The Attack One crew starts New Year’s morning 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-story 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 persons 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 questions. 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 supervisor arrives and assumes the role of EMS sector 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 transport and loaded as soon as ambulances arrive. Victim conditions are summarized in Figure 1.
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 destination 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 supervisor 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.
One of the older patients is a man who identifies himself as the owner of the house. He says they had a big family party for New Year’s Eve, and many family members were there. He knows some stayed overnight but can’t identify how many persons were in the house that morning. He believes the fire started in the basement. He had to break out a first-floor window to escape it, and someone was yelling “fire!” to try to get the others out.
The critical patients are moved off the scene, then the yellow triage victims. Firefighters come out with minor burns, a back strain from carrying out a victim and a shoulder strain from helping a victim down a ladder. Several deceased victims are found in a basement room, and the Attack One paramedic is asked to assist in making the decision to leave them in place.
So 12 victims are in the tracking system through the first hour of operations, and two are fatalities inside the building. The tracking supervisor gives a copy of the worksheet to Incident Command so there is an initial accounting for victims. It is so far not possible to identify what the relationships are among the victims and others who were in the house. The hospitals have been notified about the identification problem and that it’s not anticipated that more victims will be transported. They are advised that persons may walk in who had been in the house but were not seen by EMS, and they are requested to pass back to the field any information on the confirmed identities of patients and any further persons who show up at the hospitals.
EMS resources remain staged as the operation in the house continues, but no further live victims are found. Two more fatalities are located.
There is one more moment of crisis when the operations section chief is told by a panicked woman arriving on scene that her teenage daughter (a niece of the homeowner) had been at the house for the party and can’t be located. The crews at the scene perform another detailed search of every inch of the house but can’t find another victim. At that time the girl contacts her mother and reports that she left to stay at a friend’s house and her cell phone died.
This incident was managed to produce the best outcomes for the family. Incident Command developed a plan to effect a combined rescue and fire-suppression operation. The Attack One crew organized the resources for emergency medical care and victim identification. Fire and extrication operations proceeded quickly. As with many situations, treatment could be performed only as environmental conditions permitted and sufficient transport units could be mobilized. Hospital resources were utilized to produce the best patient outcomes possible.
Victim Identification and Tracking
The victim tracking function of the transport sector manages victim identification and all necessary documentation of victim tracking. This facilitates the work of fire (and other) investigators and communication with family and relief workers. Once the incident documentation is complete, it is ideal, for case review and risk management purposes, for the responsible EMS and/or fire agency to collect and track all scene documents, patient care reports and worksheets. These are filed in an appropriately protected area for medical documentation.
In some incidents where patients can all identify themselves, accounting for victims may be as simple as tracking them by name on scene and then gathering patient care reports from the EMS transport agencies or hospitals where patients were transported. But in other incidents—where serious illness or injury has occurred, where patients are not easy to identify, or where conditions like severe weather or scene hazards don’t allow effective on-scene operations—the identification and tracking of patients may require much more effort by EMS providers. There will still be a responsibility at the scene to identify as many patients as possible. The identification and tracking function for EMS is typically assigned to a single individual, but in large operations it may require more people, including law enforcement personnel.
Typical data elements include patient name, triage condition (and maybe the major injury or illness), transport unit, transport destination and approximate time of transport. In some cases there are significant time differences as an incident unfolds or victims are found or extricated. This information eventually needs to be assembled at a single point. In some incidents, personnel at hospitals receiving patients may assist in tracking functions and identifying patients who left the scene without a name. Law enforcement may have additional roles.
Many hospitals and other receiving centers (e.g., evacuation areas) may assist in identifying persons affected by large incidents or those where evacuations have occurred. Tornadoes, hurricanes, hazmat incidents, blackout situations and extensive wildland fires may all result in patients and evacuees showing up at hospitals for care or shelter. In many of those incidents, the EMS system is bypassed, and a complete accounting for victims and evacuees has to be organized by the hospital or public health. EMS would be accountable for those who use the EMS system for transport.
Victim Tracking in Different Incident Types
There are several scenarios for victim tracking by fire/EMS agencies, with different challenges, responsibilities and outcomes.
There are incidents where persons must be actively sought. These occur when there are life threats present and all persons who are at risk must be located—for instance, in buildings where there are fires or toxins such as carbon monoxide present. All persons must be found and moved away from danger. Certain toxins, like botulism, may produce sudden incapacitation, and persons with potential exposure must be located and evaluated. Large vehicle catastrophes—commercial plane crashes, bus accidents, “whiteout” multiple-vehicle crashes, overturned or incapacitated passenger ships, train crashes—must have all victims found and removed. These incidents can produce scenes where it is very difficult to find all victims, because the number of persons in the vehicles may not be known.
An active-shooter incident, where law enforcement may be searching for one or multiple perpetrators, may also be an active-tracking incident. When shootings have occurred in schools, theaters, malls, courthouses and office buildings, it has been necessary to find and treat victims while scenes were still hot. This type of incident can be difficult for victim tracking, most of which may have to occur after the incident, in concert with criminal investigators.
Other types of incidents have important victim tracking implications. Incidents of any type in school or business locations will need an accountability system that identifies all unaffected and ill/injured persons so that authorities can ensure every person is OK, reunified with family or identified at a healthcare facility. This can be challenging in situations like an occupied school that is severely damaged by a tornado, a business where an explosion or fire has occurred, or an office where a white powder incident has scattered employees into the street. These incidents may require EMS tracking personnel to sit with school or business administrators to compare lists and make appropriate notifications.
There are medical events where victims must be tracked, usually in association with public health authorities or personnel from a healthcare facility. These may involve food poisoning incidents or exposure to toxins or infectious agents.
Out-of-town vehicle crashes with multiple victims require not only accurate tracking but a plan to notify family that may be in a distant location. Collaboration with law enforcement will be necessary for accurate and timely notification.
There are incidents where EMS may be asked to identify certain characteristics of victims that have law enforcement implications. It is common for police to ask things like which victim was in the driver’s seat when you started extrication. There are also incidents where persons show up at a scene or hospital and say they were involved in the accident when it does not appear that they were.
This was also an incident that required rescue personnel to provide the best possible identifications and assist investigators and relief personnel in tracking persons and identifying relationships. It is clear that family reunification is a potential role for EMS personnel. At a minimum EMS must be able to track victims so family knows which hospital to go to or, in the worst situations, where a fatality was taken.
When conscious patients request a portable phone to make their own family connection, EMS personnel must find a way for that to occur. Handing a prepaid “safety phone” to a victim might be the most efficient method to manage a request.
Note that allowing a person to disclose their own medical condition to a family member or friend is not a violation of confidentiality laws, in particular the Health Insurance Portability and Accountability Act (HIPAA).
EMS customer service begins with accurate and timely identification and tracking of victims, which can then allow the beginning of recovery functions. A customer service orientation will not let affected persons be left standing in the street.
In this incident, the burn and smoke victims were tracked so extended family could understand who died at the scene, which hospitals were treating victims and even which family members were not affected.
Multiple-victim incident tracking is a difficult function and will require at least one dedicated individual to track patients and paperwork. Victim tracking has significant customer service implications but also facilitates family reunification, risk management, and investigative and law enforcement efforts.