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Case report: Illegal immigration via overloaded vans and the effects on a trauma system
DMR
Feature Article
Case Report: Illegal Immigration via Overloaded Vans and the Effects on a Trauma System Darlene Rodriguez, RN, Elizabeth Plata, BSN, and Daniel Caruso, MD, FACS
The Arizona-Mexico border consists of 375 square miles of rural desert where temperature extremes, excessive sun exposure, and a lack of food and water are common. The desert poses an especially deadly threat to immigrants who attempt to cross it on foot. In an effort to smuggle humans across this region, smugglers transport people in vans that are loaded beyond the recommended vehicle weight limitations. The unrestrained occupants change the vehicle’s center of gravity and increase the propensity for van rollovers. Van rollovers produce multiple casualties that quickly outstrip the resources of rural providers. The purpose of this article is to describe two cases that involved multiple victims injured in van rollovers that occurred on two consecutive days. The rollovers occurred in the rural areas outside of Phoenix, Arizona, and eventually taxed the entire metropolitan Phoenix area trauma system.
E
xperience is a hard teacher because she gives the test first, the lesson afterwards.dVernon Sanders Law
The illegal movement of people across the US border, also known as human smuggling, is not a new phenomenon. Along the southwestern US border, ‘‘coyotes’’ (ie, person who transport others for money) lure illegal immigrants with the promise that they will be taken to the United States. Coyotes use different ways to shepherd the undocumented migrants, including forcing them to walk across hot deserts, ride in the back of
Darlene Rodriguez, RN, is Trauma Coordinator, Elizabeth Plata, BSN, is Trauma Outreach/Educator, and Daniel Caruso, MD, FACS, is Trauma Medical Director, Maricopa Medical Center, Phoenix, Arizona. Reprint requests: Elizabeth Plata, BSN, Maricopa Medical Center, 2601 E Roosevelt Rd, Phoenix, AZ 85008. Disaster Manage Response 2005;3:4-10. 1540-2487/$30.00 Copyright Ó 2005 by the Emergency Nurses Association. doi:10.1016/j.dmr.2004.11.003 4 Disaster Management & Response/Rodriguez, Plata, and Caruso
tractor-trailers, or pile into overloaded vehicles. Human trafficking is a dangerous process because it uses remote areas of the border that are uninhabited due to temperature extremes, excessive sunshine, and a lack of adequate food and water. Trafficking is even more dangerous when the motor vehicle is involved in a crash or rollover (Figure 1).
Human Trafficking The US Department of Justice1 defines human trafficking as ‘‘a form of modern day slavery’’ and portrays traffickers as people who prey on vulnerable individuals. The Victims of Trafficking and Violence Protection Act of 2000 is federal legislation that criminalizes human trafficking done for the purposes of slavery, involuntary servitude, peonage, or forced labor.1 The victims of human trafficking are poor, frequently unemployed or underemployed, and lack access to social safety nets. They are predominately women and children who are lured with false promises of good jobs and better lives. If they arrive safely in the United States, they are forced to work under brutal and inhuman conditions.2
Human trafficking is a dangerous process because it uses remote areas of the border that are uninhabited due to temperature extremes, excessive sunshine, and a lack of adequate food and water. Illegal immigrants continue to risk the dangers. According to statistics from the Center for Immigration Studies,3 the estimated number of illegal immigrants who are now living in the United States has risen from 7 million in 2000 to 8 million in 2004. The US Government has increased efforts to stop human trafficking by increasing law enforcement efforts. The Immigration Monthly Statistical Report4 indicates that border apprehensions increased by 25% from June 2003 to July 2004. Human trafficking becomes more than a law enforcement issue Volume 3, Number 1
DMR At approximately 1:30 AM on June 17th, the Casa Grande Fire Department’s alarm room called the Phoenix Fire Department alarm room which then accessed a computerized communication system (EMSystem) to alert the Phoenix and Tucson trauma centers via telephone. Casa Grande Fire Department could not access the computerized system directly and, because of the number of patients and hospitals involved, repetitive calls had to be made to over 6 facilities.
Triage and Transport
Figure 1: Passenger van involved in rollover that produced a mass casualty incident with multiple major trauma patients. (Used with permission.) when victims are injured and are brought in for medical care. The following case report is used to describe how trafficking is causing mass casualty incidents (MCI) and how the trauma system is being affected.
Case Report Mass Casualty Incidents During the month of June 2004, two separate van rollovers occurred within 24 hours of each other in the rural areas near metropolitan Phoenix, Arizona. On June 17, 2004, a van carrying approximately 30 undocumented immigrants overturned along a remote highway in central Arizona, near Casa Grande. The rollover occurred at approximately 1:30 AM and the Casa Grande rural fire department was the first responder to arrive on the scene. The fire department assumed command and quickly assessed the magnitude of the injured by using the Simple Triage and Rapid Transport (START) triage system.5 Because of the large number of victims, a MCI and Incident Command System (ICS) were instituted. Due to darkness, the fire department used heat-sensing devices to search for patients; however even with this tech-
Human trafficking becomes more than a law enforcement issue when victims are injured and are brought in for medical care.
The geography at the Casa Grande crash site occurred along a tight curve in the road on the western edge of Casa Grande. The rough and rugged terrain surrounding this scene did not allow for a safe helicopter landing zone. A landing zone had to be established a distance away from the triage sector and ground crews were used to move the triaged patients to the helicopters. Three aeromedical companies were dispatched to this area with approximately 7 helicopters waiting on standby. Initially 28 ground personnel were used, 14 of whom were from ambulance crews. Two patients were dead at the scene, 22 required transport (21 via air, 1 via ground) to Level I trauma centers located in Phoenix. One patient died later at a Phoenix hospital. The total scene time for this incident was approximately 12 hours because of the need to do a more expansive search and rescue effort which located 7 more patients who were found miles from the crash scene.
Eleven patients were brought to Maricopa Medical Center: 6 (54%) had spinal injuries Approximately 28 hours later (at 5:15 AM on June 18, 2004), another van rollover occurred with at least 24 passengers. The rollover happened in another remote area southeast of Phoenix. The response was similar to the day before with 22 patients transported to Level I trauma centers and 2 patients dead at the scene. The 2-day total for both MCI was 55 injured passengers. Eleven patients were brought to Maricopa Medical Center: 6 (54%) had spinal injuries, 4 (36%) had a head injury, and 10 (90%) sustained ‘‘other’’ significant injuries requiring hospitalization and treatment (Maricopa Medical Center Data, unpublished data). Out of the 11 patients admitted to the ED, 6 required admission to the intensive care unit (ICU), and 2 required emergency surgery. See Tables 1 and 2.
nology, a woman was not found until approximately 11:00 AM. She had experienced a brief loss of consciousness at the scene, recovered, and was trying to escape detection. She was found later in the day when she had stopped under a bush to get out of the intense Arizona sun. The patient was later found to have a subdural hematoma.
MCIs are considered to be rare events that produce a large number of victims with a range of minor to
January-March 2005
Disaster Management & Response/Rodriguez, Plata, and Caruso 5
Discussion
DMR Table 1: Patients admitted to Maricopa Medical Center for injuries sustained in van rollover of June 17, 2004 Patient 1 29-year-old woman
2 23-year-old woman
3 22-year-old woman
Time of arrival) 3:04 AM
4:30
AM
4:12
AM
Immediate ED findings
Treatment in EDy
ICD-9 codesz
ISS
dLeft orbital wall fx dRib fxs dSpinal injuries: lumbar 1 burst fx; lumbar 2 lamina fx; lumbar 3, 4 transverse process fx; comminuted bilateral sacral fxs
d2 units of PRBC dFast exam dCT of the head, abdomen, pelvis, cervical-spine, and chest dAdmitted to ICU
802.8, 805.0, 807.01, 910.0, 924.8
22
dMultiple scalp lacerations dConcussion with decreased LOC dPulmonary contusion dLeft wrist fx
dIntubated for decreased LOC dCT of the abdomen/ pelvis/head, cervical-spine dRadiograph of left upper extremity dAdmitted to ICU
814.0, 850.9, 861.21, 873.0, 873.63
17
dLeft orbit fx dRight pneumothorax dRight rib fx dSpinal injuries: thoracic 5 burst fx; thoracic 6 vertebra and transverse process fxs; thoracic 7 vertebra fx; thoracic 8 transverse process fx
dCT of thoracic spine, pelvis, head dAdmitted to ICU
802.8, 805.0, 807.01, 860.0, 919.0, 920.0
17
dScalp laceration dClosed head injury dTraumatic pneumothorax dSpinal injuries: thoracic 5, 6 and lumbar 1,2 bilateral transverse process fxs
dCT of head, chest abdomen, pelvis, thoracic spine, lumbar spine dAdmitted to ICU
803.09, 805.0, 850.9, 860.0, 873.0, 919.0,
17
4 27-year-old woman
8:55
5 24-year-old man
12:23
PM
dLaceration to right thorax wall
dWound exploration and repair in OR dAdmitted to hospital
879.8
6 19-year-old man
12:27
PM
dRight clavicle fx dPossible right humeral head fx dPubis fx
dDischarged From ED
808.2, 810.0, 910.0, 919.0
AM
1
10
CT, Computed tomography; ED, emergency department; Fx, fracture; ICU, intensive care unit; ICD-9 codes, International Classification of Diseases, 9th Revision; ISS, injury severity score; LOC, level of consciousness; OR, operating room; PRBC, packed red blood cells. ) All patients were air evacuated. y Provided in ED only; all patients received tetanus vaccine. z Assigned on discharge from hospital.
major injuries. Emergency preparedness planners have created an ICS system to effectively manage a large number of victims, and this system was implemented successfully during 2 MCIs that involved unrestrained occupants in overloaded vans. The MCIs were unique because the victims actively avoided care despite their serious extent of injury. Overloaded vans that roll over in rural areas can quickly overwhelm rural health care providers and the trauma systems they use for back-up. The 2 MCIs on consecutive days used the services of 5 trauma centers, 8 aeromedical crews, 3 ground ambulance
crews, and 4 emergency medical service (EMS) agencies. In an effort to identify lessons ‘‘reinforced’’ and ‘‘learned,’’ a post-event evaluation was conducted that included 45 people from dispatch, fire departments, ground ambulance crews, aeromedical crews, trauma, emergency department physicians, and nurses. The following is a synopsis of major issues discussed. #1: Overloaded vans have a tendency to roll over and create a MCI. Passenger vans that are designed to carry 12 to 15 passengers are especially dangerous when overloaded. Coyotes frequently
6 Disaster Management & Response/Rodriguez, Plata, and Caruso
Volume 3, Number 1
DMR Table 2: Patients admitted to Maricopa Medical Center for injuries sustained in van rollover of June 18, 2004 Patient 1 17-year-old man
Time of arrival) 6:30 AM
Immediate ED findings
ED treatmentsy
ICD-9 codesz
ISS
dForehead laceration dClosed head injury, subdural hemorrhage dNasal fx, left orbital roof fx dRight clavicle fx dRight scapular Fx dPneumothorax dSpinal injuries: cervical 5, 6 lamina fxs
dCT of head, abdomen, pelvis, maxillofacial dAdmitted to ICU
801.0, 802.0, 810.0, 811.0, 813.43, 850.5, 860.0, 873.0,
29
2 25-year-old woman
6:52
AM
dForeign body to neck dMandibular fx dSpinal injury: cervical 3 spinous process fx
dCT of head, cervical spine, soft tissues neck, abdomen, pelvis, chest dCefazolin dAdmitted to OR for removal of foreign body, exploration of neck wound, closure of 5 centimeter laceration dAdmitted to hospital
802.2, 805.03, 874.8
3 25-year-old woman
6:53
AM
dRight rib fxs dComminuted right scapular fx dBilateral acetabular fx dSpinal injuries: thoracic 11, 12 spinous process fxs; lumbar 3, 4 lamina fxs; lumbar 5 transverse process fx; sacrum fx; separation of sacroiliac joint
dCT of head, chest, abdomen dRadiographs of pelvis, thoracic spine, lumbar, spine, head dAdmitted to ICU
805.2, 805.4, 805.6, 808.0, 811.0, 839.42,
22
4 20-year-old woman
7:40
AM
dHead laceration dClosed head injury dLeft rib fx dSpinal injury: thoracic 9 transverse process fx
dCT of head, maxillofacial bones, spine, abdomen, pelvis dAdmitted to hospital
805.2, 807.01, 850.9, 879.8, 919.0
9
5 26-year-old man
7:59
AM
Facial laceration, contusions
dCT of head, spine, abdomen, pelvis, maxillofacial bones dLaceration repair dDischarged from the ED
873.42, 910.0
1
6
CT, Computed tomography; ED, emergency department; Fx, fracture; ICU, intensive care unit; ICD-9 codes, International Classification of Diseases, 9th Revision; ISS, injury severity score; LOC, level of consciousness; OR, operating room. ) All patients were air evacuated. y Provided in ED only; all patients received tetanus vaccine. z Assigned on discharge from hospital.
transport large numbers of immigrants during the night, on isolated and difficult to access roadways. In a study comparing 51 van rollovers in Arizona and Connecticut, researchers found that the more occupants that were in the vehicle, the higher was the vehicle’s center of gravity, making the vehicle less stable.6 Speed did not appear to be a confounder in the study.
An overloaded vehicle that crashes produces a large number of victims that could constitute a MCI. A MCI is defined as a situation or event that places a significant demand on personnel resources and medical equipment.7 The fact that rollovers in this report involved 31 and 24 patients, respectively, demonstrates how quickly a smaller, rural fire department may be overwhelmed. More and more
January-March 2005
Disaster Management & Response/Rodriguez, Plata, and Caruso 7
DMR often, rural Arizona is witnessing human trafficking and overloaded van rollovers, causing multiple MCIs. #2: START triage provides multiple advantages in an MCI. At both scenes, the first responders used the START triage system which has been found to be a straightforward and easy system to use for MCI events.5 The START system allows scene providers to classify victims according to treatment priorities and allows for better resource allocation.7 Patients are triaged into 4 categories: red (priority 1), yellow (priority 2), green (priority 3), and black (priority 4). This system allows responders to quickly assess and triage injured patients (ie, respiratory rate, circulatory status or pulse, and level of consciousness), apply a tag that corresponds with their priority, and move on. START triage tags placed by the scene providers made the ongoing process of patient identification easier as it was difficult to obtain patients’ names at the scene. A scene manifest log was used to note the START tag number and patient destination. The hospital’s social service and translation departments were used to assist with identifying patients.
The first responders in this case report used heat-sensing devices to help locate 7 additional victims who were found hiding miles away. #3: An enlarged search and rescue area may be needed for illegal immigrants. Illegal immigrants can make the scene more difficult to assess because victims fear apprehension by authorities and will actively avoid medical care. The least injured are able to run from the scene and patients are found under shrubs and trees, several yards to miles away from the initial scene. The first responders in this case report used heat-sensing devices to help locate 7 additional victims who were found hiding miles away. #4: Rural providers need access to trauma center communication systems. The Casa Grande Fire Department alarm room dispatches EMS personnel to rural crash scenes in the Casa Grande area. At the time of the rollovers, the Casa Grande Fire Department’s dispatch center was unable to access the computer-based communication system used by metropolitan Phoenix. The system uses Internet access but was not available to all of the state’s hospitals because of cost issues. The June 17th event showed the need for all state EMS providers to be able to communicate quickly and effectively. The State of Arizona Department of Health Services plans to defray the cost and assist all facilities in Arizona to have access to the EMSystem beginning in 2005. The 8 Disaster Management & Response/Rodriguez, Plata, and Caruso
EMSystem would have allowed for simultaneous scene description, a patient count, and return communication of bed availability by facility, thus decreasing the time and number of repetitious telephone calls required of Casa Grande’s fire department. #5: Rural MCI can present challenges for area of operations at the scene. The difficult terrain required the Incident Commander to locate the aeromedical landing zone a distance away from the triage area. This action then required ground crews to transport victims to the waiting helicopters. If this type of triage set-up should occur again, the post-event evaluation recommended that the aeromedical crews ride the ambulances back to where the patients were to assist with the triage and treatment sector duties. This would increase the manpower at these two sectors and help the first responders closer to the scene. #6: Unrestrained occupants of van rollovers sustain major trauma, especially spinal injuries. The patients involved in the 2 rollovers had an unusually high number of documented spinal injuries. Thoracolumbar injuries are relatively uncommon in the general trauma population where the estimated incidence ranges from 64 to 117 per 100,000 patients.8 Of the 11 patients admitted to Maricopa Medical Center, 6 were found to have a thoracolumbar injury, and 3 had sustained a burst fracture. Burst fractures are caused by true vertical axial compression (ie, force applied to the top of the head or bottom of feet that causes the spine to be compressed along the axis). In addition to spinal injuries, patients had other types of major trauma. Three patients had scapular and 1st rib fractures, suggesting a large amount of force had been applied to the upper torso. The mortality rate for first rib and scapular fractures can be as high as 11.4%.9 Fractures in this area are used as a potential indicator of trauma to the great vessels, lungs, spinal cord, neck soft tissue, and head.10
Observations Two major similarities between the two consecutive van rollovers were observed after comparing the two incidents. These similarities appeared to be consistent despite the difference in the patients’ original place of origin. Patients seen on June 17th were believed to be from Central and South America and those seen on June 18th from El Salvador.
Socioeconomic Factors Both groups of patients required the hospital and support staff to use translation and interpretation services. These patients are not familiar with the Volume 3, Number 1
DMR American health care system, do not understand the language, and are wary of prosecution and deportation. The patients have paid coyotes to protect them from being found and are more trusting of the paid traffickers than of the EMS workers, nurses, and physicians who are trying to help them. Six of the 11 patients left against medical advice (AMA) or eloped from hospital grounds, probably because of fear and mistrust. Of the 5 patients that were admitted from the ED, 1 required ICU care for ventilator support and another had a 35-day length of stay. All of the 54 patients were uninsured and the hospitals received limited reimbursement through the state emergency indigent insurance fund. The estimated cost of the care for all 11 patients was greater than $100,000.
These patients are not familiar with the American health care system, do not understand the language, and are wary of prosecution and deportation.
Educational Efforts There are many immigrants who try to reach US metropolitan areas where they can secure jobs and reach family members. Public health providers in Arizona have made an effort to educate the Spanishspeaking population about the lethal dangers of desert crossings, and a Phoenix trauma center has focused injury prevention educational efforts on the phenomenon of human trafficking. Spanish outreach materials and Spanish-speakers will be used to educate the Spanish-speaking public on the dangers and the propensity for van rollovers with increased occupants. It is hoped that family members of potential coyote clients can be reached ahead of time and can be educated on the dangers that await their relatives if overloaded vans continue to be used for transportation.
Conclusion Human trafficking is continuing to occur despite legislation and law enforcement efforts. The illegal immigrants are subjected to many physical stressors, including risk of trauma if an overloaded vehicle is involved in a rollover. This case report documents that an MCI strategy was effective in triaging and treating 54 patients involved in 2 different rollovers. The metropolitan Phoenix trauma system provided a wide but uncompensated response to the victims. An MCI that involves illegal immigrants is unique in that the victims avoid revealing personal information, do not January-March 2005
seek medical care if given a choice, and have a tendency to elope if they feel threatened with deportation. The cost to facilities which treat these uninsured trauma victims can add up very quickly, as seen with the 2 separate van rollovers.
Trauma systems, EMS, and the community should look at these everyday events through a different lens to refine responses, improve communication efforts, and evaluate processes. The opportunity to evaluate and critique the events occurring on 2 consecutive days was invaluable to the Phoenix Metropolitan trauma community. After September 11, 2001, there has been an effort to explore the effects of terrorism on the trauma system, yet everyday events demonstrate that trauma systems are vulnerable to many hazards. Trauma systems, EMS, and the community should look at these everyday events through a different lens to refine responses, improve communication efforts, and evaluate processes. Acknowledgment: The authors take the opportunity to recognize contributing physicians who were principal providers of care and who assisted the authors in review: Kevin Foster, MD, Tammy Kopelman, MD, FACS, and Marc Matthews, MD.
References 1. United States Department of Justice. Trafficking in persons and worker exploitation task force. US Department of Justice Civil Rights Division. US Department of Justice, 2004. Available at: http://www. usdoj.gov/crt/crim/tpwetf.htm. Accessed August 18, 2004. 2. United States Department of Justice. Anti-trafficking news bulletin. US Department of Justice Civil Rights Division. US Department of Justice, 2004. Available at: http://www.usdoj.gov/crt/crim/trafficking_newsletter/ antitraffnews_augsep04.pdf. Accessed August 18, 2004. 3. Center for Immigration Studies. Illegal immigration. Available at: http://www.cis.org/topics/illegalimmigration. html. Accessed August 18, 2004. 4. United States Department of Homeland Security. Immigration monthly statistical report: Southwest border apprehensions. August, 2004. Available at: http://uscis.gov/ graphics/shared/aboutus/statistics/msraug04/SWBORD. HTM. Retrieved August 24, 2004. 5. Risavi B, Salen P, Heller M, Arcona S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 2001; 5:197-9. 6. Robertson L, Maloney A. Motor vehicle rollover and static stability: an exposure study. Am J Public Health 1997;87:839-41. Disaster Management & Response/Rodriguez, Plata, and Caruso 9
DMR 7. Asaeda G. The day that the START triage system came to a stop: Observations from the World Trade Center disaster. Acad Emerg Med 2002;9:255-6. 8. Holmes J, Miller P, Panacek E, Lin S, Horne N, Mower W. Epidemiology of thoracolumbar spine injury in blunt trauma. Acad Emerg Med 2001;8:866-72.
9. Veysi V, Mittal R, Agarwal S, Dosani A, Giannoudis P. Multiple trauma and scapula fractures: so what? J Trauma Inj Infect Crit Care 2003;55:1145-7. 10. American College of Surgeons. Advanced trauma life support. 6th ed. Chicago: American College of Surgeons; 1997.
Key Points First responders and public health authorities 1. Anticipate that illegal immigrants involved in human trafficking may actively avoid health care. 2. Incorporate incident command structures to manage multiple victims of motor vehicle crashes. 3. Promote injury prevention efforts that target illegal immigrant families and friends currently residing in the United States. Emergency and critical care providers 1. Recognize the pattern and severity of spinal injuries associated with van rollovers. 2. Work with social services and other advocacy groups to convince patients not to elope.
10 Disaster Management & Response/Rodriguez, Plata, and Caruso
Volume 3, Number 1
Feature Article
Case Report: Illegal Immigration via Overloaded Vans and the Effects on a Trauma System Darlene Rodriguez, RN, Elizabeth Plata, BSN, and Daniel Caruso, MD, FACS
The Arizona-Mexico border consists of 375 square miles of rural desert where temperature extremes, excessive sun exposure, and a lack of food and water are common. The desert poses an especially deadly threat to immigrants who attempt to cross it on foot. In an effort to smuggle humans across this region, smugglers transport people in vans that are loaded beyond the recommended vehicle weight limitations. The unrestrained occupants change the vehicle’s center of gravity and increase the propensity for van rollovers. Van rollovers produce multiple casualties that quickly outstrip the resources of rural providers. The purpose of this article is to describe two cases that involved multiple victims injured in van rollovers that occurred on two consecutive days. The rollovers occurred in the rural areas outside of Phoenix, Arizona, and eventually taxed the entire metropolitan Phoenix area trauma system.
E
xperience is a hard teacher because she gives the test first, the lesson afterwards.dVernon Sanders Law
The illegal movement of people across the US border, also known as human smuggling, is not a new phenomenon. Along the southwestern US border, ‘‘coyotes’’ (ie, person who transport others for money) lure illegal immigrants with the promise that they will be taken to the United States. Coyotes use different ways to shepherd the undocumented migrants, including forcing them to walk across hot deserts, ride in the back of
Darlene Rodriguez, RN, is Trauma Coordinator, Elizabeth Plata, BSN, is Trauma Outreach/Educator, and Daniel Caruso, MD, FACS, is Trauma Medical Director, Maricopa Medical Center, Phoenix, Arizona. Reprint requests: Elizabeth Plata, BSN, Maricopa Medical Center, 2601 E Roosevelt Rd, Phoenix, AZ 85008. Disaster Manage Response 2005;3:4-10. 1540-2487/$30.00 Copyright Ó 2005 by the Emergency Nurses Association. doi:10.1016/j.dmr.2004.11.003 4 Disaster Management & Response/Rodriguez, Plata, and Caruso
tractor-trailers, or pile into overloaded vehicles. Human trafficking is a dangerous process because it uses remote areas of the border that are uninhabited due to temperature extremes, excessive sunshine, and a lack of adequate food and water. Trafficking is even more dangerous when the motor vehicle is involved in a crash or rollover (Figure 1).
Human Trafficking The US Department of Justice1 defines human trafficking as ‘‘a form of modern day slavery’’ and portrays traffickers as people who prey on vulnerable individuals. The Victims of Trafficking and Violence Protection Act of 2000 is federal legislation that criminalizes human trafficking done for the purposes of slavery, involuntary servitude, peonage, or forced labor.1 The victims of human trafficking are poor, frequently unemployed or underemployed, and lack access to social safety nets. They are predominately women and children who are lured with false promises of good jobs and better lives. If they arrive safely in the United States, they are forced to work under brutal and inhuman conditions.2
Human trafficking is a dangerous process because it uses remote areas of the border that are uninhabited due to temperature extremes, excessive sunshine, and a lack of adequate food and water. Illegal immigrants continue to risk the dangers. According to statistics from the Center for Immigration Studies,3 the estimated number of illegal immigrants who are now living in the United States has risen from 7 million in 2000 to 8 million in 2004. The US Government has increased efforts to stop human trafficking by increasing law enforcement efforts. The Immigration Monthly Statistical Report4 indicates that border apprehensions increased by 25% from June 2003 to July 2004. Human trafficking becomes more than a law enforcement issue Volume 3, Number 1
DMR At approximately 1:30 AM on June 17th, the Casa Grande Fire Department’s alarm room called the Phoenix Fire Department alarm room which then accessed a computerized communication system (EMSystem) to alert the Phoenix and Tucson trauma centers via telephone. Casa Grande Fire Department could not access the computerized system directly and, because of the number of patients and hospitals involved, repetitive calls had to be made to over 6 facilities.
Triage and Transport
Figure 1: Passenger van involved in rollover that produced a mass casualty incident with multiple major trauma patients. (Used with permission.) when victims are injured and are brought in for medical care. The following case report is used to describe how trafficking is causing mass casualty incidents (MCI) and how the trauma system is being affected.
Case Report Mass Casualty Incidents During the month of June 2004, two separate van rollovers occurred within 24 hours of each other in the rural areas near metropolitan Phoenix, Arizona. On June 17, 2004, a van carrying approximately 30 undocumented immigrants overturned along a remote highway in central Arizona, near Casa Grande. The rollover occurred at approximately 1:30 AM and the Casa Grande rural fire department was the first responder to arrive on the scene. The fire department assumed command and quickly assessed the magnitude of the injured by using the Simple Triage and Rapid Transport (START) triage system.5 Because of the large number of victims, a MCI and Incident Command System (ICS) were instituted. Due to darkness, the fire department used heat-sensing devices to search for patients; however even with this tech-
Human trafficking becomes more than a law enforcement issue when victims are injured and are brought in for medical care.
The geography at the Casa Grande crash site occurred along a tight curve in the road on the western edge of Casa Grande. The rough and rugged terrain surrounding this scene did not allow for a safe helicopter landing zone. A landing zone had to be established a distance away from the triage sector and ground crews were used to move the triaged patients to the helicopters. Three aeromedical companies were dispatched to this area with approximately 7 helicopters waiting on standby. Initially 28 ground personnel were used, 14 of whom were from ambulance crews. Two patients were dead at the scene, 22 required transport (21 via air, 1 via ground) to Level I trauma centers located in Phoenix. One patient died later at a Phoenix hospital. The total scene time for this incident was approximately 12 hours because of the need to do a more expansive search and rescue effort which located 7 more patients who were found miles from the crash scene.
Eleven patients were brought to Maricopa Medical Center: 6 (54%) had spinal injuries Approximately 28 hours later (at 5:15 AM on June 18, 2004), another van rollover occurred with at least 24 passengers. The rollover happened in another remote area southeast of Phoenix. The response was similar to the day before with 22 patients transported to Level I trauma centers and 2 patients dead at the scene. The 2-day total for both MCI was 55 injured passengers. Eleven patients were brought to Maricopa Medical Center: 6 (54%) had spinal injuries, 4 (36%) had a head injury, and 10 (90%) sustained ‘‘other’’ significant injuries requiring hospitalization and treatment (Maricopa Medical Center Data, unpublished data). Out of the 11 patients admitted to the ED, 6 required admission to the intensive care unit (ICU), and 2 required emergency surgery. See Tables 1 and 2.
nology, a woman was not found until approximately 11:00 AM. She had experienced a brief loss of consciousness at the scene, recovered, and was trying to escape detection. She was found later in the day when she had stopped under a bush to get out of the intense Arizona sun. The patient was later found to have a subdural hematoma.
MCIs are considered to be rare events that produce a large number of victims with a range of minor to
January-March 2005
Disaster Management & Response/Rodriguez, Plata, and Caruso 5
Discussion
DMR Table 1: Patients admitted to Maricopa Medical Center for injuries sustained in van rollover of June 17, 2004 Patient 1 29-year-old woman
2 23-year-old woman
3 22-year-old woman
Time of arrival) 3:04 AM
4:30
AM
4:12
AM
Immediate ED findings
Treatment in EDy
ICD-9 codesz
ISS
dLeft orbital wall fx dRib fxs dSpinal injuries: lumbar 1 burst fx; lumbar 2 lamina fx; lumbar 3, 4 transverse process fx; comminuted bilateral sacral fxs
d2 units of PRBC dFast exam dCT of the head, abdomen, pelvis, cervical-spine, and chest dAdmitted to ICU
802.8, 805.0, 807.01, 910.0, 924.8
22
dMultiple scalp lacerations dConcussion with decreased LOC dPulmonary contusion dLeft wrist fx
dIntubated for decreased LOC dCT of the abdomen/ pelvis/head, cervical-spine dRadiograph of left upper extremity dAdmitted to ICU
814.0, 850.9, 861.21, 873.0, 873.63
17
dLeft orbit fx dRight pneumothorax dRight rib fx dSpinal injuries: thoracic 5 burst fx; thoracic 6 vertebra and transverse process fxs; thoracic 7 vertebra fx; thoracic 8 transverse process fx
dCT of thoracic spine, pelvis, head dAdmitted to ICU
802.8, 805.0, 807.01, 860.0, 919.0, 920.0
17
dScalp laceration dClosed head injury dTraumatic pneumothorax dSpinal injuries: thoracic 5, 6 and lumbar 1,2 bilateral transverse process fxs
dCT of head, chest abdomen, pelvis, thoracic spine, lumbar spine dAdmitted to ICU
803.09, 805.0, 850.9, 860.0, 873.0, 919.0,
17
4 27-year-old woman
8:55
5 24-year-old man
12:23
PM
dLaceration to right thorax wall
dWound exploration and repair in OR dAdmitted to hospital
879.8
6 19-year-old man
12:27
PM
dRight clavicle fx dPossible right humeral head fx dPubis fx
dDischarged From ED
808.2, 810.0, 910.0, 919.0
AM
1
10
CT, Computed tomography; ED, emergency department; Fx, fracture; ICU, intensive care unit; ICD-9 codes, International Classification of Diseases, 9th Revision; ISS, injury severity score; LOC, level of consciousness; OR, operating room; PRBC, packed red blood cells. ) All patients were air evacuated. y Provided in ED only; all patients received tetanus vaccine. z Assigned on discharge from hospital.
major injuries. Emergency preparedness planners have created an ICS system to effectively manage a large number of victims, and this system was implemented successfully during 2 MCIs that involved unrestrained occupants in overloaded vans. The MCIs were unique because the victims actively avoided care despite their serious extent of injury. Overloaded vans that roll over in rural areas can quickly overwhelm rural health care providers and the trauma systems they use for back-up. The 2 MCIs on consecutive days used the services of 5 trauma centers, 8 aeromedical crews, 3 ground ambulance
crews, and 4 emergency medical service (EMS) agencies. In an effort to identify lessons ‘‘reinforced’’ and ‘‘learned,’’ a post-event evaluation was conducted that included 45 people from dispatch, fire departments, ground ambulance crews, aeromedical crews, trauma, emergency department physicians, and nurses. The following is a synopsis of major issues discussed. #1: Overloaded vans have a tendency to roll over and create a MCI. Passenger vans that are designed to carry 12 to 15 passengers are especially dangerous when overloaded. Coyotes frequently
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DMR Table 2: Patients admitted to Maricopa Medical Center for injuries sustained in van rollover of June 18, 2004 Patient 1 17-year-old man
Time of arrival) 6:30 AM
Immediate ED findings
ED treatmentsy
ICD-9 codesz
ISS
dForehead laceration dClosed head injury, subdural hemorrhage dNasal fx, left orbital roof fx dRight clavicle fx dRight scapular Fx dPneumothorax dSpinal injuries: cervical 5, 6 lamina fxs
dCT of head, abdomen, pelvis, maxillofacial dAdmitted to ICU
801.0, 802.0, 810.0, 811.0, 813.43, 850.5, 860.0, 873.0,
29
2 25-year-old woman
6:52
AM
dForeign body to neck dMandibular fx dSpinal injury: cervical 3 spinous process fx
dCT of head, cervical spine, soft tissues neck, abdomen, pelvis, chest dCefazolin dAdmitted to OR for removal of foreign body, exploration of neck wound, closure of 5 centimeter laceration dAdmitted to hospital
802.2, 805.03, 874.8
3 25-year-old woman
6:53
AM
dRight rib fxs dComminuted right scapular fx dBilateral acetabular fx dSpinal injuries: thoracic 11, 12 spinous process fxs; lumbar 3, 4 lamina fxs; lumbar 5 transverse process fx; sacrum fx; separation of sacroiliac joint
dCT of head, chest, abdomen dRadiographs of pelvis, thoracic spine, lumbar, spine, head dAdmitted to ICU
805.2, 805.4, 805.6, 808.0, 811.0, 839.42,
22
4 20-year-old woman
7:40
AM
dHead laceration dClosed head injury dLeft rib fx dSpinal injury: thoracic 9 transverse process fx
dCT of head, maxillofacial bones, spine, abdomen, pelvis dAdmitted to hospital
805.2, 807.01, 850.9, 879.8, 919.0
9
5 26-year-old man
7:59
AM
Facial laceration, contusions
dCT of head, spine, abdomen, pelvis, maxillofacial bones dLaceration repair dDischarged from the ED
873.42, 910.0
1
6
CT, Computed tomography; ED, emergency department; Fx, fracture; ICU, intensive care unit; ICD-9 codes, International Classification of Diseases, 9th Revision; ISS, injury severity score; LOC, level of consciousness; OR, operating room. ) All patients were air evacuated. y Provided in ED only; all patients received tetanus vaccine. z Assigned on discharge from hospital.
transport large numbers of immigrants during the night, on isolated and difficult to access roadways. In a study comparing 51 van rollovers in Arizona and Connecticut, researchers found that the more occupants that were in the vehicle, the higher was the vehicle’s center of gravity, making the vehicle less stable.6 Speed did not appear to be a confounder in the study.
An overloaded vehicle that crashes produces a large number of victims that could constitute a MCI. A MCI is defined as a situation or event that places a significant demand on personnel resources and medical equipment.7 The fact that rollovers in this report involved 31 and 24 patients, respectively, demonstrates how quickly a smaller, rural fire department may be overwhelmed. More and more
January-March 2005
Disaster Management & Response/Rodriguez, Plata, and Caruso 7
DMR often, rural Arizona is witnessing human trafficking and overloaded van rollovers, causing multiple MCIs. #2: START triage provides multiple advantages in an MCI. At both scenes, the first responders used the START triage system which has been found to be a straightforward and easy system to use for MCI events.5 The START system allows scene providers to classify victims according to treatment priorities and allows for better resource allocation.7 Patients are triaged into 4 categories: red (priority 1), yellow (priority 2), green (priority 3), and black (priority 4). This system allows responders to quickly assess and triage injured patients (ie, respiratory rate, circulatory status or pulse, and level of consciousness), apply a tag that corresponds with their priority, and move on. START triage tags placed by the scene providers made the ongoing process of patient identification easier as it was difficult to obtain patients’ names at the scene. A scene manifest log was used to note the START tag number and patient destination. The hospital’s social service and translation departments were used to assist with identifying patients.
The first responders in this case report used heat-sensing devices to help locate 7 additional victims who were found hiding miles away. #3: An enlarged search and rescue area may be needed for illegal immigrants. Illegal immigrants can make the scene more difficult to assess because victims fear apprehension by authorities and will actively avoid medical care. The least injured are able to run from the scene and patients are found under shrubs and trees, several yards to miles away from the initial scene. The first responders in this case report used heat-sensing devices to help locate 7 additional victims who were found hiding miles away. #4: Rural providers need access to trauma center communication systems. The Casa Grande Fire Department alarm room dispatches EMS personnel to rural crash scenes in the Casa Grande area. At the time of the rollovers, the Casa Grande Fire Department’s dispatch center was unable to access the computer-based communication system used by metropolitan Phoenix. The system uses Internet access but was not available to all of the state’s hospitals because of cost issues. The June 17th event showed the need for all state EMS providers to be able to communicate quickly and effectively. The State of Arizona Department of Health Services plans to defray the cost and assist all facilities in Arizona to have access to the EMSystem beginning in 2005. The 8 Disaster Management & Response/Rodriguez, Plata, and Caruso
EMSystem would have allowed for simultaneous scene description, a patient count, and return communication of bed availability by facility, thus decreasing the time and number of repetitious telephone calls required of Casa Grande’s fire department. #5: Rural MCI can present challenges for area of operations at the scene. The difficult terrain required the Incident Commander to locate the aeromedical landing zone a distance away from the triage area. This action then required ground crews to transport victims to the waiting helicopters. If this type of triage set-up should occur again, the post-event evaluation recommended that the aeromedical crews ride the ambulances back to where the patients were to assist with the triage and treatment sector duties. This would increase the manpower at these two sectors and help the first responders closer to the scene. #6: Unrestrained occupants of van rollovers sustain major trauma, especially spinal injuries. The patients involved in the 2 rollovers had an unusually high number of documented spinal injuries. Thoracolumbar injuries are relatively uncommon in the general trauma population where the estimated incidence ranges from 64 to 117 per 100,000 patients.8 Of the 11 patients admitted to Maricopa Medical Center, 6 were found to have a thoracolumbar injury, and 3 had sustained a burst fracture. Burst fractures are caused by true vertical axial compression (ie, force applied to the top of the head or bottom of feet that causes the spine to be compressed along the axis). In addition to spinal injuries, patients had other types of major trauma. Three patients had scapular and 1st rib fractures, suggesting a large amount of force had been applied to the upper torso. The mortality rate for first rib and scapular fractures can be as high as 11.4%.9 Fractures in this area are used as a potential indicator of trauma to the great vessels, lungs, spinal cord, neck soft tissue, and head.10
Observations Two major similarities between the two consecutive van rollovers were observed after comparing the two incidents. These similarities appeared to be consistent despite the difference in the patients’ original place of origin. Patients seen on June 17th were believed to be from Central and South America and those seen on June 18th from El Salvador.
Socioeconomic Factors Both groups of patients required the hospital and support staff to use translation and interpretation services. These patients are not familiar with the Volume 3, Number 1
DMR American health care system, do not understand the language, and are wary of prosecution and deportation. The patients have paid coyotes to protect them from being found and are more trusting of the paid traffickers than of the EMS workers, nurses, and physicians who are trying to help them. Six of the 11 patients left against medical advice (AMA) or eloped from hospital grounds, probably because of fear and mistrust. Of the 5 patients that were admitted from the ED, 1 required ICU care for ventilator support and another had a 35-day length of stay. All of the 54 patients were uninsured and the hospitals received limited reimbursement through the state emergency indigent insurance fund. The estimated cost of the care for all 11 patients was greater than $100,000.
These patients are not familiar with the American health care system, do not understand the language, and are wary of prosecution and deportation.
Educational Efforts There are many immigrants who try to reach US metropolitan areas where they can secure jobs and reach family members. Public health providers in Arizona have made an effort to educate the Spanishspeaking population about the lethal dangers of desert crossings, and a Phoenix trauma center has focused injury prevention educational efforts on the phenomenon of human trafficking. Spanish outreach materials and Spanish-speakers will be used to educate the Spanish-speaking public on the dangers and the propensity for van rollovers with increased occupants. It is hoped that family members of potential coyote clients can be reached ahead of time and can be educated on the dangers that await their relatives if overloaded vans continue to be used for transportation.
Conclusion Human trafficking is continuing to occur despite legislation and law enforcement efforts. The illegal immigrants are subjected to many physical stressors, including risk of trauma if an overloaded vehicle is involved in a rollover. This case report documents that an MCI strategy was effective in triaging and treating 54 patients involved in 2 different rollovers. The metropolitan Phoenix trauma system provided a wide but uncompensated response to the victims. An MCI that involves illegal immigrants is unique in that the victims avoid revealing personal information, do not January-March 2005
seek medical care if given a choice, and have a tendency to elope if they feel threatened with deportation. The cost to facilities which treat these uninsured trauma victims can add up very quickly, as seen with the 2 separate van rollovers.
Trauma systems, EMS, and the community should look at these everyday events through a different lens to refine responses, improve communication efforts, and evaluate processes. The opportunity to evaluate and critique the events occurring on 2 consecutive days was invaluable to the Phoenix Metropolitan trauma community. After September 11, 2001, there has been an effort to explore the effects of terrorism on the trauma system, yet everyday events demonstrate that trauma systems are vulnerable to many hazards. Trauma systems, EMS, and the community should look at these everyday events through a different lens to refine responses, improve communication efforts, and evaluate processes. Acknowledgment: The authors take the opportunity to recognize contributing physicians who were principal providers of care and who assisted the authors in review: Kevin Foster, MD, Tammy Kopelman, MD, FACS, and Marc Matthews, MD.
References 1. United States Department of Justice. Trafficking in persons and worker exploitation task force. US Department of Justice Civil Rights Division. US Department of Justice, 2004. Available at: http://www. usdoj.gov/crt/crim/tpwetf.htm. Accessed August 18, 2004. 2. United States Department of Justice. Anti-trafficking news bulletin. US Department of Justice Civil Rights Division. US Department of Justice, 2004. Available at: http://www.usdoj.gov/crt/crim/trafficking_newsletter/ antitraffnews_augsep04.pdf. Accessed August 18, 2004. 3. Center for Immigration Studies. Illegal immigration. Available at: http://www.cis.org/topics/illegalimmigration. html. Accessed August 18, 2004. 4. United States Department of Homeland Security. Immigration monthly statistical report: Southwest border apprehensions. August, 2004. Available at: http://uscis.gov/ graphics/shared/aboutus/statistics/msraug04/SWBORD. HTM. Retrieved August 24, 2004. 5. Risavi B, Salen P, Heller M, Arcona S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 2001; 5:197-9. 6. Robertson L, Maloney A. Motor vehicle rollover and static stability: an exposure study. Am J Public Health 1997;87:839-41. Disaster Management & Response/Rodriguez, Plata, and Caruso 9
DMR 7. Asaeda G. The day that the START triage system came to a stop: Observations from the World Trade Center disaster. Acad Emerg Med 2002;9:255-6. 8. Holmes J, Miller P, Panacek E, Lin S, Horne N, Mower W. Epidemiology of thoracolumbar spine injury in blunt trauma. Acad Emerg Med 2001;8:866-72.
9. Veysi V, Mittal R, Agarwal S, Dosani A, Giannoudis P. Multiple trauma and scapula fractures: so what? J Trauma Inj Infect Crit Care 2003;55:1145-7. 10. American College of Surgeons. Advanced trauma life support. 6th ed. Chicago: American College of Surgeons; 1997.
Key Points First responders and public health authorities 1. Anticipate that illegal immigrants involved in human trafficking may actively avoid health care. 2. Incorporate incident command structures to manage multiple victims of motor vehicle crashes. 3. Promote injury prevention efforts that target illegal immigrant families and friends currently residing in the United States. Emergency and critical care providers 1. Recognize the pattern and severity of spinal injuries associated with van rollovers. 2. Work with social services and other advocacy groups to convince patients not to elope.
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