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EMS Response To The Tucson Shootings

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Now that the political foolishness has died down, it’s time to look at the EMS response to the shootings. Which were in Pima County, not the City of Tucson itself. Which has some bearing on the response to the incident. I’ve been corresponding with a friend of mine who is a retired paramedic and has lived in Pima County for about three years. Although not actively working, he remains very involved in EMS issues in the area. We also have some mass media coverage of the response courtesy of MSNBC.com. Read the entire article, including the comments. The comments cover the entire range of readers from those who know something about EMS down to those who’s knowledge comes from watching “Trauma” or “Rescue 9-1-1”. As far as mass media articles go, it’s not a bad article, although the title gives the tone of an expose of the “delay” in response. Which the text of the article explains, including that much of the delay was due to the sheriff’s department holding EMS outside of the Active Incident Area until they were sure that there was only one shooter.

Keep in mind that my comments are based on the article, my friend’s comments, and images from the scene. Scenes like this always start out chaotic, but it’s our job to take control, sort out the chaos, and treat and transport the injured.

Note that the time line in the article is not complete, since it doesn’t mention that Tucson Fire Department responded nor is it clear from the time line who decided to send medical helicopters. Thus the article and the time line should be viewed as incomplete, although they are helpful in understanding what went on.

Another factor of perspective: Congresswoman Giffords would naturally have been the focus of much of the attention from witnesses waiting for ambulances. The ambulance that took her to the hospital did arrive 20 minutes after the first 911 call, and left for the hospital 10 minutes later. That total time, 30 minutes, makes her survival of a gunshot wound to the head all the more remarkable.

A couple of thoughts on this. First it was 38 minutes from the call until Congresswoman Giffords was in the OR according to my friend. From looking at scene photos, including the one in the article, someone took the time to put the patient on a cardiac monitor and start an IV, but not to intubate her. The rule of thumb for trauma in my system is BLS at the scene, ALS enroute. There are exceptions but from my perspective wasting time putting a cardiac monitor on a trauma patient is bad medicine. IVs should be done on the way to the hospital, as should intubation  and any other treatments. Once the patient’s airway is controlled using BLS methods, life threatening bleeding is controlled to the extent possible, and a stretcher is available, transport should be the priority.

“As the ambulances arrived, they were given patients out of our treatment for transport,” Goldberg said. If the ambulances had arrived sooner, patients would still have needed to be stabilized. “You don’t just take a patient and throw them on the ambulance.”

No, you don’t throw them in the ambulance, you put them in the ambulance and start transport as quickly as possible. There is little “stabilization” that can be done to trauma victims. We don’t carry any medications that can stop the bleeding or start healing torn tissue. That’s the province of hospitals and surgeons. Transport is part of the treatment as an old partner of mine used to say.

The nationwide standard for arrival times is usually six minutes: one minute to handle a call (“dispatch time”), one minute to gear up and get on the road (“turnout time”), and four minutes to drive (“travel time”). That six-minute standard is used by the National Fire Protection Association.

This is the national standard, although the article also refers to it as a “guideline” for fire response, not for EMS response. In reality, very few agencies meet this, even though they all claim they do. In EMS the standard is eight minutes fifty nine seconds for life threatening calls. Like a lot of things in EMS this is based on weak science at best. The true standard of measurement is from the time the phone first rings until the first care giver is at the patient’s side. So, in reality, the time the EMS units spent at the staging area should be part of the response time. The article explains some of this, and the reasons for the delay.

There was further delay once the ambulances were on scene,

“I had more than enough resources to treat at the scene,” Spalla said. “We were plenty busy. Treatment never asked for an ambulance that we didn’t have for them. If there had been 10 ambulances sitting on the corner, I couldn’t have used them until I got triage going.”

In EMS we’re all trained to use the Incident Command System. Which was actually developed by the fire service originally for use at forest fires. That happened after a loss of accountability at some large fires in California several years ago. As a result of the fractured command structure, several fire fighters were lost. It works well for the fire service, it works well for EMS at events that are going to go on for a length of time. I’m not convinced that it works well for fast moving dynamic events like motor vehicle collisions and shootings. Triage should be done to determine who can be saved, who can’t, who needs transport immediately, and who can be delayed on scene until more ambulances arrive. The key is that triage should be rapid and facilitate the prioritization of transport. It’s interesting to note that Israel, where they have a lot of experience with mass casualty incidents, doesn’t hold ambulances in staging areas. One reason for that is that they want to move everyone off the scene as quickly as possible. Another is that they’ve come to realize that in the case of terrorist attack, the staging area can become a tempting target. I don’t think that anyone has really looked at the roll of the incident command system in fast moving events like this.

All of which is to say that the problems were system problems, not individual responder problems.

According to my friend, here are some other complicating factors that contributed to the delays and confusion. The fire departments (Northwest and Rural Metro) operate on different radio systems than the sheriff’s department. Not to mention that Tucson FD uses a different type of radio system. It appears that there is no direct on scene communications capability between fire, sheriff, Rural Metro, or Southwest (subsidiary of Rural Metro). That type of thing adds delay and confusion. Sadly, it’s still all too common in many areas.

Note that Giffords went by ground ambulance because “it was quicker”. It’s not at all clear who sent the helicopters. Note also that the University Medical Center is about 8 miles by ground from the scene of the shooting. My observation is that there is no way that a helicopter could be dispatched, launched, land, have the patient loaded, and then get to UMC in less time than it would take to drive them. Nor would they get demonstrably better care en route.

Despite the delays and the confusion, it seems that the EMTs and medics on the ground did a good job getting everyone off the scene in acceptable times and transporting rapidly. It’s easy to criticize either from a physical distance (like mine) or the distance of not really knowing anything. It’s much different to actually be there, make the decisions, and then live with the results.

The following comments should probably preface the rest of the article, but I’m going to place them at the end. As I said, it’s easy to criticize because everything is seen clearly when seen through the retrospectroscope. So, here are some personal thoughts from someone who has been there,

An incident like the mass shootings in Tucson is “The Big One” that most for which most people in EMS enter the field. Maybe, but they are fortunately rare events. I’ve never gone to that large a shooting, or any incident where that many people have been injured, or at least seriously injured. I’ve responded to multiple fatality, high profile, incidents in the past. Some of which have received extended media coverage. Luck of the draw, if you want to call it luck. A call like that changes you, in some ways only for a bit, in other ways forever. A divide forms between those who were there and those who weren’t. Those who were there will always have that incident in common, even if they never talk about, never work together again, or even see each other ever again. They were there, they saw the carnage first hand, they dealt with it. Those that weren’t there weren’t, didn’t, and didn’t. You can’t explain it to someone who’s never had the experience. Like combat veterans I know who never talk about their experiences outside that close group of other combat veterans, we don’t talk about that outside our group.

You don’t think about that, or at least I don’t, until it’s all over and you have time to reflect. There are victims to triage, deciding who will get treatment and who is beyond our help, patients to treat, transport to be arranged, and it all happens in mere minutes, that seem like seconds. Or seconds that seem like hours. Either way, it’s over before you realize it and then comes the time for your brain to catch up with what your body, training and instincts handled.

Even on the best run calls, there is plenty of time to look back and kick yourself for the things you didn’t do or could have done differently. I’m sure all of the field providers are feeling the effects and looking back over every second of their response. I hope that they aren’t overly critical because it’s always easy for the arm chair generals to tell them what they should have done. Especially since the arm chair generals weren’t there and probably never will be.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

9 COMMENTS

  1. This is the reason I leave EMS blogging to my friends. Your analysis is right on target, and illustrates the reasons I didn’t criticize the use of HEMS in my blog post… only asking why.

    We know Gabby Giffords was transported by ground, that she arrived in hospital rapidly and has survived despite tremendous odds. On its face, this information alone would lend weight to the argument that use of HEMS in this incident was over the top. Several jumped quickly on that bandwagon.

    But what we don’t yet know is the availability of ground units at the time of the incident, and if eggbeaters were summoned to make up a shortage. If that were the case, perhaps it was justified. In time and with examination of the facts, we may learn the answers. Until then finger pointing is uncalled for.

    Armchair quarterbacking is unprofessional. We don’t know enough about what happened, when it happened, who made the decisions, or much of anything factual to be able to render judgement from afar.

    • The article at least gives the impression that there were plenty of ground assets. I don’t understand the part about Northwest Fire – Rescue usually not transporting in their ambulances. Maybe it’s a regional thing. Hopefully as more facts about the EMS response come out, we’ll have a better understanding of this and other questions.

  2. While agree with your sentiment 100% that ALS should have been done enroute, it appears from the picture that only the pule oximeter and NIBP cables were being used, not the actual leads. It would also seem that based on the medics’ description of the scene, the little girl and tye senator should have been the 2 top priority patients and transported first and second respectively, whereas the senator was 4th to leave.
    I also like that you brought up the role of ICS in this response and how it does not seem to work in the rapid setting shere there is very little potential for extended scene time or new patients being generated. I wonder how things would have differed if an EMS only agency was in charge instead of a fire based agency.

    • If all they were using were the pulse ox and the NIBP, it’s probably worse. Neither are particularly useful in treating a trauma patient in the field. Not that BP isn’t important, but using a 22 pound monitor to get a BP is kind of silly. At least in my experience. I don’t know enough about the injuries of the other people to even make a guess about who should have gone first. The article does say that the young girl was only transported because they had plenty of resources at the scene. The other traumatic arrest patients were declared on the scene, so I’d surmise that it was the girl’s age that was the determining factor. Of which I’m not the least bit critical because young victims always amp up everyone’s anxiety level.

  3. Nice analysis, and I agree with you on the stabilization v. transport part – stabilization on scene is for those whose injuries aren’t going to kill them in the next half-hour (isolated fractures, etc.), everybody else get put in the truck as fast as possible, so they get to a hospital and a surgeon as fast as possible. Any stabilization (apart from c-spine immobilization, if needed) that you can do on scene you can do on the road.

    I’m not convinced that it [ICS] works well for fast moving dynamic events like motor vehicle collisions and shootings. Triage should be done to determine who can be saved, who can’t, who needs transport immediately, and who can be delayed on scene until more ambulances arrive.

    My experience with these types of incidents is that by the time ICS can be established, the most critical parts of the incident are over and the most critical patients have been transported.

    It did come into play – and was useful – at Virginia Tech*, but that was because of the time the police needed to clear the entire building before letting EMS in. Most of the urgent transports at the beginning were people who jumped out windows, or who were pulled out by LEO teams who went in while the entry teams were still clearing the building.

    You don’t think about that, or at least I don’t, until it’s all over and you have time to reflect. There are victims to triage, deciding who will get treatment and who is beyond our help, patients to treat, transport to be arranged, and it all happens in mere minutes, that seem like seconds. Or seconds that seem like hours. Either way, it’s over before you realize it and then comes the time for your brain to catch up with what your body, training and instincts handled.

    Amen. And when your brain catches up, the first response is usually “That only took 10 minutes?” or “It didn’t feel like it took that long!”

    * Most of my information on events inside Norris Hall is second hand – I ended up doing the initial set-up of the secondary staging area (which, due to communications issues, I initially thought was the primary staging area) until a line office arrived at our station to take command, by which point there were enough ambulances in play to do what was needed. Even then, it was still chaotic and confusing for those of us not right at the scene.

    • I think almost by definition, those who can be “stabilized” on scene are probably pretty stable in the first place. Their transport can be delayed if there aren’t enough ambulances on scene initially. Patients with wounds to the head and torso, if not in cardiac arrest, get first priority. Those who are in cardiac arrest generally shouldn’t be transported since survival is essentially zero. Not easy decisions to make.

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