Lessons Learned or Lessons Forgotten? How Can We Make Incidents Within Incidents More Dialed.
The Andrew Palmer Story.
Every year before the season starts it is drilled into our heads that there are clear and defined protocols for incidents within incidents. For those of you who haven’t heard this terminology before, this is when there is an injury on a fire and we reconfigure into a smaller Incident Command System… within an Incident Command System. The definition for that is as follows.
The Incident Command System is a standardized approach to the command, control, and coordination of emergency response providing a common hierarchy within which responders from multiple agencies can be effective.
Each year we have to go over how this works, why it works, and this should be well known to all firefighters. The question is however, why do we still have issues making it flow smoothly? There is not just one answer to this, there are a few common reasons. Now, before we get into all this we need to know how a lot of these protocols were developed. In 2008 there was a fatality in California that has been named the Dutch Creek Incident.
A firefighter named Andy Palmer died after the medical extraction went all kinds of sideways. Here is the brief from the National Wildfire Coordination Group.
On July 22, 2008 the engine received a resource order for the Iron Complex in California. The supervision at the park was motivated to see the engine crew obtain an assignment and called them in on their day off.
The crew suffered a series of complications en route to the fire, including mechanical problems with the engine that lead to the eventual separation of the crew and engine captain after arriving at the incident. The crew members were encouraged to pursue a line assignment as a falling team.
The Incident Management Team (IMT) personnel assign the crew as a falling module. During that assignment, the crew cuts a tree that is outside their falling qualifications. A class C ponderosa pine is cut, falling downslope into a fire-damaged sugar pine.
A portion of the sugar pine breaks off and falls upslope, hitting Andy Palmer, resulting in multiple severe injuries and the loss of a firefighter's life. It was Andy’s first fire assignment.
When paramedics first showed up they quickly realized that the scene was much more severe then had been communicated over the radio. They decided to package and hike out. Nearly an hour after the injury occurred the folks on scene decided to hike the patient out to an ambulance 2,000 feet below. Andy was prepared and ready to move.
Moments later another paramedic showed up and after a short chat they all decided to scrap the “hike out” and wait for the helicopter. At this point crews began to work on cutting out an extraction zone and a Coast Guard helicopter was ordered. Response time of this ship was delayed because of many reasons. The severity of the injury was still being underplayed, another helicopter was thought to be coming but didn’t because of extraction methods. Then when the Coast Guard ship did show up radio frequencies were confused and more issues occurred. Finally, over 2.5 hours later Andy Palmer was loaded into the helicopter via hoist. Andy Palmer bled out and was pronounced dead at the hospital.
The Dutch Creek Protocols were designed after this incident. These became the Medical Plan “9 line”, which have now become the Medical Plan “8 line” found HERE. These protocols were introduced to help consolidate information and provide severity levels to the incident. Also added was the Emergency Medevac Procedures/Plan which ultimately asked these three questions:
What are we going to do if someone gets hurt?
How will we get them out of here?
How long will it take to get them to a hospital?
I have heard there were 3 incidents within an incident on the Washburn Fire in Yosemite, all on the same day. Folks reached out and said things could have run smoother.
I don’t have personal knowledge of these incidents but it seems there was confusion along the way.
It has been relayed to me that the severity of injuries were not understood or translated, indecision on if it should be a green, yellow, or red incident, and terminology problems happened between resources. I’m not sure if this is fully the case but it sounds like they didn’t go perfectly. We can learn from this.
I have been involved in a few incidents within an incident. I was present for the Tanker 11 crash on the White Rock Fire. I was on the fire in Hells Canyon Idaho when the Dozer flipped down the mountain. I have rushed a dialed sawyer to the ER because he decided to try and catch a running saw. I have also been involved in hiking a packaged person off fires in Utah in tandem with other Hotshot crews.
The Hells Canyon incident was an eye opener because
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