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Institute of Medicine (US) Forum on Medical and Public Health Preparedness for Catastrophic Events. Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary. Washington (DC): National Academies Press (US); 2011.

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Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary.

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2Case Examples: 2008 Mexican Hat, Utah, Incident and 2010 Albert Pike, Arkansas, Flood

As discussed in Chapter 1, this Institute of Medicine (IOM) workshop was convened at the request of the Federal Interagency Committee on Emergency Medical Services (FICEMS) to help inform their evaluation of the response of emergency medical services (EMS) to large-scale rural transportation accidents. Following its investigation of a bus accident near Mexican Hat, Utah, that occurred January 6, 2008, the National Transportation Safety Board (NTSB) recommended that FICEMS conduct such an evaluation, and develop EMS response guidelines for states. To set the stage for the IOM panel discussions, two case examples of rural mass casualty incidents were presented by those directly involved in the emergency services response. In addition to the accounts of the Utah bus accident, a nontransportation example is provided in the accounts of the response to the rapid and severe flooding of the Caddo and Little Missouri rivers near Albert Pike, Arkansas, in June 2010.


NTSB vice chairman Christopher Hart explained that as an independent accident investigator, the NTSB's primary goal is to issue recommendations designed to help prevent similar accidents in the future. These recommendations are based on the NTSB's determination of probable cause(s) and survival factors (e.g., occupant protection, roof strength, and seat belts), as well as its review of emergency response. While the NTSB does not have the authority to mandate action, Hart noted that the acceptance rate of NTSB recommendations is more than 80 percent.

Following its investigation of the Mexican Hat incident, the NTSB recommended that FICEMS address the need for funding to enhance the communication capabilities of rural areas and conduct a systematic review of EMS response to large rural accidents. The NTSB made recommendations to the Utah Bureau of EMS and Preparedness, calling for the development of a contingency plan for large rural accidents that are complicated by severe weather. Recommendations were also made to the Federal Highway Administration, the National Association of State EMS Officials, and the American Association of State Highway and Transportation Officials to develop a risk assessment process to identify those stretches of rural roads most vulnerable to accidents in order to focus communication enhancements and response plan development.

Hart emphasized that the challenge of vast open spaces goes beyond how long it takes for emergency vehicles and responders to reach the site. Physical distance can be a significant barrier to transporting emergent patients quickly and effectively after first responders have arrived. From the accident scene in Mexican Hat, the closest medical facility with a trauma unit was 117 miles away in Moab, Utah. Five of the victims were treated at this level IV trauma center. The closest level I trauma unit was 190 miles away in Flagstaff, Arizona, and two individuals were treated there. Twenty-five accident victims were treated 75 miles away in Monticello, Utah, in a facility without a trauma center; 10 were treated as far as 230 miles away at a level II trauma unit in Grand Junction, Colorado, and three were treated 360 miles away in Salt Lake City, Utah, at a level I trauma unit.

There are a variety of exacerbating circumstances that affect rural incidents, including lack of communications, bad weather, lack of roads (of particular concern for railroad or aviation crashes), and impact on the larger community (e.g., a crash resulting in a pipeline leak or other hazmat situation). Hart emphasized the importance of state and local governments considering potential aggravating circumstances when developing response plans.

In the future, he said, we can expect to see more tour buses on rural roads as people set out on more ski trips and other expeditions to see our beautiful country “up close and personal.”


Linda Larson, EMS director for San Juan County, Utah, provided a local EMS perspective of the 2008 Mexican Hat incident. Currently an emergency medical technician (EMT)-intermediate with advanced life support (ALS) certification, Larson has been an EMS in Utah for 10 years, and was an incident commander at the scene. Though San Juan County is the biggest county in Utah at 7,725 square miles, its population only measures 14,413, an average of 1.8 residents per square mile. Larson compared that to Washington, DC, which is 61.4 square miles with a population of 599,000, or 9,300 residents per square mile.

The Accident

On January 6, 2008, 17 tour buses traveled through San Juan County, Utah, on their way to Phoenix, Arizona, from a ski holiday in Telluride, Colorado. Normally, the convoy would have traveled through Colorado, but Lizard Pass on State Route 145 was closed due to snow, and the buses were diverted through San Juan County on Highway 191. It is believed, Larson said, that instead of making a necessary turn to stay on Highway 191, five of the busses kept driving straight and inadvertently ended up on Highway 163, which is a very narrow, winding road, without a shoulder. The fourth bus failed to negotiate a turn and rolled down a 41-foot embankment. The crash site was 10 miles north of Mexican Hat, 22 miles south of Bluff, and 80 miles from Monticello.

At the time of the crash, approximately 8:00 p.m., it was already dark, very cold, and raining. Larson played an audio clip of the 9-1-1 call made by one of the victims to EMS, shortly after the crash. Given the lack of cell phone coverage in that area, it is unknown how that call was connected. From the recording, workshop participants heard that the connection was poor and was ultimately lost before the dispatcher could obtain any information other than that there had been a crash. Another 9-1-1 call was successfully completed around 8:30 p.m. by a passerby.

The Response

The first ambulance was paged at 8:30 p.m., and four ambulances were en route by 8:45 p.m. The EMS team alerted the local hospital and the emergency manager, who sent the mass casualty trailer to the scene. The San Juan County EMS is voluntary, but has a fulltime interfacility transport vehicle that just happened to be in the area, about 20 minutes away. Both of the personnel on the transport were ALS certified.

The first ambulance on the scene arrived at 9:01 p.m. to what Larson described as a messy, surreal scene of strewn skis, poles, jackets, and suitcases. The bus had gone through a barbed wire fence and made a full 360 degree roll down the embankment, losing its roof in the process (Figure 2-1).

Photograph of the wreckage of the tour bus after a 360-degree roll 41 feet down an embankment.


The fourth tour bus after a 360-degree roll 41 feet down an embankment. SOURCE: Larson, 2010.

Forty-three EMTs responded, which Larson noted as fortunate rather than routine: normally only half that number are available to respond. Two highway patrol officers responded, both of whom had some EMT experience. Due to the lack of highway traffic, patrol officers assisted EMS in beginning to move patients away from the bus. Countywide, the sheriff and 3 deputies, 25 fire and rescue personnel, and 10 county employees from the administration office, driving county vans, were among the responders. In total, 15 ambulances serviced the scene, one from as far away as 250 miles.

When EMS arrived there were around 100 people down the embankment. Approximately 50 passengers from the fifth bus had gotten out to help, such that EMS had to distinguish between healthy and wounded tourists. Ultimately, it was decided to pair passengers from the fifth bus with victims from the fourth, so each victim had an advocate who stayed with them and monitored their status. Another fortunate coincidence came in the form of a passerby who happened to have a large spotlight in the back of his truck; he stayed to illuminate the scene.

The Utah EMS Strike Team was also activated, assisting San Juan County for 48 hours by responding to all other EMS calls (discussed in detail hereafter).


Of the 53 people on the bus, there were 9 fatalities, 35 serious injuries, and 9 minor injuries. Of the serious injuries, about half were triaged red, the other half triaged yellow. Demonstrating the need to reassess triage grades throughout a mass casualty incident (MCI), one of the patients, initially triaged green, was found to have suffered a hip fracture after being evacuated to a “walking wounded” area. The majority of the seriously injured passengers sustained spinal, clavicle, rib, and extremity fractures. All of the passengers had been ejected from the bus except for the driver, and a passenger who was trapped between the seats.

Raising the issue of seatbelt use on buses, Larson noted that from 1998 to 2008, the NTSB investigated 33 motor crash accidents involving 256 passenger ejections. However, Larson pointed out that it is not possible to know how the injuries might have been different if the roof of the bus had not detached.


Eight ambulances from San Juan County and four from the Navaho Nation were dispatched to the scene. Three ambulances from Grand County EMS and two from Southwest Memorial Hospital in Cortez, Colorado, were waiting at San Juan Hospital to assist with further transport. There were no helicopters able to reach the scene due to the weather. The flight team from St. Mary's in Grand Junction, Colorado, instead drove down in an ambulance to assist with transport. As there were not enough ambulances, the decision was made to remove the seats from the three county vans and use them for patient transport. Larson recounted that though the vans did not have any medical equipment, the alternative was leaving the victims on the ground at the scene to succumb to hypothermia.

Seven people were pronounced dead at the scene. The remaining victims were initially transported to four hospitals and two clinics. Four air transport teams subsequently transported patients to other facilities. Two victims died en route to higher medical facilities. Only 7 out of the 52 passengers were released with minor injuries. Overall, victims were treated at 13 hospitals and medical centers in 4 different states (Figure 2-2).

Map of the distance from the incident site to each of the 13 facilities in 4 states that treated victims.


Victims from the Mexican Hat incident were treated at 13 facilities in 4 states. SOURCE: Larson, 2010.

Challenges and Successes

Larson listed some of the challenges facing EMS in responding to this incident, including the fact that the closest hospital was nearly 80 miles away. Limited radio communication and no cell phone service on the scene meant that communication with the local hospital consisted of a “runner” who traveled down the road in search of cell phone signal strong enough to connect with the hospital. After relaying information from the scene and receiving a response, the runner would then return to the scene to repeat the process. Coincidentally, Larson remembered that at the time of the Mexican Hat crash, there was an ongoing, heated debate about whether an increase in cell phone towers would decrease the area's inherent beauty. However, after the bus crash, a cell phone tower was installed in the area and painted brown so it blends in. Resources, including ambulances and equipment, were also limited (resulting in the use of the county vans), as was the number of ALS-certified individuals on scene to care for patients while they were waiting for ambulance transport.

Logistically, there were challenges with triage and patient tracking. Larson described the initial victim triage, using the red, yellow, green, and black labeling system, as successful. However, priority designations became muddled on approach to area hospitals as each ambulance crew felt that their patient was the medical priority. As in most MCIs, patient tracking posed challenges, and improvements are needed to better track patients and responders.

Weather acted to compound the resource and logistical challenges. Response was delayed as roads en route were closed due to snow and fog. At the scene, patient care was hampered by the rain and extreme cold. The bad weather also prevented air medical transport of victims from the scene, and delayed air transport from hospital to hospital.

Despite the challenges, Larson felt there were many things that went well. In the communications arena, the EMS dispatch did an excellent job. Hospitals were contacted early and monitored radio communications. EMS responders were well-coordinated and the “deputized” passengers from the fifth bus served as a critical resource. Though transportation was hampered by the weather, creative leveraging of the county vans, though medically unequipped, increased the number of victims able to reach area hospitals. The Grand County and Southwest Memorial ambulances were ready and waiting at local hospitals to transport arriving patients to critical care facilities. Finally, Larson reiterated that the Utah Bureau of EMS and the Southeastern Strike Team were instrumental, discussed in greater depth by Paul Patrick.

Lessons Learned

Understanding the gaps in their capability to respond to MCIs through the Mexican Hat incident, Larson emphasized important lessons learned for local EMS. Among them was the need for contingency plans should helicopters be unavailable due to adverse weather conditions. Issues of patient tracking and communications between the accident scene and hospitals (e.g., how to manage different services using different radio frequencies) were identified as areas requiring improvement. Where possible, Larson highlighted the need for plans to keep families together. Already noting progress, she said retrospective strategizing by all EMS personnel involved in the response had led to a revision of the triage protocol to avoid confusion regarding priority patients in the future.


Paul Patrick, director of the Bureau of EMS and Preparedness in the State of Utah Department of Health, explained that the state plays a supportive role in MCIs, letting incident command work as it is designed to work. A regional response is initiated as the aid of surrounding counties is sought. Because this accident occurred in the Four Corners area, surrounding counties fell into four states, Utah, Colorado, Arizona, and New Mexico.

The state's auxiliary role takes the form of helping prepare local EMS to respond, coordinating resources during an incident, and providing resources when local and regional resources are exhausted. State funding also contributes to hospitals and clinic equipment, and their personnel may be tasked with providing necessary training. Utah, in particular, has a toll-free number that is staffed by the Bureau of EMS and Preparedness 24 hours a day, 7 days a week, that anyone can call to notify the bureau of an incident. The benefit of this state-level preparation and planning was apparent in the Mexican Hat incident, Patrick said. Once the bureau received a notification of the incident it contacted EMS offices in the surrounding states to alert them that their assistance may be needed.

Strike Teams

Another resource that the state offers is the emergency services strike teams. A strike team consists of 12 members, including paramedics, EMTs, physicians, and nurses, situated throughout the state. The team is outfitted with trailers equipped to treat up to 100 patients if needed. Trained by the State of Utah Department of Health, Patrick explained that when activated, they are considered Department of Health employees. Thus, strike team members are paid for their training and for their time during a response, and are covered under the state's workmen's compensation policy.

Following an MCI such as the Mexican Hat incident, local responders are often fatigued, yet they still need to run an ambulance service for the community. In these cases a strike team from another area (so as not to further deplete local resources) is often activated to cover the routine EMS calls for a 48-hour period. After the Mexican Hat incident, the state strike team responded to calls in San Juan County, giving the local personnel a chance to debrief and refresh. In addition, the state department of health activated its critical incident stress management team to handle any potential psychological consequences of responding to the incident, providing clinical psychologists and peers, at no cost to local units. Patrick emphasized the importance of these state-coordinated services for maintaining the mental and behavioral health of volunteers and providers.

Strengths, Weaknesses, Opportunities, and Threats

In response to the NTSB, the Utah Bureau of Health conducted a strengths, weaknesses, opportunities, and threats assessment. Patrick highlighted six major threats from that analysis that affect EMS response to rural MCIs.

  • Current economic situation: The national recession and pressure to balance state budgets has lead to further reductions in grants and funding at the state agency and local levels.
  • Availability of technology: Existing technologies should be equitably distributed to all areas throughout the states.
  • Lack of data: There are not enough data to support decision making and policy development pertaining to EMS and trauma care.
  • Public misconceptions: People often believe that responders will always be immediately available during an incident. It is important for state and local EMS to educate their citizens as to the capability of their team to respond to potential MCIs, in turn encouraging citizens to be trained as EMTs.
  • Absence of best practices research specific to rural areas, rather than extrapolating from urban data.
  • Lack of focus on inclusive, regionally coordinated prevention efforts.


An overview of a nontransportation rural MCI, and the response to it, was provided by Floyd “Bud” Dunson, deputy emergency manager for the Howard County (Arkansas) Emergency Management Agency, and EMT-Basic and volunteer fire chief of Mineral Springs Fire and Rescue.

The Flood

On June 11, 2010, at approximately 2:00 a.m., Dunson's county pager alerted him that two fire departments from the northern end of Howard County were en route to respond to flooding in neighboring Albert Pike. In the Arkansan foothills of the Ouachita Mountains, Albert Pike is about 340 miles north of New Orleans and 175 miles east of Dallas. Flooding in Albert Pike is not unusual; the water has been known to rise two to three feet, then recede 30 minutes later. Procedure in Howard County dictates that if two or more fire departments leave the county for a call, a member of the emergency management team must also be deployed. At 7:00 a.m., Dunson's boss sent him to Langley, Arkansas, a town consisting of a store and a house just five miles away from Albert Pike. Initial reports indicated there were people missing and several fatalities.

Dunson described the Albert Pike campground in Ouachita National Forest as semiprimitive campground sites for about 300 people, along with private cabins in a section of land owned by a large timber company within the national forest. Determining the exact number of people in the campground is normally very difficult. Registration is on the honor system as campers place their name and fee in a box and take a ticket. The flood washed away the registration box, and with it, any record responders could use to establish how many people may have been camping at Albert Pike.

Crossing the Little Missouri River on U.S. Highway 70 on the way to Langly, Dunson expected the usual flooding but observed that the river was higher than he had ever seen. At a monitoring station eight miles downstream from the campground, the river was recorded to be 3.81 feet at 2:00 a.m., 20.57 feet by 4:30 a.m., and peaked at 23.39 feet an hour later. Analysis would show that the river rose 20 feet in three hours. The first 9-1-1 call was received at 2:30 a.m. As with the Mexican Hat incident, a lack of cell phone coverage and the absence of private homes, save one across the river from the campground, in the area obscured the identity of the caller.

Dunson described 20 flood fatalities with additional reports of fractures, severe lacerations, and, by those clinging to trees, severe “road rash” from being battered by debris that was rushing down the river.

Challenges for Responders

Eight ground ambulance companies responded, sending a total of 11 ambulances. One air ambulance also responded. Four of the ground units and the air unit were privately owned, for-profit corporations; one was a nonprofit subsidized company; and three were volunteer ambulances. Eight were ALS and the others were basic life support (BLS) units. There is no official record of the responders who were at the incident.


The first challenge, as with many MCIs, Dunson reiterated, was communication. There was no cell phone service, but an occasional text message could get through in certain areas. One technology that did work was ham radio, and as a ham radio operator, Dunson was able to set up radio relays to send outgoing messages. Another communication challenge was the inability of the ambulance crews to make full use of their radios. Ambulance crews in Arkansas generally work with two frequencies, one for dispatch and one to communicate with the hospital. Crews simply did not know which other radio channels could and should be used. Dunson provided a simple solution to this technological communications challenge: the National Interoperational Field Operating Guide lists the radio frequencies that can be used by any licensed public safety agency anywhere in the United States. Using simplex or direct channels, the ambulances can talk directly to each other over short ranges. The solution was to get all the ambulances on the same channel, so Dunson assigned one person to ensure each ambulance radio was turned to the statewide frequency. Dunson added that communication barriers are not limited to technology barriers, but also involve reaching the appropriate audience to promote efficiency. For example, all responders need to know who the incident commander is, while only specific people need to be informed of when and where helicopters will be flying.


Dunson mentioned coordination as another challenge. Dunson related the fact that no medical director was ever assigned to the scene, and EMS did not have the training that is needed in incident command. In addition, he posited that the extended time frame of the incident contributed to this challenge. The flood occurred at 2:00 a.m. Friday morning, with an ambulance remaining on the scene until Monday at noon, due to extended search and rescue efforts. Dunson listed limited access to the river and improper use of ambulances as other obstacles to efficient response efforts. When responding to an incident, an ambulance is not a hearse, Dunson emphasized. During the open discussion, a participant honed in on the difference between mass fatality planning and mass casualty planning. EMS needs to participate in the development of integrated plans for not only mass casualty incidents but also incidents with mass fatalities.

Physical and Psychological Support for First Responders

As in the Mexican Hat incident, the well-being of the EMS personnel, both physically and emotionally, was also a concern. The heat indices each day were well over 100 degrees, with humidity approaching 90 percent. Dunson explained that a cooling space was set up, and people were assigned to provide cold water to responders, reminding them to rehydrate regularly. To assist responders with the psychological stresses of responding to the incident, the critical stress debriefing team were contacted and activated. Dunson noted that it can be very frustrating for responders to be brought into an incident, placed in staging, and then never be used. Often, individuals feel that they could have made a difference, saved a life, but they were prevented. This frustration leads some to quit emergency services. Thus, part of critical incident debriefing, he said, should be to counsel responders that even though they were brought in and not used, they nonetheless contributed to the effort, perhaps by freeing someone else to go into the field just through their presence. This is regrettably not often addressed, he said.

Absence of Metrics

The absence of standardized metrics to assess an area's EMS response capabilities to an MCI hampers emergency preparedness planning, Dunson added. As a temporary solution to identified metrics, he explained that he identified a county with nearly the same population and demographics and simply started contacting people in EMS and fire departments to inquire about their equipment and resources. In contrast, Utah, like other states, has embraced broadly inclusive planning strategies by bringing together leaders from the EMS community and sharing best practices. Dunson suggested that lessons may be learned from the U.S. military emergency response efforts in Iraq and Afghanistan, which deal with similar resource and logistical issues as many local rural environments. Patrick suggested that such comparative information could be useful, noting that his EMS medical director, who is also the state surgeon, works with the National Guard and recently returned from a 3-month tour of duty in Afghanistan. Patrick noted that it was his goal to increase civilian-military collaboration in an effort to learn from each other's successes.


The Mexican Hat incident and the Albert Pike flooding were reviewed as case examples of rural MCIs, and the following challenges to EMS response emerged:

  • Communications and notification
  • Access and transportation to the scene
  • Patient tracking
  • Limited resources
  • Limited ALS
  • Availability of medical direction on scene
  • Availability of regionalized trauma centers
  • Psychological consequences to victims and responders
  • Multistate response

In the Mexican Hat incident, in spite of these challenges, communication to and from the scene was excellent, due to a particularly competent dispatch. Responders worked as teams, implemented ICS, and made use of bystanders that were available. The state strike team was also a valuable resource. Following both MCIs, responders had positive experiences with the critical incident stress management teams. It was noted that a key component of the responses was the excellent leadership by both Larson in Mexican Hat and Dunson in Albert Pike.

In Mexican Hat, some of the lessons learned that were mentioned by the panelists involved in the response effort include the need for contingency plans when weather prohibits an air response, and the importance of trying to keep families together. The experience also led to revisions of the triage protocol and patient tracking procedures.

Ongoing threats to progress include the current economic situation and its impact on the availability of funding to support development and infrastructure; lack of technology, or lack of access to existing technologies; the lack of data to support EMS policy decision making; the need for research to support best practices; and the lack of focus on coordinated prevention.

Copyright © 2011, National Academy of Sciences.
Bookshelf ID: NBK62383


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