This is not a test: In caring for airplane crash victims, training and teamwork prevailed
Teams await the arrival of the crash victims at Stanford's emergency department on July 6.
"Did you know there's been a plane crash at San Francisco airport?"
It was a little past 11:30 a.m. on July 6 when Eric A. Weiss, MD, the medical director of the joint office of emergency management for Stanford Hospital & Clinics and Lucile Packard Children's Hospital, first learned of the crash landing of Asiana Flight 214. A television in the emergency department waiting room had reported the news, which made its way to the director of pediatric emergency medicine, Bernard Dannenberg, MD, and then to Weiss, both of whom, fortuitously, were working that day.
Weiss knew that if there were casualties, Stanford — one of only two level-1 trauma centers within 25 miles of the airport, and the only one with a helicopter-landing pad — would be well-equipped to treat them.
An attending physician in the Marc and Laura Andreessen Emergency Department at Stanford, Weiss had a committed, well-drilled staff to work with, and many key emergency responders were already on site or immediately available.
At 11:50 a.m., the emergency department got a call from San Mateo County Emergency Services, asking for a count of available beds for people in three categories: immediate (critical patients), delayed (serious injuries but not immediately life-threatening) and minor.
"Our response was, we have plenty of beds and staff. We can take as many as you need," Weiss said. That call was the signal he was waiting for. At 12:05 p.m., he paged about 800 staff — including physicians, nurses, social workers, security officers and administrators — with a "code triage-standby" message, indicating an extraordinary situation had arisen that might call for additional manpower and supplies.
Weiss also dialed his partner in disaster response, Brandon Bond, administrative director of the Office of Emergency Management for Stanford and Packard hospitals. Bond, who had been at home in San Mateo, about to take his dog for a walk, immediately changed into work clothes and drove his truck to Stanford, calling the county emergency services on the way and monitoring information coming over public safety radio frequencies. The more he heard, the more grateful he was that Weiss had called the standby code: At least 200 patients from the flight were being triaged.
"His being proactive and activating the code triage-standby was really good, quick thinking on his part and enabled our response to go smoothly," Bond said.
When Bond arrived at about 12:40 p.m., a helicopter was approaching with two patients in critical condition. An ambulance was on its way carrying four patients. At 12:47 p.m., Weiss activated the disaster plan with the code "triage-major."
This aerial photo shows the wreckage of Asiana Flight 214 after it crashed July 6 at the San Francisco International Airport.
"This told everyone 'all hands on deck, expecting major casualties, open the command center, clear out the emergency department and deploy the caches of disaster equipment that had already been pulled out and pre-staged,'" Bond said.
"Within 30 minutes we had admitted or discharged most of the patients who were previously being treated in the emergency department, and we mobilized over 150 health-care providers dedicated to responding to the airplane tragedy," said Weiss, who is also an associate professor of emergency medicine at the School of Medicine. "This included physicians, nurses, technicians, clerks, registration personnel, transporters, social workers, translators and other vital specialists from throughout Stanford and Packard hospitals."
During those first 30 minutes, Bond turned to the staff on hand to get additional treatment areas ready. "Please set your food down and come with me," he said to a group eating lunch on the patio behind the emergency department.
He walked the group down to the ground floor, showed them the carts packed with disaster supplies and explained what needed to be done. "They rolled them up to the emergency department and set it up so the clinicians could do their jobs. I didn't even know their names. But I am so grateful," Bond said. "They took care of that job, and I could get on to my next one."
They had set up a mass triage area in the emergency department parking lot and equipped and staffed a large area for less-urgent casualties from the incident. At that point, seven trauma teams consisting of physicians, surgeons, nurses, technicians, radiologists and scribes were ready to receive patients.
The first ambulance arrives at Stanford with victims of the Asiana Airlines crash. Fifty-five patients were brought to Stanford's two hospitals.
"We were set up to see more patients than we initially saw. Thanks to the incredible response from both hospitals, we could have probably cared for twice as many patients," Weiss said.
David Spain, MD, chief of trauma and critical care surgery, was already on site when patients began arriving. After the helicopter arrivals came ambulances carrying three or four patients at a time. The final seven patients arrived in a SamTrans bus.
By the end of the day, close to 200 people injured in the crash had been cared for at nine Bay Area hospitals. Fifty-five of them, including 16 minors, were evaluated at Stanford's emergency department. Eleven were admitted to Stanford Hospital and seven to Packard Children's. Of the 307 passengers and crew on the flight, three girls died. Many others were injured, though most not seriously.
According to the airline's official statement, most of the passengers were Korean or Chinese citizens. In a statement, China's Ministry of Education said the plane carried at least 70 teachers and students from China who were traveling to the United States to take part in a summer program.
At Stanford, most of the patients were seen by an emergency-medicine physician, a surgeon and a nurse working together, said Spain, who is also a professor of surgery. The most common injuries they saw were spine and rib fractures. Some of the injuries were serious, a few requiring surgery, he said.
Eric A. Weiss
Many of the injuries were from blunt trauma, Weiss said — from people thrown around the plane. "Some of the injuries appeared to occur when people were thrown into an armrest," he said. "The seatbelts probably saved their life, but they don't stop side-to-side movement — so when the plane went onto its side, some sustained broken ribs. Also, the seat belt can push in on the stomach and cause internal injuries. We also saw spine injuries from compression and from heads being thrown forward and back. And lots of bumps and bruises."
Though airplane crashes are rare, the types of injuries they produce are often seen in an emergency room. In this particular case, however, there were challenges communicating with patients; many spoke little English. And when they were healthy enough to leave the hospital, they couldn't simply be discharged because they had not yet cleared U.S. Immigration and Customs Enforcement.
"They came straight from the runway," Weiss said. "They weren't officially in the United States yet." Adding to the complication was the fact that seven were minors unaccompanied by parents.
Sitting in open patient rooms and lounges, social workers, translators, Red Cross and customs officers, as well as a representative from Asiana Airlines, worked past midnight clearing patients for release.
"I can't say enough about the energy of the staff, the caring and compassion of the staff," Bond said. "It took the entire team. Everybody stepped up and did a phenomenal job."
Shortly after the "triage-major" code was called, Ann Weinacker, MD, chief of staff at Stanford Hospital & Clinics, reported in at the hospitals' emergency command center, in Stanford Hospital's board room, and found it already operational and fully staffed with about 30 people. "What was remarkable was how calm and smoothly everything was running. It was incredibly well-organized," she said.
She also did a walk-through of the emergency department and said she was amazed by what she saw. "The emergency department was calm," said Weinacker, who is also a professor of critical care medicine. "There was not a lot of drama. It was almost like business as usual — only there were many more people."
The staffs of both hospitals train regularly to prepare for disasters. In the past year, they carried out two major mass-casualty exercises — one scenario was an earthquake, the other an active shooter. And on June 14, just three weeks before the crash, Office of Emergency Management program managers Eric Giardini and Laura Harwood had led a an emergency department disaster drill of its "code triage" response.
"We've been really focusing in the last two years on improving our mass-casualty plan," Bond said. "All of that training paid off."
After the last of the patients from the airport had arrived, Christy Sandborg, MD, vice president of medical affairs at Packard Children's and a professor of pediatrics at the School of Medicine, reflected on the preparation and commitment of so many. "The breadth of support in an emergency like this is impressive and heart-warming," Sandborg said. "The planning, teamwork and quick thinking were truly inspiring, and it reflected a compassion and care that makes us all very, very proud."
Amir Dan Rubin, president and CEO of Stanford Hospital & Clinics, expressed profound thanks to the medical and support staff who rallied to care for the injured. "This tragedy demonstrated just how remarkable our people are," said Rubin. "This event will undoubtedly have a profound effect on the survivors for their rest of their lives, and hopefully, the respect, caring and compassion demonstrated by the Stanford community will start them on their respective recoveries."
Staff members in the command center organize Stanford Medicine's response to the influx of crash patients.
Lloyd Minor, MD, dean of the School of Medicine, commended the teams for the care they delivered. "Stanford Medicine's faculty and staff have done an amazing job treating people from the crash," Minor said. "As often happens in a crisis, many individuals stepped up and worked tirelessly to provide the best possible medical and social care to patients. But it was more than a willingness to help that was on display; it was the work of professionals trained to respond in an emergency situation. While this was the first time in decades that we activated our mass-casualty plan, staff took on their assigned roles with intelligence, compassion and creativity."
"There are so many selfless individuals from throughout the medical center who contributed to the response that day," said Weiss. "Transporters and security came down to set up triage and move gurneys out to be ready. Materials management staff were bringing supplies up and food. We had many translators to help us communicate with our patients. Not just official translators, but health-care providers who spoke Korean and Mandarin came to the hospital to see if they could help. I can't even begin to imagine how scared and traumatized these patients were after being in a plane crash in a foreign country where language is a barrier. I was so grateful to all of the translators, social workers and guest service personnel who continued to provide compassionate care, comfort and communication, both with the patients and their families, long after their physical injuries were stabilized."
At 8:12 p.m. on July 6, the hospitals' incident commanders approved an "all clear" for the "code triage-major." Bond deactivated the command center at 1:30 a.m. the next morning, and the seven patients admitted to Lucile Packard Children's were discharged later that day.
As of July 12, one patient from the crash, in serious condition, remained hospitalized at Stanford.
Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu.