TRAUMA AT THE TUNNEL. Trauma at the Tunnel
Los Angeles Metrolink train crash presents crews with unprecedented triage, treatment and transport challenges
Thu, Apr 30, 2009 By Marc Eckstein, MD, MPH, FACEP
It was the worst railroad accident in California history.
On Friday, Sept. 12, 2008, at 4:23 p.m., Metrolink 111, a commuter train headed northbound from Union Station in downtown Los Angeles, collided head on with a southbound freight train in Chatsworth, a suburb of L.A. The commuter trainâ€™s engineer failed to yield to a track signal that warned of the approaching freight train. The freight train exited a tunnel, rounded a sharp curve and hit the commuter train without warning to passengers.
The impact drove the locomotive pulling the passenger train back almost 60 feet into the first passenger car, instantly killing and trapping more than two dozen passengers. The impact and severe deceleration also caused multiple injuries, a fire and a diesel fuel spill. This crash killed 25 passengers and crew members and injured 133, many critically.
Notification & Response
The L.A. Fire Department (LAFD) dispatch center received the first telephone call from a homeowner in the immediate area of the crash at 4:23 p.m., and resources were dispatched one minute later to a â€œtraffic accident with trapped victims.â€ The initial response included three engine companies, a truck company, one paramedic ambulance, a heavy rescue unit, an EMS captain and a battalion chief. Another call was then received directly from an uninjured train passenger who described the crash.
After receipt of firsthand information, the LAFD dispatch center doubled the assignment utilizing the â€œtrain derailmentâ€ category, which included an additional truck, engine, paramedic ambulance, two BLS ambulances, another EMS captain and an assistant chief. In addition, LAFD air operations was notified to respond to the incident with all three air ambulances.
The responding LAFD paramedic ambulance crew established communications with the L.A. County Medical Alert Center (MAC) even before they arrived on scene, based on the information provided on the dispatch printout. The MAC helps coordinate large-scale incidents in L.A. County, especially those that involve mutual aid and the transport of more than 10 patients requiring ALS.
The MAC initiated a computer poll of all regional trauma centers in the county to determine their bed availability and inform all hospitals of a large-scale disaster, using an Internet-based hospital communication system.
Eight minutes after the actual crash (seven minutes after the initial dispatch), the first LAFD paramedic ambulance arrived on scene. Access to the crash site was limited because of its location on a remote section of track just before the tunnel. The best access route to the crash site was a narrow dirt road approximately one-quarter mile long.
The first engine company performed a size-up of the scene and reported a crash between a freight train and passenger train with subsequent derailment and fire as well as numerous injuries, fatalities and entrapped victims. They requested multiple additional resources and began initiating fire suppression activities. The next arriving resources immediately began to assist ambulatory patients off the train and performed triage utilizing the START (Simple Triage and Rapid Treatment) system and triage tags.
A Union Pacific freight train had been traveling southbound at approximately 40 mph when it collided head on with the Metrolink train traveling at approximately the same speed. Because the freight train had just exited a tunnel and was rounding a curve, the Union Pacific engineer had 30 seconds to react to seeing an oncoming train on the same track.
Because the Metrolink engineer never saw or reacted to the oncoming freight train, the head-on impact occurred with a combined speed of approximately 80 mph. No warnings or alarms were sounded to give the passengers any time to brace for the impact.
The Union Pacific freight train had two locomotives, each weighing more than 500,000 lbs., and it was pulling 17 freight cars. The Metrolink passenger train had a single 250,000-lb. locomotive that was pulling three double-decker passenger cars, each weighing 112,000 lbs. The impact resulted in the lead freight train locomotive driving the Metrolink locomotive back almost 60 feet into the first 85â€² passenger car, causing catastrophic damage. The freight train locomotive derailed, along with several of its cars, spilling their contents and igniting diesel fuel.
The fire was knocked down within 30 minutes. Incoming companies were divided into an extrication group and a medical group. Access to some of the live, trapped victims was challenging and required the extrication of multiple deceased victims in order to access the live victims.
Within 25 minutes of the crash, two of LAFDâ€™s highly skilled urban search and rescue task force companies and a heavy rescue extrication apparatus were on scene. Firefighters assigned to these resources were critical in shoring up the first passenger car, which was leaning precariously toward one side. The rescue teams performed multiple complex extrications to free the trapped victims using hydraulic spreaders, cutters, rams, reciprocating saws and other forcible-entry tools.
Aerial ladders were used to lift the deceased after extrication. The bodies were lowered to the south side of the trains, out of the view of the live victims being extricated, triaged and treated on the north side. This area was set up as a temporary morgue.
Firefighter paramedics from arriving apparatus helped perform rapid triage. A massive treatment area was established in a large, grassy area by a private school near the crash site. Color-coded tarps (red, yellow and green) were laid out to position, treat and re-triage the immediate, delayed and minor patients. Scene tape was used to further define each treatment area.
A staging area was established for incoming ambulances, and a corridor was established to allow easy loading and transport of patients. A total of 30 LAFD ambulances responded to this incident and provided patient transports. Another 31 private ambulances arrived at the incident staging area but were not utilized for transport.
One particularly challenging aspect of this incident was the extremely high percentage of patients triaged as â€œimmediate.â€ Most MCIs described in the literature typically have no more than 20% of all victims triaged as immediate. In this incident, out of the 133 patients treated, 62 (47%) were classified as â€œimmediate,â€ 23 (17%) were â€œdelayedâ€ and 48 (36%) were â€œminor.â€ Eighty-nine percent of the immediate patients were transported to trauma centers. Twenty-five passengers were declared dead on scene.
This high volume of Priority 1 and 2 patients necessitated that secondary triage be carefully performed for the â€œimmediateâ€ patients. This was particularly critical because only one helicopter could land at a time due to the remote location of the incident. A secure â€œhelispotâ€ was established in a nearby parking lot for this purpose.
This need to re-triage a high number of patients is of particular importance for prehospital providers in terms of disaster planning and MCI training. START triage doesnâ€™t further subdivide triage categories once patients are assigned as â€œimmediateâ€ and when transportation resources are limited.â€ž
Examples of patients in the â€œimmediateâ€ (Priority 1) category who were transported first were those in obvious shock and/or respiratory failure. Patients initially triaged to the â€œdelayedâ€ (Priority 2) category who were later re-prioritized to the â€œimmediateâ€ category included one patient who developed severe abdominal pain and who had obvious peritonitis on physical exam; an elderly patient (who was on warfarin) with an expanding hematoma secondary to a closed femur fracture, and a young woman with multiple traumatic injuries who developed respiratory failure and exhibited profound decrease in her mental status.
A constellation of other traumatic injuries confronted the EMS crews. Many patients had severe blunt trauma from striking hard surfaces inside the train after the severe deceleration of the crash. No restraint systems were in place in the cars; tables, open staircases and the hardened plastic of the walls and seats caused substantial injury. Patients presented with flail chests, severe head injuries, open fractures, burns, pelvic fractures and intra-abdominal injuries. The forces involved were so massive that there were two fatalities in the third (rear) car, even though this car had no visible signs of damage and did not derail.
A total of 98 patients were transported from this incident via 30 ambulances; they were transferred to 22 hospitals and eight trauma centers located within a 30-mile radius of the crash site. Patient distribution among many hospitals was a key component of the successful mitigation of this incident. Patients were transported to four Level I trauma centers and four Level II trauma centers.
Due to heavy traffic conditions at the time of the crash (rush hour on a Friday evening in L.A.) and the remote location from the rest of the city, air transport was vital to provide rapid transport of many of the most critically injured patients.
A helispot was established in a nearby school parking lot adjacent to the grass field where the treatment areas were located. Air ambulances from LAFD, L.A. County Fire Department and L.A. County Sheriffâ€™s Department responded to the incident and transported critically injured patients. Each of the LAFD and L.A. County helicopters could carry two patients at a time, and the L.A. County Sheriffâ€™s Department rescue helicopter (a Sikorsky Sky King) could transport up to five patients at a time.
A total of 34 patients were transported by 16 helicopter transfers, all of which went to Level I trauma centers. Patient distribution was as follows: 25 immediate patients went by helicopter to four Level I trauma centers; 39 patients went by air and ground to four Level II trauma centers; and 34 patients went by ground to eight local community hospitals.
Despite the usual lack of inpatient beds and high prevalence of emergency department overcrowding and ambulance diversion in L.A., the initial poll by the MAC found that hospitals indicated they could accept more than 200 immediate patients and almost 300 delayed patients.
Of the immediate (Priority 1) patients transported to area trauma centers, almost one-third were sent for emergency surgery soon after hospital arrival. As a true indication of how well this incident was mitigated, only one patient who was extricated from the train as critical but alive subsequently died; this patient had life support withdrawn in the hospital due to massive traumatic brain injury.
Despite overall good outcomes of critical patients, this incident posed many unique challenges for the responding prehospital providers. Difficult access and egress from the crash site, exposure to horrific scenes of carnage, exposure to a significant amount of blood and bodily tissues and fluids, an unusually high percentage of critically injured patients, and several highly complex extrications required a rapid and well-coordinated response.
Convergent volunteers from the surrounding community, many of whom were off-duty health-care professionals, and a large contingent of law enforcement collaborated to successfully mitigate this tragedy. The incident command system (ICS) and early establishment of a unified command greatly facilitated the organization and management of this complex incident.
The ability of LAFD, the primary responding agency, to quickly mobilize so many resources and personnel was essential to minimizing further loss of life. The commitment of LAFD resources over the 29-hour deployment included 42 fire companies, 12 truck companies, five USAR units, 30 ambulances, 28 chief officers, seven EMS captains, six air ambulances, and numerous other support staff and specialty apparatus. Extrication and rescue efforts continued until 9:30 p.m. on Day 2.
Adding to the tragedy, a uniformed Los Angeles police officer was one of the fatalities. Her body was extricated around 10 p.m. A makeshift memorial procession was held, as her flag-draped body was carried out of the wreckage by her fellow officers. She was carried past more than 100 of her fellow law enforcement colleagues, fire and EMS personnel, and numerous political leaders, and into a waiting LAFD ambulance, in a show of respect.
LAFD, along with the Glendale Fire Department and multiple other local agencies, had responded to a previous Metrolink crash in 2005. However, that incident had only 25 immediate patients and 11 fatalities, and was in an urban location much more centrally located to roadways easily accessed by responding resources. Many of the lessons learned from the 2005 Metrolink train crash were applied and incorporated into this incident. These include: Immediate implementation of ICS and early establishment of a unified command; Early establishment of communications to permit hospital notification and polling about bed availability; Rapid response of specialized urban search and rescue teams; Use of helicopters for the transport of critical patients; Effective use of the mutual aid system; Transport of the most critically injured (â€œimmediateâ€) patients to trauma centers rather than the closest hospitals; Close coordination with the L.A. County Medical Alert Center (MAC) to help scene managers determine bed availability, keep hospitals informed about the scope of the incident and the patients they would be receiving, and also coordinate patient tracking from input by hospitals; Effective use of air ambulances to send critical patients to more distant trauma centers; Accurate and timely triage (and re-triage) of patients; Use of teams to move patients to treatment and transport areas; Use of law enforcement personnel to treat and assist in the transfer of patients; and The importance of frequent MCI training, drills and interagency cooperation.
The National Transportation Safety Board investigation determined that the Metrolink engineer was text messaging just prior to the crash. This activity caused him to fail to pull onto a parallel train track to let the freight train pass. Consequently, the passenger train collided without warning with the oncoming freight train. This led to the death of 25 people and resulted in injuries to 133 passengers.â€ž
The ability of a large, fire-based EMS provider to rapidly respond with hundreds of firefighter/EMTs, paramedics and other specialized personnel, and the mutual aid response of neighboring fire departments, law enforcement and multiple other agencies, along with convergent volunteers, led to the successful mitigation of this tragic collision. All who responded to this incident demonstrated the utmost professionalism, dedication and proficiency in the finest traditions of EMS, fire service and law enforcement. JEMS
References 1. de Ceballos JP, TurÃ´gano-Fuentes F, Perez-Diaz D, et al: â€œ11 March 2004: The terrorist bomb explosions in Madrid, Spainâ€”An analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital.â€ Critical Care. 9(1):104â€“111, 2005. 2. Frykberg ER, Tepas JJ III: â€œTerrorist bombings: Lessons learned from Belfast to Beirut.â€ Annals of Surgery. 208(5):569â€“576, 1988. 3. Eckstein M, Chan LS: â€œThe effect of emergency department crowding on paramedic ambulance availability.â€ Annals of Emergency Medicine. 43(1):100â€“105, 2004. 4. Heightman AJ, Mohlenbrok S, Eckstein M: â€œDisaster on the rails.â€ Journal of Emergency Medical Services. 30(4):46â€“67, 2005. 5. Eckstein M, Fowler R: â€œScene Preparedness.â€ In Keyes C, Swienton R, Burstein SL (eds): Medical Response to Terrorism. Lippincott Williams and Wilkins: Philadelphia, 2005. pp 226â€“234.
Week 3 Assignment # 1 â€“ (4 points)
Develop a Memo addressed to the Supervising Manager (your faculty) with regard to the predisposing factors affecting the HC services delivery situation at that time. This submission does not require the citations or references. The goal is to demonstrate your critical thinking (analysis and application of the general concepts) in the assessment of an HC sector service delivery. Read more about Memo structure at https://owl.english.purdue.edu/owl/owlprint/590/ Use Microsoft word templates. Read about Critical thinking in your course Syllabus. Read about decision making at http://the-happy-manager.com/tips/7-step-decision-making-process-infographic/
Post the Memo in the Group forum and submit it to the appropriate dropbox for grading.
*List minimum 2 issues that contributed to the situation from the perspective of your job role. For example, if your role is the supply chain management one of the issues might be the absence of the sharp disposal containers due to flood in the warehouse where they are stored off-site.
*Recommend a realistic solution to each of the listed issues. For example, recommend using thick plastic water containers labeled with permanent markers as a temporary solution. (Do not use the provided example in your submissions).
*List the workforce and stakeholders necessary to achieve the proposed solutions. For example, the food supplier/manager needs to be contacted about the empty water containers. The custodial chief needs to be contacted about the storage locations and restrictions enforcement.
Week 3 Assignment #2 -4 points
Develop a Memo directed to the Supervising Manager (your faculty) informing about the population status assessment at the time and the identifiers of the needs. Provide the sources this information was pulled. This is not your job role related assignment, but rather a general topic important for all the managers to understand. Make sure to chose correctly identified risk population and appropriate identifiers.
*List vital statistics of the involved population (read about the vital statistics at www.med.mcgill.ca/epidemiology/hanley/c609/material/VitalStatisticsEoB.pdf ). Chose minimum 2 vital statistics markers and explain their significance in this situation. Make sure to provide the calculations and justification for the marker choice.
*Chose 2 specific groups and list minimum 1 need per group to address based on your population status assessment.
(read about the humanitarian need assessment at https://www.humanitarianresponse.info/en/programme-cycle/space/document/humanitarian-needs-overview-guidance-and-templates-updated-august-0 (5.41 MB)