100% Absolutely Wrong

Recently, an article was posted about a group of Prince George County, MD firefighters who violated policy and transported a child in cardiac arrest to the hospital in their fire engine with what was described as “limited medical supplies” instead of waiting for an ambulance that was less than five minutes away.  The child, who was reportedly having an asthma attack, arrested in front of the crew.  The paramedic who was on scene made the decision to start transporting in their fire truck after getting what can only be assumed was an unacceptable ETA of five minutes.  According to the Prince George County Fire Department, the patient regained pulses prior to arrival at the emergency room.

The firefighters who were involved were not suspended without pay.  Their medical control was not pulled.  They do not even appear to have been reprimanded by their department.  Instead, they have been given valor awards for their life saving actions that day.

First, I do not want to overlook the miracle that took place on this call.  A life was saved albeit using very unconventional and potentially dangerous actions.  Effective CPR was done, and the girl lived, without any residual neurological deficits.  I give them credit for their care, but only to that extent.  This does not mean, however, that these firefighters should not stand and explain their actions.

As I stated previously, the fire truck that was used on the call had limited medical equipment, and according to the press release, it was not one that was typically used for medical calls.  This leads me to believe that the life-saving actions taken by the paramedic that day was effective CPR which could have been done just as well, if not better, on the patient’s living room floor until a transport capable unit arrived.

What about the large amount of departmental liability this crew put their employer under?  The girl had no neurological deficits but if she came out of this with so much as a limp or maybe slurred speech, her family could have owned the entire department, and potentially taken that paramedic for everything he had because of what would have only been described as “gross negligence.”

This is not the first time a patient has been transported by fire truck or something other than an ambulance, and it will not be the last, but the chief of PGFD is treading on dangerous grounds by treating his staff like he has.  The next time transporting someone in a fire truck crosses someone’s mind, they’ll think “well, they were considered heroes, I have no reason to think we will not be regarded in the same light.”  How could the next group of firefighters who “think outside the box” be held accountable for an unfavorable outcome after this group was so highly regarded?

Ultimately, what went wrong here was a staffing issue.  The wrong type of vehicle was the one available.  Does Prince George County need more ambulances available?  Or maybe this station needs a backup ambulance that could have been available for this crew rather than a fire truck.  A case such as this strengthens the argument for more ambulances globally, with primary providers responding rather than first responders getting there first, knowing what needs to be done, and not being able to do for a patient what they really need.

In the public’s eye, the line between being a hero and a zero is extremely thin, and this crew, in my opinion, got lucky.  An unfavorable outcome would have changed their lives forever.  Let’s just hope that this does not repeat itself, and that people around the country recognize it for what it really was: a lucky break, and a miracle.

  • http://ems12lead.com/ Tom Bouthillet

    It’s easy to second-guess the boots on the ground but unless you’re the one there watching a child die you can’t know what it was like. There is no “absolute”.

  • Mmorsepfd

    If it were my daughter transported in the fire truck I’d be one happy dad. A Paramedic concerned with liability over patient care is a liability unto himself. Treat the patient to the best of your ability, with the resources on hand and nobody will own anybody in any court of law.

  • http://twitter.com/MedicSBK Scott

    How can effective CPR be done in the back of a police cruiser or in a fire truck or any other vehicle? Ambulances are designed as being a location where patient care can be done safely and effectively for everyone involved.

    Tom, I am not trying to arm chair quarterback anyone, although it seems like I might be, however, this is a scary precedent that is being set and could have serious ramifications in the future.

    Like I said, a miracle happened here, however, that does not mean that what was done was a decision that would also be made by that “prudent paramedic” whose standard we are all held to.

    • Fern the Fire-Rescue newbie

      Scott,

      Can you prove that ambulances are designed as a safe place for patient care and we can do CPR efficiently in the back? Look at most ambulances out there. Metal wall studs are your protection. CPR in the back of an ambulance can’t be done effectively without being seated, and even then if you’re transporting you can be thrown all over the place if you’re not holding onto something. (Which begs the question, what’s the point of 1 handed CPR? There is none. So why transport?)

      While I agree that more and more ambulances are being designed to be safer today than previously done, most ambulances out there aren’t up to anywhere near safe. Just because it’s on the floor at EMS Expo doesn’t mean it’s in widespread use nationwide. Look at all the Type II’s out there. The top’s fiberglass, there isn’t any rollover protection in that.

      Granted, it isn’t safe in the back of a fire truck either, but the stuff EMS has ain’t much better. Hell, if anything, it’s worse. At least with a firetruck you’ve got rated crash protection. Most ambulances have no crash rating on the box.

      • http://twitter.com/MedicSBK Scott

        Interestingly enough, the evidence is lacking on effectiveness on CPR in the back of an ambulance as well. That fuels the “stay and play” argument even more.. And I doubt you are going to find many studies that discuss the effectiveness of CPR in the back of a fire truck because I’m sure they do not exist.

    • Ben Waller

      To take that one step further, how can effective CPR be performed in the back of an ambulance. As Skip Kirkwood says, “CPR during transport usually results in a dead patient”.

      On the other hand, there is evidence for good CPR on scene for adult sudden cardiac arrest patients. That evidence does not apply to hypoxic pediatric cardiac arrests. The etiology is simply too different.

  • http://www.facebook.com/people/Scot-A-Kreger/1554854038 Scot A Kreger

    Question(s) that need to be asked; Was the Hospital closer than the ambulance? and If so, why the problem? It could have just as easily been the poor girl dying on the floor waiting 5 minutes for any one to show up. They did their jobs to the best of their abilities with the equipment provided to them.

  • Tragladden

    I really don’t know how I feel about this. As a parent I’m cheering for the first responders, as a medic and supervisor, I want to know why they did not wait on ALS? I can see both sides to this story. What should happen is the department should evaluate why not wait and what type of equipment is on their units. This is a very sticky situation to be involved in. I wasn’t at the scene, I may have made the same choice. Was ALS only five minutes or did they get lost? So many questions. I’m happy for the family, their child is still with them. As I said before, I really don’t know how I feel about this.

  • Angelamulkerin

    I agree that this is 100% wrong. Thinking of the liability of doing something so dangerous IS a necessary part of the job, (because really, keeping an eye on liability is putting patient welfare and safety first…youre liable when you screw up) and just because it worked out this time does not make it acceptable. If that fire truck had crashed, or if-as what is a much more likely conclusion to this call-the girl died, the entire department would be looking for work right now. I think people are so caught up in the emotion of a little girls life being saved that they’re not realistically seeing the problem here. I really think this was a case of panicking-which is totally understandable and happens to all of us on occasion, but it’s not just about doing what you can with what you have. It’s about doing the best thing for the patient. And in my opinion, even thinking of my 3 year old, the best thing is never shoddy CPR in an unsafe situation with no advanced airway, even if they did happen to luck out this time.

  • http://hybridmedic.com HybridMedic

    There really isn’t that much of the story to know what lead to that. If it were me, the memo would start with “Chief, you ain’t gonna believe this…”

    It does seem, however, like you’re advocating the prosecution of a Medal of Honor recipient because they had to disobey orders to achieve the goal.

    • http://twitter.com/MedicSBK Scott

      But was it their actions that saved that girl’s life or did they get lucky with the quality of CPR they were able to perform in the setting they were in? Now, again, I am basing this off the information I got from the press release: “Limited Medical Supplies” “ROSC prior to arrival at the ER”

  • http://twitter.com/mduschl Mathias Duschl

    First of all, there is definitely not enough information to make any judgment. Beside of this from my perspective doesn’t matter if you transport with ongoing CPR in an ambulance or in a fire truck, the effectiveness will lack anyway. Why do you see a need for punishing this crew? I totally believe that we create better medics by analyzing what they do, measuring the outcome and if something isn’t optimal we should improve it by training not by suspending people who did something that saved a life but wasn’t according to their protocol. From my perspective this would be a a part of the way of better leadership. And isn’t that the great difference between a primate and a good medic – being able to make a decision under pressure, in very difficult situations, that are mostly not just black and white, while being absolutely aware of that the decision I take may be not the right one and while taking the risk of loosing the job, instead of just following protocols?

    • http://twitter.com/MedicSBK Scott

      There was an admitted violation of policy and protocol, regardless of what the outcome was, they need to be held accountable for their actions. Without that accountability, we are on a slippery slope and where does it end?

      Ultimately the problem here was there was no ambulance available but there was staff that could have been ON an ambulance. If they were on the correct piece of equipment at that scene, we would not even be having this discussion.

      • http://twitter.com/mduschl Mathias Duschl

        Of course they need to be held accountable for their actions. But don’t you think it was absolutely clear to them that they risk their jobs? And I could imagine that there was a F2F meeting with the Chief. And after reading the second part of your answer it is pretty obvious why they weren’t punished. Because they guy who should have held accountable for forcing the people he is responsible for to make such a decision was the Chief.

      • Fern the Fire-Rescue newbie

        Knowing PG, They hate the ambo-lance. Seems the mindset down there is
        “F*ck EMS, WE WANT FIRE!”

  • http://www.romduckworth.com Rommie Duckworth

    What I would be afraid of as a chief/supervisor here is that “I was thinking outside of the box!” will become an excuse for some care providers to begin doing just whatever they want. I’m sure that any of us can envision SOME circumstances that would cause us to break with protocols. That being said, what I take away from Scott’s post is that it can be easy for providers to see this and think that they’ll need to take great risks to get great rewards (read that as “take unnecessary risks with the patient to get a medal or their name in the paper”). Was the medic in THIS situation taking unwarranted risks? Like Tom says, I don’t know. I wasn’t there. Can I picture SOME situation that would prompt me to make the same decision? You betcha. I just hope that along with the praise that those firefighters received, somebody somewhere was also working on improving the system so that medics in PGC don’t find them in the same situation again in 2012.

  • Thehappymedic

    I think calling this a miracle is a stretch. A Paramedic made a patient care decision that turned out to be the right one. We can debate the need for more ambulances, the need for less fire trucks etc, but what we can’t overlook is a medic that heard 5 minutes of CPR until a van labeled “Ambulance” arrived to do what they were already doing. Everyone take a deep breath and hold it…for 5 minutes. No, make it 7. Now tell me it was the wrong decision.
    Transporting in a truck with “limited medical equipment”?
    No oxygen?
    No AED?

    What if this was an ambulance and the medic was to be alone in the back? Is that better?

    We’re reminded so often that a full arrest is aBLS skill yet get upset when limited resources can do better than the big tool box, still responding from afar.

    I’m with Scott in saying that making this crew into heroes is a foolish move IMHO. they did their jobs and as such should be commended by their CQI Officer, but awards? No.

    The decision of the Paramedic at teh scene to transport the patient to difinitive care was the right one in this case, regardless of what kind of vehicle or what word was on the side.

    -HM

    • http://sixlettervariable.blogspot.com/ Christopher

      I think it should be brought up that the route to transport involved using a freeway. The potential for a traffic accident certainly exists.

      Regardless, I think I’d label this, “the wrong call, at the right time.” Probably doesn’t need to happen again and some work should be put into planning in their system such that it does not have to happen again.

  • ctmed5408

    Not to be that guy pointing fingers but while we’re on the topic I’ll mention it. How about the places that routinely do this. For example, Philadelphia Police transport trauma patients in cruisers or cans on a regular basis. This practice has been going on for years. Not only is it unsafe but it doesn’t help make the argument that more EMS units are needed for accurate coverage. In reality, it masks the need for more EMS units by giving the impression that calls are being covered without issue when they really are not.

    • Fern the Fire-Rescue newbie

      Correct me if I’m wrong, but isn’t Philly’s EMS system the silent version of Detroit?

    • http://twitter.com/MedicSBK Scott

      You know, I was wondering if anyone was going to bring up Philly PD. That was actually a study that was done.. Roguemedic posted the results a few months back. Basically, it showed that rapid trauma transport in penetrating chest trauma was important. Ground breaking news there.

  • ctmed5408

    Cans, vans, what’s the difference? LOL

  • http://www.facebook.com/profile.php?id=1058943893 Jason Dorval

    Scott thanks for keeping the conversation going on this

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  • Hinesight101

    How long was Fd waiting for the ambulance before the arrest started? When is it OK to use other then an approved transport vehicle?