This article originally appeared in the Nov. 18, 2016 issue of the International Association of Fire Chiefs’ On Scene and is republished here with permission.
By Mike McEvoy
The derailment of eastbound Amtrak passenger train 188 on May 12, 2015, in Philadelphia resulted in the deaths of 8 passengers and 185 transports to hospitals. The investigative report and findings of the National Transportation Safety Board (NTSB)[1]included a recommendation to several public-safety organizations, including the IAFC.
The NTSB suggested these organizations, “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.”
The introduction of paramedic-level care into EMS beginning in the 1970s resulted in dramatically improved outcomes for a variety of prehospital illnesses and injuries. As trauma care evolved in hospitals, questions began to arise in the early 1980s about the value of advanced life support for traumatic injuries. By 1996, most published evidence clearly demonstrated that trauma patients transported by friends, relatives, bystanders or police had greater odds of surviving than those transported by paramedics.[2]
While subsequent efforts to reduce scene times and expedite ALS transport brought survival of patients transported by EMS on par with those arriving at hospitals by other means, a subsequent study in 2000 showed that critically injured non-EMS-transported patients continued to arrive at hospitals earlier.[3]
Since that time, researchers have continued to follow outcomes of patients transported by EMS compared to the approximately 10 percent who arrive at hospitals by other means.[4]
Recognizing that, at times, EMS-transported patients fare worse, recent studies have sought to determine the types of injuries where rapid transport by means other than EMS may potentially improve survival.[5] It appears that very severely injured patients particularly those with gunshot or stab wounds and other penetrating trauma, may benefit from rapid private transport or rapid BLS transport when compared to paramedic treatment and transport.[6,7]
For the past 25 years, the Philadelphia Police Department (PPD) has transported patients with penetrating trauma. PPD Directive 3.14 details the responsibilities of law enforcement when responding to a variety of medical emergencies. Victims with penetrating trauma are addressed in this directive:
Persons suffering from a serious penetrating wound, e.g. gunshot, stab wound, and similar injuries of the head, neck, chest, abdomen, and groin to the nearest accredited trauma center. Transportation of such cases will not be delayed to await the arrival of Fire Department paramedics.
Philadelphia Fire Department (PFD) EMS ambulances provide transport in the city; these are primarily ALS. If EMS is on scene, they transport. When police arrive first, they may or may not transport, depending on injury severity and expected arrival time for EMS. When PPD transports, they typically don’t render care.[8]
Ordinarily, when PPD transports, they deliver patients to a trauma center. A five-year study of outcomes published in 2010 found no difference in overall survival between PPD- and EMS-transported patients with penetrating trauma and recommended that the practice be continued.[8]
The police experience in Philadelphia no doubt played into their transport of victims following the Amtrak crash in May 2015, but this was also not a unique law-enforcement response. Police transported multiple patients following the July 2012 Century 16 theater shootings in Aurora, Colorado, and during and after the June 2016 Pulse nightclub shootings in Orlando.
The question raised by NTSB is whether police transport of victims should be integrated into mass-casualty incident-response plans. The IAFC’s EMS Section is in the process of drafting a position paper on this question.
The first 911 call reporting the crash of Amtrak train 188 was received at 21:25, some 4 minutes after the derailment. Philadelphia Fire was dispatched at 21:28 and the first company arrived on scene at 21:31. The IC requested five additional medic units at 21:33 and an MCI was declared at 21:35.
Following their MCI plan, the PPD chief inspector ordered all available emergency patrol wagons to the scene in the event additional transport resources were needed. PPD policy in an MCI is to coordinate any such transportation resources with PFD EMS.
Problematically, many passengers tried to leave the scene immediately; hence, when arriving officers encountered a seriously injured person, they transported them to a hospital. There was little to no coordination with EMS, nor were hospitals provided with information about the patients they were receiving. On-scene triage stations became operational at 21:57, the same time that patients began arriving at hospitals.
By the conclusion of this incident, 186 patients were transported to hospitals, 24 by EMS and the remaining majority by police or Southeastern Transportation Authority (SEPTA) busses. Of the 43 seriously injured patients, three were transported by EMS.
While NTSB identified no negative outcomes because of the means of transportation, at least one critically injured patient transported by police to a nontrauma hospital required transfer to a higher level of care.
Additionally, the lack of transport coordination led to significant overutilization and underutilization of hospitals. For example, 43 patients arrived at Temple University Hospital, a Level I trauma center near the scene while no patients arrived at Penn Presbyterian Medical Center, another Level I trauma center within the same proximity.
The NTSB concluded that “current Philadelphia Police Department, Philadelphia Fire Department, and Philadelphia Office of Emergency Management policies regarding transport of patients in an MCI were not, and still are not, integrated.”
They recommended that “the PPD, PFD and the OEM collaborate and develop a plan that effectively integrates rapid police transport of patients into the emergency medical response plans for large mass casualty incidents, including a means of coordinating hospital destinations regardless of the method of transport.”
They went on to recommend that once the plan is developed, it be exercised periodically, “including at least one full-scale drill every 3 years, to ensure that it functions as intended.”[1]
The NTSB is an independent federal agency, charged by Congress to investigate transportation accidents, determine probable cause and issue safety recommendations. The findings of the report suggest that the police transports following the crash of Amtrak train 188 were not safe and the practice should not be recommended.
The NTSB correctly identified the long-standing practice of PPD transporting isolated cases of serious penetrating trauma as potentially helpful and certainly not harmful. Yet, the report’s authors run the risk of generalizing the research on isolated single patient instances to a full-blown mass casualty event. What occurred on May 12, 2015, in Philadelphia was a relocation of an MCI from the crash scene into several emergency departments.
It’s well established and even cited in the NTSB report that trauma activations negatively affect the care and long-term outcomes of other patients in emergency departments.[9] The NTSB report didn’t evaluate adverse effects on other patients in the emergency departments that train-crash patients were distributed to.
The definition of an MCI is any incident where needs exceed available resources. A fundamental tenet of MCI management is doing the best for the greatest number of patients. This requires rapid triage by EMS, rapid notification of available resources, treatment of life-threatening injuries, collection and sorting of casualties, prompt transport of critical and seriously injured patients and distribution of patients to appropriate hospitals that are ready and able to accept them.
Experience has taught us that panic among MCI victims is rare and that injured people will seek medical attention from any available means, often arriving at hospitals and urgent-care centers by public transportation or private conveyances. Wise planners account for this inevitability.
To portray rapid mass transportation as a primary and immediate objective, as it seems the NTSB is advocating in their report, is wrong. Doing so merely moves an MCI from the scene to an emergency department. The real breakdown in management of the crash of Amtrak train 188 was the failure to coordinate the efforts of police and fire-EMS.
This is not unique to Philadelphia. Effective implementation of an incident command system (ICS) fails regularly in virtually every jurisdiction. We all have work to do to improve on ICS.
Police transport of MCI victims seems to occur regularly. This suggests an opportunity for improved management by fire-EMS.
Quite obviously, many MCI patients will transport themselves and that behavior is difficult to control. The need for rapid deployment of other modes of transportation is a reality at many incident scenes and one that often eludes fire-EMS incident managers. The EMS Section is currently exploring the vast and often untapped private ambulance resources that are frequently within proximity to major incidents.
Municipalities such as Saratoga County, N.Y., have agreements for 24/7 immediate scene response of school buses equipped for radio communication with fire and EMS. Use of police vehicles is also a viable option, when available.
Inherent in any deployment of transportation resources at an MCI is the need for communication and coordination so patients are allocated in a fashion that does the greatest good for the greatest numbers. To transport large numbers of victims from an MCI to hospitals without coordination and communication serves only to relocate the MCI from its scene into local emergency departments.
This article originally appeared in the Nov. 18, 2016 issue of the International Association of Fire Chiefs’ On Scene and is republished here with permission.
References
1. National Transportation Safety Board. Derailment of Amtrak Passenger Train 188 - Philadelphia, Pennsylvania – May 12, 2015 – Accident Report NTSB/RAR-16/02 – PB2016-103218. Washington, DC: NTSB. May 17, 2016.
2. Demetriades D, Chan L, Cornwell E, Belzberg H, Berne TV, Asensio J, Chan D, Eckstein M, Alo K. “Paramedic vs private transportation of trauma patients: effect on outcome.” Arch Surg. 1996; 131:133-138.
3. Cornwell III EE, Belzberb H, Hennigan K, Maxson C, Montoya G, Rosenbluth A, Velmahos GC, Berne TC, Demetriades D. “Emergency medical services (EMS) vs non-EMS transport of critically injured patients: a prospective evaluation.” Arch Surg. 2000; 135:315-319.
4. Johnson NJ, Carr BG, Salhi R, Holena DN, Wolff C, Band RA. “Characteristics and outcomes of injured patients presenting by private vehicle in a state trauma system.” Am J Emerg Med. 2013; 31:275-281.
5. Zafar SN, Haider AH, Stevens KA, Ray-Mazumder N, Kisat MT, Schneider EB, Chi A, Galvagno Jr SM, Cornwell 3rd EE, Efron DT, Haut ER. “Increased mortality associated with EMS transport of gunshot wound victims compared to private vehicle transport.” Injury, Int J Care Injured. 2014; 45:1320-1326.
6. Rappold JF, Hollenbach KA, Santora TA, Beadle D, Dauer ED, Sjoholm LO, Pathak A, Goldberg AJ. “The evil is better: making the case for basic life support transport for penetrating trauma victims in an urban environment.” J Truma Acute Care Surg. 2014; 79:343-348.
7. Band RA, Salhi RA, Holena DN, Powell E, Branas C, Carr BG. “Severity-adjusted mortality in trauma patients transported by police.” Ann Emerg Med. 2014; 63:608-614.
8. Band RA, Pryor JP, Gaieski DF, Dickinson ET, Cummings D, Carr BG. “Injury-adjusted mortality of patients transported by police following penetrating trauma.” Acad Emerg Med. 2011; 18:32-37.
9. Fishman PE, Shofer FS, Robey JL, Zogby KE, Reilly PM, Branas CC, Pines JM, Hollander JE. “The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes.” Ann Emerg Med. 2006; 48:347-53.
About the author
Mike McEvoy, PhD, NRP, RN, CCRN, is the EMS chief for Saratoga County, N.Y., the chief medical officer for West Crescent Fire Department and a paramedic supervisor for Clifton Park & Halfmoon Ambulance. He is the EMS Section’s vice chair and has been a member of the IAFC since 2007.
