Is fire engine transport ever the best choice for an injured child?
First responders need to train for prolonged patient care for the calls when ambulances are delayed or unavailable
Is it a crime to transport a pediatric patient with lower body burns in a fire engine instead of waiting for an ambulance? What are the circumstances that warrant injured or ill patients being transported by a non-ambulance? Does the punishment fit the crime?
These questions are being asked and debated by firefighters and EMS providers in the wake of news that an Oklahoma City Fire Department firefighter has been disciplined by the department for violating department policy and state law for transporting a 3-year-old patient on Christmas Eve in a fire engine instead of waiting for an ambulance from the Emergency Medical Services Authority (EMSA) to arrive.
Local news outlets report that Quinn Amme, 3, sustained partial thickness (second degree burns) to her legs when the boiling oil of a fondue pot spilled on her.
Firefighters, who are cross-trained as paramedics or EMTs, arrived minutes later and began to treat the girl. After waiting for an EMSA ambulance to arrive, the firefighter, identified as Maj. Corey Britt, offered to drive the patient to the hospital. It is reported that Amme fell asleep during transport. In an interview with local media outlet KFOR, the patient’s family noted they appreciated the decision to transport and felt let down by EMSA.
Non-ambulance transport indications
Non-ambulance transport cases that I am familiar with typically involve patients with life- or limb-threatening injuries. For example, Philadelphia police transport some gunshot or stabbing victims to the nearest hospital rather than waiting for an ambulance. Theoretically, these patients are at risk of exsanguination before an ambulance could arrive.
The news reports don’t include the patient care report or a clear clinical picture of Amme’s injuries. Partial thickness burns are painful, can lead to hypovolemia, are at high-risk of infection and can cause short- or long-term disability. Based on the news reporting, it’s unlikely the patient’s airway was compromised or she was unable to adequately ventilate. One final reflection: Cast a wide net for reasons the patient fell asleep during transport. Her somnolence might have been from sedation, analgesia or being an exhausted toddler on Christmas Eve, one of the most exciting days of the year for any child. All three may have contributed to her falling asleep.
A system under stress
The EMS system in Oklahoma City is stressed. Like many communities, EMSA is understaffed, over-worked and struggling to get ambulances to patients quickly.
On Dec. 1, EMSA resumed control of dispatching and field operations after terminating its contract with AMR. In that same month, EMSA took more than an hour to respond to the scene 40 times.
Response delays are stressful for everyone – fire department first responders, EMS providers, dispatchers, patients and their families. Other than a simplistic suggestion to “drive faster,” the fire department first responders, as well as the responding ambulance crew, have few options to change response time for an individual call. Instead, their options include:
- Option 1. Continue on-scene treatment, ongoing assessment, request status updates through dispatch, and keep the patient, family and bystanders up to date on the ambulance’s arrival time.
- Option 2. Terminate that patient-provider relationship with a release, completion of care or refusal of transport. Most systems are likely a long way from treating a pediatric burn patient in place and then releasing the patient for private vehicle transport to an urgent care.
- Option 3. Transport the patient in a vehicle not designed, equipped or authorized for patient transport. In my opinion, this is the least desirable and highest risk option, and should only be considered, if ever, for patients with immediate life threats.
Which option would you have chosen? Britt and his crew chose option 3 to transport the patient by fire engine, triggering EMSA to report the incident, and the fire department to review and discipline Britt for his decision.
What’s best for the patient?
I have often counseled EMS students that when facing an ethical dilemma, they should act in the best interests of the patient and that acting on “what’s best for the patient” with their training, tools and information at hand is the best position to defend if scrutinized by their employer, the media or the legal system. As is the case in almost any scenario, we don’t have the information Britt had, know how the family was managing the stress of a burned child or the historical experience of working in the system to know if the decision to transport was in the patient’s best interests.
We do know that disciplinary options exist on a continuum, from no corrective action to criminal proceedings. The fire chief described Britt’s discipline as “internal corrective measures,” noting it does not include a reduction in pay, suspension or termination. Britt was reportedly demoted from his role as a senior company officer.
Many EMS providers say pediatric patients are their most difficult calls. Newborns and toddlers are a very small percentage of patient volume, almost always have a stressed caregiver nearby and challenge us to use different sized equipment and drug dosages. The challenges with transporting pediatric patients adds to the complexity. The ambulance cot isn’t designed to restrain a 25-40-pound patient. Improving pediatric transport equipment and techniques is a decades-long challenge for EMS.
Presumably, EMSA, guided by state law, regulation or administrative rule, has on board the ambulance seats or restraints to transport a toddler. Fire apparatus aren’t designed for patient transport and are therefore prohibited by department policy and Oklahoma state law from transporting patients. The best option for a pediatric patient in any EMS system is transport in a vehicle designed for pediatric patient transport, as well as continuing assessment and care during transport.
Train for incidents like this
If you are a training officer, company officer or educator, use this incident to plan training for your crew. Here are ideas you can use or modify:
- Review burn injury assessment and care by the EMT and paramedic. Make sure to cover burn severity, pain management and communicating with the patient and caregivers.
- Design pediatric patient care scenarios or high-fidelity simulations with 20-30 minutes of on-scene care. First responders used to clearing scenes in a few minutes should practice developing a treatment plan, reassessing the patient and modifying the treatment plan for prolonged patient care.
- Conduct hands-on practice of pediatric transport devices to refresh all personnel on the indications and how to use correctly.
- Discuss how to care for complex patient conditions, like a teenager with multiple gunshot wounds to their chest and abdomen, a toddler with an arrhythmia or a COVID-19-positive adult in respiratory failure, when an ambulance might be delayed 10, 20 or 30 minutes or more. What patient findings and response to treatment, if any, would trigger non-ambulance transport? Is that what’s best for the patient?
Next: Listen in as Fire Chief Marc Bashoor weighs in on the issue