The Three Rivers Regatta accident: an EMS perspective.

The Three Rivers RegattaAccident: An EMS Perspective RADE B. VUKMIR, MD, PAUL M. PARIS, MD The Three Rivers Regatta accident occurred on August 7, 1988 when a Formula I racing crag collided with shore, injuring 24 spectators. The authors retmspectlvely examined the prehospital-based response for this multiple-casualty incident that used emergency medical service (EMS) physicians and 32 paramedics stationed at water and land-based posts to Wage and evacuate 24 patients in 32 minutes. Patients were transported to 5 hospitals including 4 Level I trauma centers; this was accomplished in 53 minutes. The EMS response was unique In a number 01 respects. This was a prehospital-based rescue with the entire triage and stabllization phase accomplished by River Rescue units that transported paramedic divers, EMS physicians, and trauma supplies for 30 patients. Also of slgnllicance was the Inordinate proportion 01 pediatric patients that accounted for 50% (12/24) of the cases. Successful medical care was the result of planning based en “Daily Aoutlne Doctrine” or escalation of existlng treatment protocol; adequate supplies, personnel and transport adapted to local geography and patient population; communlcatlons, including all services-EMS, police, and fire; and prehospital physician Input to ensure correct triage order and patient disposition. (Am J Emerg Med lggl;g:S4-71. Copyright 0 1991 by W.8. Saunders Company) A disaster has been defined as a situation where “destructive effects of natural or manmade forces overwhelm the ability of a given area or community to meet the demand for incident (MCI) is a more health care.“’ Multiple-casualty accurate description for most disasters occurring on national and global scales, usually involving 15 to 20 casualties.’ Thus, disaster and MCI are on a continuum differentiated by both operational and logistic aspects. An MCI features a smaller number of patients, higher incidence, less emotional connotation to the descriptive term, and the capability of the health system to provide adequate care. This MCI occurred at the 1988 Pittsburgh Three Rivers Regatta, an 11th annual event showcasing the city’s waterfront activities. The location was Point State Park, a triangular land mass formed by the junction of the Allegheny, Monongahela, and Ohio Rivers. The crowd, estimated at 440,000 for the 3-day event and 135,000 on the day of the accident, was the largest ever assembled in the city. The race was the third leg of the 1988 Formula I Grand Prix series held since 1982 without incident on a 50 lap, 1.2 mile course. The racing craft were formidable with V8 engines generating 500 horsepower, weighing 1,100 pounds, 16 feet in length,

From the Division of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. Manuscript received January 9, 1990; revision accepted August 6, 1990. Presented at the International Conference of Emergency Health Care Development, Washington, DC, August 1989. Address reprint requests to Dr. Vukmir: Division of Emergency Medicine, University of Pittsburgh School of Medicine, 230 McKee PI, Suite 500, Pittsburgh, PA 15213. Key Words: Disaster, multiple casualty incident, EMS triage, prehospital. Copyright 0 1991 by W.B. Saunders Company 0735-6757/91/0901-0019$5.00/O 64

and capable of speeds of 140 mph with gravitational (G) forces of 4 to 5. The accident occurred when “Second Effort,” piloted by Robert Wood, veered from the course between the Fort Duquesne Bridge and the Point State Park turning buoy (Figures 1 and 2). The course change was attributed to loss of steering ability due to the wind forcing the right sponson below the water, or as the result of the skeg or rudder striking a submerged object. The craft veered into a crowd of approximately 800 spectators along the North Shore Vietnam War Memorial at 45 mph (Figures 3 and 4). The discussion will focus on the prehospital evaluation, stabilization, and transport of the 24 injured patients along with analysis and review of the triage process. It is emphasized that this was an MCI as opposed to a disaster, and that the medical operations of the EMS system, including municipal and medical tent service, continued without interruption. The accident was managed by escalation of routine prehospital care involving the City of Pittsburgh EMS physicians and by paramedics using preexisting evaluation and treatment protocol. EMS planning for such an event should emphasize expansion of routine medical operations until resources are exceeded, before institution of more formalized but less facile disaster plans. Finally, the unique aspects of this prehospital based MCI, including the first reported civilian amphibious rescue and the large number of pediatric patients involved, will be reviewed. METHOOS

Retrospective analysis of prehospital and hospital medical records, EMS and police radio transmissions, personal observations, and participant interviews were used for data collection. Descriptive technique including mean, range, and standard deviation represented numerical data. Triage analysis classified patients into 3 groups based on injury severity and type: high severity (Class I) with cardiorespiratory instability or open surgical and orthopedic trauma; moderate severity (Class II) with closed orthopedic trauma; and low severity (Class III) who were ambulatory with minor orthopedic trauma. Triage order (TO) assessed the sequence of transport from 1 to 15, in light of multiple patients in some units. The transport time (TT) was measured from the time on scene to hospital arrival in minutes. The City of Pittsburgh EMS system, comprised of 186 paramedics, is composed of 14 medical and 2 rescue units staffed by 2 paramedics per unit. Specialty services feature River Rescue, an independent unit staffed by paramedic divers with multiple craft capable of response to all waterways. Its annual call volume is 325 responses.3 Routine and special event medical care is provided under a protocol system with on-line physician input and field response by second- and third-year residents at the University of Pittsburgh

VUKMIR

AND PARIS n THE THREE RIVERS REGATTA ACCIDEN IT

FIGURE 1.

Formula I craft (“2nd Effort”).

Affiliated Residency in Emergency Medicine with attending physician support 24 hours per day. Its annual call volume is 68,500 patients, 16.6% of whom require ALS intervention.4 Medical care for the Regatta was based at the medical tent located at the base of the Point State Park triangle (Figure 3-l). This post was staffed by 2 paramedics, 1 supervisor, and 1 EMS physician with 4 additional paramedics and 2 mobile units to respond to park activities. The Regatta Command Post, a mobile communication center and supply depot, was staffed with 2 paramedics and 1 supervisor (Figure 3-2). The fountain post was a mobile unit with 3 paramedics located at the park apex (Figure 3-3). Race activities provided 2 additional paramedic units with a physician based on the north and south shores of the Allegheny River at the race preparation point and the Coast Guard cutter “Osage” (Figure 3-4). River rescue operations included 4 Achilles inflatable power boats with 3 paramedics respectively and 2 Boston Whaler craft with 2 paramedics, 1 police, and 1 fire personnel (Figure 3-5). Regatta staffing at the time of the accident included 7 EMS physicians, 32 paramedics, the medical director, the chief of paramedic service, and off& cials, in addition to normal citywide staffing. Communication was provided by integrated VHF transceiver (EMS, police, and fire) and secondary cellular phone system coordinated by the public safety dispatch and medic command service. The city is served by dual aeromedical systems with three rotocraft available within 3 miles. Medical facilities featured seven hospitals including four Level I trauma centers within 5 miles. RESULTS Analysis of medical care began with the triage process that involved the evaluation of 24 patients, 12 adult and 12 pediatric, with a mean age of 20.9 (range 2 to 61 years) (Table 1). The initial responder team consisted of 2 paramedics, stationed near the accident site, who furnished the first medical report indicating 20 patients involved (Table 2). Their visual assessment suggested 6 patients (EA, HJ, HJ, BD, HA, EJ) of critical status suffering predominantly from musculoskeletal injury, gross lacerations and open fractures approaching amputation. Initial triage was provided by two EMS physicians who discovered a pediatric patient (HJ) with head trauma and agonal respirations for whom airway control and transport was initiated to the nearest facility (TO, 1; TT, 12 minutes). Retrospective review revealed a patient (EE) with moderate severity injuries who was transported allegedly by an unauthorized police unit (TO, 0; ‘IT, 7 minutes). Formal triage was accomplished by the medical director, author, and remaining EMS physicians utilizing multiple physical examinations with verbal communication while

paramedic service chief assumed scene stabilization and transport roles. Triage priority was assigned by ATLS criteria for traumatic injury with focus on respiratory, hemodynamic, and neurologic function along with vital signs and patient age.5 A triage tag system was available but not implemented. Geographic triage was utilized, however, with grouping of high, moderate, and low severity patients in the transport staging area. Physician intervention revised the initial paramedic triage assessment to include two patients (MM and SJ) with previously undetected respiratory insufficiency due to pneumothoraces in both, as well as hypotension in the former patient. Patient care included cervical collar, cervical immobilization device (CID), and long board immobilization in 45.6% (1 l/24) of patients; IVs established in 41.6% (10/24); and military antishock trousers (MAST) suit inflation in 16.6% (4124). Transport was accomplished by ground, using nine vehicles to three adult (AGH, MH, PUH) and one pediatric (CHP) Level I trauma centers along with the nearest nontrauma designated facility (DP) located within a 5-mile radius. Aeromedical evacuation was not used because of the inability to secure a safe landing zone in this congested urban setting, the presence of adequately trained personnel on scene and the accessibility of local hospitals. Hospital choices for patients were determined by need balanced with space availability to accommodate an estimated number of casualties, as well as specialty consideration, eg, adult or pediatric facility. Final triage and transport assessment of 24 patients assigned 33.8% (8124) to the high severity group (I) (Table 3). Their TOs were 1 to 5 with a mean TT of 12.9 (range 10 to 24) minutes. EMS physicians accompanied 75% (618) of these patients, while the remaining 2 cases were accompanied by paramedic officials. The moderate severity group (II) consisted of 41.7% (10124) patients with TOs from 6 to 12 and a TT of 25 (range, 18 to 41) minutes. The low severity group (III) consisted of 25% (6124) patients with TOs from 13 to 15 and a mean TT of 49.7% (range 46 to 53) minutes. The mean TT was 22.4 (range 10 to 53) minutes for all patients involved. The hospitals used, AGH (1.3 miles), MH (2.1 miles), CHP (4.8 miles), PUH (4.9 miles), and DP (1.1 mile), received 6,2,8,5, and 3 patients respectively (Table 4). Ten (41.6%) of the 24 patients admitted were determined to be in critical (4), serious (3), or fair (3) condition. One

FIGURE 2.

“2nd Effort” veers to shore.

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FIGURE 3.

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Point State Park accident scene.

hundred percent (8/8) of patients in the high severity group required an intensive care unit stay or surgical intervention, while the two remaining patients were in the moderate severity group. The average hospital stay was 11.7 (range 2 to 29) days with one death. Hospital notification was accomplished by the preexisting medical communications network on dispatch channel 11. Mutual aid agreement was alerted for municipal coverage but not activated, as citywide medical care continued uninterrupted on dispatch channel 11, isolating the Regatta activities to a self-contained system. The general medical tent provided uninterrupted care using physicians, nurses, and off-duty city paramedics affiliated with the Center for Emergency Medicine of Western Pennsylvania. Over a 3-day period, 168 patients, including 4 transports, were evaluated. DISCUSSION The World Health Organization has defined disaster in a global sense as “a situation, which implies unforeseen serious and immediate threats to the public health.“6 Disaster in relative terms is an incident that creates casualties substantially in excess of the capacity of a local health system.7 Then, disaster is interpreted as a situation where resources and the ability to care for patients has been exceeded, or traditionally as an absolute number of casualties. An MCI is a smaller scale event with a manageable number of patients handled in an efficient manner that does not overwhelm health care resources. This concept allows categorization of the incident by time and resources required to provide medical care. This construct establishes Level I incidents as those requiring local resources delivered within 2 hours; Level II, those involving regional response within 12 hours; Level III, those involving statewide response within 24 hours; and Level IV, those using federal resources, requiring 24 hours for delivery of assistance.8 Traditionally, disasters have been described in quantitative terms specifying an absolute number of patients in addition to the qualitative descriptions discussed. Thus,

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accidents can be classified as a multiple patient incident resulting in 0 to 10 casualties and escalation of routine treatment protocols; a multiple casualty incident with 10 to 100 casualties based on escalation of routine protocol, but may require disaster plan implementation if resources are exceeded; and a mass casualty incident involving more than 100 patients, probably requiring regional disaster support.’ We submit that this event was in fact an MCI as opposed to a disaster, based on the number of patients encountered and the adequacy of the EMS response. Disaster planning today is represented by a number of different forms. The Civil Defense Model, based on military planning requires a predisaster alert, uses “field medical units” emphasizing first aid and BLS care, and provides rapid patient delivery to the hospital.‘.” This model is most appropriate for large-scale accidents, true “disasters” requiring national, state, or regional support, or local events where resources are limited. One such formulation is the National Disaster Medical Systems (NDMS) approach established in 1981.” This national disaster policy includes 5 medical care functions: field rescue, casualty clearing, emergency surgical stabilization. medical staging, and definitive care.” The EMS model uses central command escalation of routine response, requires no previous alert, and emphasizes triage, field stabilization, and ALS care.‘.‘* This model is probably more suitable for an MCI managed with local resources. Butman found in an analysis of 51 MCIs that most responses are based on EMS activity, not an organized disaster plan.‘* The EMS model of disaster planning was used for the Regatta accident. The success of this rescue operation is based on escalation of routine response of the EMS system using standard treatment protocols with on-site physician input. Disaster or MCI response begins with planning summarized by Nancekievill as “the least possible, as quickly as possible, as simply as possible, for as many as possible.“13 Event specifics should be analyzed to determine planning needs. Patient demographics can be predicted by the type of event. Crowd size and composition should be examined noting patient age-range, along with other factors such as alcohol or drug use. Environmental conditions also contribute to the type of medical care required. Geographic consideration

FIGURE 4.

Crash scene.

VUKMIR AND PARIS n THE THREE RIVERS REGATTA ACCIDENT

TABLE 1.

Patient Triage and Transport

Triage Classification

Patient

Age/Sex

GCSITS

Trauma Protocol

11/F

15116

7/M

416

9/M

15116

15/M

15116

3/F

15116

6/M

Ill

9/M

15116

13 14

Ill Ill

ST DN

2/M 39/F

15116 15116

46 50

15 15

Ill Ill

WR CA

23/M 24/F

15116 15116

_ _

53 53

TT (min)

often dictates the mode of medical care including patient access and transport. The geography of this event, a crowd situated on three land masses separated by two rivers, required adequate prior planning for provision of medical care, essentially an amphibious EMS response. Staffing should be adequate and include initial responders providing triage, treatment, and transport teams, ideally a continuum. Guidelines for personnel required can be extrap-

Diagnosis Pelvic herniation, left gastrocnemious laceration Subdural hematoma, right lower extremity compartment syndrome Pancreas transection Grade IV, splenic laceration, evisceration Bilateral intraarticular knee laceration Left and right tibula/ fibula open fracture, left radial/ulnar fracture Hematuria, leg laceration Right pneumothorax hemoperitoneum L2,3,4 fracture, right acetabular fracture, right Grade IV foot fx. C2,3 C3.4 subluxation pneumothorax Left thoracic contusion Multiple abrasions and contusions Multiple abrasions and contusions Right inguinal hematoma Right hip contusion Right rotator cuff tear Multiple abrasions Left lower extremity abrasion Left lower extremity sprain Thoracoabdominal abrasion Closed head injury Right lower extremity contusion Anxiety reaction Anxiety reaction

ICU

Condition

Disposition

Pt. Stay

Critical

Fair

Serious

Fair

Serious

Critical

D D Fair

D D D D D D D D D D

olated from recommendations for mass gatherings to include one physician for every 12,500 to 15,000; 2 paramedics for every 10,000; and 1 EMT for every 5,000 to 12,500 spectators. 14*153 Medical staffing at the Regatta was s&icient to provide each patient with 2 paramedic responders, physician triage, and separate paramedic transport personnel. Medical teams should have adequate supplies adapted to

TABLE 2.

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Accident

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Sequence

Time

Event

14:05

Formula I boat strikes North Shore. First radio transmission unintelligible report on police frequency. Nature of call and site identified. 15-20 patients identified with 6 critical. Notification of River Rescue units. Five adjacent paramedic units to coverage site. Medical tent staff (4 physician, 4 paramedics) proceed to the site via Coast Guard craft. Medical tent remains operational. Total on-site assembled personnel include 7 physicians, 32 paramedics, and 5 paramedic official and supervisors. Hospital notification begins. Regatta Command assumes Dispatch I priority while city-wide operations transfer to Dispatch II. First patient transport occurs. Hospitals notified of disaster status and patient information. Mutual aid agreement alert for city-wide service but not activated. First patients arrive at hospitals. Police clear ali access routes and escort all vehicles to hospitals. All patients en route to hospital (24 patients evacuated in 32 minutes). All patients arrive at hospital.

14:07 14:08

14:OQ

14:12

14:13 14:16 14:18 14:20 14:22 14:29 14:37 14:58

the particular event. This includes provision for both adult and pediatric patients along with preparation for adverse weather conditions. Regatta planning provided adequate supplies for 30 trauma patients including back board, CID, cervical collars, MAST, and IV apparatus carried by the aquatic initial responder teams. Central communications should be used emphasizing preexisting medical command frequencies with multidisciplinary involvement including EMS, police, fire, and hospital personnel, Regatta communications were coordinated through an on-site command post, and all radio transmissions including hospital notification were provided without impinging on routine, citywide EMS function. Hospital notification was completed within 13 minutes of the event by the Regatta command post, and additional patient information was provided by individual paramedic units. Examination of hospital records revealed that 4 patients arrived without standard patient notification. Communications were also scrutinized as there was a two-minute delay from the time of the accident to the EMS notification by police radio transmission. Initial reporting of a disaster has been cited as the first weak link in the communication chain.” Support for a disaster or MCI where police and fire personnel provide scene stabilization is often neglected. Fire prevention at the Regatta was provided initially by River Rescue and two Boston Whaler craft along with one standard fire response vehicle. Police provided the invaluable service of crowd control, establishing the single access route to the accident site, as well as closing all transport routes to routine vehicular tratfic while EMS vehicles completed patient transport. Mutual aid agreement with suburban EMS systems to monitor citywide operation was activated, but

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not implemented, as the five remaining paramedic units provided normal EMS coverage. The term triage originates from “trier,” French meaning “to cull” as was done by wool merchants of the period.i8 Triage for routine events involves patient classification according to need, but, for a disaster or MCI, it involves prioritization of all patients to achieve the most benefit for all. This premise can be simply stated as “the greatest good for the greatest number.“I However, in most MCIs, triage is performed improperly or not at all.” Triage assessment of prehospital casualties begins with physical examination by the most highly trained health care provider available, EMS physicians in this case, followed by paramedics, nurses, or EMTs. However, it should be emphasized that expertise in prehospital medical care is the paramount factor in this hierarchy, not job classification. Prehospital assessment can be synthesized using severity scores based on physiologic parameters such as the Glasgow Coma Score (GCS), Trauma Score (TS), Illness-Injury Severity Index, Circulation Respiration Abdomen Motor Score (CRAMS), and anatomic variables such as the Injury Severity Score (ISS).‘9-2’ The choice of the best assessment system involves analysis of validity balanced by ease of use and familiarity of medical care provider. Also important in the discussion of triage assessment systems is to realize that the most underemphasized but potentially sensitive criterion of injury is the clinical impression of the health care provider. I8 Patient assessment for the Regatta was accomplished initially using ATLS criteria for traumatic injury described previously along with two injury severity scores. The GCS assesses the degree of mental status alteration in patients with craniocerebral injury ranging from 3 to IS. I9 The trauma score is based on the GCS and weighted cardiopulmonary variables rated from 1 to 16.” These injury severity scores have been validated for neurologic, blunt, and penetrating trauma.‘5*20,24 The patients encountered in this event had a mean GCS of 14.5 (range, 4 to 15) and TS of 15.7 (range, 8 to 16). Disaster incidents have generated much controversy regarding means of triage organization, communication of priority, and patient classification. Scene organization and communications have traditionally been based on triage tag system. This premise has been acceptable in theory but has failed in common practice. 26.27 In fact, there has been no documented use of triage tags in MCIs of 25 or more patients since 1979 or in an analysis of 180 mass casualty events.‘* Even the use of dynamic victim tracking cards for moderate length drills (0 to 4 hours) or shorter drills (0 to 30 minutes) have been suboptimal with accurate triage assessment in

TABLE 3. Class

Triage Category Severity

High

Moderate

Ill

Low

Patients

Total

l-r

33.3%

l-5

41.7%

6-12

25.0%

13-15

12.9 minutes (1 O-24) 25.0 minutes (18-41) 49.7 minutes (46-53)

VUKMIR AND PARIS n THE THREE RIVERS REGATTA ACCIDENT

TABLE4. Transport Hospitals

Hospital AGH MH CHP PUH DP

Severity

Trauma Designation

Distance (Miles)

Patients (No.)

Ill

Age (AduWPeds)

I I I (Ped) I ill

1.3 miles 2.1 miles 4.6 miles 4.9 miles 1.1 miles

6 2 6 5 3

4 2 2 0 0

1 0 4 3 2

1 0 2 2 1

313 2/o 016 3/o 5/o

only 43.6% of cases in the latter.28.29 Triage tags were available but not used for this event as ample patient care resources and rapid transport were available. Geographic triage is patient classification according to location, by design, or naturally where the most severely injured are located at the area of impact while less severely injured are located peripherally; it has been suggested as an alternative approach, if scene safety is ensured.26 The advantage of this approach is that patients are categorized to some extent by the incident itself as was the case in this event with highseverity patients localized to the impact site. We hope to stress as other authors have that the “Daily Routine Doctrine” or keeping as close as possible to standard EMS operations is the most effective approach to the MCI until resources become the limiting factor.3o Finally, more elaborate mass casualty triage schemes have been suggested, using 2, 3,4, and 5 tier systems.8*3’“3 Most MCIs, however, are not limited by resources, and medical care can be atforded to all patients, negating the deceased or unsalvageable categories of the more elaborate systems. The two-category system delineating major and minor injury is the most simplistic. A three-tier system described classifies patients into those with cardiorespiratory dysfunction in 10% of patients requiring immediate care and KU stay; general medical and surgical in 30% requiring hospital admission; and orthopedic in 60% suffering from wounds and fractures suitable for hospital discharge.3’ Patients encountered at the Regatta had more extensive injury than suggested by the prior analysis or the GCS or TS assessment with 33.3% Class I, 47.7% Class II, and 25% Class III. Comparison of triage category and outcome finds that 100% of the high severity patients required ICU admission or operative intervention, while there were no cases of undertriage, where low severity patients required aggressive intervention. The moderate severity group consisted of the 2 additional patients hospitalized while 8 others were discharged after therapy. Several patients in this group may have been overtriaged, a common difficulty encountered with physician assessment at the accident scene.34 The low severity group included 6 patients, all of whom were subsequently discharged with minor injury. This group was free of under- or overtriage bias. Two cases warrant identification and explanation. Patient EE with lower extremity laceration was assigned to the moderate severity group but was the first patient to arrive at the hospital (7 minutes). This occurred because of an unauthorized nonmedical transport allegedly by a city police unit or spectator. Patients HJ (subdural hematoma) and BD (abdominal evisceration) were transported by fist unit from the scene to the closest Level I facility (AGH) in 12 minutes.

However, the second patient transported, EA (intraarticular knee lacerations), arrived at MH in 10 minutes.There was no extrication required, but the former unit encountered traflic delay before access routes were secure. We feel that patient care rendered at the Regatta substantiates the need for an EMS physician at the accident scene. Standard treatment protocols included airway support, intravenous lines, MAST, and spinal immobilization utilizing the CID, cervical collar, and long board placement for 50% (12/24) of those evaluated, including 100% (818) patients requiring ICU admission or surgical intervention. Also of significance was the large number of pediatric patients encountered, 50% (12/24), which included 75% (618) of the high severity group. Their care was provided by EMS physicians with residency training in pediatrics (5 of 36 months), responsible for pediatric trauma aeromedical transport on a daily basis. The paramedics also received pediatric inservice including pediatric intubation as a routine curriculum. This is significant in that little has been reported concerning pediatric care in disasters. The sole reference described experience with the 1,000 bed field hospital established for the air lift of 1,600 Vietnamese orphans suggesting that 20 pediatric patients exceeds the resources of most pediatric facilities.3’ Retrospective analysis of the Regatta demonstrated that physician triage allowed patients with the highest injury severity to be transported to trauma centers while patients with lower injury severity were transported to adjacent nontrauma facilities or underwent secondary transport to trauma facilities. This avoided the common disaster triage difficulty of transporting a large number of casualties to the nearest hospital, leaving the most severely injured requiring longer extrication times to be sent to more distant facilities.36 Ground transport was used exclusively for this event, although aeromedical service was available. The geography, including a hillside accident site and congested adjacent parking facilities, offered no landing zone, requiring 100 x 100 ft ground space without aerial obstruction. Proponents of aeromedical evacuation suggest that a higher level of expertise is delivered to the accident scene, transport speeds 2 to 3 times faster are obtained, and access to geographically isolated patients unreachable by ground are provided.37 These advantages were clearly not an issue in this case, and the addition of helicopter transport might have compromised scene safety. It is suggested in one study that because of logistic considerations, longer transport times are associated with aeromedical (58 minutes) than ground (35 minutes) transport. 37 The benefits of aeromedical care are sound, but are best suited for rural areas with prolonged ground transport time and low level scene expertise.

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Transport order and severity classification compared with final diagnosis, and disposition was consistent for all patients encountered with high, moderate, and low severity transported in the sequence of nos. 1 to 5, 6 to 12, and 13 to 15, respectively. All high-severity patients were transported to trauma centers (AGH, MH, CHP); the most severely injured children were directed to AGH, the remainder to CHP. Patients were transported from the accident scene to the hospital in 12.9 minutes for high severity and 22.4 minutes for all patients. These transport times compared favorably with those of a recent study that found a mean time of 18.3 minutes (“6.13) for trauma patients evacuated from the scene to hospitals within 5 miles.38 Disaster planning should have adequate provision for documentation. Regatta quality assurance analysis revealed that the documentation of patient transport records was suboptimal predominantly by paramedic units that rapidly returned to the accident scene. This has been a common finding as suggested by Vayer who stated that with a heavy patient load paperwork is the first to suffer.26 Recommendations for improvement of documentation include a requirement for early completion, even if retrospective; and the availability of unified multiple patient care trip sheets for pertinent information. Debriefing begins with a discussion of posttraumatic stress disorder (PTSD), defined as the presence of a recognizable stressor, tendency to reexperience the event, numbing of responsiveness to the environment, and at least two symptoms of altered alertness, insomnia, guilt, memory impairment, and avoidance of activities that are reminiscent of the event.39 This response is greatest in the patients involved, with 90% experiencing repeated recall of this event and 20% experiencing interference with daily activity.40 Analysis of prior disaster events show that symptoms of PTSD are also present in 80% to 90% of medical personnel involved.40,41 This response occurs in emergency care workers responding to contained small-scale incidents (MCI) as well as to devastating disasters.26*36 Prehospital personnel were affected to a greater extent than were hospital staff involved in disaster medical care.4’ Debriefing procedures for Regatta personnel were felt to be inadequate, occurring 3 months after the event as part of a generalized critical incident stress management program. Interviews with paramedics suggested that the most disturbing aspect of this event was the large number of pediatric patients encountered, reminding them of their own families. Also, the amphibious rescue “assault” resulted in recollection of wartime activities in those paramedics with combat experience. However, there were no cases of EMS personnel requiring counseling over this event. Our recommendations suggest that early debriefing by trained mental health professionals should be included in future MCIs or disasters. Finally, the need for physicians to supervise medical care at mass gatherings or disasters is not well documented, even though field triage has been associated with a 20% to 30% rate of error.42 Examination of the 1984 Los Angeles Summer Olympics found that physician intervention was required in 29% of the 5,516 patient visits resulting in a 9% transport rate. 43 Rutherford concluded that it was “a myth that medical teams should dash to the site of every major medical disaster.“2 However, he emphasized that if physi-

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cians are involved they should have EMS experience and would contribute by coordinating hospital communication, diagnosing occult injury during triage, and adapting patient injury severity to the transport hospital as was found in this case.2 The Moorgate Train Disaster allowed Finch to conclude that “any major accident plan should be based on the designated hospital; however, mobile medical teams perform invaluable on site services provided that hospital resources are not drained.“44 An increasing body of evidence favors physician intervention in disaster situations. Champion found that patients selected by physicians for helicopter transport had a significantly higher median level of injury severity.34 Meislen concluded that acute medical emergencies occur at public gatherings and that medical coverage on site has proven benefits.45 This intervention can be quantified as an improvement in outcome of patients assessed and treated by physicians in the prehospital realm.46s47 It has been found that the activity of medical teams at the accident scene clearly helps to reduce mortality and improves patient outcome of physician-staffed EMS programs.37*48.49 In this light, it is felt that physician involvement at this MCI was advantageous. First, the entire rescue response was coordinated from the scene, offering a clear advantage over hospital-based direction in that patients were directed to the proper facility and hospital overload was avoided. It should be emphasized that to be effective health care providers should have this operation mode as part of their routine protocol. Objective evidence of this contention was a correlation of triage and transport order with hospital disposition. The single death occurred in a patient who suffered significant head injury with a GCS of 4 and TS of 8, already predisposed to a poor outcome. Physician intervention was responsible for altering the initial paramedic triage assessment to prioritize two patients with occult cardiorespiratory dysfunction with hemodynamic instability (MM and SJ) in place of patients with severe orthopedic trauma. This error of omission has been previously cited, as chest auscultation is often neglected at the noisy accident scene.34 Although any error in triage is not desirable, overtriage is acceptable if adequate resources are present. CONCLUSION Analysis of the medical care rendered at this MCI suggests that positive aspects included a prehospital yet integrated response, adaptation to the geographic considerations of the waterways, preparation for pediatric casualties, and physician-directed triage and transport. The weaknesses found were of an administrative nature, namely inadequate documentation and subsequent participant debriefing. Scene control can also be cited for the unauthorized transport of a patient (EE), along with delay in the initial accident report. We conclude that the 1988 Three Rivers Regatta Accident was met with a successful EMS response based on accentuation of prehospital care provided by the City of Pittsburgh paramedics and physicians. Special thanks to Janet McGraw for manuscript preparation; Mr William Miller, Ronald N. Roth, MD, Mr Walter Stoy, Mr J. Vetter, and the West Penn Hospital Medical Media Department for photographic assistance; Presbyterian-University, Children’s, Mercy, and Divine Providence Hospitals; Daniel Diamond, MD;

VUKMIR AND PARIS n THE THREE RIVERS REGATTA ACCIDENT

and University of Pittsburgh Affiliated Residency in Emergency Medicine whose Residents and Attending participated in patient care. Finally, our sincere appreciation to the City of Pittsburgh Paramedics, Supervisors, and Chief Robert Kennedy for their invaluable assistance.

REFERENCES 1. American College of Emergency Physicians: The role of the emergency physician in mass casualty disaster management. J Am Coll Emerg Physicians 1976;5:901-902 2. Rutherford WH: Experience in the accident and emergency department at the Royal Victoria Hospital. Injury 1973;4:189-199 3. Weiss LD, McCaughan RJ, Paris PM, et al: The development of a water rescue unit in an urban EMS system. Ann Emerg Mad 1989;18(8):884-891 4. Stewart RD, Paris PM, Heller MB: Design of a resident in-field experience for an emergency medicine residency curriculum. Ann Emerg Med 1987;16(2):175-179 5. American College of Surgeons: Committee on Trauma. Advanced Trauma Life Support Program. Chicago, IL, 1989;1112 6. Lechat MF: The epidemiology of disasters. Proc Royal Sot Med 1976;69:421-426 7. Mahoney LE, Reutershan TP: Catastrophic disasters and the design of disaster medical care systems. Ann Emerg Med 1987;16(9):1085-1091 8. Geiderman J, Paris PM: Disaster planning. In Auerbach P and Geehr E (eds): Management of Environmental Emergencies. New York, NY, Macmillan, 1983, pp 556-584 9. Waeckerle JF: Recent disasters: a review of the preparedness with future guidelines. ACEP publication, 1988, WE-98;1-11 10. Melton RJ, Riner RM: Revising the rural hospital disaster plan: a role for the EMS physician in managing the multiple casualty incident. Ann Emerg Med 1981;10:39-44 11. Brandt EW, Mayer WN, Mason JO, et al: Designing a national disaster medical system. Public Health Reports 4, September-October, 1985;100:455-461 12. Butman AM: Responding to a mass casualty incident: a guide for EMS personnel. Westport, CT Educational Direction, 1982;34-35 13. Nancekievill DG: The management of the acutely ill: immediate care of casualties. In Payne JP, Hill DW (eds): Peregrinus, London, England, 1977; p 17 14. Sanders AB, Criss E, Steckl P, et al: An analysis of medical care at mass gatherings. Ann Emerg Med 1986;15:515-519 15. Department of Health, Education, and Welfare: Emergency Medical Services System Program Guidelines. August 1979, publication 79-2002 16. Brown WE, Webb B, McCoy K: EMS at the Indianapolis 500. Emergency Medical Services 1978;7:125-127 17. Moles TM: Planning for major disasters. Br J Anesth 1977;49:643-649 18. West JG, Eastman AB: Field triage in trauma, first edition, Mattox KL (ed). Appleton & Lange, Norwalk, CT, 1988, pp 79-89 19. Teasdale G, Jennet B: Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;2:81-83 20. Champion HR, Sacco WN, Carnazzo AJ, et al: Trauma score. Crit Care Med 1981;9:672 21. Bever DG, Veenker CH: An illness-injury severity index for nonphysician emergency medical personnel. EMTJ 1979;3:45 22. Gormicon SP: CRAMS scale: field triage of trauma victims. Ann Emerg Med 1986;11(3):132-135 23. Baker SP, O’Neill B, Haddon W, et al: The injury severity

score: a method for describing patients with multiple injuries. Trauma 1974;14(3):187-196 24. Alexander A, Columbo F, Nentempi J, et al: Cognitive outcome and early indices of severity of head injury. J Neurosurg 1983;59:751 25. Champion HR, Sacco WJ: The trauma score as applied to penetrating injury. Ann Emerg Med 1984;13:6 26. Vayer JS, TenEyck RP, Cowan ML: New concepts in triage. Ann Emerg Med 1986;15(8):927-930 27. Orr SM, Robinson WA: The Hyatt Regency skywalk collapse: an EMS based disaster response. Ann Emerg Med 1983;12:601-605 28. Milholland AV, Conley RA, Panos ML: Patient vital sign cards. J Trauma 1981;21(1):52-54 29. Paris PM, Stewart RD, Pelton GH. et al: Triaae success in disasters: dynamic victim tracking cards. Am J-Emerg Med 1985:3(4):323-326 30.. Byrnes DP: The Belfast experience in mass casualties. First International Assembly on Emergency Medical Services, US Department of Transportation 1982;83-84 31. deBoer J, Baillie TW: Progressive medical care in disaster situations. Am J Emerg Med 1986;1:339-343 32. Nissan S, Elder RM: Organization of surgical care of mass casualties. J Trauma 1971 ;11:974-978 33. Ammons MA, Moore EE, Pons PT, et al: The role of a regional trauma system in the management of a mass disaster. J Trauma 1988;28(10):1468-1471 34. Champion HR, Sacco WJ, Gainer PS: The effect of medical direction on trauma triage. J Trauma 1988;28:235-239 35. Stalcup SA, Oscherwitz M, Cohen MS, et al: Planning for a pediatric disaster. N Engl J Med 1975;293(14):691-699 36. Haynes BE, Dahlen RD, Pratt FD: A prehospital approach to multiple victim incidents. Ann Emerg Med 1986;15:458-462 37. Baxt WG, Moody P: The impact of a rotocraft aeromedical emergency care service on trauma mortality. JAMA, 1983; 249:3047-3051 38. Luterman A, Ramenofsky M, Berryman C, et al: Evaluation of prehospital emergency medical services: defining areas for improvement. J Trauma 1983;28:702-707 39. Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. American Psychiatric Association 1987;247-250 40. Wilkinson CB: Aftermath of a disaster: the collapse of the Hyatt Regency Hotel skywalk. Am J Psychiatry 1983;140:11341139 41. Durham TW, McCammon SL, Allison EJ: The psychological impact of disaster on rescue personnel. Ann Emerg Med 1985;14:664-668 42. Burkle FM, Sanner PH, Woldolt BW: Disaster medicine. New York Medical Examination Company, New York, NY, 1984 43. Baker WM, Simone BM, Neimann JT, et al: Special event medical care: the 1984 Los Angeles summer Olympics. Ann Emerg Med 1986;15:185-190 44. Finch P, Nancekievill DG: The role of hospital medical teams at a major accident. Anesthesia 1975;30:666-676 45. Meislen HW, Rosen P. Sternbach GW: Life suoaort systems: emergency. medical care for conventions. J Am Coll Emerg Physicians 1976;5:351-354 46. Pantridge JF, Geddes JS: A mobile intensive care unit in the management of myocardial infarction. Lancet 1967;2:271 47. Jacobs LM, Sinclair A, Beiser A, et al: Prehospital advanced life support: benefits in trauma. J Trauma 1984;24(1):813 48. Gerace RV: Role of medical teams in a community disaster plan. Can Med Assoc J 1979;120:923-928 49. Jacobs LM, Sinclair A, Beiser A, et al: Prehospital advanced life support: benefits in trauma. J Trauma 1984;24(1):813

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