By Norm Rooker, EMT-P
"I have a bus on its side and bodies everywhere!" reported REMSA Careflight pilot Paul Milton as he approached the scene of a tour bus accident on Interstate 80 in the Sierra Mountains, roughly halfway between Truckee, CA, and Reno, NV.
Just before 5 p.m. on September 26th, 1998, a Coach USA charter bus carrying 40 passengers en route from San Francisco and Sacramento to casinos in Reno and Sparks, NV, lost control on a downhill rain-slicked curve.
The bus struck the right-hand guard rail on the exit ramp, rolled over and down onto a sandy embankment, finally coming to rest on its left side. The accident resulted in two fatalities and 39 people injured.
This mass casualty incident, in a rural mountain setting, with, in the words of one rescuer, "snotty weather conditions," would be successfully resolved in less than 90 minutes by rescuers responding from multiple agencies located in two different states, who did not share a common radio frequency and had never worked together.
The other major responding agency was REMSA (Regional Emergency Medical Services Authority), a nonprofit public utility model organization that provides EMS for Washoe County, NV, an area of 9,000 square miles including the cities of Reno, Sparks and Carson City. REMSA has 17 ALS ambulances, a wheelchair van and runs two Careflight helicopters.
Off-duty REMSA paramedic Darin Huard and his wife Kathy were driving home from the San Francisco Bay area when the accident occurred.
"The weather and road conditions were anything but good," says Huard. "The clouds were down to the mountain tops in the passes, there was snow on the higher elevations and the rain was just a couple of degrees above freezing. In addition, the roads were really slick as this was the first storm of the season. It was a miserable drive--nothing to fool around in.
"We were the first vehicle to stop at the scene. The top wheels of the bus were still spinning and there was white smoke coming from under it. My first impression was it looked like an ant hill with people coming out of the roof escape hatches, the exit windows on the side of the bus, and the rear emergency exit. We tried to call the accident in on our cell phone, but there was no service in the canyon we were in.
"As my wife and I got out of our car to start sizing things up, California Highway Patrol Officer Todd Ketwig pulled up and told us he had already called the accident in and requested air ambulances from Reno and Sacramento. The officer and I decided to initiate START Triage (Simple Treatment And Rapid Transport), and I called into the open roof hatch for anyone who could move to exit out of the rear emergency door. I then directed the people on the top of the bus to get back in and exit out the back door as the bus appeared to be unstable and slowly slipping down the sandy embankment."
As Darin went to the back exit of the bus to start evaluating patients, he came upon a 44-year-old man lying on the ground with his lower legs pinned under the bus.
"He had been ejected from the bus and the bus then rolled over him," explains Darin. "The man had massive injuries to his head and chest and he was Guppy breathing (agonal respirations). His son was shouting hysterically, begging his dad not to die, and trying to pull him out from under the bus. I explained to the son that there was nothing we could do for his father. While I was doing this, the patient went into arrest. By now several cars had stopped to help so I called a bystander over. We covered the patient with a blanket, which seemed to calm the son down. I asked the bystander to stay with the son.
"By now, almost everyone was out of the bus and the CHP officer wanted me to confirm his findings of a second fatality. I found an older woman lying with her neck at a very odd angle and in full arrest.
"At this point, there must have been over 100 people milling about the accident. Everyone was either an EMT, paramedic, doctor, nurse or member of a volunteer fire department. No one was in uniform except for the CHP officer. One man who was carrying a walkie talkie identified himself as a Truckee firefighter and stated that resources were on the way but that they were having a tough time fighting their way through the rapidly developing traffic backup on Interstate 80. I continued to help get the patients organized. You couldn't really tell how bad their injuries were. Everyone was complaining of neck and back pain. Finally a fire truck pulled up on scene. I reported the events to the captain and turned the scene over to him. I went back to the treatment area and had just identified the two most severely injured patients when I heard Careflight coming in for a landing."
REMSA Vice President Herb Brady and Director of Education Don Bonarx (both paramedics) were in the dispatch center when Careflight pilot Milton radioed in his report.
"We were already on yellow alert for an earlier auto accident that had occurred in Reno," says Brady. "A yellow alert recalls management and puts off-duty REMSA personnel on standby. That day we had seven ambulances on duty, and Don and I were in communications when the pilot radioed in his report. I took it on myself to self-dispatch to the scene and directed Kendra Davis, an EMT and REMSA dispatcher, to put out a red alert. The accident was only 14 miles outside of town and since it occurred in the eastbound lanes, traffic westbound was not affected so we were able to get to the scene within 15 minutes."
After listening to additional radio updates from the flight crew, Herb Brady activated REMSA's MCI plan en route.
Truckee FPD Chief Mike Terwilliger responded to the scene directly from his home, which was only six miles from the accident site.
"I was the first one there from my department. I did a scene size-up, then set up my incident command post 200 yards west of the incident so that each arriving unit would check in through me and I could avoid being sucked into the energy and dynamics of the scene.
"As I set up the command post, I learned that Careflight was on final approach to the incident, but that the CHP helicopter out of Sacramento had to turn back because weather conditions over the pass were below flight minimums. Careflight, coming in from the east, flew in below the cloud cover, which was down to the mountaintops, and followed I-80 through the canyons. All the pilots we deal with are just fantastic. They routinely fly in bad weather conditions.
"As my resources started to arrive, I initiated only those parts of the Incident Command System that we needed to take care of this accident. Over the two and a half years that I've been deputy chief and now chief of this department, this is the fourth bus accident we've had to deal with.
"Bus accidents tend to follow a pattern," Terwilliger continues. "A bus is a tough vehicle that handles a crash well; however, the contents inside the bus--the driver and passengers--get tossed around quite a bit. These accidents usually have one or two fatalities and three or four seriously injured patients, with the rest of the patients suffering from neck and back pain, bumps and bruises.
"You don't have to fill out an entire ICS chart to run one of these accident scenes. Unlike a fire, which is a dynamic and constantly changing or evolving event, a bus accident is a static event that is pretty stable and only going to get better with your efforts.
"With this in mind, I assigned my first three arriving paramedics to fill out the three Ts: Triage, Treatment and Transportation. Everyone else staged on arrival with their vehicles or were assigned patient care for these three sectors.
"The accident scene itself was very stable. We literally had the Interstate shut down eastbound so traffic was not a safety issue. We still had enough light to work by, and the accident occurred in an area that contained the occupants as they exited the bus and made it easy to account for everyone.
"Initially we had two problems to deal with. The first was organizing and managing all the spontaneous volunteers. One of the advantages of being rural is that it does take some time for your resources to trickle in, so you're able to get your ICS system set up and in place before resources arrive. The spontaneous volunteers responded very well to my people as they arrived and took over the scene, in part because we were organized and had a plan.
"The second problem we had to immediately address was exposure to the elements. It was still raining and the temperature was somewhere around 38°. We had to stabilize the patients and move them out quickly, not necessarily due to their injuries but to prevent hypothermia."
By this time, REMSA paramedic Darin Huard had assisted the Careflight crew in getting the two most seriously injured patients packaged and airborne. Just as Careflight was lifting off, Herb Brady and Don Bonarx arrived in the first REMSA Ambulance.
"We had a difficult time establishing contact with the Incident Commander," explains Herb Brady, "because we came in from the east and the Command Post turned out to be west of the accident scene, and as we didn't have a common radio frequency, our arrival was a surprise to the folks working the accident.
"Although we hold two Mass Casualty Incident drills a year with the fire departments we work with in Washoe County, we had never worked with the Truckee Fire Protection District before," continues Brady. "Here we were, two of the largest EMS providers in the area, separated by 40 miles of nothing and a state border. It turned out we were speaking literally two different languages as far as who does what in the IMS system.
"Instead of getting frustrated with the fire captain who seemed to be running things, I went back and started staging our additional arriving ambulances and resources. We eventually had 10 ambulances committed to this incident and two more responding mutual aid units from the Carson City Fire Department (NV)."
Chief Terwilliger adds: "One of my captains informed me that REMSA had shown up on scene with 'a lot of ambulances.' Since almost all of the patients were going to be transported to medical facilities in Reno anyway, I elected to utilize them and canceled most of the other mutual aid units responding to this scene. We can respond with up to 15 ambulances in the Truckee Tahoe area, but I felt no need to strip the area of resources just because this was a California incident."
Near the head of the stopped eastbound traffic was an All West Tour Bus that was also heading for Reno and was only about a quarter full. Chief Terwilliger had the CHP move the bus through traffic and the 10 walking-wounded, or green patients, were loaded on board, along with one REMSA paramedic and two REMSA EMTs, and sent on their way to Washoe Medical Center in Reno.
Weather conditions continued to deteriorate, falling below flight minimums for Careflight to return for additional patients. The next 70 minutes were spent establishing patient treatment areas by rigging salvage covers off the guardrails and fire apparatus to serve as protection from the elements, while the process of backboarding, treating and transporting the 29 remaining patients progressed.
Along with the 10 REMSA ambulances and three Truckee FPD ambulances on scene, an additional unit was provided by Donner Summit Fire Department (CA) and two more by the North Tahoe FPD (CA). The two Carson City FD ambulances were canceled en route and one REMSA ambulance made two trips. The last patient was transported from the scene and the accident was declared under control at 18:20 hours PST.
REMSA's Herb Brady says that the biggest problem was lack of communication between the responding agencies.
"We need to learn the capabilities of other agencies--their system and language, and hopefully set up some mutual drills in the very near future."
On reflection though, preplanning, training, firefighter and medic ingenuity, a willingness to keep egos in check and work together to get the job done, along with sound management, all came together to overcome the numerous obstacles to successfully handling this bus accident while still meeting the fire, EMS and rescue needs of the respective jurisdictions involved.
| Norm Rooker is a rescue paramedic for the City of San Francisco Fire Department. He has been involved in EMS since 1973, is a heavy-rescue instructor for the California State Fire Marshal's Office, an EMT-T, and a member of the Advanced Rescue Technology editorial advisory board. |