The Field Hospital Surge After a Stadium Collapse
A stadium roof partially collapses during a concert, producing an estimated 180 casualties. You are the incident commander for the medical branch. The nearest trauma center is 12 minutes away but has 14 open beds; two other hospitals are 25 and 35 minutes away with 30 and 50 beds respectively. A federal medical station can be stood up in 4 hours at a convention center 20 minutes away. On scene you have 6 ALS units, 10 BLS units, and 30 walking wounded who are being corralled by ushers. A structural engineer says the roof is unstable and the interior is unsafe for another 45 minutes. Weather is 38°F with rain, and the walking wounded are outdoors without blankets.
1. How do you structure the medical response for the first 60 minutes - command, triage, treatment, and transport - given the unstable structure and the cold, wet conditions?
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Command: establish a single medical branch under the IC, with sectors for triage, treatment, transport, and a walking-wounded holding area. Assign one person to transport coordination and one to hospital notification.
First 60 minutes:
- Do not send responders into the unstable interior until the engineer clears it; rescue task forces stage at the perimeter. Extrication of the accessible perimeter casualties proceeds now.
- Triage at a CCP outside the collapse zone; tag every patient. Expect a large Immediate and Delayed load.
- Walking wounded: move them indoors or into heated buses immediately - 38°F and rain create hypothermia risk that turns minor patients into cold casualties. Blankets, dry clothing, and warm fluids.
- Treatment: a treatment area with ALS capability for reds; splinting, hemorrhage control, and warming for all.
- Transport: distribute by capability, not by distance - the 12-minute trauma center gets the most critical but is capped at 14 beds; the 25- and 35-minute hospitals absorb the Delayed and lower-acuity loads. Notify all three of the patient mix and ETA.
- Request the federal medical station now so it is available for the tail of the surge and for lower-acuity overflow.
2. At minute 90, the trauma center reports it is at capacity and is diverting. What do you do, and what principles guide your transport decisions for the remaining casualties?
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Actions:
- Stop routing to the diverting trauma center except for patients who truly need trauma surgery and cannot survive a longer transport; coordinate directly with the hospital's charge nurse and the regional medical coordination center rather than relying on a blanket diversion notice.
- Activate the federal medical station for lower-acuity and walking-wounded overflow, freeing hospital beds for the sickest.
- Re-triage the treatment area - some Delayed patients may have deteriorated (especially with cold exposure) and some may be stable enough for the field station.
- Balance transport: send critical patients to the 25-minute hospital if it has surgical capability; send Delayed to the 35-minute hospital and the field station. Do not overload any single facility.
Guiding principles:
- Capability over proximity - the closest hospital is not always the right one.
- Distribute, don't concentrate - avoid overwhelming any single receiving facility.
- Match acuity to resource - critical to ICU, moderate to floor beds, minor to the field station.
- Keep the system breathing - preserve surge capacity for the next wave of casualties still being extricated.