What does all of this have to do with EMS and rescue? If you're an emergency prehospital-care provider, you will probably be involved in a high-rise emergency at some point in your career. Obviously, if you work in an urban area, you have probably already responded to several.
On February 26, 1992, a bomb exploded on level B2 of the World Trade Center in New York City, killing six people and injuring more than 1,000. This was the largest number of injuries known in a single high-rise emergency. Imagine the surprise of the volunteer responders who were alerted to provide mutual aid to New York City.
Other past notable fires and emergencies include: the Westvaco Office building, New York City, 137 injured; the Joelma Building, San Paulo, Brazil, 180 dead; and a hotel in Seoul, South Korea, that left 163 dead. These fires occurred during the '70s and '80s, but high-rise emergencies go back further in time. One of the earliest recorded high-rise fires occurred in New York's Asche Building in 1911. In 1945, the Empire State Building was struck by a military bomber, and in 1946, fire destroyed the Winecoff Hotel in Atlanta and the Hotel LaSalle in Chicago. And who can forget the rooftop helicopter rescues at the MGM Grand Hotel fire in Las Vegas?
Although high-rise fires are dramatic and draw tremendous media attention, responders report to many other types of vertical emergencies, such as scaffold and elevator emergencies, fume problems and power failures.
Due to the unique requirements of high-rise emergencies, EMS providers must develop action plans before these incidents occur.
In 1971, the International Conference on Fire Safety in High-Rise Buildings issued this definition: "A high-rise structure is one that is taller than an aerial ladder can reach." This definition is confusing, because there is no standard height for aerial ladders, and some communities have different sized ladders within their own fire department. Later, a better definition was coined: "A high-rise is any structure where the height can have a significant impact on evacuation."
Some jurisdictions classify only commercial properties as high-rise structures, but both residential and commercial buildings should be included. The exclusion of residential buildings is usually based on the difference in fire behavior between the two types of buildings.
In a residential high-rise fire, the fire is usually limited to the contents of one apartment. Unless there have been modifications to the building or a delay in getting water on the fire, it rarely extends into other units. The smoke, however, can travel throughout the structure. In a commercial office tower, there are usually few fire stops on a floor. Most floors have large areas of open space that are frequently divided by partitions that don't extend to the ceiling. This type of configuration allows fire to spread very rapidly across the floor laterally. If the fire should vent through the windows, vertical fire spread also occurs. This simplified description of fire spread does not take into account fuel type, mixed use or specialty buildings like hospitals and hotels.
EMS providers have to be prepared for multiple victims, no matter what type of structure is involved. For this reason, EMS personnel should not exclude any type of high-rise building from preplanning.
The first step in preplanning is to identify any buildings in your area that could pose a problem due to height. In a large city, preplanning for specific structures may not be feasible, but a generic response plan can be developed. Some specific factors you should include are: location of freight elevators, off-hours access, communication difficulties and specialty occupancies.
Also, some buildings, particularly commercial structures, have several sub-basements. Your radios will become useless as you descend into the bowels of the building. Reaching the dispatcher should not be problematic, since telephones are usually readily accessible, but there may be a problem with loss of power. Most commercial office switchboards will not function without power.
On-line medical control poses its own set of problems. If your ALS treatment protocols are dependent on sending an EKG via telemetry, you will have the same radio difficulties as trying to contact your dispatcher. You should have a protocol regarding loss of EKG capability that allows you to contact medical control by telephone.
Ideally, when confronted with a malfunctioning, occupied scaffold, two EMS units should respond. One crew reports to the floor where the rescue will take place, while the second crew remains on the ground floor outside the building to watch the rescue and prepare to treat patients who may fall to the ground. The crew on the upper floor is responsible for treating injured rescuers and victims when they are brought inside. Along with traumatic injuries, there is a possibility for hypothermia. Although the temperature on the ground is 60º F, with a 0-mph wind, there may be a constant 30- or 40-mph wind where the scaffold is located.
Elevator emergencies rarely produce patients who require EMS care at the scene. A notable exception is a unique inner-city sport known as "elevator surfing." Youngsters ride on top of an elevator car and jump from car to car as they pass in a common shaft. Occasionally, a child misses and becomes trapped between the car and the shaft or tangled in the cables. Frequent injuries include amputation, crush injury, traumatic cardiac arrest and death.
Unless there is an entrapment outside the elevator car, which can also occur while a maintenance worker is repairing the elevator, most responses will require only one unit. Just like a scaffold emergency, an entrapment must be approached as a technical rescue. Properly trained and equipped response personnel should handle the actual rescue.
The 911 caller usually reports that an elevator is occupied by a person with a medical condition. Most callers believe if the stuck occupant is not sick, rescue personnel won't respond and they will be forced to wait for maintenance workers. Generally, the only care required is a brief examination after the occupants are freed. They rarely require treatment and usually refuse to be seen. They are upset about the inconvenience and just want to be on their way.
Carbon monoxide buildup usually occurs in residential buildings that have a common furnace or water heater. When these units malfunction, primarily as a result of incomplete combustion, carbon monoxide fills the structure. If a central heating, ventilation or air conditioner (HVAC) unit fails to function properly, either by not drawing in enough fresh air or not venting properly, the air becomes oxygen-deficient. EMS providers need to be prepared for multiple victims, with symptoms ranging from mild headache to cardiac arrest. Local protocols for managing carbon monoxide-affected patients and multiple-casualty incidents must be reviewed. Most disaster plans are trauma based, but, in this case, all of the patients will be medical cases.
If your system's disaster plan was designed with a plane or bus crash, or some other type of catastrophic incident in mind, does it take into consideration an incident where the majority of patients are medical in nature? Use of an incident-management system is key to handling such an incident.
The EMS command officer must report to the interagency command post to coordinate operations with the incident commander. The number of EMS resources that ultimately responds will depend on the type of building, time of day and number of occupants. As searches are conducted, all victims should be brought to a triage area. Rescue personnel should know the location of the triage area in advance. Conversely, the EMS command officer needs to know when searches are completed.
As the searches are completed, the number of EMS resources at the incident can be adjusted, based on search outcome. Coordination between the different operational divisions is crucial to the successful outcome of the incident.
Using the same basic management techniques, other types of fume incidents can be handled. Once the type and source of the fumes have been identified, treating the patients will be easier. Until fume identification is confirmed, patients should be treated symptomatically, according to local protocols. First-arriving EMS units must show restraint and not enter the building unless they are properly equipped and trained to operate in a hazardous environment. As a responder, ask yourself if you're willing to bet your life on a bystander's identification of an unknown fume.
When EMS resources are limited, keep them available in a central area, sending out a medical team only when a patient is found by other personnel. In commercial buildings, in particular, there will be numerous calls to 911 after a power failure, where the caller will ask when the elevators will be running because there is someone with a cardiac history who does not want to walk down the stairs. By the time that information is relayed through the dispatcher to the interagency command post and on to the EMS operations officer and crews, the nature of the call becomes cardiac arrest. This is the adult version of the childrens' game of Telephone.
Using the building's overhead paging system, which is usually used to give information during a fire alarm, most occupants can be instructed to stay in place. Since the elevators are out of commission, your most likely source of patients will be during self-evacuation of the building. As people leave their work area for lunch and begin to walk downstairs, anything can happen. With a large number of people descending the stairs, one person sometimes trips, in turn tripping others, like a silent movie sight gag. But more serious problems can occur: Walking down 20 or 30 flights of stairs may trigger someone's underlying asthma or cardiac problem, and, if the stairwells are hot, heat-related problems may result.
Some of the building's occupants may have a normally sedentary lifestyle and consider walking to the corner for a newspaper strenuous work. When they're forced to walk down several flights of stairs, various underlying medical conditions will arise. If forced to wait someplace for an extended period of time, people who are on maintenance medications may not have enough with them. This will be a greater problem if the evacuated building has an observation deck near the roof, since many day-trippers or tourists don't carry spare medications with them.
As discussed earlier, managing stuck, occupied elevators is essentially not a concern of EMS responders. The difference during a power failure is the scope of the problem. Instead of one elevator, all elevators will be affected. By keeping your approach methodical and directed, you will be able to expand your operations to meet the incident's needs.
As you arrive, you see fire-suppression crews entering the building in full protective gear. People are exiting the building, some coughing and hacking; police officers are establishing a perimeter and starting to direct traffic away from the area. Reviewing your copy of the preplan, you respond to the staging area and begin to assemble your equipment. Looking up, you see a 40-story glass and metal office tower. Fire is coming out of several windows at about the middle of the building. Television crews are arriving. What do you do now?
If this scenario seems farfetched, picture yourself as the first arriving responder in the incident. If there are high-rise buildings in your district, you should be thinking about when an incident will happen, not what if one does. You might also be called to give mutual aid to a neighboring community.
A fire service friend once told me, "The only difference between a routine room-and-contents fire on the ground floor and the same fire on the 20th floor is the length of the stand pipe." While this is an understatement, by following some simple rules and doing what you do regularly, those camera crews will film an impressive, professional effort and you can try to get on one of those reality-based television shows.
The first rule is simple: Take a deep breath and do not panic. If you are watching the scene intently and don't look where you're going, you're going to get hurt. This is a classic example of "tunnel vision." Take a moment to do a 10-second scene survey; it might save your life. Look for falling objects. Where is the fire? Where is the smoke going? Is there a safe way to get into the building? Is your staging area appropriate? If you answer these basic questions, you have much of the information you need to set your strategy. If there is safe access to the building, make your way to the lobby.
This is probably the only time you'll willingly take your crew and equipment into a burning building, but if the fire is on the 27th floor, there is probably little danger in the lobby. While your crew sets up a triage area in the lobby, find the incident commander and get a status report on the incident. Let the incident commander know that you are the EMS command officer and where you will be setting up EMS operations. The IC, usually the fire chief, will be at the building's fire command station, which is the place where all of the fire alarms are wired and all essential building services are controlled, and there is usually a way to communicate with each elevator car and each floor. A large amount of good information can be obtained here. Use this information to continue to plan your strategy. Just as with a "fumes call," the status of searches, number of victims being brought down and number of fire-suppression crews committed will determine whether you escalate or de-escalate your operation.
Using an incident-management system, you can simply expand your operations to meet the evolving needs of the incident. Some areas you need to address are: multiple triage and treatment areas, off-site operations, hospital overcrowding and logistical problems. Since most of these areas are interrelated, making adjustments in one will impact the others.
Because high-rise buildings are constructed with several stairwells, triage teams will be needed at each stairwell and the elevator bank. As patients are triaged, they should be moved to a treatment area outside the building. The lobby is not a suitable treatment area, since the fire-suppression crews will be mobilizing there with their equipment and because a lobby becomes crowded very quickly. If the building is large and has multiple entrances, you may establish several outside treatment areas. A central staging area can feed numerous treatment areas with ambulances.
When helicopters are used to rescue people from a roof, an entirely separate division needs to be established at the landing zone. This includes triage, treatment, transport, safety and staging. You may be too far away to use the incident's staging area. Helicopters performing rescues need to be directed where to bring patients, since not all of them will be owned by rescue agencies. Clear lines of authority and their roles should be spelled out in advance for private helicopters. The lead agency should have a Memorandum of Understanding with the private companies that includes an EMS component.
As with any multiple-casualty incident, care must be taken to prevent hospital overcrowding. Many walking wounded will go to the nearest hospital on their own and, when your crews start to arrive, they will find an already overcrowded ED. Advance warning will go a long way in assisting the hospital. When you alert a hospital about an incident, however, you are also responsible for notifying them when the incident is over.
Logistics play a key role in this type of incident. Sufficient oxygen and medical supplies will be needed at the scene. Disaster plans should be up to date, since there will be more medical than trauma patients. Review your agency's disaster plan. It probably tells you how to get long backboards to the scene, but does it include how to support 30 asthmatics and 15 cardiac patients at the same location?
As the incident progresses, it may be possible to send medical teams to the upper floors to begin patient care. Both the EMS command officer and the incident commander must agree on this strategy and coordinate the location of the upper floor treatment area. A good spot for the treatment area is five floors below the fire-affected floor. The treatment floor can then be combined with the rehabilitation area.
Safety is the prime concern of all responders. Using five floors below the fire for treatment and rehabilitation is only a generalization, since each incident is different. When you factor in vertical time, the sooner you can begin patient care, the better the outcome will be. If a patient has to be carried down 30 or 40 stories to be seen by an EMS provider, patient outcome will be poor. It may take up to an hour to evacuate a nonambulatory patient, which is a very long time for a smoke-inhalation or burn victim to be delayed from receiving oxygen.
Patient care should take place at the highest floor possible where it is still safe. Rather than EMS providers going to every patient, fire-suppression personnel can bring the patients to an upper triage area. Using fire-suppression personnel is necessary because there are more of them at the scene than EMS providers.
Even when the upper treatment area has been established, vertical time will work against you. If the upper area needs more oxygen, for example, and the tanks have to be hand-carried up 30 stories, it may take over an hour to get them there. Rather than having one group carry equipment all the way to the top area or transport patients all the way down, a better solution is to set up relay carrying teams in stairwells. Each relay team can be responsible for five floors. If the stairwells become crowded with fire-suppression personnel moving up or walking evacuees going down, relay team members can take refuge on the floors near the stairway doors. Planning to support an upper treatment area is a necessity. Just realize that there is an extended time factor in getting supplies to the upper area.
By following some simple rules, planning ahead and exercising the plan, a high-rise fire will not be a monster to handle. Although the buildings are imposing, incidents don't have to be.
Any time your local fire department conducts high-rise emergency drills, there should be an EMS component present. The first time you meet your fellow officers from other agencies should not be when a building is on fire.
Classroom training, backed by drills at different sites, increases your effectiveness in responding to high-rises. Preplanning and updating your disaster plan also play a pivotal role in operations. There is a need to educate EMS providers and show them that the majority of patients at these types of incidents are medical, rather than traumatic in nature.
The buildings may be large, but the problems they pose are not insurmountable. Unlike Superman, we cannot leap tall buildings in a single bound, but, by working together and using an incident-command system, we can solve any potential problems.
| David Fenton, EMT-P, is a lieutenant with the New York City Fire Department, Bureau of EMS, and an ex-captain with Port Washington (NY) Volunteer Fire Department. He has responded to many high-rise emergencies during his 16-year tenure with emergency services. |