Two passenger cars on their side and the remains of a damaged passenger car after derailing on a curve in Philadelphia
COURTESY OF NATIONAL TRANSPORTATION SAFETY BOARD

AAOS Now

Published 7/1/2015
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Terry Stanton

Trained for Trauma

Philadelphia hospitals were well prepared for the mass casualties of an Amtrak crash

Tuesday, May 12, 2015, would be a long day for Herbert Cushing, MD, chief medical officer for Temple University Hospital in Philadelphia. He’d been up much of the night before taking calls about an electrical project at the hospital. At 4 a.m., realizing he had passed the point of sleep, he rose and went to work and a series of budget meetings.

He finally went to bed about 10 p.m., but no sooner had he lay down, than he received a call from Amy Goldberg, MD, Temple’s interim chair of surgery and chief of trauma and surgical critical care. An Amtrak train had crashed in Philadelphia, a couple of miles from the hospital, and large numbers of casualties were expected.

The train crash occured at 9:28 p.m. Barreling around a curve at 106 miles per hour, it had flown off the rails, its cars careening and crunching and tossing passengers within like dolls in a clothes dryer.

When Dr. Cushing reached the hospital around 10:15 p.m., “the emergency department (ED) was in full swing,” he recalled. “Patients were streaming in.” They came by ambulance, in police cars, in public buses. Several arrived in private cars driven by citizens who had helped at the scene.

As a Level 1 trauma center, Temple would handle the most patients that night—54 of the more than 200 injured in the accident.

Calling all hands
The first emergency activation bulletin was level 2—Prepare. “Very quickly we elevated to a level-4 Code White, which is the highest level—all hands on deck,” Dr. Cushing said. “We locked the facility down and secured the perimeter. The staff was not allowed to leave, and anyone available was asked to come in. The trauma chief, the ranking ED doc, and I decided who to call in, based on what we saw.”

They called in the ophthalmology chief because they thought one patient had a globe rupture. Other calls went to pulmonary critical care and hospitalists because many victims were covered with soot as if from a fire. “I thought we might have smoke inhalation on top of the traumatic injuries,” Dr. Cushing said. “I wanted surgeons to be in the operating room (OR) and the ED, so I had the medical people taking care of the patients in the ICU and any admissions until they were stable.”

Clearly a high-speed accident of this magnitude and severity would bring numerous injuries requiring orthopaedic care, and Dr. Cushing sought to deploy resources efficiently but with margin for error. “Most of the issues were orthopaedic,” he said, “though we did not have to operate as much as I thought we might. We thought about which docs to call. It turned out we only did three OR procedures that night, but we never would have anticipated that. I had no idea how many ORs we were going to need to open up, so we had five ORs ready.”

Easwaran Balasubramanian, MD, the on-call orthopaedic surgeon, responded and Matthew P. Lorei, MD, was already at the hospital finishing up his joint replacement cases for the day. They were joined by five orthopaedic residents. Saqib Rehman, MD, director of orthopaedic trauma, arrived early the next morning to assume care for all of the orthopaedic consults.

“The injuries ranged from upper-extremity fractures to severe limb-threatening injuries,” Dr. Rehman said. “Some patients are still with us, undergoing limb-salvage surgeries. We saw clavicle fractures, acetabulum fractures, mangled extremities, and some unusual injuries. A few of the open fractures were particularly contaminated—very dirty injuries, not always typical for urban trauma. There were soot, burn, and presumed inhalational injuries.”

One of the injured taken to Temple died at the hospital; he was one of eight fatalities. “He had a flail chest and at least four other fatal injuries discovered on autopsy,” Dr. Cushing said.

According to neurosurgeon Erol Veznedaroglu, MD, who oversaw patient treatment at Hahnemann University Hospital and Aria Health, the overall pattern of injuries differed from that seen in automobile accidents. Many of the injured passengers had been tossed about in an unconfined space, rather than fixed in close quarters, which resulted in several spinal cord injuries. “They used violent words—‘thrown around,’ ‘flipped upside down multiple times,’” Dr. Veznedaroglu told the South Jersey Times.

Many of the injuries treated at Temple were to the chest. “Almost every trauma patient had rib fractures,” Dr. Cushing said. Of the three patients who underwent surgery, two had open type III fractures; the third had an ankle injury that could have been deferred if the ORs had been at capacity.

Prepare to be prepared
Luckily for the injured, the Amtrak derailment occurred in an area with ample, well-equipped and well-prepared medical facilities (see “By the Numbers”).

The ED at Temple University Hospital, which Dr. Cushing described as the top Level 1 center for penetrating trauma in the Northeast, receives more than 80,000 patients per year. Had the accident occurred farther south, more patients would have gone to Hahnemann and Jefferson hospitals.

Although the numbers of patients seen that night “wasn’t all that different from a normal Saturday night,” according to
Dr. Cushing, the number of trauma cases was much higher. The rapid, coordinated response by Temple and the other hospitals may well have saved lives and limbs.

Experience in handling volume is just part of disaster preparedness, Drs. Cushing and Rehman said. Having a plan and actually practicing it as often as possible are critical to a successful response to a real emergency.

Temple University Hospital does tabletop preparation exercises each month and conducts an annual active drill for mass casualties and decontamination. “We do a lot of drilling,” Dr. Cushing said. “It’s important to make people participate. They can’t all be tabletop exercises. Hospitals need to practice their incident command structure, to practice the roles so leaders understand what they need to do. You have to make sure the internal and external communication plans are tight. There is not a lot of time to call people; you need automatic messaging to get alerts out.”

The lesson of Boston
Like other trauma centers and EDs, Temple intensified its preparedness after the 2013 Boston Marathon bombing. Just 3 weeks before the Amtrak crash, the hospital conducted a tabletop exercise for the Broad Street Run, a 40,000-participant event that passes through the heart of the Temple campus. “The drill was for multiple planted bombs that caused mass casualties,” Dr. Cushing said. “So we had all the same folks in the tabletop exercise very recently.”

Those efforts largely proved their worth, agreed Drs. Cushing and Rehman. The alert system to call in appropriate personnel largely functioned as designed. When patients arrived, the night’s on-site trauma surgeon, Joseph Rappold, MD, assigned a nurse and a resident to each. He told the residents, “This is your patient. You stay with them until they have been assessed, we know they are stable, and we have a plan.”

The resident pairing was part of Temple’s disaster protocol. “It was clearly something they had drilled on,” Dr. Cushing said. “You can miss someone who is critical if he or she gets shoved in a corner because everyone is all-hands-on-deck.”

Dr. Rehman praised the contributions of the residents, including the orthopaedic trainees. “Either they were there and stayed late or they came in. You may hear about residents hiding behind work-hours restrictions to simply clock in and clock out, but if an institution has a culture of professionalism and leadership, people will step up as they did here and work as a team. We were pleased with how our residents responded.”

Much of what transpired during the emergency was anticipated, but as with any large-scale disaster, unexpected events and circumstances did arise. For example, many patients arrived without identification. “We did a good job of assigning numbers to Jane and John Does and tracking them to ensure we could appropriately match them up with their lab results, imaging studies, and medications,” Dr. Cushing said. “It took hours to figure out who everyone was. It was surprising how long it took to identify all the patients and where they had been sent. The families searching for their loved ones went from hospital to hospital.”

Because this accident involved travelers, many of the patients were not from the Philadelphia region. “One of the more difficult things with this incident was that we had many patients who were dealing with severe injuries far from home,” Dr. Rehman said. “Working with family members and deciding when it is appropriate to let patients return to their home towns have been challenges.” Several patients had to cope with mental trauma in the accident’s aftermath.

Looking back, looking forward
In a review of adequacy of resources and equipment, timely availability of imaging was identified as a concern. “We concluded that every trauma patient needed a CT scan, and there was a bit of a bottleneck,” Dr. Cushing said.

Dr. Rehman agreed. “Being able to get imaging in a timely fashion was difficult.”

Overall, however, planning and preparedness meant an organized, effective response to a trying and potentially chaotic situation. “People kept their cool,” Dr. Rehman said. “Our team sees a lot of trauma and we were working in an environment that we’re accustomed to, if slightly changed.”

He added, “No matter how well you plan at institutional or departmental level for disasters, communication, leadership, and teamwork are critical to successfully handling an influx of patients like we had. Without proper communication, people could not have been called in, and it would not have been clear as to who was really needed and what needed to be done. A culture of professionalism is necessary to adapt to the situation.”

For orthopaedic surgeons, Dr. Rehman said, the Amtrak crash can serve as a call for preparedness. “It is a reminder that you have to be prepared for something that is far worse,” he said. “Departmental action plans are not that common in orthopaedic departments, but they can really help in a situation like this. Calling in everybody is not always the best thing. Having a protocol of who is in charge and who needs to be called is helpful.”

Dr. Rehman singled out the Disaster Preparedness and Response Training program, developed in partnership with the Society of Military Orthopaedic Surgeons (SOMOS) and the Orthopaedic Trauma Association (OTA). In fact, he said, on the night of the accident, he and his team were in contact with Christopher T. Born, MD, who, with current Academy President David D. Teuscher, MD, co-chaired the AAOS-OTA Disaster Preparedness Project team.

“The leadership of Drs. Born and Teuscher, along with the AAOS, the OTA, and SOMOS, helped teach us the importance of disaster preparedness and having a systematic method of responding to a disaster,” Dr. Rehman said. “That message should go out, so hospitals can avoid mass confusion and deliver effective care.”

He and his colleagues are continuing their preparedness efforts and refining them further. “We have already started to put our heads together to deal with an even bigger and badder disaster,” he said. “We believe we can always do better.”

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

By the Numbers
Amtrak train 188 ran the Northeast Corridor route—which also carries the high-speed Acela trains—between Washington, D.C., and New York. It carried 238 passengers and 5 crew members. En route to New York, the train stopped in Philadelphia minutes before it went off the rails while rounding one of the sharpest curves in the Corridor. Although the maximum speed was 50 mph, Amtrak 188 was going 106 mph. Six of the cars overturned after derailing, and at least one appeared to slam and hinge into a trackside vertical support structure.

Seats on Amtrak trains do not have seatbelts, and many injuries occurred because passengers were tossed about and forward as the cars tumbled and then ground to a halt. The engineer operating the electric locomotive said he has no memory of the crash; he had activated emergency braking just seconds before the derailment.

At this writing, safety investigators have no explanation for why the train was traveling so far over the speed limit.

More than 200 patients were injured, and 8 died. Temple University Hospital received the most among area facilities, taking in 54 patients and admitting 24; with subsequent transfers, Temple would eventually see a total of 64 patients. Other area hospitals received the injured as follows*:

  • Aria Health–Frankford Campus: 26 patients treated or transferred
  • Aria Health–Torresdale Campus: 30 patients seen
  • Einstein Medical Center: 10 patients seen
  • Hahnemann University Hospital: 28 patients seen
  • Holy Redeemer Hospital and Medical Center: Five patients seen
  • Penn Presbyterian Medical Center: Two patients seen
  • St. Joseph’s Hospital: Five patients seen
  • Temple University Hospital-Episcopal Campus: 12 patients treated or transferred
  • Thomas Jefferson University Hospital: 26 patients seen

*At press time, most patients who were treated had been released; some hospitals reported having patients still under care. Abington Memorial Hospital reported treating and releasing one patient the day after the accident; Paoli Memorial Hospital reported admitting one patient transferred from Temple.

Sources: Philadelphia Inquirer and Daily News and the Associated Press.