NIOSH Cedar Fire Report
CDF Cedar Fire Report
Novato FPD Investigation Analysis
Draft Standard Operating Procedures
Inaja Fire Tragedy
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NOVATO
FIRE PROTECTION DISTRICT
Investigation Analysis
of the
Cedar Fire Incident
Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003
Cedar Fire Lessons Learned
ALS Equipment
Pre-Incident
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All Novato Fire District Type I Engines and Ambulances are ALS equipped
and staffed with Paramedics. The District Truck/Medium Rescue Company
is ALS equipped but typically not staffed with Paramedics. Type III
Engines are BLS equipped.
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65 out of 70 of the District line personnel are or have been State
licensed and County accredited Paramedics. As members promote, the
current MOU allows them to maintain State Licensure without County
Accreditation. Paramedics without County Accreditation operate at
the BLS level.
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All County Accredited Paramedics are certified in Expanded Scope
Skills which include nasotracheal intubation and Advanced Cardiac
Life Support (ACLS).
-
The EMS Division is managed by a Battalion Chief who is also a Paramedic.
The Division includes a full time Medical Director/EMS Educator who
is a licensed Physician and certified Paramedic. All EMS continuing
education classes are provided in house by the EMS Division.
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In a pre-Cedar Incident EMS Continuing Education class, the Medical
Director/EMS Educator conducted a class on recognizing the need for
Rapid Sequence Intubation (RSI). Specifically discussed was the need
to hyperoxygenate for a period of 15 minutes prior to performing the
RSI procedure.
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RSI is used to chemically paralyze the conscious patient in respiratory
distress so that the airway can be secured with an endotracheal tube.
RSI is not currently included in the scope of paramedic practice in
the State of California.
Incident
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The crew of Engine 6162 was made up 4 current or past Paramedics.
Captain McDonald is a former Paramedic, Engineer Kreps is a State
Licensed Paramedic, Engineer Steve Rucker was a County Accredited
Paramedic as well as FF/PM Smith.
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Recognizing that Engine 6162 , a Type III Engine, was only BLS equipped,
Engineer Kreps and FF/PM Smith placed two 1000cc IV bags, tubing and
start kits on the engine as a precaution prior to departing Novato.
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Following the burn over at 920 Orchard Lane the crew of Engine 6162
realized that Captain McDonald was significantly burned. The crew
proceeded, in Engine 6162 , to the intersection of Orchard Lane and
Hwy 78 where other fire crews Novato Fire Protection District were
staged. Upon arriving Engineer Kreps and FF/PM Smith determined that
they were the only Paramedics at that location.
-
While injured themselves, they performed an Advanced Life Support
(ALS) assessment on Captain McDonald. They determined the immediate
need to secure his airway due to thermal burns. Captain McDonald was
still conscious and exhibiting signs of respiratory distress.
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As a result of the continuing education class, on RSI, Engineer Kreps
recently attended, he recognized Captain McDonald as a candidate for
RSI. Also recognizing there was no equipment or trained personnel
capable of delivering RSI, Engineer Kreps and FF/PM Smith requested
a medical helicopter with RSI capability.
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While waiting for transportation, Engineer Kreps and Firefighter/Paramedic
Smith established two large bore IV lines on Captain McDonald.
-
Captain McDonald, Engineer Kreps, and FF/PM Smith were transported
by ground ambulance to a helispot where they met up with a CDF helicopter.
Engineer Kreps instructed the CDF crew to hyper-ventilate Captain
McDonald for 5 minutes anticipating that the Air Ambulance would RSI
him before transport to the burn center.
-
The CDF helicopter transported Captain McDonald to Gillespie Field
in Ramona, where he was transferred to an Air Ambulance helicopter.
The Air Ambulance crew performed RSI on Captain McDonald on the tarmac
at Gillespie Field. Captain McDonald was then transported to UC San
Diego Hospital Burn Unit.
Captain McDonald sustained respiratory burns to 30 percent of his
lungs and upper airway. He also sustained second and third degree
burns over 28 percent of his skin.
Post-Incident Considerations
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The Fire District has debated placing ALS equipment on Type III
Engines for several years. The reasons the equipment was not placed
on the Type IIIs were: lack of consistent paramedic staffing, available
space on the engine, the cost of purchasing and maintaining the ALS
equipment, the perceived need and frequency of use.
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The ability to immediately secure and control an airway is vital
to the patient’s survival. The recognition of the need to initiate
RSI on Captain McDonald greatly enhanced his survivability. While
performing ALS procedures without all of their equipment, technically
out of their scope of practice, the early establishment of IVs allowed
the Air Ambulance crew to perform RSI faster. This also enhanced Captain
McDonald’s survivability.
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The immediate availability and strategic deployment of trained and
equipped Paramedics rather than EMTs on the fire ground enhances the
survivability of firefighters and civilians.
-
Further, the availability of ALS medical personnel on the fire ground
to promptly provide RSI will enhance the survivability of firefighters
and civilians. It is far more important to rapidly secure the airway
than it is to promptly provide BLS air transportation. Airway management
applies to burns and traumatic injuries as well as medical emergencies.
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RSI should be included in the Paramedic scope of practice in California.
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