As medical providers we are somewhat prepared for mass casualty/injury incidents in our cities with natural disasters or plane crashes, etc. This report describes management of a mass casualty/injury incident in the wilderness with minimal resources.

Introduction to the Case

It was the last day before new interns were to hit the wards at Cascades East Family Medicine Residency in Klamath Falls, Oregon. We had a tradition to take the interns on an optional river rafting trip on the Class IV Upper Klamath River. The trip was the typical fun bonding event for the residents, faculty, and family.

After a brief post-rafting celebration, everyone loaded up on the shuttle bus. The road out was a very safe, one-lane gravel road, and everyone was excited and talking. The trip leader was standing at the front of the bus narrating some interesting history of the old logging community, now abandoned, that we were passing through.

All of a sudden, the front wheels caught some loose gravel at the side of the road. The bus, in slow motion, rolled over a 15-foot embankment and landed upside down in an old, now dry, irrigation ditch that had been taken over by blackberry bushes.

As we rolled, there were screams and a few grunts as unrestrained bodies met various obstacles, followed by a cloud of dust and a deathly silence for about four seconds, which seemed like an eternity. Finally, the driver started screaming and then there were calls from the back of the bus of "anyone hurt?"

Stage I - Extraction

We were upside down, with unknown injuries to manage. Our first job was to get everyone out of the bus. The door and emergency exit were both lodged against the embankment. The windows were out of position. Upon rolling, the roof had collapsed to about six inches above the upper seat level and sheared to the original left side of the bus. Lying on the inverted roof (now floor) was one passenger temporarily passed out and being held in C-spine stabilization by his girlfriend, one of my residents. Another passenger had a 15 cm head laceration that was bleeding heavily. Some of the passengers were able to knock out a window near the back, and most of us evacuated out that back window. It took about 30 minutes to get everyone out of the bus. The driver, who was one of only two people that were wearing seat belts, had her seat belt jammed by her upside-down weight. She was cut loose with a pocket knife.

Stage 2 – Inventory and Job Assignments

We were on a remote road near the California/Oregon border. The rafting company had a satellite phone. It would take one to two hours until Emergency Medical Services (EMS) could get to us. We had a first aid kit on the bus, one structural aluminum malleable (SAM) splint and no backboards. A second year resident had led the extraction effort—ripping out windows, etc. A third year resident and one of my Wilderness Medicine Fellowship candidates, who had assisted me in teaching an Advanced Wilderness Life Support (AWLS) course 10 months prior, led in the triaging of injuries. I had another former AWLS instructor who was now faculty with the residency there, but she had a moderate concussion and struggled to maintain focus. I had two minimally injured incoming interns that were doing anything needed, and I had three uninjured significant others assisting. I was residency faculty and had 20 years of experience teaching AWLS. I assumed the incident commander role; however, my role was complicated by the “foggy brain” of concussion, and I was in denial of my head injury. I also had facial lacerations and a broken nose and was covered in blood—my own and that of others.

Stage 3 - Triage

A second bus from the rafting company arrived with additional supplies. My third year resident and fellow candidate in the Academy of Wilderness Medicine (FAWM) had triaged the below major injuries. All victims were previously healthy and aged 25-40.

1. Female—15 cm head laceration, tender neck, tingling in fingers, lying in shade of a tree on top of blackberry bushes (triaged as head concussion, head laceration, possible cervical neck fracture). ER evaluation revealed head concussion, head laceration, cervical neck sprain.
2. Male—significant other of my triage leader, with head concussion, loss of consciousness (LOC) greater than five minutes, para-cervical neck pain, negative screening neuro exam, sitting upright and moderately uncooperative (triaged as head concussion and cervical sprain, rule out cervical neck fracture). ER evaluation revealed head concussion, cervical fracture.
3. Male—squatting on ground, oriented times three but not acting right, did not feel right. Later leaned forward and was moaning on the ground. Chest and abdomen were non-tender, radial pulse strong and in 50’s. Normal respirations, neck non-tender (triaged as something wrong but didn’t know what). ER evaluation revealed liver fracture in capsule, head concussion.
4. Female—Low back pain and tingling to toes but able to move toes, lying on the inner side of the ditch at a 30-degree angle. Neck pain and tingling in fingers (triaged as probable lumbar fracture, probable cervical spine fracture). Patient during secondary assessment was in tandem shifted to flat area at top of ditch, keeping lumbar and c-spine protected. ER evaluation revealed lumbar fracture, cervical sprain.

We did not have any backboards, and therefore used the ground as our backboard until EMS arrived. We placed a SAM splint on our most injured patient. We got a Philadelphia collar along the way and placed that on our second most suspected cervical injury. The one person that ended up with a true cervical spine injury was moving his head so much that we decided that if he had a c-spine injury, it must be fairly stable.

Everyone else had climbed or was pushed up the 15-foot bank and were on the road above, including my second year resident that had been heroic in leading the effort to get everyone out of the bus. He was confused and repeating himself. He ended up with amnesia of the whole event and a significant head concussion.

Minor Injuries triaged:

1. Head concussion and clavicle fracture, total amnesia of event
2. Head concussion, six fractured ribs, non-tension pneumothorax
3. Head concussion, nose fracture and lacerations, forehead laceration, left palm laceration
4. Head concussion, ear laceration
5. Head concussion, forehead laceration, total amnesia of event
6. 5 others had head concussions
7. 5 had no identified injuries

Three additional passengers suffered a head concussion alone, and five passengers plus the driver had no discernable injuries.

Stage 4 – Wait for EMS and Prepare for Evacuation

It took about two hours for EMS to arrive with about five fire trucks from two or three stations. While waiting, we had several uninjured passengers rip out more bus windows and lay them down over the blackberry bushes to create a pathway around the bus leading out to an open field where we assumed the helicopters would land. We pulled out a vinyl runner from the up-side down floor of the bus and laid that over the windows on the ground to stabilize.

Stage 5 – EMS Evacuation

Once EMS arrived, the triage leader gave her report to EMS, and each person from the accident was mass casualty triaged with a triage tag. We had no deaths and therefore by definition, no black tags (unlikely to survive or dead), and no red tags (immediate intervention) since it had already been two-plus hours. We had the above four triages with yellow tags (delayed—serious but no life-threatening injuries). Everyone else was walking around or had minor injuries and where therefore given green tags.

Three of our most seriously injured victims (numbers 1, 3, and 4 from Stage 3) were triaged to helicopter evacuations. We were then out of available helicopters. Victim number 2 was evacuated by ambulance. Two other green-tagged victims were sent out by ambulance to different hospitals, the closest of which was two to two-and-a-half hours away. Three of us traveled by company van to our home ER.

One minor thing worth noting is that one fire truck on the scene had brought several cases of water bottles in a huge ice chest. The temperatures were in the 80’s, and we were incredibly appreciative of the water to quench our thirst.

Stage 6 – Post-Incident Management

The first message out to family and friends was cryptic: "We were in a roll-over bus accident. I am OK, others aren't." This message was sent from one of the ambulance transports by our triage leader once she reached cell service. A good four hours after the accident I was able to get a very static-filled message to my wife that my 14-year-old daughter and I were OK. I gave up on the satellite phone and about an hour after that was able to text my Family Medicine Residency director about the accident. After being contacted by the triage leader and hearing news reports, she had already assembled a crew of residency faculty who were en route to the probable hospitals where our residents were taken.

En route back to Klamath Falls, one of the other green-tagged passengers among the walking wounded, advised me that she might have broken some ribs. She was only mildly dyspneic, so I just kept an eye on her during the 2-hour drive back. She ended up with six rib fractures, a non-tension pneumothorax and was admitted to the hospital. Nearly everyone had head concussions.

While our residency program does have a back-up call plan, having seven of eight interns, three upper-level residents, and three faculty incapacitated for one week to six months challenged our program for the first few weeks to months of the residency year. It took over six months to get everyone back to work. Our residency program became very adept at managing concussions and prevention of post-traumatic stress!

Lessons Learned

1. AWLS and similar wilderness medicine courses prepared us well to manage a mass casualty/injury incident in the wilderness.
2. Triaging is not perfect and you will make mistakes.
3. It is wise for residency programs to have a corporate disaster plan. However, how can one really be prepared for every possible scenario? You just do what you need to do and everyone pulls together.