The politics of transporting a patient in a fire engine

Image credit: WJLA-TV News 7

The EMS blogosphere, Facebook fan pages, and internet forums are buzzing with discussion (and criticism) of the firefighters who transported a pediatric asthma patient in a fire engine rather than wait for the ambulance.

Apparently a 5 year old girl named Christina Luckett was having a severe asthma attack to the point where volunteer firefighters (at least one of whom was paramedic trained) started chest compressions and mechanical ventilations. I wasn't there but I have my doubts as to whether or not the patient was truly pulseless but that's besides the point.

The ETA of the transport ambulance was reported to be 5-minutes. The hospital was 2.8 miles away down a highway. Rather than wait for the ambulance to arrive, they placed the child in the back of a fire engine and transported the patient to the hospital, continuing care en route.

She lived. 

Fantastic, right? Well, not exactly. Plenty of folks are second-guessing the actions of these firefighters. Scott Kier called it 100% absolutely wrong. None other than Thom Dick commented on JEMS Connect: "Really, 5 minutes? I congratulate the crew and the Good Lord for their outcome. But I generally wish first responders would just do their own jobs well. This makes me think of the prospect of a transport medic fiddling with a pump panel, over an engineer's shoulder. There's no ME in TEAM."

That seems a bit harsh to me. I considered the example of the transport medic fiddling with a pump panel over an engineer's shoulder for about 24 hours and ultimatley reached the conclusion that the parallel doesn't work. This would be more like a paramedic in a third service agency who also happened to be a firefighter arriving at the scene of a structure fire on an ambulance and making a rescue prior to the arrival of the first-due engine. 

If that happened I would hope that no one from fire department wouldn't say, "You know, I thank the Good Lord for this rescue but I honestly wish the transport medic would leave the firefighting to the real firefighters." Ummm…. you mean the ones who weren't there? Yeah, those ones. You're right, Mr. Dick. There's no "me" in team.

That means we can all be happy when a teammate scores a goal.

The Social Medic (David Konig) gets it. "Rules can be wrong. That’s a possibility few people take into consideration, but an important possibility we always have to look at. Especially when we are leaders looking at the actions of our crews, which is why it was refreshing to see the leadership of Prince George County recognize the efforts of their crews with commendations instead of condemnations."

What's important is that Christina Luckett is alive.

See also:

Firefighters honored for saving girl's life

Firefighters ignore the rules, save girl

5-year-old Md. girl thanks firefighters who saved her life

5-year-old thanks Md. firefighters for breaking rules

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  • Scott Kier says:

    Hi, Tom. 
    First of all, thank you for sharing your views  on this issue.  I do, however, stand by my opinion.  What I personally see here is a group of providers who panicked and abandoned their traning.  If this was an 85 year old who coded in front of them what would they do?  Start their care, wait for an ambulance and perform quality CPR on their patient.  In my opinion, the care provided for this patient should have been no different.
    We ARE all human, and we run off of emotion sometimes which is what I feel happened here, but that does not make their decision right.  We need to remember our training and stick to it.  It will not fail us if we do.
    I am not overlooking the fact that a life was saed here, and personally, I feel that if they HAD stuck to their training, the same outcome would have been reached.  "Limited equipment" and "ROSC prior to arrival at the ER tells me that."
    The bottom line is this, one of the beauties of being a blogger in this community is I have a means by which I CAN look back at a situation and share not only what was done, but what SHOULD have been done and what we can learn from it.  What I fear will come from this is a scary precident set that will result in this same decision being made down the road with a far less desireable outcome.
    Once again, thanks for everything you do, Tom!
    Scott Kier
    EMS in the New Decade –

  • Brandon O says:

    IMO we've stretched this scenario about as far as it can get from the rough information publicly available. I think most of us would agree that there's no true all-or-nothing answer to the general questions here; it really comes down to whether a rule needs to be broken in the *specific* situation, and we lack those details. The fact that there was a good outcome ends up being the key thing, I suppose, but (speaking broadly) I think we also have to appreciate cases where the outcome was good but the decision was wrong — because those are the freebies, the "teachable moments" that give us a chance to change our methods before the time comes when the wrong decision does have consequences.

  • That's true, Brandon. In the fire service we often "get away" with doing things on the fire ground that are risky but don't cause a firefighter LODD. That doesn't mean it was a good idea.

    The Naitonal Fire Fighter Near Miss Reporting System illustrates this with a pyramid. At the bottom are unsafe acts, then near misses, then minor injuries, then major injuries and at the top a fatality. So maybe only 1 out of every 10,000 unsafe acts causes a LODD. That doesn't mean we shouldn't minimize the number of unsafe acts. 

    I'm not suggesting what these firefighters did was wrong. I'm only suggesting that "no harm no foul" is not an acceptable point of view when it comes to patient safety.

    The most important advice to someone who is going to break a rule or countermand an order is "be right!" (or at least don't be wrong).

  • Kyle Norris says:

    Perhaps instead of focusing on the firefighters decision should focus on the system failings that led them to feel like they had to transport her in the engine. Specifically, does PG Co not put an adequate number of transport units on the road? Propping up the EMS system with engines isn’t a solution. Are critical life-saving treatments such as epi for pediatric asthma available to the first responders?. If they aren’t, why? If they are, why weren’t they utilized? Lack of education?

    The result in this case shows justification, but a serious review needs to be done about why these guys were ever put in this position.

  • Matt, FP-C, NREMT-P, CCEMT-P says:

    Come on guys. What happened to “do whats best for the patient”? The firefighters, including one that had paramedic level training, probably did what they thought was best at the time given the information they had. The young girl needed definitive medical care. Do we know if the engine company had meds, airway equipment, etc…?
    I’m with Bouthillet. If its my children and I have two, both 9, I dont care how the get to the ED. Paramedic engine or paramedic transport unit.

  • Scott – I agree with you with regard to adults who experience sudden cardiac arrest because CPR and defibrillation are key. One also assumes this BLS engine had an AED although I don't know that for a fact. I just don't think a peri-arrest pediatric asthma patient is the same.

  • Brandon O says:

    I think what's key is that, when it comes to "intelligent rule breaking," the true way to "be right!" isn't per se to have a good outcome — because that's probabilistic, and you can always get lucky/unlucky. The way to be right is to accurately assess the situation, apply a correct understanding of the principles (of medicine/firefighting/safety/whatever), and make the right call based on the odds. If you go out on a limb by transporting a patient by hangglider, or cover a baby with therapeutic maple syrup, or whatever, the outcome may determine the tone of the aftermath, but I hope that the people who sit in judgment on you are looking at the information you had, whether your decision was appropriate in light of it — and whether you were accurately assessing your OWN capability of making that call. (E.g., the worst thing you could do is "break the rules" because you thought you knew what's what, were very confident in your knowledge, but were wrong — especially when your situation is exactly what the rules had in mind!)

  • Steve says:

    We all know pediatrics go from being in trouble to being dead in nothing flat. We also know the number one couse of cardiac arrest in pediatrics is respiratory arrest. So I think we can say it is a possibility that this girl did go into arrest. Now they say the ambulance was 5 min out plus the minute it would take for them to carry their gear into the house, load the pt onto the stretcher, do their own assessment or listen to the story from the on scene crew (because no crew is going to walk into the scene with epi in their hands without an assessment and give it to the child), and lets say going code to the hospital 2.8 miles away on a highway would take roughly 4-5 min after loading and unloading pt. At this point the pt is at the hospital receiving the exact same care he would have gotten in the field in what looks to be about the same amount of time. So seems to me the critics are the egotistical medics out there that think only they are good enough to take a pt to the hospital no matter what. That how dare a lowly firefighter think they can make a judgement call on what good pt care is, even when that firefighter is a fellow medic.
    I do agree there is some truth to the no harm no foul idea. But it still sounds to me like there is more ego at play coming from the critics here then the idea of what was best for that particular pt at that moment. Should a pt be transported to the hospital via ambulance when possible? Yes. But sometimes common scene needs to considered not just what the rule book says. I say good work from the on scene paramedic that made the call and good on the agency for recognizing their people!

  • I'll stand by what I said over at JEMS Connect. We know almost nothing about the care provided, especially in regards to the care provided at the hospital on arrival. That last part is what's important for deciding this case since ROSC was obtained prior to reaching the hospital. As such, there isn't enough information to know whether ROSC was obtained because of the transport, in spite of the transport, or if deciding to transport had no actual effect on the chance of obtaining ROSC.
    My biggest issue with this is people like Steve (immediately above me) who thinks that because the outcome was positive, it was the correct decision and anyone who disagrees is simply being egotistical.

  • Medic77 says:

    I think the crew was very lucky with the outcome. I also have my doubts about being truly pulseless. People are failing to see the difficulty of performing a quality resuscitation in a fire engine. What happens to the unrestrained child if engine crashed? I believe the same outcome would have occurred if they stayed onscene. The only difference would be nobody would know about it because no recognition would have been given because a Medic did there job.

    I don’t feel ego has anything to do with it. Its a bad Practice that hopefully isn’t contagious.

  • Philip says:

    I guess the issue here is how far is it okay to flee the reservation in time of crisis? Thank God everything worked out and the child surrvived, maybe it was the result of the decision they made, maybe it was the result of care that could have been provided on scene till the ambulance arrived. The problem I see, is the thought process behind it all. If something really, really terrible is happening, (such as a bus full of hemophiliac orphens and nuns that collided with a glass truck) then it must be okay to do something radical and unheard of. Problem is, if we start to think that anything is okay in time of crisis, then how is the care going to be regulated and directed? Whats going to ensure that providers are not going to get hurt and unable to return to work because someone wanted to transport 15 people on the hose bed of a fire truck and a few patients got nocked off on the way? The point I am trying to make, if we want to provide the best care, not get sued and keep our jobs, then we must stick to our training and our protocals, even more so during time of crisis. This might have been an innocent occurence, everyone is alive, well and happy, but that still does not make it right. 

  • Ben Waller says:

    Scott Kier,
    You are alleging "panic" on the part of the personnel involved when there has not been a single published report that any such thing actually took place.
    On what do you base your allegation?

  • Rob M. says:

    The role of the EMS system is to deliver viable patients to definitive care in a timely fashion while doing no harm.  Did the providers do any harm? NO.  Did they deliver a viable paitent to definitive care? YES. Did they save the paitent minutes? YES.  We're not talking about firefighters with a first responders certification.  These crews are EMT-Bs at a minimum.  To be so narrow minded as to say that the crew's outcome was based on luck is a joke.  We are first & foremost problem solvers & critical thinkers.  Do I think the patient was pulseless?  Maybe, maybe not.  I wasn't there.  However, as a NREMT-P & a MD Paramedic, our pediatric protocols indicate that in a infant or pediatric patient who is bradycardic (<60bpm)  despite oxygenation & ventilation, then we are to do compressions.  That is an ALS algorithm in the MD Medical Protocols.  The most common cause of pediatric codes is respiratory arrest, thus it is plausable that she was brady, they paramedic trained volunteer directed BVM ventilations, the pulse did not improve, they began compressions & started for definitive care.
    I guess we're forgetting the study that stated that the most effective way to treat & transport SCA victims in Manhattan was to place AEDs in every taxi, dispatch the nearest taxi, & have them haul tail to the ED.  We need to stop letting our egoes get in the way of doing whats best for the patient.  If this were a career fire engine, would there be the same stink about what they did?  I don't think so.  This crew thought outside of the standard EMS model & thought process in order to do what was necessary to sustain/save the patient life.  We need to pull our heads out of our collective rears & remember why we're here.  We're here for them, not for us.
    For those of you interested is the MD Protocols.  The appropriate algorithm is on page 61 of the pdf file.

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