At first, you aren't sure if you heard the dispatch correctly. A commercial airplane crash? In the fields just outside your small town? Those things happen in New York City, Los Angeles, Miami not your little corner of the world. But as your rig drives out of town on the freeway, you can see the smoke rising over near the water tower. There is a huge gouge across the wheatfield. A large silver airplane tail is visible through the cottonwood trees.
You and your basic life support (BLS) firefighters are first on the scene. It would be real easy to get overwhelmed. But that's not part of your job description.
An incident management system (IMS) is a priority. Give your on-scene report and request second and third alarms in succession. Establish level two staging for the responding second- and third-alarm units at Exit 101 from the freeway and make yourself "Freeway Command." It is important to divide this emergency into fire and EMS components (segments under IMS). Your first responsibility at this point is to save lives.
You and your firefighters handjack a line to the fuselage where black smoke is pouring out. Using your compressed-air foam, you achieve conversion of the fire you see and have fire control.
You need to get a body count, dead and/or alive, and do the fastest assessment possible on that many victims. The "ooh-aah" crowd of citizens is gathering. You know another decision must be made. Victims are going to be brought out in rapid succession. You need to set up a treatment area. These citizens who have gathered around can be put to good use. You look at Scott, the firefighter still holding the nozzle.
"You stay here. Set up the treatment area under that cottonwood over there. Use these people once we get the patients out to you."
He nods and you head inside with two of your firefighters. You station them at the entrance and then head down the aisle. You have two goals. One, you are counting bodies, dead or alive. Two, you are doing a fast, very fast, assessment of injuries.
There is a very grim reality you must deal with at this time. Some of these people are dead. There is nothing you can do for them. Reality demands you hurry on to the live ones to try and save them. Still, another reality looms large. Some of these people are dying. There is a man with horrible burns over much of his body. He's moaning. You've seen burn victims. You know he will eventually die. He can't be saved. But, hopefully, there are others which can be saved from this tomb of death.
You've reached the back of the fuselage. There looked to be about 80-plus souls on this plane and about 10 are obviously still clinging to some stage of life. The key word is "obviously." What you can see with your eyes. There's no real time to check pulses or get in-depth assessments right now. You have to get the survivors out of this hot, smoke-filled plane. There could be an explosion. Fire might flare again. You radio your report. Those at the alarm room know what else they need to dispatch. Those other resources coming know what to expect.
"Engine 2 on the scene," you hear the report on the radio.
"Engine 2, set up Treatment Sector under that big cottonwood tree," you order.
"Engine 2 copy. We will set up Treatment Sector under the big cottonwood tree."
Triage is the order for this type of incident. The dead and the dying go to the bottom of the list. Those who have life-threatening injuries but still have a chance of survival go to the top of the list: Priority 1.
Now you hurry to get to those patients who have a chance to survive. None of them are up and moving around. All are still strapped in their seats. Here is what you see:
- A man with a gash on his forehead, altered level of consciousness.
- A teenage girl moaning with rattled breathing, probably flail chest, alert.
- A woman who is crying and reaching for her legs, one of them obviously broken, alert.
- An elderly man with no obvious injuries but he's covered with soot and moaning, unconscious, unresponsive.
- A girl has curled up into a fetal position and is rocking in her seat, alert, anxious.
- A woman has her arms wrapped around herself and her head is going back and forth, decreased level of consciousness.
- A young man is looking at you blankly. Blood is coming out of his nose and he's making strange oral noises, decreased consciousness.
- A woman is squirming in her seat with altered levels of consciousness.
In this situation, you need fast action to get survivors with the best chances for survival out of a bad environment. There is no time to really start working on them now. Just get them out to the Treatment Sector where they will be worked on.
Priority 1 patients will be those with respiratory problems, cardiac problems, severe blood loss, unconscious, severe shock, open chest or abdominal injuries, burns involving the respiratory tract, severe medical problems induced by the incident such as a heart attack, major fractures such as the pelvis or flail chest.
Another serious aspect to take into consideration in this situation is time. You come upon a patient who has an injury or problem which will involve time and/or will be labor intensive such as CPR. You have other patients awaiting urgent care. At this point, you cannot afford to spend too much time on one specific patient. There will be times when you must write off a patient with time- and labor-consuming injuries in order to get to the patients who can more easily be saved. The cruel reality is that it's better to save two lives than one. Time versus benefits. Cervical spine precautions should be taken. Apply C-spine collars or maintain the neck somehow. But, again, you can't spend a lot of time with this.
You know what you've seen. Now you start having your firefighters haul them out in an organized triage method. The man with the gash on his forehead and altered levels of consciousness must wait. The teen-age girl moaning with rattled breathing probably has a flail cheat injury. She needs to go. The woman crying with the broken legs can wait if the fire potential is stable enough. Broken legs aren't life-threatening. The elderly man with no obvious injuries will come later. The girl curled into the fetal position and rocking in her seat must go. She possibly has internal injuries which could lead to shock. The woman with her arms wrapped around herself should go. She too probably has internal injuries. The man with blood coming out of his nose should go. His airway could be threatened. The woman squirming in her seat should wait.
"Ladder 1 on the scene."
That's Captain Smith and his crew. You have an option of transferring command to him. He's outside while you're busy. It's your call. You decide to maintain command.
"Ambulance 1 on the scene."
You've got a plan and it's now falling into place.
"Ladder 1, set up Transportation Sector near Treatment Sector," you order. "Ambulance 1, report to Transportation Sector."
"Ladder 1 copy. Set up Transportation Sector."
Your firefighters have taken out the original eight patients. Now you can start looking at patients more closely. But the same rules apply.
There is a woman slumped over in her seat. No apparent injuries. She's not moving. You check breathing and pulse. She has a pulse but is not breathing. Blocked airway? You lift up her head. Still not breathing. Could be the carbon monoxide. Then you notice the guy next to her. Open femur wound. You check. He has a pulse and he's breathing. You make the call. You're probably going to have to do time-consuming CPR on her. He has a better chance. You have your firefighters quickly apply a bandage to stem the blood loss and take him out.
Priority 4 patients, those who are dead or dying, should not be moved unless it is absolutely necessary to treat other patients. Those which must be moved should be covered and placed in an out-of-the-way location. If possible, mark the position of the body before moving.
"Battalion 1 on the scene."
The battalion chief is going to take command. It's best to transfer command face to face. But in this situation that isn't the case. You make your report and transfer command by radio. You let him know how many patients have been extricated, how many are left and what sectors have been set up.
"Copy, I have Freeway Command," the chief responds. "Engine 1, you will maintain as Extrication Sector."
The three major sectors of an EMS call extrication, treatment and transportation have now been set up. The battalion chief may put these sectors under an EMS branch and establish a separate fire branch with sectors.
You continue your job of triage and extricating. As you work your way through, you are able to be more discerning with each patient. You can hear on the radio that the chief is assigning the first advanced life support (ALS) unit to Treatment Sector. Each ambulance is immediately assigned to Transport Sector. No more crews were assigned to Extrication Sector simply because the limited space of the narrow aisle allowed for only two firefighters at a time to be in there working. But, finally, the chief relieves you and your crew. It appears you're pretty much dealing with dead bodies by now. Plus, you've been working with full gear on and you are just about out of air.
The time will come when you will reflect on what you did. Questions will arise. Did you do the job exactly the same way Captain Smith or Chief Jones or any other firefighter would? Probably not. Somewhere along the way, they probably would have made a different call than you did.
Most likely, no two people would make the same identical decisions in that environment. But you did the best you could in an IMS structure and triage protocol getting those with the better chances for survival out of a dangerous environment. You can sleep well. (For related information, see Fire Psychology on page 26.)
Decker Williams, a Firehouse® contributing editor, is a 27-year veteran of the Phoenix Fire Department currently serving as a battalion chief. One of Arizona's original paramedics, he teaches the incident management system at medical incidents for firefighter safety and is a staunch supporter of the dual role of fire service first responders. Tim Simmons has been with the Phoenix Fire Department for 12 years and currently is assigned to the Division of Corporate Communications. He is also a volunteer captain in the Nogales, Mexico, Fire Department.
