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EMS Transport: Coming Full Circle

On May 12, 2015, an Amtrak train rounded a curve in Philadelphia at 106 mph. The train was on a curve that was restricted to 50 mph or less. As the train entered the curve, the locomotive engineer applied the emergency brakes.

In just a few seconds, the train, with one locomotive and seven passenger cars, derailed. A total of 245 passengers, 5 on-duty Amtrak employees and 3 off-duty Amtrak employees were on board; 8 passengers were killed, and 185 others were transported to area hospitals.

Of the 185 transported to hospitals, only 24 were taken to a hospital by an ambulance. The other 161 patients were transported by police cars and public-transportation buses. The Philadelphia police used their “scoop and run” policy, which normally applies to shooting and stabbing victims.

Firefighters did complain in interviews to the NTSB that police cars had blocked access to the crash site and that police had refused their request to triage patients. As a result of no coordination of patient transport, some hospitals were overloaded with victims while others received no patients at all.

What raised eyebrows in the fire and EMS community were the recommendations from the National Transportation Safety Board, the federal agency responsible for investigating the crash.

In the long list of recommendations from the NTSB was one recommendation that the mayor of Philadelphia

facilitate the collaboration among the Philadelphia Police Department, Philadelphia Fire Department, and Office of Emergency Management to develop a plan that effectively integrates police transport of patients into the emergency medical response plans for large mass-casualty incidents and to practice the plan periodically, including at least one full-scale drill every 3 years.

A second recommendation to national fire and police organizations said,

Educate your members regarding the details of this accident, including the lessons learned from the emergency medical response, and the potential utility of integrating police transport of victims into mass-casualty incident response plans.

Presumably, one of those national fire organizations would be the IAFC.

One could almost conclude that we have come full circle from days of funeral homes using station wagons or Cadillac ambulances with a single driver to transport critically ill and injured patients to the hospital.

A step up from that was when EMS started to mature and things started changing. Several changes included raising the roof the ambulance so the patient’s face wasn’t against the ceiling of the vehicle and the addition of an attendant in the back.

When I started my career in St. Louis in 1977, I was at the front end of when they started putting an attendant into the back of ambulances. Being a rookie, I was put in the back of an ambulance to treat patients. Unfortunately, I had no EMT or paramedic license and my training consisted of a fire-academy instructor mainly showing us how to take a pen apart and stick it in someone’s throat to open an airway.

Fortunately, I never had to do that.

Before there was standardized training and licensing of personnel who deliver care in a prehospital environment, many people were transported in police cars or vehicles that would normally transport prisoners when not being used as an ambulance. Or they may have been transported in ambulances from funeral homes with a single driver. There was no medical training for the people driving these vehicles and you were lucky if there was a bottle of oxygen in the back.

How many people over the years died because no one opened an airway, no one suctioned vomit or blood from an airway? How many bled to death because a wound was not dealt with and the person exsanguinated? How many people were removed from vehicle crashes without proper cervical or spinal immobilization and later died or suffered some level of paralysis because no cervical or spinal precautions were taken?

We’ll never know the numbers. We just know what those veterans of yesteryear tell us about how things were.

There are several studies that try to contend that there’s no statistical difference with the mortality of a trauma-victim transport to the hospital in an ambulance and one that comes by another type of vehicle. Unfortunately, these studies look at generalities and don’t look at wound type, seriousness of the patient or other factors that can determine patient outcomes.

EMS has been an evolutionary process. There is nothing revolutionary. Each step up the ladder, we have learned from empirical data and experiences as we have continued to improve the delivery of emergency care in the field.

Ambulance designs, education standards, curriculum changes, equipment improvements and treatment modalities have all been part of the evolutionary process since the EMS Act was signed by President Nixon in 1973.

I suspect we’ll see this issue become more prevalent as police vehicles are used more often to transport injured to the hospital, as was done at the Aurora Theater active-shooter incident in 2012, when 27 shooting victims were transported by police cars.

Fire chiefs who manage fire-based EMS transport agencies should have this issue on their radar as more advocate for nontraditional transport vehicles to begin transporting patients.

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