On May 12, 2015, a northbound Amtrak train derailed outside of Philadelphia, killing eight people and injuring more than 200. Anne Klimke, MD, MS, FACEP, was heading to her shift at Einstein Medical Center in Philadelphia when she learned of the accident and that trauma patients would soon be arriving at her emergency department.

Dr. Klimke
Photo courtesy of Wesley Hilton

recently sat down with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, to talk about the experience of caring for those hurt in the crash and how her disaster medicine training and experience with the FEMA Urban Search and Rescue group equipped her to deal with the volume of patients and the rapid triage needed to care for the injured.

Dr. Kevin Klauer: Tell me about your training background.

Dr. Anne Klimke: I started at Einstein in 2005, and I did the four-year residency program there in emergency medicine. I was really lucky to be able to do a combined residency and fellowship in emergency medical services (EMS) and disaster medicine. In five years, I came out with a master’s degree in disaster management from Philadelphia University.

KK: What ere you doing when you were notified that there might be a disaster?

AK: I had just gotten into my car to drive in for my 11 p.m.–7 a.m. shift when I got a phone call from one of my colleagues, Ryan Overberger. He said, “There was a train derailment at Aramingo.” There was definitely a lot of adrenaline and mental coaching for myself on the way in. I was thinking, “OK, what’s the mechanism of injury? What kinds of injuries do I anticipate? We should probably call the other portable tech for radiology to come down from doing in-patient films so that we have the two portable machines down there. We should make sure that we have enough supplies for casting. We have a cart-based system, so we should pull all the carts up into A Pod and let central supply know that we may be calling them for more. Am I going to see neurosurgical cases?” The trauma attending called in the neurosurgeon just because brain injury is highly likely with a train crash.

When I got to the ED, my colleagues were already in the midst of trying to decompress the emergency department and get all of the admitted patients out. They made the phone calls to notify trauma, anesthesia, orthopedics, and neurosurgery. We were definitely ramping up to receive lots of trauma patients.

The NTSB Go Team arrives on the scene of the Amtrak train No. 188 derailment in Philadelphia, Pennsylvania.

KK: You said they were trying to decompress the ED. Tell me some of the things you and your colleagues did to decide which patients needed to go upstairs immediately without a workup and which did not need to be seen in the ED at all.

AK: We have a medicine chief and a night chief on overnight, and they did a great job sending me down residents to make sure that admission orders were written for everyone who needed to go upstairs. Everyone who needed to go upstairs was out of there in two to two and a half hours of our disaster plan implementation. Anyone else who had a minor workup already in progress was dispositioned; most of them were sent home. Our neurology resident actually cleared out the neurology step-down unit so that we would have extra step-down beds if needed. Everyone was being very judicious about assigning levels of care. A patient who was being intubated while I was on the phone with the administrator on call went right up to the medical intensive care unit as soon as his chest X-ray was shot.

KK: Based on your ability and your skills, did any patients appear less injured than they really were?

AK: One patient came in walking with her family assisting her. I flagged down the senior resident and said, “Please make sure you take a really good look at her.” There was a language barrier, and she was clearly distraught, in pain, and not really ambulating on her own power. It turned out that she had three cervical spine fractures, and so she went to the surgical intensive care unit.

Dr. Klimke (right front) with her Pennsylvania Task Force 1 medical team during Superstorm Sandy.

KK: What percentage of patients do you think were ultimately upgraded for whatever reason?

AK: About 20 percent. Twenty percent is even on the low end of the disaster literature, but I say that’s right about where we were. Over-triage is more acceptable than under-triage, which is definitely something that you need to be aware of. Again, triage is very fluid, an ongoing process.

KK: Tell me if you agree with this: Although you could do it, it’s very ill-advised to downgrade somebody’s triage status. Unless it was completely erroneous, someone may have seen something that you aren’t seeing now. What are your thoughts about whether you should downgrade people or not?

AK: I think you do wind up downgrading them just because in the emergency department it’s a much more controlled situation. You have better light, you get the patients fully undressed, you can have a conversation with them, and you can see them in the context of everybody else as well. They may have had interventions already that had stabilized them to the point that they were able to be downgraded a little bit.

KK: So with more resources, a more controlled environment, and perhaps even more extensive training, it is reasonable to say, “We can slow this down a little bit and take a more detailed look.” How has this affected you personally?

AK: I don’t want disasters to happen, but when they do, I want to be able to help. A large part of me really wanted to be in the field rather than in the emergency department, but I recognized that I was really able to facilitate things. The deployments that I’ve been on so far with Pennsylvania Task Force 1 have been natural disasters where we’ve deployed to pre-stage for hurricanes, and then I responded and deployed for Superstorm Sandy. What I saw was a lot of property damage but not a lot of injured patients. Then there’s the issue of why this even happened. Everyone knows why a hurricane happens. It’s a natural disaster. An earthquake or a tornado, it’s nobody’s fault, but this disaster had a very human factor in it, and we still don’t know exactly what caused the incident. Nobody knew if it was an intentional act of terrorism, if it was accidental, or if there was someone or something that would ultimately be shouldering the blame. This gives the disaster an additional emotional component that I hadn’t experienced in my natural disaster responses.

On a side note, I’ve used the term “so-and-so is a train wreck” throughout my career; I will never say that again without thinking of this incident. This really gave meaning to the term.

KK: What kind of emotional support did you provide for the patients? Were social services available?

AK: I pointed out to our emergency managers that all of the people who were now in the department from the accident were actually in transit. They weren’t from Philadelphia. They didn’t know the area, and they certainly didn’t intend to stay there that night. So we set up a hospitality center. We talked about helping them get cell phone chargers and making arrangements for housing or for other means of transportation for those who were discharged from the emergency department. There were a lot of people from European countries and East Asia who use rail travel as their means of transportation probably more than your average American. We used our translation language line and other resources.

KK: Did you help them get in touch with their families?

AK: That was very emotional for me. As I was wrapping up at the end of my shift, we started getting phone calls from family members who hadn’t been able to locate their loved ones. I don’t know if the Amtrak hotline was overwhelmed or if it was operational yet, but we were taking phone calls and would respond, “I’m sorry, no, we don’t have anyone who’s unidentified.”

Dr. Klimke taking a break from rope rescue training with Zeus, a retired search-and-rescue canine.
Photo courtesy of Kurt Braunle

KK: That had to be very emotional, realizing some of the people you’re talking with have loved ones who’ve died but haven’t yet been identified. How did you work though this following the disaster?

AK: I’ve found in the course of my career that coming home and watching the news, whenever something bad has happened, is a double-edged sword. On the one side, you want to understand the total context of what happened. While I was sitting on the couch and seeing the images of the derailment, damage to the cars, the seats, etc., I hit a point where I said, “I have to turn this off, or I’m never going to get sleep.”

I had a lot of people reach out to me, both medical and nonmedical, in my group of friends and family. I got a lot of support from my fiancé and everyone just checking in to see if I was OK. I don’t want to say that I was fine, but it’s definitely one of those things that you process and you learn from.

KK: You, your colleagues, hospital, and EMS system should be commended for a job well done.