Injuries
An often overlooked issue in emergency planning and response to an aviation disaster is the essential role of EMS and medical facilities.

It truly can be said that no one walks away from a major airplane crash without injuries. The occupants of a downed aircraft are physically exposed to tremendous impact forces, toxic smoke, and intense heat caused by an ensuing fire.

Typically, those aboard sustain three types of severe injuries.

1. Traumatic injuries, including head injuries, damage to the spinal cord, broken bones, massive lacerations, and even amputations, are caused by the enormous force of a crash, debris, sharp edges of the fuselage, and the airborne contents of overhead bins, etc.





2. Burn injuries and smoke inhalation result from the ignition of spilled jet fuel from disrupted tanks and lines. Burning extremely hot, jet fuel causes immediate, painful injuries. Third degree burns often effect the whole body system, leading to shock together with the failure of kidneys and other vital organs, creating lifelong disfigurement and disability. Sometimes, even after weeks of hospitalization, victims will die. Those who survive burn injuries will face long periods - sometimes years - of agonizing plastic surgery and skin grafts. Smoke inhalation, the breathing of extremely hot and/or toxic gases, is the most common cause of death in fiery airplane crashes. Survivors will experience life-threatening lung deficiencies that can last for months or years. These and other injuries are often not initially felt by crash survivors and, without clear symptoms and with limited diagnostic equipment, not always obvious to EMTs.





3. The emotional and psychological impact of a plane crash, due to unexpected and intense forces, can overwhelm body and soul. Because of its "out of human experience" nature, such an event can leave a lasting impression of horror and terror with everyone involved.

David Koch, a survivor of the February 1, 1991, USAir Boeing 737 crash at Los Angeles International Airport, describes the first minutes after his escape from the burning aircraft:
"Unfortunately, most people were very dazed and were walking around like zombies. No one spoke to each other and most people were disoriented and confused. They remained silent and stared at each other. A number of the passengers were shaking violently and sobbing."

Almost every plane crash survivor develops some kind of post-traumatic stress disorder (PTSD), which can, in some cases, lead to lifelong disability.

Again, no one can be considered unharmed after an airplane crash. It is essential that every survivor receive comprehensive medical attention in a hospital setting so that injuries that may be initially hidden are not overlooked.

Triage, Treatment, and Transportation
The EMS procedure used for mass casualty incidents worldwide, is the concept of Triage, Treatment, and Transportation.

Triage
Triage is a technique for assigning priorities for the treatment and the transportation of disaster victims when resources are limited. The idea is to do the greatest good for the greatest number of casualties. In a rural area with limited medical resources, triage is an extremely important issue.

In a metropolitan area with numerous responders, ambulances, EMS units available within minutes, and multiple hospitals nearby, triage should not be a major issue. The challenge in this case is to coordinate the available resources for treatment and transport, and to ensure that victims are conveyed to the proper medical facilities, without overwhelming any particular hospital.

Triage may very well require life or death decisions. Responders will need training on an ongoing and regular basis, focusing on medical treatment, inter-organizational coordination and cooperation, the constant flow of information regarding victims' status, requirements, and all available medical resources.

Treatment
After evacuating and/or rescuing occupants from a downed aircraft, the provision of pre-hospital care -particularly live-saving intervention- is the next priority.

All activities and available resources not needed for secondary search and rescue operations, scene safety, and fire or ignition control must be assigned to support medical activities. Unfortunately, it is often observed in real incidents and in airport training exercises, that casualties are left unattended while fire/rescue personnel are idle or occupied with nonessential tasks.

Transportation
Again, a critical factor in emergency response is the rapid distribution of victims to the appropriate medical facilities. Even in a "Mass Casualty Incident" (MCI), the arrival at the hospital within the first "golden" hour must be the goal for each and every victim with serious injuries.

The severity of traumatic and burn injuries may often require highly specialized facilities (i.e., neurosurgical capabilities, burn centers). Helicopters are an excellent way to transport victims quickly to appropriately equipped hospitals, which may be far away from the crash site. Helicopters allow the distribution of the severely injured to more trauma centers and, therefore, help avoid overwhelming the hospitals nearer the accident location.

Transportation Officer
The early assignment of a well-trained transportation officer is crucial for the successful and smooth transit of casualties. The tasks of this individual will be:

• to request helicopters, ambulances, and other means of transportation (i.e., buses, shuttles, taxis);
• to assign patient transportation in coordination with the treatment area;
• to establish and maintain communication with medical facilities that have ICU/OR/ER capabilities;
• to maintain patient tracking records.