Lessons learned from an incident during which no one could get a handle on command & communication

Story by Bob Kolva
Photo iStock

Have you ever been on a call where communications started off on the wrong foot, and you never stopped stepping into snares of confusion until you were safe at home with your feet propped up? In order to save you from making the same mistakes we did, as you read this article, make note of the command and communication errors that leap off the page. I found at least 10 errors. How many can you catch? At the end, we’ll cover each error and what we should have done instead.

The Incident
I was working as the weekend duty officer for our small, rural, volunteer fire department when I received a page to call dispatch. Dispatch informed me that a deer hunter had shot himself in the foot and was attempting to descend from a mountain on the northern edge of our district. The patient was stable, alert and oriented, with minor bleeding. He was attempting to meet our responders on the county road about 2 miles from our station. (Apparently, the same ATV they would use to pack out that monster buck would now be carrying two-legged game.)

Dispatch was in the process of sending out a page directing our personnel to stage at our station. I requested that they change the staging area to the road intersection where the patient was heading. The first page went out as I was wrapping up my conversation with the dispatcher, and the second page with the updated staging information went out just moments later. As I was speaking with dispatch at the time of the page, I knew the information being transmitted and did not bother to read my pager.

En route, one of the firefighters radioed me, asking if we should launch Medstar, the regional medevac helicopter, since we were responding to a “delta call” stroke with a 45-minute ambulance ride to the stroke center. Not a bad suggestion—if we were responding to a stroke, but we were not, or were we? I informed him that we were responding to a shooting with a stable patient and, therefore, Medstar was not needed.

It was time to figure out what was going on. Checking my pager for the first time, I discovered that we were responding to a stroke at the station. I immediately phoned dispatch to determine just how many calls we were working. At that moment I’m sure my fellow responders shared my confusion, wondering if we were going to a stroke as dispatched or to a shooting as mentioned on the radio. While speaking to the dispatcher, she discovered that she had entered the wrong code into the computer. After making dispatch aware of the mistake, I proceeded toward the location of our shooting victim without giving a second thought to requesting a corrected page.

Once on scene, I encountered a half-dozen EMTs perplexed as to why they were milling about in the middle of nowhere, waiting for a stroke patient to materialize. They levied a barrage of questions, for we had no visible patient. What we did have was conflicting information regarding the nature and location of the call and EMTs with sufficient time to let their imaginations wander onto the myriad possibilities as to why they were on this wilderness adventure. Adding to the confusion were sheriff’s deputies buzzing to and fro like busy little bees, dropping pollen grains of facts peppered with ample amounts of supposition to our volunteers as they flew off down another road.

As time crept on, we were no closer to locating our patient. I sent a brush truck staffed with two EMTs down the road about a mile on a fact-finding (patient-finding) mission. As Brush 1 rounded the first bend in the road, we lost communication with it. It dropped into one of our district’s many “communication black holes.” Our community encompasses a lake within a mountain-rimmed valley. These mini-mountains and the intervening valleys, saddles and gullies wreak havoc with radio and cell phone communication.

The remaining EMTs and firefighters grew more impatient, wondering why they weren’t more involved. For firefighters, idle hands are truly the devil’s workshop.

Stirring the pot of annoyance: Although I was weekend duty chief and incident commander (IC) at the scene, both of our deputy chiefs were also on scene; and while the chiefs were clear with me that I was in command, this was not clear throughout the ranks, as evidenced by the district chiefs repeatedly fielding questions by the idle responders as to their next activity. The chiefs did their best to clarify the command structure, but that message did not always hit the target.

We soon started receiving garbled reports from Brush 1. After relaying the information through dispatch, we learned that Brush 1 had made contact with someone from the hunting party. I sent another brush truck to meet the Brush 1 crew on the county road, but little did I know they too were about to “disappear.” After a few minutes of radio silence, we decided to move the command post down the county road in the direction I had sent the brush trucks.

When we arrived at the new staging area, we found a couple of private vehicles and an empty sheriff’s patrol car—but no brush trucks. With the information gathered from the garbled radio traffic from Brush 1, we determined that they might be headed up a muddy skid road in hopes of accessing the patient, but we had no idea of Brush 2’s location—that was until we heard Brush 2’s radio transmission to dispatch cancelling Medstar. This brought up a few questions: Why were they cancelling the medevac helicopter that had never been requested and why were they cancelling Medstar when that was the responsibility of incident command? Did this mean that they had reached the patient? How did they get there? (I wouldn’t learn the answers to these questions until the post-incident critique.)

The next twist came when Brush 1 finally arrived at the mountain peak and located the patient. Transporting him over a mile down the mountain on the back of an ATV was not an option, and with no room in the cab of the brush truck, our EMTs came up with another option that involved my personal pickup. With the next best option being carrying the patient by hand down the mountain in a Stokes basket, I agreed to this arrangement.

As we loaded the back of my pickup with the Stokes basket, tech rescue gear and ambulance medic, the command post became mobile. After 20 minutes of crawling up the mountain, we reached the peak. We then filled the Stokes basket with the rescue gear and ventured toward the rock outcropping where our patient was perched, along with our personnel who were tending to his wounded foot.

While interviewing the patient, we discovered that he believed he had found the perfect observation post and had sat back awaiting his quarry. In order to keep the end of his rifle barrel out of the dirt, he rested it on his boot. As the hunter attempted to get up, the gun discharged, firing a .270 round through his foot.

While the medic was examining the patient, we formulated a plan for extracting the patient from his roost up the steep grade back to my pickup. As we were rigging the Stokes to carry the patient up the slope, the medic informed us how we were just going to grab the patient by the shoulders and “walk” him up the hill—apparently she was now in charge. Rather than debating the medic on the best method of low-angle rescue and the inherent dangers to our personnel and the patient encountered with “walking” a patient up a steep, rough and brushy incline, I briefed our personnel on the risks and took as many precautions as possible. Needless to say, the medic was not involved with any of the “heavy-lifting”—that was left to our personnel. Fortunately, when his fellow hunters realized what we were attempting, they were able to get an ATV within 50 yards of our location so we did not have to hand-carry the patient nearly a quarter of a mile back to the vehicles.

After maneuvering our patient up the steepest portion of the incline without major incident, he was placed on the front of the ATV and carried the remaining distance to my pickup. We crept down the mountain loaded with the patient and what seemed like half the rescuers. The patient was then loaded on the waiting ambulance and transported to an area hospital for minor surgery.

The After-Action Report
As we do with most major or unique incidents, we reviewed the call at the next training. We found 10 command or communication errors that occurred during the course of this incident. How many did you catch?

1. As I was speaking with dispatch at the time of the page, I knew the information being transmitted and did not bother to read my pager. Never make assumptions like this!

2. While speaking to the dispatcher, she discovered that she had entered the wrong code into the computer, resulting in a stroke rather than a shooting. The dispatcher did not check the information going out in the page. After being made aware that incorrect information was sent out, the dispatcher did not send out a correction.

3. After making dispatch aware of the mistake, I proceeded toward the location of our shooting victim without giving a second thought to requesting a corrected page. I did not ensure that the proper information was going out to our personnel.

4. Once on scene, I encountered a half-dozen EMTs perplexed as to why they were milling about in the middle of nowhere, waiting for a stroke patient to materialize. Adding to the confusion were sheriff’s deputies buzzing to and fro like busy little bees, dropping little pollen grains of solid facts peppered with ample amounts of supposition …. Once all personnel were staged (especially since there was nothing else to do), there should have been a briefing that provided the same set of facts to all personnel.

5. Brush 1 dropped into one of our district’s many “communication black holes.” Many terrain-caused radio problems have no simple solution, but there are quick fixes that might help. If you’re using handheld radios, switch to your vehicle’s radio. On channels that are repeated, try using dispatch to relay the information. Alternately, go to a non-repeated channel. In our region, our “fireground” channels do not go through a repeater and can be very effective for local communication. We have been on scene where you could literally see the individual but could not speak with them on a repeated channel. If you don’t have non-repeated channels, consider purchasing some inexpensive FM radios. Many of these units can transmit 2 miles in uneven terrain. Many hunters use these radios to keep track of their party’s relative location. Also consider changing your location. In many cases, a slight elevation change is all that’s needed.

6. For firefighters, idle hands are truly the devil’s workshop. Whenever possible, keep your people busy. Whether they are preparing gear, discussing strategy or polishing trucks, firefighters are men and women of action.

7. The chiefs did their best to clarify the command structure, but that message did not always hit the target. Regardless of how things work back at the station, the command structure on scene needs to be crystal clear to everyone. Lives depend on it. At our all-volunteer fire department, the first person on scene is not always an officer, but they are incident command until command is transferred. As a young firefighter, I learned a valuable lesson when the chief left me in charge of an incident after his arrival. It was the best form of on-the-job training. He was there if I made a critical error, but other than that, I had total command of the scene. Since that time, I have served under other chiefs who say you are in charge but can’t keep their fingers out of the mix or their thumb off the radio transmit key. Remember: There can be only one IC, so lead, follow or get out of the way.

8. We had no idea of Brush 2’s location. After Brush 2 left the new staging area, they should have communicated their plans to the IC.

9. Why were they cancelling Medstar when that was the responsibility of incident command? Spelling out the responsibilities of incident command is a training issue. Brush 2 cancelling a resource that had not been ordered only added to an already confused scene.

10. Rather than debating the medic on the best method of low-angle rescue and the inherent dangers to our personnel and the patient encountered with “walking” a patient up a steep, rough and brushy incline, I briefed our personnel on the risks and took as many precautions as possible. I compromised the safety of my crew to avoid conflict. If you feel that an activity isn’t safe, even if only minor injury will result, do not compromise! As it turned out the patient was rescued without incident or even anything that could be construed as a near miss. Were we lucky or was I just over-cautious? The medic’s method was by far the simplest means of patient transport. Plus, when a medic arrives on scene, do they automatically assume responsibility for all patient care decisions?

In Sum
Other than the technical issues with the radios, most of our problems came down to a couple basic communication principles: 1) Never, ever assume anything; and 2) restate any command or instruction given. We should have learned the first rule in grade school and the second back in Firefighter 101. Clear communications are bilateral, not unilateral. Unless information is flowing in both directions, the sender has no idea how, or even if, their message was received. As the sender of a message, never assume someone has a clue of what you are talking about; instead, confirm the receipt and understanding of the message. As the receiver, never ask yourself, “What did they mean by that?”; instead, you should ask the sender, “What did you mean by that?”

Unfortunately I will never know if you have any clue as to what I am getting at. I guess I will just assume that I got my point across!

Bob Kolva is the former chief and 18-year veteran of the Newman Lake (Wash.) Volunteer Fire Department. Kolva currently serves the department as a volunteer firefighter and EMT.

The 7 Deadly Sins of Command & Communication
• Assumption
• Unclear command structure
• Not restating instructions
• Compromise
• Totally relying on technology
• Not following established protocol
• Not updating the troops on your plan

Copyright © Elsevier Inc., a division of Reed Elsevier Inc. All rights reserved.
SUBSCRIBE to FIRERESCUE