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CASE REVIEW By James J. Augustine, MD, FACEP 12 OCTOBER 2015 | EMSWORLD.com ABOUT THE AUTHOR James J. Augustine, MD, FACEP, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University; as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH; and on the EMS World Editorial Advisory Board. Contact him at jaugustine@emp.com. THE ATTACK ONE CREW STARTS New Year's morn - ing by doing station cleanup, with the overnight crew crawling out to their vehicles after a busy shift. Then the dispatch tones ring out for a fire with possible trapped victims. Attack One's crew is quick to the vehicle and out the door into the cold morning. First-arriving crews report heavy fire from a two-sto- ry home, with persons trapped on the porch roof. All arriving crews will be performing rescue operations, and a second alarm is requested to bring additional equipment. Incident Command is established, and the persons on the roof are quickly lowered using ground ladders. But command reports there are multiple per- sons still trapped, including some in the basement of the home. Attack One is designated to serve as triage. The scene is busy, on a narrow residential street. First-arriving fire engines and a ladder truck fill the road. Victims are being brought out of the house and worked on in the street or the yard across it. When Attack One arrives they begin work with some of the firefighters who are doing CPR on a young boy. The Attack One paramedic throws a tarp on the ground to designate a receiving area for the victims being brought out. She assumes the role of triage supervisor and designates an area where incoming ambulances can be directed for rapid transfers of care. Another child is laid on the tarp; adults are starting to come out too. Attack One's crew asks the fire operations officer how many victims are expected, and at this point he has no idea. "There were a lot of people in the house," is all he can report. Quietly he tells the paramedic several people are trapped in the burning basement and likely to be fatalities. Three persons came off the front roof, and at least one more bailed out a side window and is injured. At that point two adults are carried out, both in respiratory distress and unable to respond to ques- tions. That makes a total of four critical patients on the tarp, two young boys and two middle-aged adults. There are three others who have smoke inhalation and various injuries but are not in distress. The paramedic also anticipates that some of the firefighters doing the rescue work are going to be injured in the process of working this incident. The paramedic asks command to request a total of eight ambulances to provide transportation. An EMS Victim Tracking at a Major Incident A fre ravages a family—what's the best way to keep the patients straight? supervisor arrives and assumes the role of EMS sec- tor director; he requests the Attack One paramedic evolve into the role of treatment supervisor, since the triage function is complete. Treatment and Transport The pace is rapid, it is very cold, and there is little space to conduct triage, so victims are treated on the tarp and then carried to ambulances that are moving through the staging area a couple of blocks away. In the vehicles the victims are fully exposed and treated, with short scene times before they are transported to receiving hospitals. There is no requirement for a treatment sector and little room to accommodate one, as rapid movement into an ambulance matches the patients' treatment needs. The four critical victims are prepared for rapid trans- port and loaded as soon as ambulances arrive. Victim conditions are summarized in the graphic on page 14. The transport sector is managed by another EMS officer, who has activated the hospital notification network to give the nearby hospitals, burn center and children's hospital time to prepare for patients. The children's hospital will get the two red-category children. The hospital with the burn center will get the two worst adults. Two other hospitals closer to the scene will get the other victims. The hospitals are advised that an unknown number of persons may still be pulled from the house and need care. Another EMT serves in the transport sector as the victim tracking supervisor, tracking each victim by name, triage class, transport ambulance and destina- tion hospital. He uses a worksheet for this purpose. That EMT has to work quickly, as victims are not to be held for any period. He asks the less-injured adults to help give names to the victims. A problem arises when they can't identify which of the young boys is which. There were two cousins of similar age in the house that night, and it's not easy to differentiate the boys even if they weren't having CPR performed on them. The two adults in distress are the parents of one of the boys. The tracking supervisor tells the transport super- visor that the boys will have to go to the hospital as unknowns until someone can identify them. The adults will have names, but their ages will be "around 40," and their medical histories unknown. Copyright granted for this ar ticle for depar tment use only up to 20 copies.