By Art Hsieh

The suspension and reinstatement of two volunteer firefighters for transporting a possibly critically ill 18-month-old child in their fire engine brings up several issues that are not likely to be reported in the mainstream media. The child survived.

The incident points to the concept that out-of-hospital care is provided through a system of processes that work in conjunction with each other.

Whether the actions of the crew had anything to do with the child's outcome is debatable. Not working within the system can initiate a series of consequences and risks that can endanger the patient, the crew and the community at large.

First, rarely does the end justify the means. We have no idea what was happening with the patient, nor do we know what the outcome was. The crew’s decision to transport using their engine may — or may not have — contributed to the patient's outcome in one of three ways:

1. No difference

The patient was not critically ill and saving a few minutes made no difference to the child's outcome.

2. Negative

Something was happening that was so significant, that early definitive intervention by EMS providers might have made a difference, but because of the transport, care was delayed and there was a negative result to the child's outcome.

3. Positive

Something was happening that was so significant to the child's life, such as an airway compromise or uncontrolled bleeding wound, that shortening on-scene and transport time made a positive difference to the child's outcome.

The third scenario, a positive outcome, is very rare.

The first scenario, no difference, is more likely. For example, Todd’s paralysis after a seizure is a transient problem after a seizure. It is an idiopathic problem that requires symptomatic treatment.

Transport is an intervention

Scenario 2, a negative impact on the patient's outcome is significant. Transporting in the cab of a fire engine with just one crew member to monitor and treat the patient would make it very difficult to manage any airway compromise, life-threatening hemorrhage or inadequate ventilation.

Could the core cyanosis be managed with positive-pressure ventilation? Were there secretions that needed suctioning? Either of these procedures could have been more easily managed at the scene, by the two EMT-trained firefighters, available BLS equipment and space to work.

Those definitive interventions for life-threatening emergencies, if needed, could have been applied 13 minutes sooner. We won’t know if it would have made a difference until the investigation is complete.

But what if that was the scenario? Transport is an intervention in field care and it has to be delivered at the appropriate time, to the appropriate patient.

Another issue is the communications that occurred — or didn’t occur — as the event unfolded. Stafford County is not small. Its fire and rescue department deploys numerous fire and EMS units out of 13 stations spread across 280 square miles, covering a population just under 137,000.

In other words, it’s difficult to know where every unit is at any time — even for the dispatcher overseeing the system. GPS and automatic vehicle locators can be of assistance for real-time views, but there’s no indication that the crew had access to that information.

In such circumstances crews have to rely on accurate information provided by other field units and the communication center to relay that information in order to best estimate arrival times of additional resources.

Here’s one more issue. What if the patient was not 18-months-old, but a school-aged child, 25-year-old adult or a 75-year-old adult? At what point does the value of a life become so great that not using a properly prepared and authorized transport unit is justified?

That is a personal, moral decision that goes beyond the boundaries of a system designed to manage the majority of cases. How such a decision tips the risk-benefit scale is evaluated on a case-by-case basis. Nevertheless the dangers of such risk must be accepted by those who make such decisions.

About the author

EMS1 Editorial Advisor Art Hsieh, MA, NREMT-P currently teaches at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. In the profession since 1982, Art has worked as a line medic and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. A Past President of the National Association of EMS Educators, former Chief Executive Officer of the San Francisco Paramedic Association, and a scholarship recipient of the American Society of Association Executives, Art is a published textbook author, has presented at conferences nationwide, and continues to provide patient care at a rural hospital-based ALS system. Contact Art at Art.Hsieh@ems1.com.