Indiana State Fair Stage Collapse: ED Response/Immediate Planning for the Anticipated Surge

Indiana State Fair Stage Collapse: ED Response/Immediate Planning for the Anticipated Surge

Ed Bartkus, MD, FACEPEd Bartkus, MD, FACEP

Faculty DisclosureFaculty Disclosure

• Purpose: Educational

• Conflicts of Interest: None

• Commercial Support: None

Indiana University Health Methodist Hospital EDIndiana 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 CountyMarion County

Trauma CentersTrauma Centers

111

2

• Indianapolis Convention Center• Lucas Oil Stadium• Indianapolis Motor Speedway• 500 Festival Mini Marathon

Methodist Hospital Planned Event Preparation

Methodist Hospital Planned Event Preparation

Historical Events in Central IndianaHistorical Events in Central Indiana

1960: Indianapolis 500 scaffold collapse

1963: Coliseum explosion

1965: Palm Sunday tornado outbreak

1987: Ramada Inn air crash

2003: I-465 box truck fire

Disasters/Mass Casualty Incidents:

Historical Events in Central IndianaHistorical Events in Central Indiana

1960 Indy 500 scaffold collapse

Indymotorspeedway.com

Historical Events in Central Indiana

Indystar.com

1963 Coliseum Explosion

Historical Events in Central Indiana

1987 Ramada Inn plane crash

Indystar.com

wikipedia.com

SaturdayAugust 13, 2011

8:46 p.m.

Indiana State FairgroundsApproximately 12,000 Sugarland fans are gathered for

the concert

Meanwhile, 4 miles away....

Acuity Bed Name Age/Sex Visit Reason LOS2 M01,1 Bates, Gerald H 47 years Chest pain, n/v/d 0:422 M02,1 Lemmon J, Daniel 53 years AMS 4:592 M02H,1 Williams, Tambra 33 years APA, n/v 3:352 M03,1 Balutis, Nicole 31 years OD - lithium 0:142 M04,1 Goins, Linda F 61 years X 3:002 M04H,1 Nguy, Muoi 79 years Acute SDH 2:432 M05B,1 Bolden, Mose E 56 years Hypertension 4:192 M05C,1 Conwell, James E 83 years Large pleural effusion 8:202 M05D,1 Reed-black, Amie L 88 years Dyspnea 8:032 M05E,1 Foster, Curtis 49 years Chest pain, sepsis 2:452 M05F,1 Exford, Nakila 36 years Chest pain 4:212 M09,1 Leining, Deborah G 57 years COPD 1:022 M09H,1 Montagano, Cathleen 53 years Chest pain, weakness 5:132 M10,1 Monk, Cheryl R 57 years Chest pain 0:122 M11,1 Mills, Mark A 51 years Chest pain 0:142 M12,1 CALDWELL, KRISTINA M 26 years T2 - abdominal pain 1:362 M13,1 Fleming, Jack 60 years AMS 0:582 M14,1 Franklin, Kathleen 59 years AMS 3:523 M15,1 Williams, Carol F 65 years R ear pain, leg pain 0:213 M16,1 Bailey, Roy 61 years High BP 5:403 M17,1 Hurt, Hazel 73 years Abscess R leg 2:383 M18,1 Wilburn, Lorraine 62 years Sore throat 7:302 M20,1 Welch, Patricia Ann 68 years AMS 5:594 M20H,1 Scott, Destiny Lashae 18 years Feels like having sz 7:023 M21,1 Hawsawi, Nusaybah 24 years Abd pain 2:063 M22,1 Franklin, Randy Lee 59 years Bundle branch block 1:143 M23,1 PERDUE, ASHLEE D 19 years Vag burning, + preg 1:413 M24,1 Webster, Hope T 41 years Abd pain 3:163 M25,1 Madison, Mary 86 years Gastric outlet obstruction 3:242 M26,1 Eldridge, Nancy 65 years Syncope 1:014 M27,1 Adams, Barbara J 75 years L hip pain - no injury 1:153 M28,1 Hammond badger, Stevie N 25 years L flank pain 3:12

3 M29,1 Schuck, Heather D 35 years UTI, fever 1:393 M30,1 Walters, Maurice 30 years L leg pain, ha 3:193 M31,1 Young, Thomas W 58 years EtOH, back pain 0:183 M32,1 Whiteford, Sarah A 28 years L LE pain w/ swelling 3:043 M33,1 Bronson, Bobby 55 years ARF, hypoglycemia 1:053 M33H,1 JOHNSON, STEPHEN 32 years EtOH 5:493 M34,1 Calloway, Kwamesha Janay 19 years Incr hr 1:023 M35,1 Tord, Bernardo M 43 years R leg tingling w/ pain 3:023 M36,L Whitton, Janice E 62 years Abd pain 1:053 M36,R Martin, Abigail Lynn 15 years RLQ pain 0:103 M37,1 Sumner, Michael 26 years Abd pain 1:073 M38,1 Golden, Ronald H 54 years Syncope, chest pain 3:534 M42,1 Chapman, Michele R 45 years Eyes are swelling 1:174 M44,1 Ringer, Janet R 20 years Chest and back pain x 1 month 0:514 M46,1 Rushton, Veronica K 34 years L hip pain - no injury 0:484 M48,1 Turpin, Michael Anthon 40 years Back pain 0:424 M52,1 Jackson, Jibril M 6 years Cough 1:194 M54,1 Johnson, Tybarius L 17 years L elbow blisters 0:404 M55,1 Nichols, Mia J 11 years R wrist injury from fall 0:333 M56,1 Hornaday, Gabriel 1 month Thrush, fussy 1:373 M57,1 Einsla, Peggy 49 years Poss. wound infection 4:162 M58,1 Fairrow, Joe B 65 years Hypoglycemia, pre-syncope 5:514 M59,1 Albertson, Mellina Marie 12 years Dental abscess 1:013 M61,1 Jewell, Virginia Lee 81 years Frequent nose bleeds 5:413 MG111 Haywood, T Arnold 77 years Foot pain 8:012 MG112 Wilson, Josh 22 years MVC 6:522 MG125 Canady, Henry 51 years Chest pain, dyspnea 6:492 MG127 Jacobs, Estella L 48 years Chest pain 7:092 MWR Flexman, Juanita B 91 years Pancreatitis 0:013 MWR Pride, Teandre 26 years Jaw pain from fall 0:034 MWR Rankin, Hughe 12 years R elbow injury 0:013 MWR Rooney, Mary jo 53 years R 5th digit injury 0:173 MWR Todd, Kimberly 41 years Dyspnea 0:07

The Tracking Board…The Tracking Board…

ED StatusED Status

∞

Pts. CapacityCritical Care 18 19Delta 1 12 12Delta 2 14 14Delta 3 8 11Fast Track 4 8Observation 4 10

60 74Waiting Room 5

• 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

Notification?Notification?

Social MediaSocial 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 SurgeED 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…Discharges and Moves Before the First Ambulance Arrived…

Pts. Capacity D/c MovedCritical Care 18 19 7 2Delta 1 12 12 3Delta 2 14 14 0Delta 3 8 11 4Fast Track 4 8 3Observation 4 10 0

60 74Waiting Room 5 5

Capacity of 10 CC patients now…

How many victims?

FINALLY…..They Begin to Arrive 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 VictimsStage 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 EMTCBack 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/weekSenior Admin is available 45 hours/week

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

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Who will be the Incident Commander and hold other key positions the other 123 hours (73%) of the week?

Critical Patients Stop ArrivingCritical 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 PointsTake-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 PointsTake-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!

• 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..

RealityReality

RealityReality

• Hospital workers are typically unaware of secondary devices!– Bombs, Shrapnel devices, Incapacitating Devices, Multiple

Snipers/Terrorists, Delay Devices

After-Action ReportAfter-Action Report

ReflectionsReflections

• 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