, their utility is suspect and can lead to confusion and delay.