# St John too busy for dying woman



## ArcticKat (May 17, 2011)

No ambulance was sent to the aid of a shot and dying Otaki Beach woman this month because staff were busy on other calls.

The 23-year-old mother was allegedly shot by her partner on May 8. Firefighters and police gave her first aid but firefighters became so concerned with the St John response they called off-duty paramedics to the scene themselves, the Dominion Post reported. 

Read The Article


----------



## MrBrown (May 17, 2011)

Brown is no fan of St John but will defend them in this case.

The town concerned is half way along State Highway 1 between two major metro areas (Wellington and Palmerston North) with a small population, like a couple thousand small.  They have one crew, Levin (about 20 minutes north) have two, including an Intensive Care Paramedic.  Paraparaumu to the south (about 20 minutes) also has one crew as it is a small population centre.

All four were out at jobs, the Levin crews (probably three officers) were at a cardiac arrest and the Otaki crew were transporting somebody to hospital, which is an hour way one way.  Brown does not where the Paraparaumu crew were transporting but it is up to an hour each way as well for them.

Any road response from Palmerston North is going to take nearly an hour even at increased speed, being a rural area they do not have Oscar/Tango available (Jeep based rapid response) and the only resources available are station-based crews, who again, were all busy.

Fire Service does provide emergency first response for the Ambulance Service when appropriate and they are trained in advanced first aid.  In this case they were probably totally outside of their educational or experience level but knowing what the local volunteer Firefighters are like, they would have given 400%.

This is not a case of "somebody has exceeded their regulated driving hours and we did not call them" as has happened in the past but it sounds like nobody was actually free.  Like any jurisdiction we have a finite amount of Ambulance resources and if they are busy, what do you do?

Being a small community it sounds like the Fire Service did call back the off duty crew who took about half an hour to locate, so they were obviously not in the town otherwise it would only take a few minutes.  We do not respond off duty crews (i.e. who are off roster) because that is what we have on-duty crews for.

Brown agrees with St John (this is a rarity make some sort of note of the date and time) that in this case, the best resource (the only resource) was a HEMS Intensive Care Paramedic from Palmerston North.  They are a seconded, road based crew so took a few minutes to get to the helicopter, although the helicopter and ambulance station are on the hospital grounds that is not to say they were not returning from a job and had to get into their HEMS jumpsuit.

So despite Brown not actually liking a lot of what St John does, Brown agrees that in this case the response was appropriate.


----------



## medicdan (May 17, 2011)

My only question is why two ambulances were tied up with a code... on a patient with a DNR order...


----------



## MrBrown (May 17, 2011)

emt.dan said:


> My only question is why two ambulances were tied up with a code... on a patient with a DNR order...



Because it was not apparent at time of dispatch that she had a DNR, we always try to get three staff to a cardiac arrest and Levin 2 was probably one up (solo Officer without volunteer) as it was a day shift.


----------



## bigbaldguy (May 17, 2011)

Too bad you folks didn't have a few half trained poorly educated American style medics floating around to pick up the slack, but I'm sure the woman would have preferred to wait for someone with 6 years of advance medical training under their belt anyway.


----------



## MrBrown (May 17, 2011)

bigbaldguy said:


> Too bad you folks didn't have a few half trained poorly educated American style medics floating around to pick up the slack, but I'm sure the woman would have preferred to wait for someone with 6 years of advance medical training under their belt anyway.



The amount of education our Ambulance Officers receive has nothing to do with how many are available at any one time in a given geographical area.

We are resourced with a finite amount of crews appropriate for the given workload of the area.  The area in question is predominately rural with a small population centre (only a few thousand people) so has one ambulance crew on duty at any one time.  The larger population centre to the north (Levin) has two, however both were busy at a cardiac arrest.

It is simple deductive reasoning that the most appropriate resource was in the largest population centre (PN) which was unfortunately, the most distant and therefore, going to take the longest to arrive.


----------



## mycrofft (May 17, 2011)

*I think what bigbaldguy is saying...*

is that in a "saturation" plan (lots of less-trained vollies in rural areas, as opposed to the "smaller numbers of better trained and qualified responders" plan) someone could have come, although in this case with a GSW I doubt (without much info on the pt condition, here I go again) that a lesser responder could have done much but boogie her to a hospital. 

Between reading the article and Brown's expansion, sounds like it was one of those things you have happen rarely, and folks involved tried their darndest to make it work nonetheless.


----------



## MrBrown (May 17, 2011)

There are four ambulance stations on the 150km stretch of highway concerned, five ambulances in total to coincide with the population centres, three of which are very small (several thousand people) one one of which is slightly larger (maybe ~15,000 people) so it has two ambulances including an Intensive Care Paramedic.

All vehicles were busy, the off duty crews would have had no vehicle to respond in, and the volunteer Ambulance Officers are watch/roaster based and not "on call" so are they supposed to drive to this job, with no medical equipment beyond the AED and Thomas Pack the Fire Service has and do what exactly?

We do not know where she was shot or what she died of.  On the surface it looks poor form but it is a simple equation that is experienced by dozens of jurisdictions, you have a finite number of resources for a given planned workload and exceptions from time to time will occur, this being one of them.

Lets not get all silly and say "oh the half hour it took the ambos to come meant she died!"


----------



## mycrofft (May 17, 2011)

*30 minutes could make the difference, but maybe not in this case anyway.*

We can get into the "Paramedic on every corner" syndrome if we start mincing minutes too finely.

Face it, when you don't live in an urban setting, you face potentially longer response times (although in some underserved US cities' neighborhoods that is questionable). Distances are longer, roads scarcer, and resources are thinner because there are both less profit and fewer voters.

I do not see any realistic failure in this system from what the article had to say.


----------



## MrBrown (May 17, 2011)

Exactly, there was no failure.  It is simply that a job came in when the Otaki crew were transporting, Paraparaumu and Levin were also busy.

It is something that Brown knows has happened before, you are talking about small population centres along a major state highway with very long transport times and it does not justify having extra vehicles on all the time.

It just so happens in this case, it was a shooting and not somebody with the sniffles.


----------



## enjoynz (May 17, 2011)

*Here is another article about it.*

http://www.stuff.co.nz/national/5017216/Help-for-dying-woman-not-good


The area talked about here has had on going problems with lack of ambulance officers for years.
I would put it down to a certain amount of the issues between St John paid staff and management attitudes, along with the funding issues.

These areas in years gone by had a large group of volunteers, but as time has gone by, they have left the service and not been replaced or become paid staff.

People that have fulltime jobs and look at volunteering for St John, have to take so much time off their paid jobs to fulfil the training needed now, that it is just not worth it.
Also alot of employers will not let their staff take that amount of work off. Something the service should think about, in their goal for excellence. 

Enjoynz


----------



## bigbaldguy (May 17, 2011)

Nah I just felt like winding Brown up.

Hey brown I'm thinking about going back to Sydney should I fly Quantas?


----------



## samiam (May 17, 2011)

MrBrown said:


> There are four ambulance stations on the 150km stretch of highway concerned, five ambulances in total to coincide with the population centres, three of which are very small (several thousand people) one one of which is slightly larger (maybe ~15,000 people) so it has two ambulances including an Intensive Care Paramedic.



Interesting I would think that the likely hood of there being a situation with the need for more then two ambulances at a single given time in a fifteen thousand population would occur frequently. no?


----------



## ArcticKat (May 17, 2011)

MrBrown said:


> There are four ambulance stations on the 150km stretch of highway concerned, five ambulances in total to coincide with the population centres, three of which are very small (several thousand people) one one of which is slightly larger (maybe ~15,000 people) so it has two ambulances including an Intensive Care Paramedic.



That is interesting, how much time do those ambulances spend on task?  I have three ambulances to serve a population of about 4000 to do about 500 calls per year.  We do quite a few transfers to a tertiary centre though and that can have an ambulance tied up for 7 - 12 hours on one call.


----------



## enjoynz (May 17, 2011)

samiam said:


> Interesting I would think that the likely hood of there being a situation with the need for more then two ambulances at a single given time in a fifteen thousand population would occur frequently. no?



I think Mr Brown is a bit light on the population of these areas.

Stats last taken for this area (Otaki and Levin, with 3 ambulance stations, Mr Brown forgot Foxton) was 29.868 in 2006 at the last census,
which would be higher than that now, 5 years down the track.

The area of Paraparaumu (with one ambulance station, which is not run by St John) had 46.197 at the 2006 census.
This area has grown steadily over the years, as the greater Wellington (Capital city) population moves further out into urban areas.

There has not been enough ambulances or crews to manage these areas well enough for years...funding and manpower are the main issues.
Should we have a major incident within this area, (i.e. earthquake) I'd hate to think what would happen.

I'm sure there are areas within the USA and Canada that have the same issues??


----------



## medicdan (May 17, 2011)

What would have changed, or been different if fire brigade (department) personnel had more training, or a vehicle to transport this patient in?


----------



## johnrsemt (May 17, 2011)

There are area's all around the world that has issues like this.  It isn't just the management that doesn't schedule enough crews, but also a world that does not pay enough for people to want to stay in EMS.    
   If services got paid $800-1000 for each transport the companies could and would schedule more crews because they would be able to hire more people and keep them.

   My old service lost people to Fast Food chains, because they paid more.


----------



## HotelCo (May 17, 2011)

Welcome to Detroit.


----------



## samiam (May 17, 2011)

HotelCo said:


> Welcome to Detroit.




Agreed. Last time I was talking to one of the medics there were 18 units out to cover a 140 sq mile area 713,777 people and half the calls were owww my toe hurts take me to the hospital.


----------



## Foxbat (May 17, 2011)

I remember hearing at some con-ed lecture that in certain large city/cities in the US (Philadelphia?) PD normally transports stabbing/shooting victims in their cars rather than waiting for fire/EMS, and they actually have very good survival rates. Can anyone give more info on that?


----------



## samiam (May 17, 2011)

Foxbat said:


> I remember hearing at some con-ed lecture that in certain large city/cities in the US (Philadelphia?) PD normally transports stabbing/shooting victims in their cars rather than waiting for fire/EMS, and they actually have very good survival rates. Can anyone give more info on that?



In general:

http://www.myfoxdetroit.com/dpp/news/sound_off/fox-2-focus_detroit-ems-response-time

More specifically to your question:

http://www.clickondetroit.com/news/27493777/detail.html


----------



## mycrofft (May 17, 2011)

*Rural or isolated urban disasters are special cases*

When a real disaster strikes, chances are the indigent response force is out of service.n Help comes in from neighboring areas, and any organic response in the disaster area has to be happenstance and community training based. Trick is to have mutual aid planned and provided for, means for them to get in, and somone to call for them...oh, and hope they aren't out of service too.

Los Angeles, Calif has been closing emergency rooms due to their being crummy. Then your ambulances have no place to go anyway.

This is a good relative case for studying the "saturation" versus "quality" theories of EMS deployment.


----------



## MrBrown (May 17, 2011)

enjoynz said:


> The area talked about here has had on going problems with lack of ambulance officers for years.
> I would put it down to a certain amount of the issues between St John paid staff and management attitudes, along with the funding issues.



While Brown does not like St John by any stretch of the imagination is there a workload to justify an increase in resourcing?

What is needed? One more full time crew? A day only crew on black watch? Oscar? Perhaps a PTS vehicle during the day? 

How many jobs are you getting down there?  If transporting to Palmerston North is an hour away that's a problem you cannot really get around.



enjoynz said:


> People that have fulltime jobs and look at volunteering for St John, have to take so much time off their paid jobs to fulfil the training needed now, that it is just not worth it.  Also alot of employers will not let their staff take that amount of work off. Something the service should think about, in their goal for excellence.



Well that is unfortunate but the Primary Care volunteer is no longer acceptable clinically and it should have happened a long time ago.

Brown knows for a fact that the NDAP is run online and has 14 two-day weekend blocks.  There are exceptions, but if over 800 people have done it since its inception in 2005 so its not impossible.

Weekly training to do the CCE modules is most often held at night or on weekends when most volunteers are not working.  Again Brown says most because some are, which is why Clinical Education offer more than one opportunity to do each module.

The bottom line is that the Diploma and CCE are now the minimum requirements as they should be, the Degree will very soon be required for paid staff, as it should be.  



ArcticKat said:


> That is interesting, how much time do those ambulances spend on task?  I have three ambulances to serve a population of about 4000 to do about 500 calls per year.  We do quite a few transfers to a tertiary centre though and that can have an ambulance tied up for 7 - 12 hours on one call.



The average out of chute time is an hour per job.  If you transport from this area it is going to be two hours give or take round trip.



emt.dan said:


> What would have changed, or been different if fire brigade (department) personnel had more training, or a vehicle to transport this patient in?



No.


----------



## DrParasite (May 17, 2011)

MrBrown said:


> Exactly, there was no failure.


I throw the BS flag on this one.  the system did fail, just like it fails in urban cities all over, by not having enough EMS units to cover the call volume.  the patient needed an ambulance, nor a FD first responder.


MrBrown said:


> It is something that Brown knows has happened before, you are talking about small population centres along a major state highway with very long transport times and it does not justify having extra vehicles on all the time.


 I am sure the family of the deceased will take great solace in that.


----------



## MrBrown (May 18, 2011)

DrParasite said:


> I throw the BS flag on this one.  the system did fail, just like it fails in urban cities all over, by not having enough EMS units to cover the call volume.  the patient needed an ambulance, nor a FD first responder.



We are talking about a low workload rural area that is an hour one way by road from hospital.  They have one duty crew to cover the expected workload with two vehicles to the north (one of which is an ICP) and one to the south that cover their expected volumes.

Two ambulances were transporting patients, the local ambulance has a one hour transport time each way and both are required to transport away ie moving further from where this incident happened.  

The other two vehicles were at a cardiac arrest.  Brown would imagine once they decided not to resuscitate the patient the second ambulance got what we call R99 or told that a P1 job awaits.  Even if the Ambulance Officer said OK I will respond, he is going to have to drive twenty to thirty minutes south in order to reach the patient.  It's going to be quicker to get the Intensive Care crew from PN in the helicopter and have them go as they were probably already in the air by that time.

What you have here is the simple problem that an exception occurred to the norm, it happened that Levin was busy with the cardiac arrest and Otaki and Paraparaumu were transporting, again up to an hour each way so there was no free resource in the area.  It is a rural area with a low workload, so what, is there supposed to be a magic ambulance that appears out of nowhere with a crew to crew it? 

It happens that this time the job was a shooting and not somebody with the flu.  It is unfortunate but in reality isolated incidents do not mean it justifies having another vehicle in one of the population centres all the time.  

We are not talking of an area where you can move another resource in to provide cover, because there is no other bloody resource to move, anything that comes from Palmerston North is going to take an 45 minutes to an hour to get down there at normal road speed.  



DrParasite said:


> I am sure the family of the deceased will take great solace in that.



So what, now instantly it is the Ambulance Service's fault she died?


----------



## BEorP (May 18, 2011)

DrParasite said:


> I am sure the family of the deceased will take great solace in that.



Just because a patient died and there was a delay to an ambulance arriving does not mean the delay of the ambulance caused the death. 

Brown, maybe I missed this somewhere else in the thread, but is there any kind of deployment strategy that involves pulling in other ambulances for coverage under the unique circumstances when all four area ambulance are out on calls? Or is there anyone close enough who could be pulled in for this.

This really seems like a case of bad luck and limited resources. And I don't mean for there to be negative connotations when I say "limited resources" - that is the reality of everything in healthcare. We're trying to make the most of the limited resources we have to use. 

Even _if_ this lady could have been saved had there been another ambulance in the region, would the cost of having an extra ambulance on duty indefinitely justify this maybe 1 in 100 year occurrence of all ambulances being occupied at once when a saveable patient waits be worth it? Almost surely not.

This isn't a time for emotions. Yes, it's sad she died, but it is like triage. Sure it is sad, but that doesn't change the reality of limited resources.


----------



## MrBrown (May 18, 2011)

BEorP said:


> Brown, maybe I missed this somewhere else in the thread, but is there any kind of deployment strategy that involves pulling in other ambulances for coverage under the unique circumstances when all four area ambulance are out on calls? Or is there anyone close enough who could be pulled in for this.



Yes we have such a plan in place called "fluid deployment" where resources are moved to other stations to cover for mandated breaks or if all ambulances are busy.  In Metro Auckland and other large population centres it is easy as we have Oscar/Tango (rapid responders), motorcycles and a larger number of stretcher based ambulances to cover the expected, and historically actual, workload.

The area in question is not really one in which such a methodology can be deployed.  The main feature of the area is State Highway 1 which runs from north to south and is sparsely populated except for number of small population centres.

Get out Google Maps and look at how far from Palmerston North Paraparaumu is and you get an idea of what is being covered.  Foxton, Otaki and Paraparaumu have one ambulance and Levin has two.  They were all busy.

In reality it took a half hour for the helicopter to reach the patient, in that amount of time it is reasonable that given the distance to travel and resources available that it was going to be the quickest way to get there.




BEorP said:


> This really seems like a case of bad luck and limited resources. And I don't mean for there to be negative connotations when I say "limited resources" - that is the reality of everything in healthcare. We're trying to make the most of the limited resources we have to use.



True but everybody has finite resources; the bank, the fast food place you sit at for thirty minutes in drive thru, it is not exclusive to healthcare.



BEorP said:


> Even _if_ this lady could have been saved had there been another ambulance in the region, would the cost of having an extra ambulance on duty indefinitely justify this maybe 1 in 100 year occurrence of all ambulances being occupied at once when a saveable patient waits be worth it? Almost surely not.



Exactly, this was an unusual circumstance in which the available resources were busy, and unusual again that it just happened to be a critical patient.


----------



## medicsb (May 18, 2011)

Foxbat said:


> I remember hearing at some con-ed lecture that in certain large city/cities in the US (Philadelphia?) PD normally transports stabbing/shooting victims in their cars rather than waiting for fire/EMS, and they actually have very good survival rates. Can anyone give more info on that?



The Philadelphia Police Department has a policy/directive, which is supported by the local trauma centers, to throw the victim in the back of the car and haul *** to the hospital.  A study from Temple University Hospital of penetrating trauma victims who required emergency department thoracotomy found that the PD transported patients had double the survival over ambulance transport.   A study from the university of Pennsylvania was more broad and (I think) found no difference in outcomes.  Considering the number of PD cars over ambulances and their speed of response and transport, from time of the shooting to arrival at trauma center could easily be under 10 minutes.  In Philly or any other city, that isn't happening with an ambulance except in exceptional circumstances.


----------

