big meadows fire
TRANSCRIPT
Big Meadows Fire Incident-Within-An-Incident Lessons Learned Review
Incident Date: June 16, 2013 Final Report Date: July 3, 2013
Big Meadows Fire Lessons Learned
Table of Contents
Introduction ................................................................................................................................................. 4
Summary ...................................................................................................................................................... 4
Evolution of Events ..................................................................................................................................... 5
Background ............................................................................................................................................... 5
Big Meadows Firefighting Activity .......................................................................................................... 8
June 16, 2013—Incident-Within-the-Incident .......................................................................................... 9
After Incident Response .......................................................................................................................... 13
General Observations ............................................................................................................................... 15
The Swiss Cheese Model of System Accidents ...................................................................................... 15
Medical Standards ................................................................................................................................... 16
Emerging Themes ..................................................................................................................................... 18
EMS/Rescue Program Professionalization ............................................................................................. 19
Planning and Preparation ........................................................................................................................ 22
Employee Support ................................................................................................................................... 26
Teamwork, Cohesion, Interoperability ................................................................................................... 27
Team Recommendations and Observations ........................................................................................... 30
Parting Thoughts from Luther and Paula .............................................................................................. 31
Acknowledgments ..................................................................................................................................... 31
Additional Documents .............................................................................................................................. 32
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TEAM MEMBERS
William Shott Regional Chief Ranger National Park Service, Intermountain Region
Alex Robertson BLM/FS, Deputy Fire Staff Officer Central Oregon Fire Management Service
Joe Sean Kennedy USFS, Battalion Chief Grindstone Ranger District, Mendocino National Forest
David Carter FWS, Assistant Regional Fire Coordinator R-6 Regional Office Refuges
Dave Horne Branch Chief of Law Enforcement and Ranger Activities National Park Service, Intermountain Region
Allison Fullerton Park Ranger-Interpretation, Video Specialist, National Park Service National Park Service, Intermountain Region
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Introduction
As a result of the serious emergency medical incident occurring on June 16, 2013, the superintendent of Rocky Mountain National Park (RMP) requested a Lessons Learned Review of the incident and issued a delegation of authority to the Intermountain Region Chief Ranger of the National Park Service (NPS). While the incident had a positive outcome, the superintendent expressed a desire to share the successes of the incident so others may learn from the experience, and explore areas of improvement for future operations using the Facilitated Learning Analysis (FLA) process.
The Regional Chief assembled an Interagency Lesson Learned Review Team and developed a methodology to achieve the desired results outlined in the superintendent’s delegation of authority. The methodology identifies four stakeholder perspectives including Administrative and Policy level, Agency Administrator, Incident Management Team, and line/field personnel. Each stakeholder provided their perspective of the incident to reach the following objectives:
1. Highlight successes and identify current and future best practices
2. Identify areas of potential improvement operationally and programmatically
3. Link prior lessons learned with this incident to demonstrate the progression and evolution of best practices for future incident planning
4. Develop a unique product that will reach a broader audience, speak to each identified stakeholder, can easily be utilized for continued education, and can be used as a resource for incident management
Summary
On June 10, 2013 park visitors witnessed a lighting strike start a fire in the Tonahutu River Drainage northeast of Big Meadows within RMP. The fire grew significantly with high potential to spread to the south and west, threatening the community of Grand Lake. The decision was made to suppress the fire and a Type-2 Incident Management Team (IMT) was ordered on the evening of June 11, 2013. The RMP superintendent signed a Delegation of Authority (DOA) and letter of intent, authorizing command of the incident to an Incident Management Team (IMT). The IMT was in-briefed at 1800 hours on June 12, 2013 and assumed command of the fire at 0600 hours on June 13, 2013.
The IMT deployed four Interagency Hotshot Crews (IHCs) and one Type-1 Wildland Fire Module (WFM) due to the significant hazards which included remote location, steep terrain, and an abundance of snags. A spike camp and helispot (H 1) were established in a large meadow
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along the southern edge of the fire. Approximately 100 firefighters were operating out of this spike camp including all four IHCs, WFM, local resources, miscellaneous overhead, and two line paramedics.
On the morning of June 16, 2013, while en-route to their assigned area of the fire, an IHC crewmember collapsed and quickly became unresponsive. Another crew member immediately assessed the patient and confirmed his breathing and heart rate had stopped. Emergency Medical Technicians (EMT) from two crews began Cardio Pulmonary Resuscitation (CPR) and one of the IHC Superintendents initiated a medical emergency response via radio. Paramedics from the spike camp were deployed to the scene. An Automated Electrical Defibrillator (AED) was successfully utilized reestablishing a pulse in the patient. After medically stabilizing the patient, he was carried by stokes litter approximately one quarter of a mile to H 1 and transported by air ambulance to St. Anthony’s Hospital in Lakewood, Colorado.
The patient was admitted to the intensive care unit. The IMT immediately initiated an all-fire safety stand down and provided after-incident care on-site for affected crews. The IMT also deployed resources to provide family assistance, injured firefighter assistance, and addressed employee benefits.
Evolution of Events
Background
The timeline for this incident began in 2005. The Rocky Mountain National Park staff experienced an employee fatality when backcountry Ranger Jeff Christensen died (Christensen Serious Accident Report) while on a backcountry patrol within the park and was located only after an extensive search. This was a sea change event for RMP management as it highlighted the risk of backcountry operations to both fire and non-fire personnel and predicated several operational changes. Since this incident, RMP’s management team has been very mindful of how park operations are implemented and how sufficient emergency planning is completed to ensure employees who have emergencies in the field are afforded an appropriate and timely response.
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The Iron Complex in 2008 resulted in the death of NPS Firefighter Andrew Palmer and also played a key role in decision making among the management staff at RMP. As identified in the Dutch Creek Serious Accident Investigation Report, the failure to adequately plan for medical evacuation resulted in this fatality. The Wildland Fire community reacted to the incident with increased awareness of medical emergency planning. The Dutch Creek Protocols were also developed and implemented.
The Dutch Creek Protocols reinforced the need for emergency response planning during the Big Meadows Fire particularly due to the remote nature of RMP.
The Cow Creek-Round Mountain Fire in 2010 was another challenging fire for RMP. The complexity of the remote terrain along with problematic fire behavior made suppression of the fire difficult. The park staff and the Type-2 IMT worked diligently at making solid, risk based decisions regarding where and when to deploy firefighters to suppress the fire while ensuring adequate emergency planning. This was RMP’s first opportunity to implement the Dutch Creek Protocols within the park.
These three incidents (Christensen, Palmer, and Cow Creek) played a key role in how the park staff made decisions when the Big Meadows fire started on June 10, 2013. The decision was made to suppress the fire due to its proximity to the community of Grand Lake, the continuous timber fuels to the west with no natural barriers to limit fire spread, and the current drought conditions. Consideration was also given to the growing fire activity throughout the state of Colorado and the potential future availability of firefighting resources. The RMP superintendent and Fire Management Officer (FMO) crafted the delegation of authority and leader’s intent that specifically directed the IMT to implement the Dutch Creek Protocols on the incident. The leader’s intent also prioritized the ability to quickly evacuate injured firefighters over wilderness resource protection concerns. The RMP staff approved the use of helicopters, chainsaws, and pumps to be used in the wilderness to ensure the IMT could not only get injured firefighters out, but had all the appropriate tools to suppress the fire.
In May of 2013, the Rocky Mountain Geographic Area Executives, which include all participating state and federal agency representatives, held a meeting to discuss fire related issues. One of the topics discussed was Dutch Creek Protocols and how the Rocky Mountain Incident Management Teams planned on implementing them during the 2013 fire season. This was an important process that the executives implemented to ensure IMTs understood their leader’s intent and the importance of IMTs planning for medical emergencies.
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The Rocky Mountain IMT assigned to the Big Meadows Fire was very busy during the 2012 fire season and used that experience to further develop their Incident Emergency Action Plan Checklist and their ICS 206 Medical Plan. The team continued to adapt those lessons to make their team process for medical emergencies easier to understand and simpler to communicate with the resources that work at their incidents. The IMT experienced turnover for the 2013 fire season that included a new Incident Commander. In addition, the IMT did not have a primary medical unit leader due to the lack of qualified medical unit leaders available in the system. The IMT recognized that their established processes for medical emergencies would not be inherently known
throughout the team so they decided to address this issue early on at the Big Meadows incident. On the second day, the IMT was in place and simulated a medical emergency in order to test their Incident Emergency Action Plan Checklist.
The Rocky Mountain IMT was delegated authority to take command of the Big Meadows Incident at 0600 hours on June 13, 2013. The IMT immediately started their planning cycle including their incident-within-an-incident plan and how they would meet the Dutch Creek Protocols. The IMT owns three AEDs which the safety officer had inspected through the local county ambulance company assigned to the incident. Although the team’s incident-within-an-incident plans did not directly include staging an AED at the spike camp, the county ambulance paramedic who inspected the AED’s in discussion with the team safety officer and the line paramedics, decided to take one of the AED’s with their gear to the spike camp. This was the AED that was used during this incident and its close proximity to the patient saved his life.
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Big Meadows Firefighting Activity
On June 10, 2013 park visitors witnessed a lightning strike start the Big Meadows Fire in the Tonahutu River drainage just north of Big Meadows in the Rocky Mountain Park Wilderness. The fire was managed with a suppression strategy due to the proximity to the Town of Grand Lake and the potential for the fire to burn all summer. Conditions that afternoon were isolated thunder showers with gusty erratic winds (Initial Spot Weather Forecast). Initial response was an initial attack (IA) Squad of NPS firefighters hiking in from Green Mountain Trailhead. Due to the weather conditions and hazards of fighting fire in the dark with the large stands of beetle-killed trees, the firefighters opted to hike out for the evening and return in the morning. The firefighters returned to the fire the next morning and began suppression activities. With red flag warnings (low relative
Evolution of Events RMO Superintendent RMO Fire Management Officer RMO Chief of Resources Management RMO Law Enforcement Specialist
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Video Link: http://youtu.be/mp1wW8b2Ad0
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humidity, high temperatures and wind speed) again that day the fire began making a substantial run for about 300 acres, and the decision was made to order a Type-2 Incident Management Team (IMT2). There was minimal fire growth for the next couple of days due to favorable weather conditions. On the 5th day of the incident the fire increased to almost double in size due to a large burnout. For the duration of the incident the fire growth was minimal due to suppression activities and natural barriers which contained the fire.
June 16, 2013—Incident-Within-the-Incident
Big Meadows Incident Narrative - Morning Briefing to Safety Stand-Down
On June 16, 2013 around 0730 hours the two California IHC’s were listening to the morning briefing over the radio as they were hiking up the Tonahutu creek trail on DIV Z. After hiking in via the Green Mountain Trail, they arrived at spike camp which also served as a helispot (H 1), utilized to support the crews by serving as an air medical evacuation location and an equipment and personnel drop site as needed. H 1 was about a four to five minute flight from the helibase located at Harbison Meadow.
The crews assigned to DIV Z had completed a burnout and had secured the division. The risk of active fire behavior and fire spread was low the morning of the 16th. However, dangerous conditions still existed such as: steep inclines, snags, scree fields, wildlife encounters, and the danger of falling trees. Some crewmembers
paused approximately four minutes up the trail just after crossing a second rudimentary bridge across Tonahutu River to allow the crew superintendent to listen to the morning radio briefing. The briefing gave them pertinent information such as weather information, fire activity, safety messages, aviation activity, and tactical assignments. One of the crewmembers, Luther, recognized it was Father’s Day and was congratulating the other fathers on the crew, exchanging handshakes.
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After these exchanges between crewmembers they continued up the trail. At approximately 0737 hours a crewmember was heard falling. As the crewmembers closest to him turned to look they realized the victim was Luther. Luther (hereafter referred to as “the patient”) is a veteran of the Horseshoe Meadows Hotshot crew (Horseshoe) and has been on the crew since 1987.
One of the crewmembers closest to him shouted, “Murph” – a former EMT who had just shaken the patient’s hand. When he heard his name he turned around and observed the patient slumped on a rock with his back against a tree and appeared to be having a seizure. He swiftly moved next to him to assess the situation. He called out to his crew EMT who joined him and also began assessing the patient’s condition. Moments later the Horseshoe superintendent was on scene. The superintendent immediately radioed to make the division supervisor and the IMT aware of the medical situation. The EMT and Murph, thinking he was having a seizure, followed protocol for making sure he was safe and not a danger to himself or others by laying him down in the middle of the trail away from hazards.
The helibase manager and helitack crew were also listening to the morning briefing when they heard a report of an emergency medical situation. The crew at H 1 began to execute the pre-rehearsed medical plan. The crew, without direction, assumed the roles that were assigned to them the day before. The Air Base Radio Operators (ABROs) responded with one taking notes and the other monitoring radio frequencies to relay information from the crew and the on-scene IMT.
The hotshot crewmembers monitoring the patient’s status realized they could no longer see or feel breaths in the patient. An EMT checked for a carotid pulse while a crewmember checked for a radial pulse. Both confirmed the patient had no pulse. Crew EMTs asked other crewmembers present to step back as they needed space to begin CPR. As soon as they discovered there was no breathing or pulse they requested other line EMTs. Joined by the Arrowhead Hotshots, the crews began implementing their incident-within-an-incident plan. The EMTs conducted CPR while aiding and coaching each other. They were led by Horseshoe’s EMT who called individuals over as needed to relieve personnel providing CPR.
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The Horseshoe superintendent, knowing Arrowhead had an AED staged at the camp, called over the radio for the AED and a litter so they could carry the patient to spike camp.
A few crewmembers were directed to drop their line gear and quickly retrieve the AED. They immediately sprinted down the trail, spreading out in a relay fashion, in order to relieve each other as they tired. They were met by spike-camp-stationed line paramedics who produced a different AED (they did not know that Arrowhead had an AED staged there). The AED belonged to the IMT and had been brought up with other medical supplies because they too weren’t aware the crews had an AED with them.
Once the helibase heard the call by the superintendent for the AED, the helibase manager launched the NPS short-haul helicopter with paramedics on board. The NPS crew brought the county medic to assist. The IMT initiated the order for an air ambulance to H 1. This order led to some confusion at the helibase about which helicopter would initially transport the patient. The IMT made the decision to use an air ambulance to transport from H 1. This decision was made to reduce the amount of time the patient was not in Advanced Life Support (ALS) care. In the meantime, another helicopter was dispatched with additional medical supplies, including a wheeled litter and sked.
On the trail, the AED voice command instructed the EMTs to administer one shock. The crews continued CPR per standard protocol after the shock. Further shocks were not advised. The AED evaluated the patient while EMTs continued cycles of CPR. The crews continued coaching each other and communicating any indications of change. Eventually Luther regained a pulse, respirations, and a normal range of blood pressure; however, the crewmen recognized they needed to immediately transport the patient to a higher level of care. The medics continued to monitor, record vital signs, establish IV lines, and administer oxygen.
Along with the AED, a stokes litter had arrived with the flight paramedics. Once better vital signs returned, the patient was packaged onto the litter and monitored until a decision was made that he was stable enough to be transported. Meanwhile the non-medical crewmembers (approximately 40) were on the trail awaiting instruction on how they could assist.
The process was discussed as to how they would carry the patient out on the litter. One of the NPS medics instructed a conveyor belt method where the crew lined the trail on both sides and passed the patient down with the crewmembers on the end moving around the group to the front. The crewmembers quickly realized this method was not practical due to the width of the trail and foliage on either side.
The crews made a joint decision to hand-carry the litter and trade off as they tired. This was accomplished by the crewmembers calling out commands like; “middle right” or “front left” to let the members on standby know where relief was needed. It was emphasized by members of
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both Arrowhead and Horseshoe that the communication throughout this entire incident-within-an-incident was paramount to their success. Also noted, the two crews knew each other well and regularly worked, recreated, trained together. This added to the support, teamwork, communication, sense of duty, and ultimately success of this operation.
The IMT ordered an air ambulance to go into air standby near spike camp around 0745 hours. The Horseshoe superintendent, still monitoring the radio and trying to establish communication with the air ambulance, reported to the IMT that the patient was packaged in the litter. The IMT knew RMP had a standard operating procedure for air ambulance radio frequencies but the frequency listed in the emergency medical plan did not match the RMP standard air ambulance frequency. This discrepancy was quickly discovered and communication was established between the resources on the ground and the air ambulance.
While the leadership of the incident was communicating and coordinating, the crew was carrying the litter down a narrow, marshy, sometimes steep trail. The crews continued to take turns, carrying the litter and changing out as each pair tired. There were two potentially hazardous river crossings, one being much smaller and slower moving than the other. The crews sent members ahead to assess the river crossings. The reconnaissance crews advised using a chaining method through the river as the most effective way to cross due to the small size of the temporary bridge.
The second river required the same process - this time the bridge was narrow enough that the crew could pass the litter directly over top of the bridge to ensure that if the litter slipped, it would fall on the bridge and not in the water. This demonstrated the crews’ situational awareness and teamwork to mitigate risk to the patient.
Paramedics and EMTs continuously assessed the patient, which added a little more time to the carryout. The teams arrived at spike camp around 0840 hours and noticed the air ambulance on the ground. The air ambulance shut down and the crews were directed to lay the patient in a shady area and wait for instruction from the aircrew. The medics from the scene briefed the air ambulance aircrew on the patient’s current condition and provided the pertinent medical history from the time the incident occurred at 0738 hours until arrival at camp including: IV fluids, blood pressure, blood sugar, pulse rate, oxygen administered, heart monitor read-outs, and respirations. At 0852 hours the patient was loaded into the air ambulance which departed H 1 at 0902 hours. The time elapsed from the patient’s collapse on the trial to transfer of patient care to Flight For Life was approximately one hour and fourteen minutes.
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After Incident Response
While the patient was being loaded into the medevac helicopter, it was decided the superintendent of the IHC would be immediately flown to the helibase and head to the hospital via ground transportation. The IMT decided to fly Arrowhead and Horseshoe IHCs out due to their long history of working together and the emotional impact of the event.
Immediately after the patient was loaded into the air ambulance, the division supervisor asked the two paramedics to brief all involved personnel at the scene on the patient’s condition. The paramedics gave credit to the two IHCs for saving the patient’s life and added that if CPR was not done immediately, or the medical plan was not effectively implemented, the probability for survival would have been low.
At 0852 hours the IMT issued an immediate minimum 30-minute safety stand down until further analysis of fire conditions and safety measures could take place.
Incident-Within-An-Incident Timline Helibase Manager (trainee) Air Base Radio Operators Horseshoe Hotshot Crew Arrowhead Hotshot Crew Grand Canyon Aircrew and Paramedics IMT Helispot Manager
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The IMT safety officer responded to the helibase and conducted an After-Action-Review (AAR). The IMT safety officer and the operations section chief then flew to H 1 to evaluate all personnel remaining on scene.
The IMT arranged for busses to transport the two IHCs to St. Anthony’s Hospital (about 2 ½ hours) to be with the patient. Hotel rooms were acquired within blocks of the hospital. The crews stayed for several days until the patient’s condition stabilized; they were then released back to duty and were reassigned to another fire on June 20, 2013. Prior to their departure the crew participated in interviews for the Lessons Learned process.
The Command and General Staff considered next steps in this incident. The IMT did not have a plan in place for a post-incident serious accident response. The Deputy Incident Commander referenced the Little Venus Fire shelter deployment incident and realized the need for an after-action response which addressed employee needs.
The IMT implemented an impromptu plan to take care of the two IHCs. A family liaison and crew liaison were assigned from members of the IMT. Also the Interagency Regional Representative (IARR) was notified and started working with both IHCs. The IARR became the family liaison when the IMT was demobilized until arrangements could be made for someone from the home unit to travel and be there for the duration of the patient’s hospital stay. A crew liaison remained to support the patient and family for the next several days.
A phone call was made to the Wildland Firefighter Foundation (WFF) who took the necessary steps to bring the patient’s family to his side immediately. Two days later an Emergency Invitational Travel was authorized for the family by the patient’s home unit and the family was taken care of for the duration of their stay.
The actions the IMT executed provided lessons learned, and should be considered for future events. A Serious Injury or Fatality Response Guide was developed by the IMT based on the model of the Deputy Incident Commander’s home unit’s plan (RMT-A SARG).
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General Observations
The Swiss Cheese Model of System Accidents
Defenses, barriers, and safeguards occupy a key position in the system approach. High technology systems have many defensive layers: some are engineered (alarms, physical barriers, automatic shutdowns, etc.), others rely on people (surgeons, anesthetists, pilots, control room operators, etc.), and yet others depend on procedures and administrative controls. Their function is to protect potential victims and assets from local hazards. Mostly they do this very effectively, but there are always weaknesses.
In an ideal world each defensive layer would be intact. In reality, however, they are more like slices of Swiss cheese, having many holes—though unlike in the cheese, these holes are continually opening, shutting, and shifting their location. The presence of holes in any one “slice” does not normally cause a bad outcome. Usually, this can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity—bringing hazards into damaging contact with victims (Reason, 2000).
Employee Support Horseshoe Hotshot Crew Arrowhead Hotshot Crew
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Even though the participants identified weakness in the protection controls (e.g. medical standards, confusion over EMS credentials, different radio frequencies for FFL, etc.) many positive actions, including teamwork, quality trained individuals, CPR & AED, simulated rehearsal, pre-planning, and a lessons learned culture, lined up to block this unforeseen medical emergency from a catastrophic result.
Medical Standards
One topic, and potential latent risk, that was raised in several interviews was the procedures for testing medical standards. The medical standards for firefighters (arduous duty) have been the same for all agencies since accepted and authorized for implementation by the Federal Fire and Aviation Leadership Council in 2003. Dr. Kate Sawyer MD, Medical Officer for the Department of Interior (DOI), believes the standards will remain the same based on current information but procedures used for testing these standards may continue to be different among firefighting agencies.
Dr. Jennifer Symonds MD, Medical Officer for the US Forest Service (USFS) Washington Office, Wildland Fire and Aviation program and current Medical Qualifications Program Manager, reports the Forest Service is working to implement a comprehensive medical qualifications program.
Dr. Symonds explained that the USFS’s current testing program involves the use of a Health Screening Questionnaire (HSQ) which they have used exclusively since 2009 when the Medical Standards Program practice of medical evaluations was put on hold. The HSQ is filled out by the employee and if medical conditions are not disclosed the employee is cleared for participation in the arduous duty work capacity test (aka Pack Test). If the employee does report a condition on the HSQ the employee is required to complete a physical examination (OF-178). Many crewmembers made the conclusion that if you check one of the ‘yes’ boxes, you don’t get to work. However, if the employee does report a condition on the HSQ the employee is required to complete a physical examination (OF-178).
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Dr. Symonds reports that the USFS pays for the required physical, but the USFS does not provide or maintain an approved list of physicians for this task, therefore the employee needing the physical may utilize any physician or provider of their choice. If a physician determines the employee fit for duty they are eligible to take the Pack Test and, assuming they pass, engage in arduous duty work. If the physician determines there is an abnormality, the record is sent to Dr. Symonds for determination if the employee is eligible for a waiver. Dr. Symonds reports that there is not a comprehensive waiver process but that she considers all information available in making a determination.
Dr. Symonds and the USFS are currently in the process of building a more robust medical qualifications program. The program, when implemented, will provide an agency funded physical for all arduous duty employees every three years and requires an annual self-certification questionnaire. This information will be managed by an Electronic Medical Records system which will allow real and effective use of pertinent employee fitness for duty data. Though implementation of this improved program is not eminent as reported by Dr. Symonds, it is her hope that it can be utilized for next year’s “fire hire” and believes the largest obstacle at this point is completion of the Electronic Medical Records system. This program will be much more effective in identifying existing or developing conditions which may put firefighters at risk in the field.
In regard to testing standards for DOI’s agencies, Dr. Sawyer has similar recommendations including a standardized exam from an agency approved practitioner every 3 years, recording/monitoring baseline heart, lung, and hearing function, and comprehensive blood work. Though Dr. Sawyer doesn’t believe a health screen questionnaire is adequate for monitoring employees’ health between physicals she does recommend an annual health status change statement be required.
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Emerging Themes
The following themes were developed through interviews with individual field, overhead, and administrative employees who were involved with the incident. These four themes, common among all groups, highlight critical components contributing to the success of this operation.
EMT Crew Member Quote
The successful outcome of this incident was in large part due to the presence and action of an EMT crew member. The EMT’s recognition of a life-threatening situation and the immediate supportive actions taken, ensured that the patient had the greatest potential for a positive response to delayed paramedic interventions. We can say with absolute certainty that the favorable outcome of this incident is due in large part to the initial care administered by EMT crew members. Training in hemorrhage control, airway management, and CPR makes EMTs a valuable resource in the wildland firefighting community. Every crew would benefit from having one or more EMT-trained crew members while on assignment.
Swiss cheese Model Horseshoe Hotshot Crew Arrowhead Hotshot Crew
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On-scene Paramedic Quote
The chain-of-survival is a “chain”. Just as removal of a link in a chainsaw would result in it becoming disconnected and not working, the same is true in the chain-of-survival. Had any of the above steps been removed, the outcome of the incident would not have been successful. This incident was centered around a cardiac arrest, but any medical emergency or injury needs all of its necessary resources, not just a few. The Big Meadows incident lays out an example of how to do things right and take care of those who are risking their lives for others. It was an honor to be part of this incident. My hope is that we can use this to provide a framework and standardization that means no matter where people are fighting fires they can do so knowing that if a medical emergency arises, they can depend on a world class response that we can be proud of.
EMS/Rescue Program Professionalization
Successful aspects of the Wildland Fire EMS program were identified as were opportunities for continuous improvement to ensure timely emergency medical service to line firefighters.
Training Support
A common theme among all groups interviewed is the challenge of limited support for Emergency Medical Service (particularly EMT) providers in obtaining their initial certification and maintaining necessary proficiencies through continuing education. Wildland firefighters typically pay for their own EMT training, which they accomplish on their own time.
Individuals are willing to accomplish this due to a sense of duty as well as to improve their résumé and marketability for jobs. This proves to be an effective practice due to supervisors’ confirmation that, with all other things equal, they would prefer to hire a qualified EMT before those who do not have this certification.
Standardized EMS/Rescue Equipment
EMS and rescue equipment was heavily discussed throughout the interviews. During this incident, all necessary EMS and rescue gear required to effectively provide emergency medical
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service, litter carry-out, and helicopter evacuation was readily available, including the crucial lifesaving AED used during this incident.
In this operation, extra effort focused on planning and pre-staging EMS equipment prior to the incident was fundamental to its success. However, this approach is not consistently executed on all inter-agency assignments. For example, crews do not generally carry EMT equipment on the fire line due to the added weight. Most line firefighters stage medical equipment where, if needed, they hope it can be accessed in a reasonable amount of time.
Medical Direction/National Registry/Credentialing
A significant theme of concern among fire professionals is the lack of established service-wide medical direction and credentialing. EMTs involved with this incident expressed concern over practicing their EMT skills outside of their home jurisdiction. Firefighters from agencies involved in this incident expressed particular concern over the potential for litigation as a result of practicing emergency medical skills outside the county where they are registered as an EMT. The National Park Service has adopted the national registry system for EMT certifications. To implement this program the NPS established four doctors who serve as medical direction for the service-wide program. In addition, there are 142 doctors who provide medical direction at individual parks throughout the system.
A May 28, 2013 National Wildfire Coordinating Group (NWCG) memo establishes an Administratively Determined Pay Plan for arduous duty line Emergency Medical Technicians; however, the issue of credentialing across state lines has not yet been addressed. As quoted from the safety advisory attached to the memo, consideration was given to the need for these positions to maintain an Arduous Fitness level:
1. Line going emergency care providers will carry all the prescribed medical equipment andtheir line gear to sustain them through a work shift requiring above average enduranceand superior conditioning.
2. The very purpose of providing emergency medical care to an employee in the fireenvironment means they may be called upon to respond on foot at a rapid pace in adverseenvironmental conditions. The pace of this work is set by the emergency.
3. Once on scene, the EMS resource will provide for patient care. The physical action oftransporting the patient will typically be carried out by fire line resources on scene;however the physical demands of maintaining patient care may last for an extendedperiod of time in adverse environmental conditions while carrying fire line gear.
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Big Meadows Fire Lessons Learned
Team Staffing Guidelines
Currently, minimum EMS training standards do not exist for line firefighters. However, these skills are highly sought after by hiring officials. Some regions have identified First Responder as a minimum first aid certification, but many teams actively recruit for higher certifications, particularly EMT-Basic.
Aviation Support (Short-haul/Hoist Capabilities)
In this incident the capability to provide emergency medical evacuation from the fire line was instrumental in the survival of the patient. Having this capability was due to a concerted effort prioritized in the planning processes due to events occurring years before the Big Meadows Fire. The management team’s decision-making process included incorporating the Dutch Creek Protocols, learned lessons from RMP staff fatality in 2005, and other previous fires resulting in the ordering of the appropriate available helicopter.
EMS/Rescue Professionalization
Horseshoe Hotshot Crew Arrowhead Hotshot Crew Grand Canyon Aircrew/Paramedics IMT Medical Unit Leader IMT Safety Unit Leader Grand County Paramedic
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Video Link: http://youtu.be/oVwaoq79EZ4
Big Meadows Fire Lessons Learned
Lessons Learned
1. Firefighters also want to be EMTs, and EMTs are needed on the fire line. BasicEMTs, who were the first responders, proved to be crucial in saving the patient’s life.Many firefighters reported the only incentive needed to become an EMT is training madeavailable by the agency.
2. There is confusion at all levels regarding who can practice EMS and where.Developing an interagency EMS system similar to what the NPS has (RM-51) maysignificantly reduce exposure to litigation when practicing EMT skills in the field.
3. The best lessons are the ones we don’t forget. Utilizing historic events as referencesthe management team, in collaboration with the Incident Management Team (IMT),placed life safety as the preeminent and driving priority in the planning process.
Planning and Preparation
The team had an operational plan for an emergency response. The subsequent execution of that plan during this incident significantly increased the probability of success. The planning measures carried out include:
Relevancy of Incident History
The RMP staff experienced a backcountry employee fatality in 2005 that clearly reinforced the need for thorough planning and preparation. Since that fatality there have been other incidents, as noted in above timeline of events that have significantly reinforced the necessity of planning and preparation. These incidents include the Andy Palmer fatality at the Iron Complex, and the Cow Creek Fire where RMP and IMT had many issues with meeting the Dutch Creek Protocols developed after the Dutch Creek Incident.
These past incidents at RMP resulted in a heightened sense of awareness when the Big Meadows fire started. RMP agency administrators actively focused on their leader’s intent document that was issued to the IMT. Complicating factors included remoteness of the fire, steep terrain, and the significant abundance of snags in the fire area. This led the IMT to utilize that specific leader’s intent to focus on developing clear and thorough planning for emergency medical procedures and incident-within-incident protocols.
RMP also assigned four key individuals to work with the IMT. The four areas assigned to those individuals were emergency management, fire management, resource protection, and agency administrator representative. Establishing these team members ensured effective coordination between RMP and the IMT within these critical areas.
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Big Meadows Fire Lessons Learned
Successful highlights of this planning are: Incident Emergency Action Plan Check List, the Incident Medical Plan (ICS 206), and situational adaptive aviation resource planning resulting in negotiations to trade a B3-A Star for an NPS 407 with short-haul capability and backcountry seasoned paramedic crew. The IMT also took the opportunity, on the second day of their operational command, to simulate an incident-within-an-incident. The non-regular team member Medical Unit Leader and all involved staff intimately knew their Incident Emergency Action Plan Check List. This ensures the plan is understood and that roles for each individual during an incident-within-an-incident could be successfully executed.
EMS/SAR Med-Planning, checklists, protocols,
Several efforts have been made throughout the Wildland Fire community to implement the Dutch Creek Protocols. Checklists have been developed to ensure team members know what to do during emergency situations. They also exist for stocking medical bags and wildland engines, but there is no national standard. If a standard were developed, resources assigned to incidents nationally would have a clear understanding of what is available when medical supplies are staged. A standardized approach to executing an EMS plan could increase the interoperability between agencies.
Practicing, simulating, continuously briefing spike crews of emergency protocols
When the IMT received the delegation of authority and leader’s intent from RMP, they immediately started planning and preparing for an incident-within-an-incident. The RMP assigned the RMP Emergency Services Coordinator to work with the IMT to ensure their medical emergency planning was coordinated with the RMP, the local EMS system, and RMP dispatch. RMP has exclusive jurisdiction for all emergency services within the park. Having the RMP Emergency Services Coordinator linked with the IMT is critical to ensure that this responsibility is seamlessly coordinated with the IMT’s emergency planning.
The Incident Emergency Action Plan Check List was established and simulated to ensure accuracy and efficiency. The IMT noted that the simulation completed two days prior to the incident was critical to their success. When the incident happened, the team members involved at ICP went directly to the same seats that they sat in during the simulation. All involved were calm, collected, and did their jobs just like they had practiced two days prior.
The ICS 206 incident medical plan was inserted into daily Incident Action Plans (IAP) and briefed to line resources located at the spike camp on a daily basis. It was noted by participants that this was invaluable to being prepared and for the responders not having to “figure out what to do”.
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Aircraft (configurations, capabilities, and availabilities for extraction)
The IMT knew when they took command of the incident and received the delegation of authority and letter of leader’s intent that to meet the objectives they would need the capability of either a hoist capable aircraft or a short-haul capable aircraft. The team worked with the Colorado National Guard to ensure the availability of their Rescue Blackhawk with hoist capability. They ran into some concerns with the after-hours availability and the guarantee of having a paramedic on board the ship when dispatched. The IMT contacted the Intermountain Regional Aviation Manager to assess the availability of short-haul capable helicopter. The Grand Canyon short-haul helicopter was found working elsewhere in the region. Upon receiving this information the IMT negotiated a trade with the other unit to acquire it for the Big Meadow incident.
Planning for staging AED in spike camp
An AED was staged at H 1 Spike camp. The AED was critical in saving the patient’s life. AEDs are now a common component of workplace environments, but there is currently no standard for their availability at fire camps or remote fire areas such as spike camps. The IMT owns three AEDs that were acquired the end of last year. The IMT safety officer requested the county paramedic assigned to the helibase to inspect the AED at the beginning of the assignment. The line paramedics that were assigned to H 1 Spike camp took inventory of their gear and with discussions with the county paramedic and the team safety officer; it was recommended that the line paramedics take one of the team AEDs to H 1 Spike Camp. Also, one of the IHCs that were assigned to H 1 spike camp had an AED in their gear but that was not known to the rest of the personnel.
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Big Meadows Fire Lessons Learned
Lessons Learned
1. Delegation of authority does not mean delegation of (your) responsibility. Host unitresponsibility is demonstrated by having several key agency representatives workingdaily with the IMT including: Agency Representative, Emergency Services Coordinator,Resource Advisor, Finance Liaison, Fire Operations Specialist, Public InformationOfficer, and Law Enforcement Specialist.
2. Don’t fall into communication silos, make communication expectations clear. Robustcoordination between the Safety Officer, Medical Unit Leader and the line Paramedics isparamount to ensure the appropriate resources are located in the appropriate locations.
3. Words matter. Participants mentioned numerous times that there was confusion in whataircraft was the “medevac” helicopter. During the incident, the NPS short-haul helicopterand the air ambulance were both being called “medevac”. This confusion did not have animpact on the outcome of the medevac but contributed to some uncertainty among
Planning and Preparation
IMT Incident Commander IMT Operations Chief IMT Medical Unit Leader IMT Safety Unit Leader
Helibase Manager (trainee)
RMP Emergency Services Coordinator
Horseshoe Hotshot Crew Arrowhead Hotshot Crew
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Video Link: http://youtu.be/BieS5lXSDOA
Big Meadows Fire Lessons Learned
participants and required some additional communication to ensure that the air ambulance would be the transport helicopter.
4. There is a cumulative effect of learning. This incident demonstrated that the learningculture continues to significantly and positively impact operations.
5. Know what the lines on a community map mean. Although RMP has exclusivejurisdiction for emergency services within the park, other units that don’t have the samejurisdiction should use the same planning process to ensure coordination with localemergency responders and that evacuation planning is complete.
6. Plan-B might be Plan-A. Every situation will be different. Having both groundevacuation plans and air evacuation plans is imperative. Relying on air evacuation is notreliable in every case and the type and capability of aircraft won’t fit every situation. TheRMP emergency service coordinator prefers to first having a reliable ground evacuationplan.
7. Be realistic; know what resources you can get. The type and availability of specializedresources required to realistically meet Dutch Creek Protocols can be significant,especially in remote and rugged areas, and when resources have limited availabilityduring busy fire seasons. Trained aircrews that are certified in providing Advanced LifeSupport service and human external load capabilities (short-haul or hoist) are few and farbetween and are currently limited to a small number of National Park Service assets andsome state and county units. Reliance on the military to provide this service in shortnotice situations can be logistically and financially difficult.
If agencies wish to increase opportunities for success in effectively implementing DutchCreek Protocols, increasing the availability of these specialized resources should beconsidered. While this was not a relevant factor in the outcome of this particularincident, and a short-haul capable aircraft and NPS/ALS flight crew was in fact availableif needed, the incident does underscore the importance of this resource type andimmediate availability if and when needed.
Employee Support
Employee and Family Support Pre-planning and IMT Standard Operating Guidelines
The first AAR was conducted with the IHC which was taken aside by the paramedics and briefed on what happened. The IHC commented later that what took place on the helispot was a beneficial and appreciated action.
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Big Meadows Fire Lessons Learned
Realizing the two IHCs were mutually affected was an important aspect of this operation. The fact that both crews were flown off the incident and made available to support the patient was extremely important for the wellbeing of the crews.
The IMT did not have current standard operational guidelines for managing a serious accident to an assigned firefighter beyond the initial medevac. This was a low frequency, high consequence, event which the team successfully responded to. They realized pre-planning would be valuable. In this case, adapting a home agency plan from the Deputy Incident Commander worked well. Picking the right person to become the family liaison and bringing the family in as soon as logistically possible was critical. The Wildland Firefighter Foundation was extremely helpful in providing initial assistance and support for the family.
Giving the crews the option to either hike down or fly down let the IHCs figure out what was best for their employees and was considered a sound decision.
Lessons Learned
1. When addressing employees’ wellbeing, start now. Immediately starting CISM and/oran AAR as soon as possible is crucial. The longer either is delayed, the greater thepotential for misunderstanding what happened or for taking longer for those involved tomove past the emotional stress of the event.
2. Be inclusive. Talk to everyone involved. If the second IHC was ignored there could havebeen negative consequences. The tie between crews may not be apparently visible, butasking folk’s opinion goes a long way in maintaining trust.
3. Emergency plans come in many flavors. Having a plan for all low frequency highconsequence events is extremely valuable. The first part of getting the patient off the hillwas planned using the Dutch Creek Protocols, and was a good first step, but was only thefirst step to taking care of our employees. Taking care of the residually affectedemployees and the patient’s family were the next two steps. The IMT took the time afterthis event to develop and adapt a plan that fits their needs for future reference.
Teamwork, Cohesion, Interoperability
Team selection and cohesion is by far the most consistent theme discovered by this team. Hotshot crews, medical personnel, IMT members, and park management team members all referenced Teamwork in one manner or another as being a key component leading to success in this incident.
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Big Meadows Fire Lessons Learned
Both Hotshot crews combined report over 300 years of experience and they attribute this low turnover/high continuity as being critical to how they responded to the incident. In addition, both of these involved crews are duty stationed within close proximity to each other and have for years worked, trained, and recreated together which, as reported by the individual members, led to a more efficient response.
These unanticipated benefits gained from the proximity and mutual exposure of the crews played such a critical role that many crew members recommended utilizing planned interaction, training, and communication with other crews to realize future and broader benefits.
Medical personnel involved in the incident had strong opinions regarding teamwork and interoperability. There were no less than five different organizations providing EMS. The consensus among these providers is that everyone’s professionalism and mission cohesion had a direct impact on the outcome. Of note, as reported by medical personnel and observers, there was never confusion over which provider was “in charge” of the patient. This fact alone speaks to the lesson of acknowledging designated and functional leadership (deferring to expertise) which has been relevant in past incidents and will be for future EMS providers. Designated leadership was clear for all positions in the field for normal operations and was identified as a positive condition by crew members, superintendents, and the division supervisor. When the incident within the incident occurred, those leaders stood and adapted to the change while additional EMS personnel were added that quickly adapted to functional leadership. Despite this addition of critical personnel without designation, it was clear to all involved where all patient care and transport direction was coming from.
There were recommendations from both crew’s EMTs and flight personnel that a more comprehensive medical plan briefing be conducted to further ensure that EMS provider responsibilities and capabilities are understood.
The IMT identified teamwork and team selection as key to their success despite some recent key personnel changes. As noted earlier, this event was the first for the Incident Commander (IC) which took over leadership for the IMT due to the standing IC’s assignment to another detail. The Medical Unit Leader had been a member of the team before, but was called to this event as a single resource as she’d left her role as a primary team member over a year prior.
Despite these changes, the team felt that they overcame any potential teamwork issues through training and communication. The team specifically mentioned the medical evacuation simulation training and felt that this and other team practices led to a better response to the incident.
Several IMT members identified team practices such as using assertive but calm communication and recognizing operational pressures as also leading to better communication. One recommendation for future improvement was to use consistent terminology regarding medical and aircraft operations.
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Big Meadows Fire Lessons Learned
Video Link: http://youtu.be/vLE3Wb3zEb4
Lessons Learned
1. Teamwork and Team Cohesion are quantifiable assets. Teamwork strengthens allother systems. Seek tangible ways to increase these assets in both the long and shortterm. What was your last planned team building exercise?
2. Simulation training works, and builds confidence. One rehearsal of this incident’smedical plan made an enormous difference in how it was executed during the event.Having a great plan is less useful than having a great plan that is practiced at least once.
3. Be inclusive with information. Crew members believe that including medics in medicalplan briefing so that they can brief crew EMTs and First Responders would be beneficial.
4. Words matter. By consistently using standardized terminology you will lessen potentialconfusion during high stress incidents.
5. The right person for the right job is a force multiplier. Recognizing and utilizing teammembers personal attributes strategically in a team reaps benefits. Who’s the best forcommunicating stressful information? Who will have the desired demeanor andcompassion when working with family members?
Teamwork and Interoperability Horseshoe Hotshot Crew Arrowhead Hotshot Crew
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Big Meadows Fire Lessons Learned
6. Act commensurate with your qualifications. Consider designated leadership andeffective (non-assigned) leadership role and function when planning for an incident-within-an-incident. Do responsibilities change when new personnel arrive? Is there achance of confusion when new personnel arrive?
Team Recommendations and Observations
Review Team Recommendations
1. Evaluate National Park Service EMS “White Card” model and develop an inter-agencyEMS Program that includes EMT/Paramedic credentialing, equipment standardization,minimum suggested EMT/Paramedic crew staffing, and national registry medicaldirection to ensure EMS providers are legally able to practice wherever they may beassigned and needed. Have AEDs available through the NFES cache system and considerproviding CPR, first aid, and AED training for all fire line qualified personnel.
2. Develop a standardized decision tree or matrix for implementing the Dutch CreekProtocols, for IMT use, that include an assessment process for establishing rapidevacuation methods for firefighters on assignment and take into consideration air assets.
3. Develop, distribute, and implement taking-care-of-our-own protocols for IMTs thataddress employee and family support after serious accidents.
4. Develop and implement a thorough and complete interagency medical standards programfor all fire line qualified personnel.
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Big Meadows Fire Lessons Learned
Parting Thoughts from Luther and Paula
Acknowledgments Thanks to all participants who not only provided their story and insights but also their
personal experience.
Thanks to RMP and the Agency Administrator for assigning this team so that thisimportant story is passed on.
Thanks to Clay Fowler, Colt Mortenson, and Jim McMahill of the IMT for their supportand assistance in initiating the lessons learned process.
Thanks to Itsel Gourmelon and Clarissa Vigil for their technical support.
Thanks to Mike Lewelling for his assistance in coordinating team activities within RockyMountain National Park.
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Video Link: http://youtu.be/Bv4qReLGD94
Big Meadows Fire Lessons Learned
Additional Documents
The following document links are reference documents associated with this incident as well as recent examples of Incident Management Team emergency planning.
Big Meadows Fire Emergency Medical Procedures
Big Meadows Fire Emergency Summary of Management Activities EMT Position
Descriptions for line firefighters
EMT out of medical direction form
Fireline EMT Arduous Duty Guidelines
First Responder Qualifications--USFS
RMT-A_Medical_Emergency_Plan
RMT-B_Medical_Emergency_Plan
RMT-C_Medical_Emergency_Plan
RMT-Type-I_Medical_Emergency_SO
USFS First Responder Policy
NWCG Dutch Creek Protocols Memo
USFS Dutch Creek Accident Review Board Safety Action Plan
Big Meadows Fire Decision Table
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