Surgeons treat spine, other orthopaedic injuries

William “Woodie” Cross III, MD, a senior resident in orthopaedic surgery at the University of Minnesota, had just made it home from work on Wednesday, Aug. 1 when he saw the news: the I-35W bridge between Minneapolis and St. Paul, Minn., had collapsed during the height of the evening rush hour, plunging dozens of cars and their occupants as much as 60 feet onto the roadways below and into the churning Mississippi River.

“About three minutes into watching the coverage, I received a call from the University of Minnesota Medical Center (UMMC) emergency department (ED) about a patient with an open fracture from the bridge collapse,” remembers Dr. Cross. “At that point, I knew it was going to be a busy night.”

As he rushed back to the hospital, Dr. Cross readied himself to respond to the mass casualty disaster.

“The whole way into the ED, I was thinking about the injuries I was expecting to see and how I was going to triage them,” he says.

Nearby, at Hennepin County Medical Center (HCMC), Andrew H. Schmidt, MD, was already treating a patient in the hospital’s ED trauma room when the first phone call came in about the collapse.

“At first, no one was sure which bridge had collapsed, since that particular highway divides into east and west branches, and each crosses both the Mississippi and Minnesota Rivers,” says Dr. Schmidt. “We weren’t sure that it was the I-35W bridge over the Mississippi, less than one mile from the hospital, until another HCMC staff orthopaedist, Dr. David Templeman, paged me and asked if I needed help. He was watching the news, and was able to provide us with the first accurate information about the scope of the collapse.”

The staff at HCMC prepared to receive victims of the disaster.

“The ED had several ambulatory patients with fractures who had just arrived, and we immediately splinted them and got them out of the ED in anticipation of a mass casualty alert,” explains Dr. Schmidt.

HCMC and UMMC, both located a short distance from the bridge, received most of the victims; eight other local medical facilities also treated patients.

Mobilizing the medical response
When Dr. Cross arrived at UMMC, the hospital had already called a “code orange,” activating its mass casualty incident emergency management plan. The on-call trauma staff ran the incident command center, located in the ED. Dr. Cross and Jonathan P. Braman, MD, an attending orthopaedic surgeon who was on call that evening, treated the disaster victims; orthopaedic resident Jason C. Glynn, MD, stayed late to assist.

“When I arrived at our main campus hospital, I immediately became involved in the triage and evaluation of incoming patients,” says Dr. Braman.

“Some of the first responders had transported the patients directly to the ED in the back of pick-up trucks,” says Dr. Cross. “The UMMC trauma teams stood by the ED entrance so they could get the patients’ histories directly from the first responders as the patients were brought in.”

Orthopaedic residents Elspeth Kinnucan, MD, and Amy Lelwica, MD, along with trauma fellow Jodi Siegel, MD, assisted Dr. Schmidt at HCMC, which had also activated its emergency management plan for mass casualty incidents. Two other HCMC orthopaedic faculty/staff physicians, Pat Yoon, MD, and Jonathan Haas, MD, remained at the hospital. Dr. Templeman also drove to the hospital to offer his assistance because overloaded cell phone networks made it difficult for him to stay in contact with HCMC.

Patient injuries
All told, 13 people died in the disaster, and nearly 100 others were injured.

UMMC received 25 patients; 11 needed orthopaedic care. Drs. Cross and Braman evaluated and treated them the night of the accident and in the ensuing days.

According to Dr. Cross, axial load injuries consistent with falls from a height accounted for most of the injuries.

“We expected more severe injuries; we think that the bridge absorbed much of the impact as the metal spans collapsed,” he says. “Also, the cars—particularly their shocks and wheels—absorbed much of the impact. Car safety devices such as air bags and seat belts also helped limit the number of injuries.”

David Polly, MD, professor and chief of spine surgery at UMMC, treated all nonsurgical spine fracture patients received at the facility.

“Most of the fractures were in the thoracolumbar junction region, where the spine goes from stiff to mobile. It’s a common site for fractures due to a fall and impact injury,” explains Dr. Polly.

HCMC treated a total of 24 patients, most of whom arrived by ambulance.

“The large number of spine fractures seen at all the hospitals was striking,” says Dr. Schmidt. “Most of the injured were passengers who simply fell in a sitting position. Their spines were vulnerable to the sudden loading while their extremities and pelvises were relatively protected.”

“We saw only a few forearm and foot fractures, and not a single tibia, femur, upper arm, or pelvis fracture,” he continues. “We were surprised at the small number of injuries, given what we saw on the news.”

Communication challenges
As panicked families tried to locate their loved ones, cell phone lines became overwhelmed.

“I could not answer pages on my way into the hospital,” says Dr. Cross. “We had to try an average of four or five times before a call would go through.”

In contrast, communication inside the hospital continued without interruption.

“We were able to use the hospital phones; the landlines were very reliable,” he says.

Dr. Schmidt also found that communicating by cell phone was difficult after the bridge collapse.

“The cell phone system was inundated with calls from people all over the world who have friends in Minneapolis,” explains Dr. Schmidt. “The situation improved when news broadcasters asked people not to use their cell phones so that the emergency personnel could make phone calls.”

The importance of teamwork
Dr. Braman is grateful that the bridge collapse didn’t cause more injuries and fatalities, particularly aboard a school bus carrying more than 50 children.

“It’s a testament to the first responders, the civilians on the scene, the triage system, the ancillary staff, and my colleagues that more patients were not severely injured or killed,” he says. “Their work made it possible for me to simply do my job of managing orthopaedic trauma patients.”

The entire emergency response was well-coordinated, says Dr. Polly.

“The city of Minneapolis did an unbelievable job of responding to the bridge collapse,” he says. “It was so well-organized and ran so smoothly that it could be a textbook case for future mass casualty responses. They really got it right.”

Experience is the best teacher
“Proper training and preparing for the worst really helps a mass casualty response go smoothly,” says Dr. Cross. “I was a hospital corpsman in the U.S. Navy and we were trained extensively in triage. I used those skills in thinking about the injuries from this incident and how to deal with them.”

Dr. Polly, who served in the U.S. military for more than 20 years, agrees that the emergency medical training military surgeons receive is invaluable.

“I was the chairman of orthopaedic surgery at Walter Reed Army Medical Center before I retired,” says Dr. Polly. “I was at Walter Reed on 9/11 when the Pentagon was hit, so I had experience responding to a mass casualty disaster. People on the bridge were either walking wounded or had been killed. That’s very similar to what happened at the Pentagon and the Twin Towers.”

Dr. Braman says that his previous residency training in trauma at a busy, urban medical center helped prepare him for the disaster.

“Trauma response is difficult to learn in a weekend course, and this was no exception,” he says. “While the patients came in, we did what we had been trained to do: evaluate, diagnose, stabilize, and treat orthopaedic injuries.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org