1. Indiana State Fair Stage Collapse: ED Response/Immediate Planning for the Anticipated Surge
Ed Bartkus, MD, FACEP

2. Faculty Disclosure Purpose: Educational Conflicts of Interest: None
Commercial Support: None

3. Indiana University Health Methodist Hospital ED
Level I Trauma Center
Comprehensive Stroke and Vascular Center
>100,000 annual visits
Typically received ~100 ambulances each day
Academic training site including a large EM residency program (72 residents and fellows at any given time…)

4. Marion County

5. Trauma Centers 2 1 1 1

6. Methodist Hospital Planned Event Preparation
Indianapolis Convention Center
Lucas Oil Stadium
Indianapolis Motor Speedway
500 Festival Mini Marathon

7. Historical Events in Central Indiana
Disasters/Mass Casualty Incidents:
: Indianapolis 500 scaffold collapse
: Coliseum explosion
1965: Palm Sunday tornado outbreak
1987: Ramada Inn air crash
2003: I-465 box truck fire

8. Historical Events in Central Indiana
1960 Indy 500 scaffold collapse
Indymotorspeedway.com

9. Historical Events in Central Indiana
1963 Coliseum Explosion
Indystar.com

10. Historical Events in Central Indiana
1987 Ramada Inn plane crash
Indystar.com
wikipedia.com

11. Saturday August 13, 2011
8:46 p.m.

12. Indiana State Fairgrounds
Approximately 12,000 Sugarland fans are gathered for the concert

13. Meanwhile, 4 miles away....

14. The Tracking Board…

15. ED Status ∞

17. Notification?
All cell towers became inoperable almost instantly due to volume of attempted calls – none get through…
Texts on personal cell phones start, yet no official word

18. Social Media
Do we rely on informal/personal communication to activate emergency response plans?
In this case, YES. Facts corroborated by multiple known entities (our staff at the scene…)

19. ED Response: Immediate Planning for the Anticipated Surge
Notify On-call Administrator
Tier 1 and 2 notifications
Discharge as many patients as possible NOW
Admit as many patients as possible NOW – move upstairs – hospitalists will see and write orders
Let patients in WR know that our beds are “on hold” right now…
Clear patients from Critical Care area
Assign roles using HICS model
Upper-level EM and Surgery residents to CC

21. Discharges and Moves Before the First Ambulance Arrived…
Capacity of 10 CC patients now…

22. How many victims?

23. FINALLY…..They Begin to Arrive
At 9:32 pm (46 min after the collapse), the first two critical patients arrived in the same ambulance
Nine “red” and one “yellow” patient arrived within 12 minutes
Followed by a 27-minute delay
Total of twenty four State Fair patients were treated in ED
This included one who was ultimately convicted of fraud (presented via POV)

24. First Hour of Patient Surge

26. Stage Collapse Victims
5 deaths on-scene
58 injured
47 transported by EMS
24 to Methodist
9 reds – primarily CNS trauma
2 died, bringing total deaths to 7

27. Back at the EMTC EMTC Leadership arrives Staff are pouring in to help
All Services
Chaplains
Social Workers
ICU/OR staff
Environmental Services
Supply Chain

28. Senior Admin is available 45 hours/week
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
0000
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
Who will be the Incident Commander and hold other key positions the other 123 hours (73%) of the week?

29. Critical Patients Stop Arriving
Within two hours all critical State Fair patients had been cleared from EMTC
“Walking Wounded” continued to drift in through early morning hours

30. Take-Away Points
Design an ED Emergency Operations Plan (EOP) which takes into consideration the following:
The vast majority of “MCIs” have 5-10 patients
Write and practice a plan for this number
EDs are typically over-run with minor casualties first, potentially before the “disaster” has even been called…
Less than 50% of patients typically arrive via EMS (pre-triaged…)
The public will go to the closest hospital, regardless of trauma status or capacity

31. Take-Away Points
Design an ED Emergency Operations Plan (EOP) which takes into consideration the following:
Patients will not be decontaminated when they arrive, so consider moving Triage out of the building and PPE should be provided, at least initially…
Up to 1/3 of your staff will not be available for recall to the ED
Don’t send hospital personnel to the scene!

32. Reality
Only physicians and nurses specially trained to work in the field environment should do so
Only if physicians are in surplus in the hospital/clinic environment should they be sent to the field as care providers
Evidence preservation at scenes is not a strength..
Physicians and nurses depend upon monitors and equipment, not available in the field
On-site chaos of disaster may prove disabling.
Goal of disaster medical response planners is to assign personnel to roles that are as familiar as possible and to enhance flexibility of response to extraordinary circumstances.
Only physicians and nurses specially trained to work in the field environment should do so.
Only if physicians are in surplus in the hospital/clinic environment should they be sent to the field as care providers.

33. Reality Hospital workers are typically unaware of secondary devices!
Bombs, Shrapnel devices, Incapacitating Devices, Multiple Snipers/Terrorists, Delay Devices
-rescuers are TARGETS!!! (Atlanta abortion clinic bomb, Centennial Park bombing, recent incidents in Iraq, Israel, etc…)
-could be…..
A booby-trap (explosive or other type) (set off inadvertently by a rescuer or victim on-scene)
A command-detonated explosive (or timed device)
A chemical intended to harm rescuers
A biological agent intended to infect/harm rescuers
A group of armed individuals who fire upon rescuers and/or their vehicles at a very unexpected time to cause casualties, interfere with the disaster response, cause chaos, confusion, and generally terrorize the rescuers and population even more.
New/novel device or tactic
Any combination of devices/tactics (some attacks have been extremely well-planned and coordinated, and utilized multiple personnel, fake uniforms, fake ambulances, faked distress calls, firearms, explosives, etc…)
(your official uniforms/patches/credentials/vehicles are assets to terrorists……….keep them secured at all times and report thefts of these items IMMEDIATELY to law enforcement)

34. After-Action Report

35. Reflections Activate early Assign roles immediately
Anticipate the worst
Communicate housewide
Education and constant state of readiness is key
Don’t forget night shift and weekend staff
DEBRIEF, DEBRIEF, DEBRIEF