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Home > Topics > Mass Casualty Incidents
December 17, 2013
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The Ambulance Driver's Perspective
by Kelly Grayson

EMS events that shook 2013: Boston, West, D.C. and Detroit

Criminal acts and civic crises abounded this year

By Kelly Grayson

This time last year, I was preparing for the end of the world. The Mayan Long Calendar was supposed to end on December 21, and I was ready. I had laid in supplies of Twinkies and ammunition, told my supervisors what I thought of them, and prepared to ride out the apocalypse with the love of my life, Christina Hendricks, by my side.

It’s amazing the difference one year and a restraining order makes, folks. So here I sit, still working on an ambulance, still no Christina Hendricks, still sitting here naked in my beanbag chair, surfing the Internet in search of my lost muse.

And still oversharing, obviously.

But enough about me. Without further ado, my take on some of the notable EMS events of 2013:

Spinal immobilization

In January, the National Association of EMS Physicians published its official position paper on spinal immobilization and EMS use of the long backboard. The document takes a much softer tone than the draft document that was leaked and linked widely in EMS blogs and forums in 2012, but still looks to radically change the way we view the long-standing EMS practice of spinal immobilization.

I’ve been speaking against unnecessary spinal immobilization in print, online and at EMS conferences around the year for 10 years now, and quite frankly, given the volume of research, it is entirely possible that all spinal immobilization is unnecessary, and that good outcomes for patients collared and boarded with spinal fractures were in spite of the treatment rather than because of it.

And while a great many EMS systems have implemented selective spinal immobilization guidelines, and a brave few have abandoned the practice altogether, there remains a substantial number of EMS providers who are either ignorant of the current science, or simply choose to ignore it in favor of dogma and tradition.

Hopefully, the NAEMSP position paper will be a big step forward in curtailing the barbaric and ill-supported practice of boarding everyone with a boo-boo and letting the Emergency Department sort them out.

Field EMS Bill

In February, Rep. Larry Buchson (R-Indiana) introduced HR 809, the Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013, to the 113th U.S. Congress. The legislation, commonly known as the Field EMS Bill, proposes to establish a lead federal agency for EMS. The proposed agency would be known as the Office of Emergency Medical Services and Trauma, and housed within the U.S. Department of Health and Human Services (HHS).

The bill has garnered 15 Congressional co-sponsors, and a number of endorsements from EMS advocacy organizations such as NAEMT, but still is a subject of much debate among EMS leaders. While many tout a single federal EMS agency as a pipeline for research opportunities, grant funds, and administrative support, or as a panacea to the fragmented state of EMS in this country, many others respond with Ronald Reagan’s admonition, “The nine most terrifying words in the English language are: I’m from the government and I’m here to help.”

Whether you believe the Fed.gov is the answer to EMS prayers or the best method to screw things up on a national scale, now is the time to make your voice heard. The bill currently languishes in subcommittees and has yet to come up for a vote. Call your Congressman and voice your support of (or opposition to) the Field EMS Bill, and put some muscle behind our dreams for self-determination.

Detroit Fire follies

In the battle for the title of Most Poorly Run EMS System in the country, DC FEMS wins hands-down.

At least in Detroit, where the ambulance fleet is falling apart, shifts are overworked and understaffed, and response times can be measured with a calendar, the problems with their EMS system all have a simple explanation: they’re broke.

And we’re not talking “let’s reduce expenditures a bit” broke. This is a full-on, “rolling pennies for gas, eating ramen noodles three meals a day, using toilet paper one square at a time, the rats are starting to look pretty tasty” broke. In fact, the city of Detroit, faced with $18-20 billion in debt, filed for Chapter 9 bankruptcy on July 18, 2013.

Detroit has been losing population and industrial base for a generation, and decaying infrastructure and declining tax revenues have hit the city hard. Of course, those factors only paint a partial picture of exactly how the city went broke. Corruption, waste, fraud, and bureaucratic incompetence also played a large role.

Whether that waste, fraud and incompetence can be eliminated after bankruptcy proceedings are complete remains to be seen, but at least we’ll still have WJBK Fox affiliate reporter Charlie LeDuff holding the city’s feet to the fire over the sorry state of their fire department and EMS system.

The EMS system in our nation’s capital, however, seems immune to public ridicule and large infusions of cash. Detroit is broke. DC FEMS is just broken.

DC FEMS WTH

In DC, where the EMS system is second only in dysfunction to Congress, we have ambulances repaired with street signs, only five of twenty-six ladder trucks passing safety inspections, and most fire apparatus missing annual safety inspections for three years.

I suppose that improvising an engine heat shield from a street sign beats delaying brake repairs for months, at least for those unfortunate medics reduced to stopping their ambulance with the Fred Flintstone method. They’ve got ongoing staffing shortages, ambulances catching fire, and ambulances dedicated to the Presidential detail running out of gas.

And to add a lovely toilet paper garnish to this crap sandwich, we have Fire Chief Kenneth Ellerbe publicly accusing his crews of intentionally delaying responses and setting fire to ambulances.

But hey, at least Ellerbe has hired nine new paramedics, which only leaves DC FEMS a mere forty or so medics short of being adequately staffed, and we hear those new ambulances they’ve been promised for a couple of years will be delivered any day now.

It’s time to stop polishing the turd in the District of Columbia, and start over with a wholesale system overhaul. With each new story on DC FEMS, it becomes increasingly obvious that the only solution is, to borrow agreat movie line, “Take off and nuke the entire site from orbit. It’s the only way to be sure.”

The myth of scene safety

In the years since the Columbine shooting, law enforcement response to active-shooter scenarios has evolved from “surround and contain” to “surround and engage,” acknowledging the ugly truth that the best way to minimize body count is to take the shooter out as quickly as possible.

And until recently, the role of EMS in those situations had always been to stage outside the scene and wait for law enforcement to declare it secure.

However, some EMS experts are starting to question the wisdom of that strategy. In October, tactical EMTs were credited with saving the lives of several children in a shooting at Sparks Middle School in Reno, NV. In combat casualty care, it is considered axiomatic that minutes wasted mean lives lost. Often, the minutes spent staging until the scene is secure can be the difference between life and death for some of the victims.

Enter the tactical medic, a specially trained EMT who is an integral part of a SWAT unit. The tactical medic goes in with the entry team and renders care while the scene is still unsecured. That’s what the REMSA tactical medics did in Reno.

There is, however, a flaw to that approach. Tactical medics embedded with SWAT teams still require SWAT to be activated, when current law enforcement doctrine in active shooter scenarios is to surround and engage the shooter with immediately available personnel. To wait for SWAT only increases the body count.

If law enforcement is engaging the shooter before SWAT is deployed, this negates the effectiveness of the tactical medic. A number of pundits are openly advocating that EMS personnel no longer stage, and instead enter immediately behind law enforcement, even if the shooter is still at large. The idea is that law enforcement will contain the shooter, and medics will provide care inside the warm zone of those rooms already cleared.

It’s an idea that has merit, in my opinion. I’m not advocating that we rush willy-nilly into every hot scene. What we should pursue is a policy of calculated risk. Is the risk of entering an unsecured scene worth the care we can provide, and what tactics can be employed to mitigate those risks? If the events of 9/11 and acts of violence against EMS providers have taught us anything, it is that no scene is ever truly safe. The name of the game is risk mitigation, because risk elimination is an unreachable goal.

Home-grown terrorism

On April 15, two self-styled terrorists detonated two bombs improvised from pressure cookers near the finish line of the Boston Marathon. Two hundred and sixty four people were injured, and three died. The ensuing manhunt, shootout and apprehension of the surviving terrorist dominated news coverage and virtually paralyzed the city of Boston for the better part of a week.

Unfortunately, in the media coverage of the event, the need to be first came in a distant second to the need to be accurate. Rumor, speculation and outright guessing was passed off by journalists as objective fact, and it was quite some time before the actual facts of the bombing were known.

One thing that was clear in the aftermath, however, was that Boston EMS handled a very chaotic, large-scale event with aplomb. Boston EMS trains and approaches large event medical support as sort of a slow-motion MCI, and when the real MCI happened, all the pieces were already in place. They coordinated triage and treatment through Alpha Tent, their main medical support tent already established not far from the finish line and site of the explosions. All told, 264 victims were transported to area hospitals, and the scene was clear of victims 18 minutes after the second explosion.

That’s strong work, by anyone’s standard.

West, Texas explosion

With the airwaves still dominated by media coverage of the Boston Marathon bombings, April 17 saw a fire and subsequent explosion at a fertilizer plant destroy most of the town of West, TX. The blast killed fifteen and injured 160, and the EMS community worldwide was soon horrified to learn that 10 of the dead were EMTs or firefighters, members of West’s fire department and ambulance service.

Twenty-two EMT students, attending class at the time of the fire, rushed to the scene, and four were killed in the explosion. The ambulance service headquarters was flattened and virtually all of their equipment and ambulances were destroyed, and the West EMS medical director, Dr. George Smith, was himself injured in the explosion.

Proving that you can’t keep a good Texan (or EMT) down, the 18 surviving EMT students who responded to the scene graduated from their EMT class in July. The four students killed in the blast were named honorary graduates.

West continues to rebuild, and the ambulance service still manages to provide EMS to the community despite the near-total loss of system resources, much of which still has not been replaced.

Ambulance and helicopter crashes

Despite more stringent safety and equipment standards for helicopter EMS and a growing movement to curtail lights-and-siren responses, ground ambulances continue to crash, and EMS helicopters continue to fall out of the sky at an alarming rate.

No one disputes that EMS is a dangerous profession, but our utilization of resources makes it more dangerous than it should be. It has become apparent that requiring ambulance crews to wear helmets, or better ambulance module design, or requiring terrain avoidance systems and night-vision gear on EMS helicopters is not enough.

We need a radical shift in thinking, and realistic standards on what requires a lights-and-siren response or a helicopter launch. Until we do that, our brethren are going to continue to die needlessly.

Well, those are my notable EMS events of 2013. Did I miss any? Let me know in the comments!

About the author


Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (www.facebook.com/theambulancedriverfiles), or email him at kelly.grayson@ems1.com.

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