EMS Crews Shine During MCI
The Northwest Fire Rescue District (NWFRD) serves a suburban area of Tucson, Ariz. Eleven years ago on April 8, 2000, NWFRD responded to the crash of an MV-22 Osprey, tilt-rotor, military aircraft carrying 19 personnel. The crash killed all 19 on board, including 15 combat troops and four crew members.
The emergency service community heard little about the coordinated response and use of resources by the NWFRD and its mutual aid agencies that day because there were no survivors.
But on Saturday, Jan. 8, 2011, in a twist of fate, NWFRD and other responders were thrust into the forefront of media attention worldwide. Rep. Gabrielle Giffords and 18 other people were shot in rapid succession at close range by 22-year-old Jared Loughner in a suburban Tucson shopping center.
Coincidentally, NWFRD responders arrived on scene to also find 19 victims. This time, however, there were 14 survivors, including the critically wounded U.S. congresswoman and several gunshot victims who were already receiving medical attention from bystanders, police and congressional staffers.
All but one victim dropped to the ground when they were shot and remained in an eerie row of carnage 20–30 feet long; one victim left the scene and drove himself to a nearby hospital with an extremity wound.
An NWFRD paramedic rescue ambulance and three ground ambulances from Southwest Ambulance were dispatched on the basis of information received from the initial 9-1-1 call. Three ALS engines, a ladder company, an EMS captain and Battalion Chief (BC) Lane Spalla also responded on the first-alarm MCI response. Three medical helicopters were placed on standby based on the scope of the incident.
The first EMS/fire units arrived on scene in just five minutes but were held off scene in a safe staging area by law enforcement for three minutes until the scene was declared safe for entry. The BC then assumed incident command (IC) and began assigning command roles and unit deployments.
Firefighter/paramedic Anthony Compango was on the first arriving NWFRD ALS engine and assumed the role of triage officer. He found multiple critical patients on scene, several already covered because they exhibited mortal wounds, and dozens of witnesses in need of emotional support.
He immediately reported the scope to the BC/DC. The IC then called for an MCI response that brought 10 ground and three air ambulances to the scene. In addition to NWFRD resources, the Golder Ranch Fire District responded with an ALS engine, ambulance and support staff. Tucson Fire Department sent three paramedic ambulances, an EMS captain and a BC to assist on scene. Rural/Metro Corp. responded with three ground ambulances and a BC.
Realizing the scope of the all-hands, rapid onset MCI, Compango assumed the triage officer role and began to prioritize and assign victims to arriving EMS crews. He found representative Giffords critically wounded and 9-year-old Christina Taylor Green receiving CPR.
Aware that he had a dozen ambulances and helicopters en route, and his rapid assessment quickly identifying the immediate concerns, Compango delayed any minor patients in the small impact area. He elected not to place triage tags on each patient and asked transportation officer, Mike Balta—a Southwest Ambulance shift supervisor—to begin assigning patients to units for rapid treatment and transport from the scene.
The child had a significant chest wound and wasn’t responding, but Compagno and Balta elected not to write her off because they had adequate EMS resources on scene to care for all the patients. So they had Giffords and the young trauma code transported immediately. Once the helicopters arrived on scene, they were used to transport other patients.
The first seven patients were triaged, treated and transported from the scene in just 25 minutes. All of the injured had been removed from the scene in 45 minutes.
—A.J. Heightman, MPA, EMT-P
The Fire Department of New York’s (FDNY) EMS Division overhauled its policies for responding to calls in snowstorms following a horrible outing during a December blizzard.
The operational changes came on the heels of a shakeup at the top of the organization after a storm dumped nearly two feet of snow the city, leaving FDNY units stranded in snowdrifts and a backlog of 1,300 unanswered 9-1-1 calls.
“On the grassroots level, we’ve deployed tactics in the field, including chains on the ambulances,” newly named FDNY EMS Chief Abdo Nahmod says, outlining the changes.
“We’ve used chains, and they proved to be beneficial in some of the hilly areas,” Nahmod says. “We’re learning at what point you put them on and at what time.”
In the past, FDNY avoided the use of chains because of their tendency to fail once a vehicle hit clear blacktop, occasionally resulting in ambulance breakdowns. FDNY is also considering drop-down snow chains on future ambulance purchases, Nahmod says.
FDNY was far from the only EMS organization struggling in what has been a storm-filled winter. For example, in parts of Monmouth County, N.J., where side streets were impassable for days, squads parked their ambulances several blocks away, and crews ventured in on foot to access patients.
The FDNY situation, however, was the most visible, largely because the organization took the hit for the city sanitation department’s failure to get streets
Adding chains to EMS units was just one change, says Nahmod. FDNY has also deployed the use of Sked stretchers, which will allow crews to leave an ambulance on a clear road and get to the patients.
“It was a lesson learned from the last storm,” Nahmod says. “If we need to get the equipment down the block, we can use them. You would then lay the patient back on the Sked and pull them out.”
Likewise, FDNY will now call on their trucks to aid ambulances stuck during storms. And they’ve activated an incident management team (IMT) for big storms to help with logistics and planning. “When you’re starting to see them forecasting a large storm, IMT proves to be beneficial,” Nahmod says.
Working in storm conditions is a challenge, often requiring cooperation between agencies—and sometimes improvisation.
In Dane County, Wis., the EMS operations work closely with road crews to get streets cleared when there’s an emergency. The county deployed two “snowbulances” to get to people in situations in which ambulances can’t reach them. The units, which cost about $9,000, are pulled by ATVs or snowmobiles and allow a patient and caregiver to ride protected from the elements.
“We needed to have a resource to get out there and get those patients back in,” says J. Timothy Hillebrand, EMS coordinator for Dane County.
Still, the rough winter has many organizations reevaluating future bad weather plans.
JEMS.com columnist JP Molnar, MEd, says planning for bad weather responses should include additional driver training, something often overlooked.
“It’s already complex enough to drive in an urban environment if it’s clear out,” Molnar says. “Now you’ve got snow in there. It’s like, wow, this rig becomes even more challenging,” he says.
Despite all the challenges agencies face nationwide, FDNY’s Nabob says some good came out of a bad situation.
“People are a little bit more aware of what they have to do in a snow emergency,” he says. “If those streets are plowed, it makes our job a lot easier.”
—Richard Huff, NREMT-B
In January JEMS, “The Plunger Method” reported that impedance threshold devices are not for sale in the U.S.; however, it’s only the ResQPump device that isn’t for sale in the U.S.
In February JEMS, the photo shown next to the review of Innocase Rugged Holster Combo from Seido in Hands On is a photo of the T-10 tablet PC. To see a photo of the Seido holster, visit www.jems.com/photos/hands-january-2011.
We apologize for the errors. JEMS
Boston EMS has a new tool to help keep themselves and their bariatric patients safe: It’s an ambulance retrofitted with a lift and special stretcher. The lift folds out of the ambulance’s back door and can be lowered and raised via a conveniently located switch.
“A little over a year ago, a lot of our EMTs and paramedics realized we were getting a lot more bariatric patients,” Boston EMS Captain Jose Archila says. “Back injuries are one of our biggest issues. That is what shortens the [career] of an EMT or paramedic.”
Boston EMS purchased the ramp from California-based MAC’S Lift Gate Inc. for $12,000; the stretcher cost $8,000. The ramp can lift up to 1,000 pounds. Since Jan. 11, when the ambulance went into service, it has been needed about once a day.
The benefit isn’t just for EMS providers. The ramp also offers psycho-logical support for some patients. The first man to use a lift was a repeat patient suffering from chest pains. “He was always thinking the EMTs or paramedics might drop him, but with this lift, he felt comfortable that nothing was going to happen,” Archila says. This new ambulance will help Boston EMS keep patients and crews safe.
CIRC Trial Concludes
The Circulation Improving Resuscitation Care (CRIC) trial, supported by ZOLL Medical Corp., concluded in January. The CIRC trial set out to measure the survival-to-hospital-discharge rates of out-of-hospital cardiac arrest patients.
It began in 2007 and included 4,000 patients. The study compared patients treated with a load-distributing band device to those who received manual CPR. One of the trial’s findings was that the ZOLL AutoPulse is equivalent to a Class I-American Heart Association recommended therapy.
The trial’s principal investigator was Lars Wik, MD, PhD, who worked to ensure the trial included sites in the U.S., Austria and The Netherlands. “This is the first large-scale, randomized resuscitation trial to come to a successful conclusion with a statistically significant result,” says Wik.
More complete results and the trial’s findings will be published later this year.
Off-Label Drug Uses In EMS
A fair amount of media attention has been focused on so-called “off-label” uses of drugs lately. Off-label simply refers to the use of a drug in a manner other than described in the approved product labeling by the Food and Drug Administration (FDA). When new drugs are approved by the FDA, the manufacturer must also prepare and submit for approval extensive labeling information on the chemistry, pharmacology, indications, contraindications, risks and benefits of the drug. That labeling information, incidentally, also forms the basis of that drug’s entry into the widely used Physicians’ Desk Reference—a compendium of virtually all FDA-approved drugs.
A number of lawsuits have been brought against drug companies related to their off-label marketing and promotion practices. Although federal law restricts the manner in which drug companies can market off-label uses, the law doesn’t prohibit physicians from prescribing drugs for purposes other than those approved by the FDA in the product labeling.
The FDA regulates the approval and marketing of the drugs, and the Drug Enforcement Administration enforces the nation’s controlled substance laws, but neither agency regulates the practice of medicine by physicians and other practitioners. That’s almost universally a function of state law.
As long as a state, such as by regulation of its medical board, doesn’t restrict the off-label use of a particular drug and provided the drug appears on the state’s EMS formulary (the list of medications and solutions approved for EMS use), physicians (or other practitioners with prescribing authority) may prescribe the drug for any purpose—regardless of whether that particular use appears in the product’s approved FDA labeling information. This means that EMS medical control physicians are free to order the use of the drug in the prehospital setting, whether by protocols, standing orders or via online medical direction, and EMS providers are permitted to administer the drug for off-label uses, provided it doesn’t exceed their scope of practice.
We aren’t aware of any cases in which legal liability arose merely by an EMS provider using a drug for an off-label use. Off-label uses are generally accepted as being within the standard of care in the practice of medicine. As long as there’s no state prohibition against its use, the administration of a drug for an off-label purpose would be measured by the same standard of liability as in any other malpractice case—whether the use of the drug was reasonable under the circumstances.
The use of a drug, for any purpose, falls within accepted standards of care as would be testified to by a reputable expert in the field. So the use of that drug—whether off-label or on—would be defensible in court, should the quality of care be called into question.
Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information.
Names in the New
The National Association of Emergency Medical Technicians (NAEMT) has announced its new Board of Directors, which took office Jan. 1.
President Connie Meyer;
President-Elect Don Lundy;
Secretary Charlene Donahue;
Treasurer Rick Ellis;
Immediate Past President Patrick Moore;
Region I Director Jennifer Frenette;
Region I Director Jim Slattery;
Region II Director Dennis Rowe;
Region III Director Aimee Binning;
Region III Director Sue Jacobus;
Region IV Director K.C. Jones;
Region IV Director Rod Barrett;
At-Large Director C.T. Kearns; and
At-Large Director Jules Scadden.
NAEMT has also announced Pam Cohen as the new executive director.