Last Jan. 13, the Air Florida and Metro subway disasters revealed a lack of coordination between the various jurisdictions involved in rescue operations -- which stirred new scrutiny of the region's ability to mobilize in such incidents. This month, a subway disaster drill was depicted as a success by many of the individuals and agencies involved. This highly complex drill was well organized and executed, without injury to any of the estimated 1,000 participants, and it demonstrated significant improvement in disaster management by the participating agencies. But it also highlighted areas that need continued effort.

The drill involved four Metro cars packed with passengers and stopped underneath the Potomac between the Rosslyn and Foggy Bottom stations. It became rapidly clear that both the D.C. Fire Department and the Metro police had made a professional commitment to the successful management of this make-believe crisis. The fire department quickly established a command post that functioned effectively throughout the drill. Firefighters arrived rapidly at the Foggy Bottom station, but had to wait 12 minutes as two paramedics, loaded down with huge amounts of medical equipment that was never used, struggled down to the train. 5 The train doors were opened and, after a brief survey, the walking wounded were taken to a rescue train. This left the seriously ill, the dying and the dead on the train, with two paramedics and a number of firemen determining the nature and extent of injuries. Colored tags were attached to the victims for this purpose.

In a real disaster, this can be a life-or-death decision -- determining the timing and level of medical care. But over the next hour, it became clear that management at the scene of the disaster had three major deficiencies:

The determination of injuries was largely performed by unskilled personnel and was therefore ineffective.

There was a lack of needed medical personnel and supplies.

6 The evacuation of the seriously ill and critically injured from the train was a major problem.

The only additional medical supplies that were brought to the scene were packs of new stretchers without restraints, not even out of their plastic wrappers, that proved so hazardous to the patients that a medical observer stopped the stretcher evacuation of victims. In a real disaster, this evacuation would have taken many hours. The delay would have resulted in additional deaths. No patients at the scene received any form of advanced life support or higher medical care. All but one or two of the victims walked from the incident train to the rescue train.

Clearly the fire departments responded instinctively to the disaster, giving priority to rescue, fire suppression and security ahead of medical needs, which should have received equal and concurrent attention. Emergency medical care, always the neglected component, was again neglected in an otherwise sterling fire department response. The real- life horror of more than 100 victims with serious or lethal injuries -- confined in a Metro tunnel with only two paramedics and many well-meaning but medically unskilled fire fighters -- should be prevented.

Once the victims arrived by rescue train at the Foggy Bottom and Rosslyn stations, medical care was available. The treatment site was well organized and managed. Paramedics and intermediate paramedics determined injuries and provided initial medical care. Victims were then taken up the escalators and out of the stations.

Outside of the Foggy Bottom station, the transport area had been cleared and more than 30 ambulances and fire vehicles from the region waited in line a block away to be summoned and loaded with patients. Patients were evacuated to hospitals promptly with only minor problems. Meanwhile, the number of available hospital beds had been predetermined by the D.C. Fire Department and relayed to the back of an ambulance at the top of the subway escalator.

Communication between prehospital and hospital care in the District was found again to be deficient and was exacerbated by a long delay between notification of the disaster and arrival of the first patients at some of the hospitals.

This metropolitan region is almost unique in its constraints on effective disaster management, with eight major jurisdictions, many municipalities and a wide variety of interested federal and state agencies. The disaster drill of Nov. 7 clearly identified significant strides in our civilian disaster management planning and operations.

Since this drill, there have been numerous evaluations conducted by the participants. It was clear on Jan. 13 that there was no shortage of emergency medical services or fire department help in the metropolitan region. As of November, it is apparent that with further training and drilling, the coordination and command of these services can be effective. What is also clear is that the regional disaster response has a long way to go before it can maximize patient survival through prompt medical care -- which is, after all, the ultimate objective.