Rapid response: Plan, train for vehicle vs. pedestrian MCIs now

Vehicle vs. multiple pedestrian incidents, especially terrorism attacks, are high-risk and happen with surprisingly common frequency


What happened: A Canadian man drove a rented cargo van onto a crowded sidewalk, killing 10 people and injuring 15 others. The driver was arrested by a Toronto police officer several blocks away a short time later.

Police do not suspect terrorism was the driver’s motive, but also have not released information on the reason for the driver’s attack on pedestrians. Toronto Paramedic Services responded to the incident with multiple ambulances, quick response vehicles and a mass casualty bus.

Why it's significant: Pedestrians are a soft target for terrorists intent on causing maximum death and injury with an easy-to-access, obtain and operate weapon. Yesterday’s incident, potentially an attack, like others before it, is noteworthy for how easy it was for the attacker to inflict immediate mass harm, as well as exacerbate terrorism-related fears in every community in North America. The frequency of vehicle attacks, partially listed below, is a striking and worrisome development for emergency managers, chief officers and field personnel.

Toronto Paramedic Services responded to the incident with multiple ambulances, quick response vehicles and a mass casualty bus. (Photo/Sky News Live Feed)
Toronto Paramedic Services responded to the incident with multiple ambulances, quick response vehicles and a mass casualty bus. (Photo/Sky News Live Feed)

Top takeaways on vehicle attack of pedestrians

A vehicle versus a single pedestrian is a common response for any EMS agency. Vehicle versus multiple pedestrians incidents happen frequently enough that service chiefs, directors, officers and field personnel should plan for and train to respond to  multiple persons injured by a vehicle.

As I consider the deadly Toronto attack, as well as similar incidents, here are my top takeaways.

1. Understand common causes of vehicle versus pedestrian incidents

Recent incidents can be examined in three major categories – terrorism, impairment and age-related decline.

Terrorism, which is the use of violence to accomplish political aims, is perhaps the best known category of vehicle attack incident. Because there is an intentional effort to cause harm, targets in this category are potentially predictable because traffic patterns and congestion locations are well known and possibly preventable with barriers, deterrence and a visible law enforcement presence.

Recent terrorism vehicle attacks include:

There are also non-terrorism, intentional acts of violence, like the Las Vegas woman who drove onto the sidewalk killing one and injuring 37. Or a New York City man who drove into a crowd after a fight broke out.

Alcohol or drug impaired drivers can unpredictably strike anywhere and anytime. EMS providers know well the meaningless tragedy inflicted by drunk drivers. Some recent incidents with multiple injuries and fatalities from impaired drivers include:

Cognitive and motor-sensory decline, often age-related, is another cause with seemingly random frequency and location. A driver might be certain their “brakes were stuck” as they drove into a building or through a crowded farmer’s market. Some recent incidents involving drivers described as confused after the incident include:

2. Anticipate blunt trauma injury patterns

Mass shooting and mass stabbing victims are likely to have penetrating trauma injuries which can cause life-threatening hemorrhage and respiratory compromise. Tourniquets, compression dressings, gauze, airway adjuncts and chest seals are the primary treatment tools for penetrating trauma.

When a vehicle attack is the mechanism of injury, anticipate patients are more likely to have blunt trauma to their head, neck, chest, abdomen and extremities. The patient’s severity may depend on the number and location of injuries. Extremity fractures, without significant blood loss, may look gruesome to bystanders and other emergency responders, but may not require immediate treatment. Expect to use more splints and immobilization tools during patient care.

Triage is especially important to identify the patients with critical blunt head, neck, chest and abdomen trauma which is causing shock, traumatic brain injury or respiratory compromise. Also use triage and re-assessment in the treatment areas to differentiate the critically injured from the less critically injured.

3. Consider the vehicle a hot zone

The significantly higher fatalities in terrorism vehicle incidents is a sharp contrast to the other categories. Because the perpetrators’ clear intent was to cause harm, assume the driver may be armed with a firearm or edged weapon, might have loaded the vehicle with explosives or have co-conspirators positioned to conduct a hybrid-targeted violent attack aimed at other locations, fleeing pedestrians or arriving emergency responders. Use verbal commands to direct the walking wounded out of the warm zone and towards casualty collection points.

Don’t become a target for further violence. Strongly consider planning and training to move the injured victims away from the vehicle, as well as its past or intended path of travel, to a casualty collection point of relative safety. A casualty collection might be out of direct line of sight of the vehicle and assailant, offer cover or concealment and improve access to the patients by responding ambulances.

4. Expect scene protection from law enforcement

The location of the attack – a busy sidewalk and roadway – by its nature makes it vulnerable to additional attacks or accidental secondary collisions. The threat hasn’t necessarily passed if the assailant vehicle driver is in custody.

Pre-plan with law enforcement to restrict vehicle access to emergency responders only, establish a perimeter to monitor for street level threats, and make sure law enforcement is scanning for explosive devices as well as shooters which may be pre-positioned above the incident. Follow a unified command approach to ensure communication and coordination between responders from law enforcement, fire and EMS.

5. Deploy the MCI bus

A Toronto Paramedic Services bus responded to the scene. Early deployment of an MCI bus brings a large cache of equipment, additional personnel and a protected treatment area for the injured. If your community has an MCI bus, make sure it’s included in mass casualty training drills and law enforcement understands the access it needs to the scene.

Learn more about mass casualty incidents

Here are some other articles from EMS1 and a learning opportunity from the EMS1 Academy on blunt trauma, splinting, mass casualty incidents and bleeding control.

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