Read Part 1: Mass casualties at a meat packing plant

An ammonia leak at a meat packing plant left several emergency agencies struggling to handle more than 100 casualties. Worse, the incident happened indoors in the dead of a South Dakota winter.

The first half of this two-part article discussed the concepts for handling a mass-casualty incident. This second half describes a 100-person winter MCI and the lessons learned from it, and also offers some ideas on preparing your system to handle an MCI and developing the interagency capacity to handle such an emergency.

The Morrell meat packing plant employs more than 3,300 employees, so accountability for the workers, many of whom self-evacuated, was an ongoing problem at the incident.

On Feb. 12, 2004, at around 11:30 am, there was an initial report of a person trapped in a piece of machinery at the Morrell meat packing plant. One fire unit was dispatched to the incident, along with one ambulance. Later this report was changed to a possible pallet that was on fire. Finally, it was changed to an ammonia leak that was causing the evacuation of the building. Remember that the first report of any major incident is almost always incorrect, so one needs to be able to quickly adapt to any circumstance.

Morrell’s Sioux Falls plant employs more than 3,300 employees, and at any time there can be thousands working in the complex. Many of the workers are immigrants from around the world, and more than 50 languages spoken in the plant.

Incident command considerations

Before the Incident Commander can set out on a course of action for any incident, he or she has to determine the big picture and not get trapped in tunnel vision. With any event, the IC has the responsibility to set out the overall incident priorities, strategic goals and tactical objectives. Each is critical to operational success, and they need to be done in order.

Briefly, the incident priorities encompass three key points: life safety, incident stability and property/environmental conservation. The strategic goals are developed to provide direction to meet the priorities. Finally, the tactical objectives provide actions to meet the strategic goals and are generally where the functional units under the Incident Command System, such as branches, are developed.

Using these with any incident, one can quickly lay out what the IC will need to successfully complete. With this incident at the meat packing plant, there was a hazmat leak, people possibility trapped or needing rescue, and a mass-casualty event. Using the above concerns, this illustrates one way to develop a big-picture approach concerning the first priority, life safety.

Incident priority: Life safety, preserve life and prevent injuries

• Strategic goal
  1) Remove and rescue trapped workers:
  
  Tactical objectives: 
    1) Provide interior rescue in a potential IDLH (Immediately Dangerous to Life and Health) atmosphere
    2) Evacuate injured workers to safe areas and decon if necessary
    3) Establish a Rescue Branch to accomplish the tactical objectives
• Strategic goal
  2) Provide medical care to injured patients:
  
  Tactical Objectives:
  
    1) Provide immediate life-saving measures
    2) Determine the number and severity of the injured
    3) Provide evacuation of the injured to hospitals
    4) Establish a Medical Branch to accomplish the tactical objectives, which will develop into the tasks of creating a Triage Group, Treatment Division and Transport Division.

Once the necessary actions are broken down into priorities, strategies and tactics, the IC will have a clear picture of where incoming resources need to be allocated.

Unified Command

A guard shack at the meat packing plant was commandeered as the Incident Command Post. It offered an excellent view of the incident and maps showing all of the buildings.

Due to the size and scope of the incident at the meat packing plant, the IC determined that using a Unified Command would be a better method to handle the incident.

Normally, the IC is one person determining the overall priorities and strategies for the incident. If the incident grows or is more complex, however, using Unified Command brings key decision-makers from other agencies into the command system. This allows a collaborative approach to command of the incident and allows a direct pipeline to other organizations. UC can incorporate representatives of fire, law enforcement, EMS, and public works, though this will vary with the incident.

One key task is to establish a command post, which allows one location for overall command and control. And by allowing the IC and/or the UC personnel to process information with fewer distractions, the CP helps ensure that they’re thinking on a broad strategic level and not getting trapped in minutiae. The command post allows the IC/UC to be the coach of the team. Once the IC steps out of the CP, he or she can become part of the incident rather than managing the incident.

For this incident, a guard shack was secured as the CP. It offered a safe location with an excellent view of the incident, and there were maps already there showing all the buildings, which made it easier to control the incident.

Early complications

The accountability of the hundreds of workers was a major concern, for three reasons. First, as units arrived on scene, they were met by hundreds of workers exiting the various buildings. With the outside temperatures at 10 degrees F (–20 degrees C), workers were leaving the area to stay warm. Second, since the leak happened over the various shift lunch breaks, some supervisors weren’t sure where their employees were. Finally, many of the plant translators weren’t available, which added to the difficulty of communicating with patients to determine the extent of injuries.

The first fire person assigned as the EMS Branch Manager was told that injured workers were filling up the cafeteria, and that many of those could not speak English.

Gaining control

With any situation, size-up is a critical component and should not be overlooked. In this incident, it was important to see where patients already were, and that was one of the main floor cafeterias in the administration building.

Prior to selecting the cafeteria as a triage/treatment area, we determined that it was in a safe area and a separate building. However, because it was a cafeteria, there was a mix of both injured and uninjured workers. Uninjured workers were there to stay warm, use the bathrooms and use the vending machines. They were removed, and security was placed on all entrances to ensure that only the injured were allowed into the building.

The traditional methods of setting up a treatment area would not have worked. Most of the training and references for setting up triage and treatment areas are designed for large open outdoor areas. This is in part to make training easy, but it does not prepare rescuers with the knowledge to quickly adapt to unusual circumstances. In this situation, the classic approach of setting up triage, treatment and transport in an open field next to a road was not an option. With winter temperatures and winds, it was necessary to develop a new skill set.

The first steps were ensure that the directions of the Medical Branch where aligned with the overall directions from the UC. These were to secure the cafeteria for the injured only, designate a triage officer and set up treatment areas.

The cafeteria would be the treatment area since it was where the patients were already. As patients were brought into this area, they would be triaged and sent to the appropriate treatment area. The injured could then be moved to the exit that was the pick-up area for ambulances.

The EMS Branch

One of the walls in the cafeteria happened to have green stripe, so this area was designated for Minor patients.

The EMS Branch was set up inside the cafeteria with the various areas of the room designated for Minor, Delayed, and Immediate patient care areas. By chance, one wall of the dining area was painted with a green stripe, and another wall had a red stripe. This naturally divided the patients into a Minor area (green wall) and Delayed or Immediate area (red wall). As patients entered the cafeteria, they were triaged into the most appropriate area and had a triage tag placed on them.

One small problem was how to identify whether patients had been decontaminated. The initial idea was to tie a ribbon around each patient’s wrist to identify whether they were contaminated or not. This was changed to using triage tags that had a way to identify if a patient was contaminated. Although the fire and EMS agencies had worked together, as a system there was no standard for triage tags. As a side note, following this incident the entire state adopted the same triage tags used by the fire department to ensure that this confusion does not reoccur.

One concern at any MCI is the need for enough ambulance units to transport the more critically injured patients. To meet the need, a request for buses was made to transport the patients who were only mildly injured. Initially, a law enforcement prisoner transport bus was to be used. However, since many of the patients could not speak English, there was a concern that they could think they were being arrested. So a city bus was used instead to transport these patients and was staffed with EMTs to oversee the Minor patients.

It took just over three hours to handle the incident’s medical operations, which had a total of just more than 100 patients. Not all of these patients went through medical operations, as some bypassed the system and drove directly to a hospital. This required constant communications with the three hospitals to ensure that they where not being overwhelmed with walk-in patients.

One other complication was that because of the administration building’s construction, there was only a small area of about 3 feet square where radio and cell phone reception was accessible. To keep this area clear, a security guard stood on that spot so that supplies or patients would not block it.

Interagency operations

Another part of the cafeteria had a red stripe on the wall, so it was set aside for patients triaged as Delayed and Immediate.

As in any major incident, along with the roles of fire, EMS, and law enforcement, large supporting roles are played by other agencies. For example, the city transit system brought in several of their buses, which were used both to transport patients and as warming areas for responders and workers. The use of buses is now part of normal operations for any major event in Sioux Falls.

The county emergency manager was a vital part of the incident, since his office is the conduit for state assistance and because the EM has access to other resources that may be available on request.

And since this incident involved hazardous materials, the local and state health departments were notified. In addition, the USEPA was alerted to the incident in the event of a federal request for assistance.

After-action review

After-action incident reviews are a crucial way to ensure that a system’s strengths and weaknesses are brought up. An after-action review needs to be done in a productive manner and is best started with a set of ground rules to ensure that the meeting doesn’t get out of control.

The review will list the strategic goals, tactical objectives, whether those were achieved, strengths, weaknesses, and lessons learned. Ideally, this framework should be used on all larger incidents so that it’s part of the organization’s or system’s culture. Ideally, the first time one conducts an after-action should not be on a large event.

Several areas were identified as needing improvement following the meat packing plant MCI.

• System-wide training in MCIs and ICS
• System-wide MCI worksheets, compliant with the National Incident Management System and OSHA
• Identification of off-duty personnel
• System-wide compatible equipment
• System-wide triage tags
• Stockpiles of
  
  – Triage tags, in all vehicles
  – Airway maintenance equipment
  – Irrigation solutions
  – Wheelchairs
• Dedicated phone lines to hospitals

In addition, several areas were shown to have went well.

• Rapid implementation of ICS
• Ability to triage
• Rapid set-up of medical area
• Rapid deployment of BLS MCI equipment
• Willing to listen and follow directions by personnel at the scene
• Reallocation of personnel by IC
• Use of fill-in trucks in the city to handle other emergency calls

Tips to help strengthen interagency capabilities

1) Develop an Emergency Operations Center. Even if it’s just a classroom, designate a location and let everyone one involved in on that process. By identifying this location before an incident, you take the first step to handling a major incident. It’s also a useful tool to develop your team.

2) Identify the key people needed to fill the roles of Unified Command and the Operations, Planning, Logistics and Finance sections for any major operation. They will likely be from various agencies in the community. Let those people know what’s expected in a major incident and get the tools needed to handle their area of responsibility. Also, they need to develop their own chain of command in the event they are absent.

3) Have regular (at least quarterly) meetings of all the key stakeholders, preferably in the EOC. This brings people together on a regular basis and develops familiarity. The time to first meet the Logistics manager is not right after a tornado.

4) Drill, drill, drill. Have a yearly drill. It doesn’t have to be an all-out drill. Each section or branch can develop mini-drills for their specific area. For example, the Planning Section can set up a drill to determine the planning needs 12 hours after a mass evacuation of 2,000 people.

5) Everyone needs to take the National Incident Management System training programs. These are free, and some are online. The training helps ensure that everyone is using the same terminology and is grounded in the core concepts of NIMS.

6) Make cheat sheets so that during an event, all the forms, terms and necessary NIMS paperwork are available. This is all available online.

Conclusion

The critical core concepts at the command level to manage any incident are incident priorities, strategic goals and tactical objectives. Once that approach is understood, one can successful begin to manage any event. Major medical events can be more complicated, but prior planning and training will help a system navigate the most complicated situation.

If you would like more information on any areas covered, NIMS forms, organizational charts or other information, feel free to contact the author at Sideras@post.harvard.edu.