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

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

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…)

Marion County

Trauma Centers 2 1 1 1

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

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

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

Historical Events in Central Indiana 1963 Coliseum Explosion Indystar.com

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

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

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

Meanwhile, 4 miles away....

The Tracking Board…

ED Status ∞

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

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…)

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

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

How many victims?

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)

First Hour of Patient Surge

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

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

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?

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

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

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!

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.

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)

After-Action Report

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