“The worst part for me had little to nothing to do with what was happening medically. It was seeing and knowing the grief going on outside. I'm taking care of someone whose mom may not even know they are here.”
Stacie Liles was 12 when a trailer broke free from a truck on Gunbarrel Road, smashing head-on into her dad's pickup truck, in which she and her brother were riding.
She ended up at T.C. Thompson Children's Hospital needing intestinal surgery, and was amazed at how caring the staff was.
"It has always stuck with me — the ambulance ride, the emergency room — it fascinated me how all of these people were working on me," she said. "People making sure I stayed calm, that impacted me a lot."
Years later, after a marriage, a child and a divorce, that experience motivated her to go back to school for training as an emergency medical technician and then as a paramedic.
And now here she was, 26 years later, at 3:30 p.m. on a Monday afternoon in November, the first paramedic on the scene of the Woodmore school bus crash, fighting to save the lives of young children who reminded her of herself those many years before.
A police car had arrived before her and neighbors — two young women, some older women, and a man, she remembers — were helping get children off of the bus, which was on its side with the roof smashed against a tree.
But when she got out of her Hamilton County EMS ambulance, only about four minutes after the call came in, everyone turned to her.
"I'm walking up and everybody is looking at me: 'You've got to tell us what to do.' And I'm thinking, 'I can't believe this happened,'" she said.
"We are trained in mass casualties. We do it once a year, but never with children," Liles said. "I was still emotional, but I was able to do my job because I know that I can break down later. They're looking at me, I had to be strong. I had to pull it together and do something."
A paramedic's training is straightforward: Find the most critically injured, and if they can be helped, take care of them. If they need more care than you can provide, then stabilize them and get them to the hospital as fast as possible.
Neighbors and police officers helped get most of the children off the bus.
"That's where the neighbors came in handy; they got a child and passed it to another neighbor. They got in the front and were able to get the children who were able to get out on their own."
Four children in the bus were beyond saving. But more than two dozen others were scattered around, some walking, some sitting on the ground, others still trapped on the vehicle. Some were bleeding, some had glass from the bus windows embedded in their faces, others had broken arms or legs or head injuries.
Liles told the neighbors to get all of the "walking wounded" — children who were able to move by themselves — to one place until help arrived.
She radioed her dispatcher.
"I basically let them know that we had more than what we could handle," Liles said. " I was trying to make sure they knew this was a school bus, and that we needed all available resources."
Within minutes, her supervisor, Lt. Tony Sylvester, arrived and took over coordinating the rescue effort until his boss, Hamilton County EMS Director Ken Wilkerson, got there.
Now Liles turned to her greatest challenge — helping the children still inside the bus.
"I needed to go to the ones who can't get out right now, some who were alive and trapped," she said. "That's where I had to go to."
The impact with the tree caved in the roof, pinching it down onto the metal seats below. Some of the children in those seats were killed, but four others were pinned and injured. Liles did what she could in the cramped, mangled interior, checking vital signs — pulse, blood pressure — looking for spinal damage and dressing bleeding wounds, but she needed help to get those four children out.
Ambulances don't carry the gear needed to pry open a crushed vehicle but firefighters do, and several firetrucks were on the scene only minutes after Liles arrived.
She realized she needed more gear and popped her head out the back door.
To her surprise, she saw her husband, Keith Liles, a captain in the Chattanooga Fire Department. The couple's convoluted schedule only coincides one day a week, but this was that day and his fire station in Brainerd was only minutes from the crash scene. His firetruck was the second to arrive, she said.
"I looked out and there he was," Stacie Liles said. "It was a feeling of relief."
Grabbing his gear, Keith Liles joined his wife in the bus. They worked side by side for the next two hours — Stacie treated and consoled the injured children while Keith and other firefighters worked feverishly to free them from the twisted metal debris.
Five miles away, another mom was preparing to take over caring for the children Liles and the other paramedics and EMTs were sending her way.
Dr. Lisa Smith, a pediatric surgeon in the emergency department at Children's Hospital at Erlanger and the incident commander for the Woodmore accident, was buying groceries when she got the call. As the on-call surgeon, she dropped everything and headed for the hospital.
There, a simple message was broadcast through the sprawling building: "Triage alert."
Triage is when medical personnel are faced with a large number of injuries or wounds and need to quickly decide who is critically injured and needs immediate attention, and who can be treated later.
Messages went out via text messages, beepers and phone calls. Doctors, nurses and other staff from all parts of the hospital hurried to the children's emergency department on the ground floor. Within minutes, about 75 people were waiting for assignments, said Dawn Morrow, the nurse manager for the children's ED.
The accident happened just before shift change for many hospital departments.
"That's when we needed the bulk of those resources, on the front need, when more of the critical patients were coming in and the stakes were higher and care more complex," said Dr. Darwin Koller, the medical director of the children's ED.
Within eight minutes after the hospital was notified, the first patient arrived, Morrow said.
The emergency department is a major facility, with 33 beds and multiple trauma bays. Other than painted tiles on the ceiling and murals on the walls, it looks like any other ER. Each trauma room has two beds and many pieces of equipment that can be customized according to a child's age and size. Color codes determine the correct size for items such as catheters or face masks, and supplies in the cabinets that line the walls are color-coded, as well.
It was cold on Nov. 21, so each child was greeted with a warm towel pulled from warming cabinets in each room.
"These kids were cold because they were on the bus for a long time," Morrow said.
When the supplies ran low, staffers brought more from elsewhere in the hospital, she said.
To deal with the most critically injured, Smith set up teams of two doctors and two nurses for five of the ED's trauma bays. Seven more teams were set up in the facility's extended stay area, while other rooms had two nurses assigned to them, Morrow said.
"I ended up as a giant air traffic controller," Smith said. Dr. Donald Barker, the adult trauma surgeon on call joined her, "making sure we had a second set of eyes coordinating the whole thing," she said. Among those she was directing was her own husband, Dr. David Bruce, an orthopedic surgeon who operated on one of the critically injured children.
Unlike with tornadoes or an explosion or mass shooting, where information about victims can be sketchy at the outset, the medical staff knew from paramedics at the scene how many children were on the school bus and what their conditions were.
As children came in the door, they were checked by doctors and nurses and assigned to a team, depending on the nature of their injuries.
"We got six patients in short order, all critical," said Dr. Greg Talbott, the director of the pediatric ICU at Children's Hospital.
They were unable to save one of the first patients, who suffered cardiac arrest. But they went to work on the rest, focusing on the most serious injuries.
"If they had life-threatening injuries, if they were bleeding internally, you don't care if their wrist is broken," Talbott said. "We addressed the big things first — life and limb and vision."
Some children needed surgery, while others were stabilized and moved to intensive care.
"We had so many critical patients requiring so many procedures, that we used our entire stock of pumps, catheters, central venous lines, all our emergency lines, breathing tubes — they all got restocked multiple times that night," said Talbott.
Morrow said many of the doctors and nurses were sweating, but not just from the pressure. The temperature in the emergency rooms is kept high because "kids lose body heat so quickly," she said, so everyone was perspiring heavily.
But there was no yelling or confusion, people who were there said. "It was quieter than what the lay person would think or what Hollywood would think," Smith said. "This isn't TV."
Just because some children were labeled "walking wounded" didn't mean they weren't seriously hurt.
"We had head injuries, broken bones, one kid who was walking and talking had a serious liver laceration," Koller said. "We had abdominal injuries, lung injuries. Several had fractures, they had shards of glass throughout half of their face and may be disfigured for life. That is not a serious life-threatening injury, but it is life-altering."
One initial challenge was identifying kids who were unconscious or unable to identify themselves.
It is not uncommon for a child to be brought to the hospital with no ID, from an auto accident, for instance. But these children were without their parents, and they were all wearing school uniforms: white shirts or blouses and dark blue skirts or khaki pants. Almost none had identification.
Hospital staffers took photos of their faces as a precaution — often an injured person's face will swell and complicate identification, Morrow said. They called Woodmore teachers to go bed to bed to help with the identifications. Parents were asked to describe their children's shoes, and sometimes nurses had to dig through bags of clothes cut from children's bodies to describe underwear.
At the accident scene on Talley Road, a steady flow of ambulances was moving injured children to the hospital.
Paramedic Chris van Austin and partner Tom Mundy are based at the EMS station on Amnicola Highway and were among the first four ambulances sent to the scene
"There were bystanders all over the place, police units everywhere, fire apparatus," van Austin said. "I could see the bus when I got out of the ambulance, down the road a little bit, but I never got to the bus. I had my patient at the back of my ambulance by the time I got to the back side of it."
Inside the overturned bus, Stacie Liles was holding hands with trapped children, trying to keep them from thinking about the scene around them and what had happened to them.
"I drowned out the noise and focused on the patients," Liles said. "It was cramped, obviously, a very small space, and we ended up with more than one fire department personnel back there with us."
Liles dealt with three children trapped on the back end of the collapsed roof, while another paramedic and firefighters worked to extricate another child from the front end of the bus.
"I'm a mother and I comforted," she said, "and you have medical treatment, too. You are only able to do so much. You put a collar around their neck, hold them as still as possible while the fire department is working around us."
"I would hold a hand, I talked to them about their favorite TV shows, anything that gets their mind off the fact that they are scared," Liles said. "I tell them I'm going to stay with them, that I'm not going to leave them until it is time to go to the hospital. I kind of refrain from saying everything's going to be OK. At the time, I'm not OK. This isn't OK."
Having her husband beside her helped. "That was my rock right there," she said. "I know there was a time when I was about to break down, and I looked at him and he said, 'You're doing a great job.'"
It took two hours to get the last child out of the bus.
"The three from the back, it was one at a time because of how they were positioned. They were in different sections, so we worked on the one closest to the door, who was the easiest to get out, OK, then go to the next one."
But finally the bus was empty. "As soon as the last patient was handed over to the medics and sent to the hospital, it was just a I don't even know how to explain it," she said. "It was relief, it was sadness — everything, all of these emotions came flooding at me."
Supervisors sent the Lileses home.
"That's what we needed," Stacie Liles said. "I don't think I could have finished out my shift."
Their three children were not there, so the couple sat together and talked. "We talked about certain patients, about the job we did, about other things we saw. We talked about everything," Liles said. "That helps. You have to talk about it, you can't leave your feelings bottled up."
The situation in the lobby at Children's Hospital was becoming chaotic.
Parents began to fill the small space within minutes after the accident. The emotional crowd kept growing, spilling out of the entrance onto the sidewalks. Hospital administrators called for extra security as some desperate parents tried to push through the doors into the emergency department.
"We heard people pounding on the doors of the unit while we were trying to do patient care," Talbott said. "Our team had to deal with all that going on. It was very unstable."
But the doctors understood what the family members were feeling.
"If you're one of those family members in the lobby, and you are waiting for your name to be called and it doesn't get called the lack of info is the worst-case scenario," Koller said.
"The worst part for me had little to nothing to do with what was happening medically. It was seeing and knowing the grief going on outside. I'm taking care of someone whose mom may not even know they are here."
Many families brought friends and neighbors; hospital officials said eventually some 800 people were waiting on word from the hospital staff. Some families included more than 40 people and one had 80 family members and friends, Erlanger officials said.
Initially, as families and children were matched up, a few close relatives were allowed to stay at their children's bedsides. But Children's Hospital, built in the 1970s, doesn't have enough private rooms to offer much privacy. Children with relatively minor injuries were in beds separated only by a curtain from the critically injured, while nearby, paramedics and EMTs wheeled in more seriously injured children.
Smith and Morrow conferred and made a difficult decision.
"We had four family members in with their kids, but we did a horrible thing," Morrow said. "We asked them to leave. It was easier for them not to see these kids being brought through these doors."
But that still left the children themselves. Nurses tried to shield those who were not badly hurt from seeing the seriously injured, but the crowding made it sometimes impossible. As one child lay dying, a young boy peered around a curtain from an adjacent bed, one staffer said.
"In reality, our infrastructure was not built to handle this type of response," said Children's Hospital CEO Don Mueller. "To have kids dying next to kids not dying in the pediatric intensive care unit is not what we need in this community."
Eventually, most of the less-injured children were moved to the general pediatric office and to other makeshift spaces throughout the hospital.
There were other disturbances, as well. Despite warnings to the news media to stay out of the hospital, a reporter for a national news network was kicked out of the lobby.
"We had predatory lawyers getting upstairs," Talbott said. "One showed up at the [pediatric intensive care unit]."
At some point, hospital staffers realized the parents still waiting in the lobby would not find their children in the hospital. The bodies of the four children who died at the scene were taken by EMS to the medical examiner's office. Now someone had to break the news to the families.
"If you have a beating heart, you have to bleed and suffer for these people," Koller said.
A team consisting of a hospital chaplain, a police representative, Erlanger chief nursing executive Jan Keys, and Children's Hospital medical director Dr. Alan Kohrt, who lost his own son earlier this year, took the lead. As Kohrt and a chaplain broke the news to one family crowded into a small conference room, grieving relatives rushed out, pinning the chaplain behind the door and knocking Kohrt to the floor, an ED staffer said.
It was between 10 and 11 p.m. before the last child left the emergency department. Nineteen were treated and released within two hours. Twelve were admitted, and six of them moved upstairs to the pediatric intensive care unit, where one would die a few days later.
Finally, there was time for those involved to confront their emotions.
"It was late at night in the ICU, when we could finally settle things down," Talbott said, "and I was walking with one of the nurses, and we rounded a corner and saw a nurse who was just weeping. She had already handed over her patient, and could not hold it in any longer."
"You ask yourself, did I do everything I could do, did I do everything right?" said paramedic van Austin. "You think about your own family — I have kids. These are the kinds of calls you will remember forever."
"My worst [incident] before this one happened seven years ago — it was also a child and I can remember everything from it," Stacie Liles said. "Now this is my worst. I want this to be it. No more worst."
An earlier version of this story misspelled the name of Dr. Darwin Koller.