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 will discuss the concepts for handling a mass-casualty incident. The second part will describe a 100-person winter MCI and the lessons learned from it, and will also offer some ideas on preparing your system to handle an MCI and developing the interagency capacity to handle such an emergency.

The definition of what constitutes an MCI will vary, depending on your individual community, because an MCI can be any incident that taxes a community’s response and medical resources. For smaller communities, this could be a 10-person incident.

One of the largest and oldest meatpacking plants in the country has many structures where thousands of employees worked.

The potential for an MCI to occur needs to be considered in your agency’s training, but unfortunately the daily requirements of staffing, managing operations and normal responses can make preparing for na MCI a daunting task.

Command of the Incident

Because an MCI be overwhelming, one of the most important tasks is to first establish an Incident Commander. This critical decision determines who is in charge, establishes one point of contact for resources, and ensures that the overall strategies for the incident are developed.

If the incident continues to grow, or becomes increasing complex, the IC may decide to bring other key people into the command role as a team effort to manage the incident. This Unified Command brings other key decision-makers together to allow collaboration to occur without excessive filtering of information.

The most common members involved in Unified Command are representatives from fire/rescue, law enforcement and emergency management, as well as any other decision-makers who may be needed. It’s important to determine who should be part of the unified command for various incidents, and this is best done by building relationships ahead of time. Keep in mind that there can be many issues that the IC/UC may need to address, including evacuation, hazardous materials and traffic control.

The ammonia cloud photographed several miles away.

And as an incident grows in complexity and/or duration (more than 24 hours), activating (or creating) an emergency operations center could help a community from being overwhelmed.

By developing quarterly planning and educational topics, communities can make the EOC part of their regular training program. By bringing together all the people who will fill the various roles together on a regular basis, there will be familiarity when the EOC needs to be activated.

Common Problems

Within all disasters, there are a couple of common problems. In the broadest sense, these deal with communications and logistics.

The first thing to keep in mind is that the first report of any major emergency is almost always incorrect. This is because people calling 911 often have only their individual perspective of the incident. The caller is not trained to analyze the situation, and while reporting the incident, they will be trying to process information that may be beyond their ability to understand at that moment.

The second problem concerns logistics, or getting the right equipment to the scene. Since the initial information may be lacking, the necessary resources might not be first to be dispatched to the incident. The IC might also fail to realize the time delay to get the proper resources to the incident.

Workers evacuating the plant as ammonia fills the working areas. Since this occurred over lunch, accountability of employees was a concern.

This is especially true when the resources are not organic to the organization and may have to be brought to the scene by other agencies or by private contractors. To avoid potentially long delays in getting critically needed resources on scene, the rule is to “Go ugly early.”

This means to begin requesting resources to the scene in advance of the requests. An example would be to request city buses to possibly transport patients with minor injuries, thereby keeping the ambulances available for the more critically injured patients.

Ways to decrease the potential for any delays in requesting or locating resources is through the use of both Logistics and Planning branches under the Incident Command System. Their roles are to plan for longer-term issues and to locate key resources that will be needed. These roles are defined in the National Incident Management System and allow the IC/UC to use their time wisely.

Priorities in any MCI

The initial priorities for medical response can be broken down into three areas: triage, treatment and transport. If these are put into action in this order, managing an MCI will be easier.

The first step is to begin to triage patients. There are many methods to triage patients, and one of the easiest to implement is the START method. START stands for Simple Triage and Rapid Treatment and uses a simple way to triage patients into 3 groups: Immediate (red), Delayed (Yellow) and Minor (Green).

Once triage has begun, treatment areas are designated and set up, ideally to correspond to the severity levels of Red, Yellow and Green. Within these groups, the most severe of each group can be prioritized in the order in which they’ll be transported to treatment facilities.

The plant was filled with miles of piping through any packing plant, makes the risk of an hazardous materials and mass casualty incident a real concern.

The transportation of patients is the final priority to be completed. One key element to making this part of the operation run smoothly is an ambulance staging area. This differs from fire staging in that with fire staging, trucks stage and then move forward to stay at the incident. With ambulance staging, the rigs will stage and then move forward to receive patients, and finally leave the scene to travel to treatment facilities.

Overview of Sioux Falls

Sioux Falls is in the southeastern corner of South Dakota, 10 miles from both Minnesota and Iowa. The city’s population of 150,000 increases by 20% during the day as commuters drive to work. The major industries within the city include healthcare and banking, and Sioux Falls is also home to one of the nation’s largest meat packing plants.

Because the city is on the northern plains of the United States, temperatures can range from -20 degrees Fahrenheit in the winter, to over 100 degrees in the summer.

Sioux Falls has three major medical centers: Sanford Healthcare System, Avera Healthcare System and the Avera Heart Hospital of South Dakota. There are also a large Department of Veterans Affairs hospital and a children’s hospital.

Sioux Falls Fire Rescue has 194 uniformed personnel, 11 fire apparatus and two command cars; 54 personnel are on duty each shift. All SFFR personnel are certified to the EMT Basic level. Although some personnel are trained to higher levels (approximately 20 paramedics and four registered nurses), they are allowed to deliver care only at the EMT Basic level. Advanced Life Support care and transport are provided by Rural Metro Ambulance, which staffs three to four ALS ambulances daily.

Overview of the Incident

On Feb. 12, 2004, at about 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 and one ambulance were dispatched to the incident. Later this report was changed to a possible pallet on fire. Finally, it was changed to an ammonia leak that was forcing an evacuation of the building.

The structure involved was a several-story building where hogs are slaughtered, butchered and packed for shipping. This is part of a larger complex of storage buildings, curing areas, stock pens, support buildings and administrative buildings. Originally built in 1909, the complex has been expanded almost continually since then, so that in many areas, there is an intricate maze of passageways connecting buildings.

Morrell employs more than 3,300 employees, and at any time there can be thousands working on the complex. Many of the workers are immigrants from around the world, with the result that probably more than 50 languages are spoken there.

The second part of this article will discuss the response to this mass-casualty incident, the lessons learned, and how to prepare your system to handle an MCI.