What we learned from… Flight 232
By Alex Strauss
Disaster preparedness is no accident and every hospital, fire department, and emergency management agency knows it. When lives are on the line, the ability to mobilize quickly, communicate effectively, and triage efficiently are critical. They are the primary goals of every disaster drill and simulation.
But, regardless of how many such drills and simulations they are involved in, most medical professionals also know that the odds are against their ever encountering a mass casualty disaster like the crash of an airliner. That is what neurosurgeons Quentin Durward and Ralph Reeder assumed, too. Until July 19, 1989.
“I had just finished an operation at Marion Health Center (now Mercy Medical Center) in Sioux City. I went out to speak to the patient’s family and heard that there was maybe going to be an airplane crash,” recalls Quentin Durward, MD, who is now with the CNOS clinic in Dakota Dunes. “So, I wandered down to the ER to see what this was all about.”
When he arrived in the Emergency Room, Dr. Durward learned that David Greco, MD, Director of Marion Health’s Emergency Department, had already boarded a helicopter and headed for the airport. Durward listened as Dr. Greco radioed his eyewitness account of the incoming plane to his tense ER colleagues. “He described the plane coming in and said it was moving very fast,” says Dr. Durward. “At first he said it looks like it’s going to make it. But the next thing we heard was yelling in the cockpit and we knew that it had crashed.”
For a variety of reasons that would be exhaustively examined in the months after the accident, the first victim of Flight 232 arrived at the Marion ER a miraculous 16 minutes later.
Dr. Ralph Reeder, Dr. Durward’s colleague at CNOS and the only other neurosurgeon in Sioux City at the time of the crash, had moved to town just two weeks earlier. “I barely knew where the bathrooms were,” he says. “I knew maybe 7 physicians in town. I hadn’t yet even had an orientation.”
Fortunately, he had had plenty of trauma experience and had been through multiple mass trauma simulations as a resident at Dartmouth. By sheer happenstance, hundreds of Sioux City’s medical and emergency response personnel had themselves gone through a simulated airline disaster at the airport just two years prior to the crash. The new relationships that were fostered between key emergency response agencies during that simulation helped ensure that, when the real thing happened, they were ready and able to coordinate a smooth response.
“The other thing that was as critical part of the speed with which they got going was that the guy in the tower recognized before anyone else that there was a potential massive disaster,” says Dr. Durward. “He called an Alert 3 before the plane crashed.”
The Alert triggered the county’s Emergency Operation Plan and mobilized an army of fire trucks, ambulances, helicopters, and personnel. At Marion, where a shift change was in progress, everyone was asked to stay, trauma surgeons were located and summoned, the ER and ICUs were cleared of non-critical patients, the ER parking lot cleared, and personnel assembled drugs, carts, surgical packs and IV setups. Although technically premature because the disaster had not yet occurred, the early Alert 3 proved to be lifesaving.
“If there is one thing we learned it is that, in a trauma situation, minutes count absolutely,” says Dr. Durward. “The fact that we were able to get these precious 30 minutes of forewarning thanks to the dispatcher in the tower who recognized that this was very likely going to be a mass casualty situation made all the difference.”
Dr. Reeder had just finished a carotid endarterectomy in the Marion OR and was closing when he lost his entire surgical team to the commotion in the ER. When the procedure was finished, he too, joined the throngs of medical personnel treating incoming patients.
“It started out very surreal and got very real, very fast,” says Dr. Reeder.
Because there were medical personnel already at the airport when the impact occurred, including the hospital ED director, injured passengers were immediately triaged. Those with burns or orthopedic or non-life threating wounds were sent to St. Luke’s Medical Center and those with head, spine or other life-threating injuries to Marion. At Marion, Dr. Mike Wolpert, the hospital’s head of trauma and most experienced trauma surgeon, put his skill to work sorting patients, a decision Dr. Durward calls “brilliant”.
“Even though he was the most experienced trauma surgeon, he recognized that his talents would be best used this way. This is an important lesson for any mass casualty.”
At first, Drs. Durward and Reeder tag-teamed the serious head and spine cases. When Dr. Durward was called to St. Luke’s to perform emergency surgery on a previously undiagnosed head injury, Dr. Reeder prioritized cranio-spinal traumas on his own.
“I think I quickly screened at least 40 patients,” says Dr. Reeder. “I can’t tell you the number of bedside consults. I was running from place to place.” Fortunately, he had plenty of help. Hundreds of volunteer physicians, nurses, and medical techs flocked to the hospitals – many of them with no previous trauma experience.
“We had podiatrists, psychiatrists, family doctors. Everyone was there, doing what they could,” says Dr. Reeder. “The thing that I took away from this is that, when it really mattered, people didn’t’ worry whether or not they were qualified. No one was concerned about hierarchy or privilege. We all just saw jobs and did what had to be done. Because you knew that if you didn’t do what you could, right then, the person was going to die.”
Both Dr. Reeder and Dr. Durward have vivid memories of patients who did not make it, despite their efforts, and others who made remarkable recoveries. The woman whose unrecognized epidural hematoma Dr. Durward rushed to St. Luke’s to treat recovered well. A child with a head trauma who was in a coma for three weeks, woke up a day after Dr. Reeder had begun to doubt that she would, and grew up to be an honor student.
Of the 296 people on the plane, an amazing 184 survived, thanks to the phenomenal skill of the flight crew in the air and good planning, early warning, and quick thinking on the ground. When they remember the events of July 19, 1989 and the blur of non-stop workdays that followed, both doctors say they are humbled by the experience.
“I really think it was one of the greatest, most heroic moments in flight,” says Dr. Durward. “And the community response spoke very highly of Sioux City. In my career, I have never seen anything even remotely like it.”
“I feel like there was a plan for my life and I was supposed to be there,” says Dr. Reeder. “I wouldn’t want anything like this to happen again, but we’re prepared. To me, it’s just what you do.”
What Did Flight 232 Teach Us About Trauma Situations?
Disaster drills can be invaluable
The earlier the alert is sounded, the better response
Emergency vehicles should be walked to through a debris field to avoid injuring survivors
There is no substitute for medical expertise on the scene early
Sometimes the most experienced doctors are most valuable directing triage
Minutes matter
Communication is crucial
Dividing types of injuries between hospitals simplifies triage
Cleared routes to the hospital improves response
Serendipity plays a role
Siouxland residents are willing to help when it counts
Timeline – United 232
15:16 - #2 Engine Explodes
15:26 – Sioux City Airport Alert 2
15:34 – Alert 3
15:52 – 1st Helicopter Takes Off
16:02 – United 232 Crashes
16:17 – 1st Patient Arrives at Marian (Mercy)