San Antonio Fire Dept

[BBFDMedic28]

So San Antonio gets a head on collision early one morning. Two pts are critical, one is serious, and one is pronounced DOA. One hour later the Medical Examiner came to the scene and discovered the DOA pt STILL BREATHING! This is crazy! So S.A. was called back to the scene and xpted pt to the trauma center where she later died. I am sensing a certification getting pulled. I will keep yall posted on details and what happens to the medics. San Antonio does not have the greatest reputation and i am certain this will not help any.

 

[Ridryder911]

Couple of things... this happens quite a bit and it is easy to arm chair quarterback, especially without any true facts. If it did occur, it is a shame...

Lastly, how many multiple trauma patient calls have most here have really performed in real life?

R/r 911

 

[ffemt8978]

I wasn't there, so I'm not going to armchair quarterback. I will say this much, though. If the crew on scene was doing triage because they had more patients than they could handle, then sometimes a person is "black" tagged as dead even though they are technically alive.

Here are the links to the news stories about this incident so far:

Woman Mistakenly Declared Dead by San Antonio EMS

Texas Victim Mistakenly Left for Dead Succumbs to Her Injuries

Boss Stands by San Antonio Medics Over Untreated Patient

 

[BossyCow]

I can understand the triage of not treating the pt. who was fatally injured. That just makes sense. But, the issue of leaving her in the car without passing on the correct information of her status has me puzzled.

The accounts are inconsistant. "She'll stop breathing in a few minutes" if a correct quote, means they knew she was still, technically alive and as such should have been treated as a pt. though a pt. lower on the treatment list than the two who survived. But as in most newspaper accounts, this may or may not be an accurate quote.

Were the injuries of the other two life threatening?

 

[r6yr]

this is crazy. im an EMT-to-be but know nothing about it yet. ive been reading on here though and i saw something that said that there is a rule that an EMT is supposed to treat either the most badly injured victim first or the least badly injured victim first? is this true and if it is which one is it? i saw this on a thread about something like "even if a drunk driver causes the accident and he is the worst injured you HAVE to treat him first". if this is true wouldnt the quote "she'll stop breathing in a few minutes" be wrong and wouldnt the paramedics supposed to have treated her first? is it possible that a person is still breathing but technically dead? remember i know nothing about it and im just trying to get as much information as i can so please excuse my ignorance lol.

 

[BossyCow]

You will cover this under 'triage' in EMT class. Triage is the assessment of multiple casualties determining the order of treatment. The purpose is to make the best use of your time. You don't want to spend all your time working a trauma code who is by all odds going to die anyway, when there is someone else on the scene who needs your intervention to make the difference between living and dying.

For example, would you spend all your time on scene doing CPR on someone who is going to be determined as an in field death once ALS arrives or would you rather take care of the other pt with an arterial bleed? Someone who is yelling and screaming over a painful fx or facial lac may be in pain, definitely needs treatment, but not at the expense of someone else's life. Who do you treat first?

Often on an MCI, the victims are divided into dead, gonna be dead soon (mostly dead), needing immediate intervention that has a high probability of success, and those who are hurt with non life threatening injuries. This requires a bit of monitoring because their situation can change at any time.

According to the news report, the girl who died was determined to be fatally injured. This means that in the opinion of the medics, her injuries were so severe that she was going to die from them, maybe now, maybe later, but she was going to die. They determined that any time spent on her care, would not make any difference in the eventual outcome of dead. So they chose to spend their time on scene treating the pt's who were going to benefit from their care.

There is so much more to this story that is not in the paper, that its not right to make any kind of evaluation of the medics' actions. I see questions that could be asked, but all of them would start with the assumption that there was probably more information that was left out because it diminished the shock factor of the story.

 

[MayEMT]

According to the news report, the girl who died was determined to be fatally injured. This means that in the opinion of the medics, her injuries were so severe that she was going to die from them, maybe now, maybe later, but she was going to die. They determined that any time spent on her care, would not make any difference in the eventual outcome of dead. So they chose to spend their time on scene treating the pt's who were going to benefit from their care.

There is so much more to this story that is not in the paper, that its not right to make any kind of evaluation of the medics' actions. I see questions that could be asked, but all of them would start with the assumption that there was probably more information that was left out because it diminished the shock factor of the story.

rumors had been floating among medics that there was grey matter present. and a recent article in the local news paper showed she died from a brain injury. so the medics did triage and made their call on the situation. however the comments of our fire chief did nothing to help people understand the procedure. thats where a lot of the controversy lies. but oh well its not the first time ems procedures are attacked and definatly not the last :wacko:

 

[BossyCow]

And do you really want to tell the family that there were chunks of their loved one's brain lying about the accident scene? But, the place where the attorneys will live is they left her there, while she was still breathing. It's a shame that the best defense against the family's claim that she was mistreated will be to give them ghastly images of her last moments that may be worse than the ones they are imagining.

 

[firetender]

"According to the news report, the girl who died was determined to be fatally injured. This means that in the opinion of the medics, her injuries were so severe that she was going to die from them, maybe now, maybe later, but she was going to die."

Triage does not mean you leave someone who is living at the scene to die. They knew she was living according to the quotes.

Triage means you attend to the salvageable FIRST, but don't abandon anyone. It means you ORDER A BACKUP. If the medics or system gets screwed, it's gonna be over this, and rightly so. The ambulance a couple hours later was not a back up.

 

[VentMedic]

I understand triaging for the most treatable. But, I agree with firetender, if there is still a heart beat and breathing, don't just walk away and leave the scene.

I live in an area where head-on collisions are common. We just mobilize the resources. Unless we can confirm obvious death or follow our protocols to call a death at scene, we will find a way to get that patient and every patient to a hospital. It should not be too unreasonable for a metropolitan area to have back up either from you own resources or mutual aid.

What happens in this area if they have an industrial or a school bus accident that may involve more than 3 patients?

I have also seen people who sustained major injuries, including many TBIs, pull through with little deficit. Many of these patients were so badly injured that it was difficult to continue to work on them in the ED. But, something kept us at their side for that shift and many more difficult shifts. The brain and body are amazing.

And yes, there have been quite a few that involved multiple systems that we did cease to work. However, especially in TBIs, if at all possible in our trauma center, the ED physician will make the decision based on the neuro team physician's assessment for viability. Life support may then be continued until the family arrives unless nature takes its own course sooner.

On another view, a TBI patient is an excellent organ procurement candidate. The patient should then be treated with the utmost respect with appropriate resuscitation efforts to sustain life. The family would then have had "their" time, and not the media's, to spend with their loved one while knowing her death could bring hope for others.

This remark from one article really came across as callous in my opinion. I see where Hood has offered apologies for some of his remarks in more recent news articles.

I don't foresee any discipline for (the paramedics)," Hood said, adding, "There's nothing to apologize for. We weren't driving the vehicle that hit the car."

http://www.emsresponder.com/online/article.jsp?siteSection=1&id=6738

 

[ffemt8978]

Triage does not mean you leave someone who is living at the scene to die. They knew she was living according to the quotes.

Triage means you attend to the salvageable FIRST, but don't abandon anyone. It means you ORDER A BACKUP. If the medics or system gets screwed, it's gonna be over this, and rightly so. The ambulance a couple hours later was not a back up.

I agree 100%...triage means saving the ones you can with the resources you have. As more resources become available, you go back to the ones you left earlier and start treating them.

I will say this much...if brain matter was exposed, that qualifies as obvious death in our system - provided they're pulseless and not breathing.

 

[skyemt]

i don't really think you could claim obvious death when they are still alive...

triage is sorting and prioritizing... not abandoning...

i think no matter how you look at this, it was poor decision making... i'm sure they will be held accountable... unfortunate, as this situation was very avoidable...

 

[ffemt8978]

i don't really think you could claim obvious death when they are still alive...

triage is sorting and prioritizing... not abandoning...

i think no matter how you look at this, it was poor decision making... i'm sure they will be held accountable... unfortunate, as this situation was very avoidable...

Which is why I stated that they have to be pulseless and not breathing.

 

[BossyCow]

It sounds to me like the Chief is defending the medics' decision not to treat while ignoring the part about how they left her there 'as if' she were already dead.

There will be some very wealthy heirs to this event and San Antonio's liability insurance premiums will most likely go up. And think of the lawyers who won't go hungry! There's always an upside!

 

[medic417]

I just wonder how reliable the officers statement was that the paramedics said she'll die soon. Did he really hear that?

I also do not understand why with 4 medics that they could not have at least 2 people verify death. No one else was hurt badly.

 

[BossyCow]

I just wonder how reliable the officers statement was that the paramedics said she'll die soon. Did he really hear that?

I also do not understand why with 4 medics that they could not have at least 2 people verify death. No one else was hurt badly.

There were three other patients. Two critical and one serious. I think the consensus is that the issue is not the medics decision not to treat the gal who died but their failure to pass on accurate info about her status. Dead or 'mostly dead'

Okay, on a side note.... through this discussion, I keep replaying that scene in Monty Python's "The Holy Grail"... you know.. "Bring out your dead!"

 

[medic417]

There were three other patients. Two critical and one serious.

There were 3 patients. In my part of the world thats often 1 ambulance, with 2 medics dealing with them all. There they had 2 ambulances 4 paramedics. If overwelmed they should have requested another ambulance to help. They should have had more than one paramedic confirm death.

If they in fact told the cop that she would quit breathing soon they should be dealt with severly. If they knew she was breathing they should have taken action.

Another point I have pondered is why the fire department had not extricated the body. Had they done this they would have found out she was alive.

But regardless the biggest screw up was the drunk driver. That person needs to rot in jail.

 

[Ridryder911]

I can understand their reasoning, and really do not fault them. I have called soon to be dead persons dead before they became pulseless. It happens everyday, part of EMS life and yes, I have even done it (several times). Yes, it would be nice if injuries were black and white on what to do.

When one has multiple patients (heck even one patient) that is entrapped or when there are other patients that can potentially survive and that one cannot a triage decision can be made. Patients with mortal wounds or wounds that are incompatible with life (open skull w/brain matter, partial decapitation, etc..) then the attention should be focused upon those that will benefit.

In fact ironically, I got called into the office for continuation of a traumatic arrest of patient that had brain matter exposed. The ER staff complained that I continued care of mortally wounded patient. In all rights, I probably should had not worked them, however; one of the reasons was there was proper CPR being performed upon arrival and a large crowd. I had not fully assessed the patient until they were inside my EMS unit and then found brain matter. (What was I supposed to do now? Dump, the victim back outside?) so I continued.. yeah, had to perform several procedures that I had not performed in a while. I notified ED staff ASAP for them to be aware, so the efforts could be d/c upon arrival, in which it was. From what I understand they were irritated because it made a mess, and yes there is a ton of paperwork associated (even if you don't anything).

Usually, I don't ever work pre-arrival traumatic arrest, in fact the first one in several years. (p.s. my administrator agreed with my decision, that it was based upon individual field judgement at the time)

In regards to organ donor program, I agree it is a good program if it works. Unfortunately, in my area they are real active only if the patient has been a in-hospital patient. As well, in this situation this was an M.E. and they can still obtain some tissue if possible.

This is a gray area (no pun intended) that is always risky. Personally, I think it needs to be reviewed but in realistic work, punishment should not be carried out. I have worked at trauma centers that allow ..."nature to take its course".. no difference.

R/r 911

 

[BossyCow]

I'm not disagreeing with the conclusion that stuff wasn't done correctly here. Obviously, the medics should not have left a breathing pt. even one fatally injured, on an accident scene without some sort of care.

But, two ambulances and four medics on a MCI - MVA. They have two ambulances to transport 3 patients with significant injuries. I would think they were pretty busy.

Triage determined how to allocate resources for the call, and should have included some sort of tx plan for the one who was still breathing but soon to die.

The lawyers will hash over all the details in that Abandonment/negligence lawsuit that I'm sure is being formulated even as we speak. It is a shame that the medics who were probably doing what they thought was best, will probably pay a higher price for this than the drunk who caused the event.