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msnbc…
The emergency
response in Tucson: Timeline shows ambulance delays
By Bill Dedman, Investigative reporter
AP Photo/Arizona Daily
Star, Dean Knuth
How fast was the emergency response in Tucson?
It depends on your perspective.
The Pima County Sheriff's Office released on Friday a timeline of the
shooting in Tucson, Ariz., of Rep. Gabrielle Giffords and others,
appearing to show the first ambulance arriving 20 minutes after the
first 911 call came in.
That information seemed to match reports just after last Saturday's
shooting, in which witnesses told reporters that ambulances were 10 to
15 minutes behind the first sheriff's deputies.
It turns out that that's not quite what happened. The sheriff's press
release was incomplete.
The first fire/rescue medical personnel arrived at a staging area near
the Safeway supermarket 8 minutes after the first 911 emergency call
came in. The first ambulance for transporting patients arrived a minute
later.
But these units and later-arriving ones were held away from the Safeway
in a staging area, even several minutes after the gunman's weapon was
secured, out of fear there was a second gunman. This is standard
operating procedure in emergency services. First responders who become
victims can't help anyone.
The first medical units didn't actually reach the Safeway until 11
minutes after the emergency call. Even then, some were held back for
safety. During that time, members of the congressional staff and other
volunteers provided first aide to the injured.
And it was not until 16 minutes after the first emergency call that the
medical response was upgraded to a mass casualty incident, although the
initial 911 call reported that there were "multiple shot." The
battalion chief said he never makes that call until one of his crew is
on the scene to confirm initial reports, which often are misleading.
Perspective matters
Counted as police and firefighters count their response times, the
medical units arrived only five or six minutes after they were
dispatched.
But counted from the time the 911 call came in, it was 11 minutes or
more before patients were being treated.
"Yes, from the perspective of someone on that horrible scene, calling
911, and waiting and waiting and waiting, it would seem like a long
time," said Tom Brandhuber, fire chief for the private Rural/Metro Fire
Department in Pima County, whose ambulances responded. "The units got
there as quickly as possible. They all descended on the scene at once.
And they were able to get all the patients off the scene quickly."
Another factor of perspective: Congresswoman Giffords would naturally
have been the focus of much of the attention from witnesses waiting for
ambulances. The ambulance that took her to the hospital did arrive 20
minutes after the first 911 call, and left for the hospital 10 minutes
later. That total time, 30 minutes, makes her survival of a gunshot
wound to the head all the more remarkable.
The timeline
Here's a timeline of first responders for last Saturday's events,
compiled by msnbc.com by merging information from the Pima County
Sheriff's Office, the public Northwest Fire District, and private
Southwest Ambulance and Rural/Metro Fire Department. Two cautions:
Times were given in whole minutes, and clocks could vary from one
computer-aided dispatch center to another.
10:10 a.m.: The shooter opens fire. Nineteen people are shot.
10:11 a.m.: Pima County Sheriff's Department receives the first of many
911 calls about a shooting with multiple victims at Safeway, 7100 N.
Oracle Road, Tucson. That call was taken by a general call taker, who
determined that this was both a police and medical emergency, and
transferred the information to specialists for both types of calls.
10:14 a.m.: First medical units are dispatched. Northwest Fire/Rescue
(public) sent a "first alarm medical," a higher level of response than
a simple heart attack or single gunshot victim would receive. That
included three fire engines with advanced life support capabilities, a
battalion chief, and three ambulances. Those ambulances aren't normally
used to transport patients to a hospital, so two ambulances were also
dispatched by private agencies with contracts with the county,
Rural/Metro Fire Department and its sister company Southwest Ambulance,
to provide not only treatment but also transport.
10:15 a.m.: Southwest Ambulance dispatches a second ambulance.
10:15 a.m.: Deputy Thomas Audetat is the first sheriff's deputy on
scene and detains the suspect.
10:16 a.m.: Deputy Georgina Patino is second on scene and secures the
weapon.
10:17 a.m.: Southwest Ambulance dispatches a third ambulance.
10:19 a.m.: The first medical personnel begin arriving, from the county
agency, Northwest Fire/Rescue, but are held in a staging area nearby to
make sure the situation was secure. Northwest's first responders were
six firefighters with medical certification as paramedics or EMTs, on
two vehicles, a paramedic fire engine and a paramedic ambulance. These
vehicles are fully equipped for medical treatment, but don't transport
patients except when no other transport is available.
10:20 a.m.: The first ambulance for transport arrives from Southwest
Ambulance, Paramedic 838, and is held for safety. It was Southwest's
second ambulance dispatched, and arrived first, five minutes after it
was dispatched.
10:22 a.m.: Northwest paramedics and EMTs are allowed to move to the
treatment area and start working. Even then, not all the units moved in
at first. "Even when they said it was safe to send in, I sent one
rescue company and engine company, until I knew it was safe," said
Battalion Chief Lane Spalla from Northwest Fire/Rescue. "It's hard for
us to sit on the corner while people need help, but we have to make
sure it's safe. And we have to make sure we're sending the units to the
right place. Those are always good minutes that are needed. I thought
law enforcement did a fantastic job clearing the scene in three
minutes. We've been on calls for individual gunshot victims that took
longer."
10:23 a.m.: Second and third ambulances from Southwest Ambulance and
its sister Rural/Metro Fire Department arrive (Paramedic 837 and Rescue
76). They are held at the staging area waiting for the "all clear."
They arrived in the staging area six minutes and nine minutes after
dispatch.
10:23 a.m.: Six more Northwest firefighters arrive, for a total of 12
medical personnel in the treatment area, with others waiting in the
staging area.
10:24 a.m.: The three ambulances from Southwest Ambulance and
Rural/Metro Fire are given the all clear, and move to the treatment
area by the Safeway.
10:24 a.m.: A neighboring firefighter unit arrives. By now there are 30
or more medical personnel making their way from the staging area to the
Safeway.
10:27 a.m.: Northwest Fire/Rescue upgrades the call to a "second alarm
medical," indicating mass casualties. This effectively doubles the
response, sending three more fire engines, three more ambulances, and
other officers.
10:27 a.m.: A fourth ambulance from the private sector, a Rural/Metro
Fire Rescue unit, is dispatched.
10:31 a.m.: This entry in the sheriff's public timeline is a source of
confusion. The sheriff's office reports that Rural/Metro's Paramedic
831 is the first ambulance on scene, but this turns out not to be
correct. It's the fourth ambulance for transport on scene, not the
first. This ambulance had not been dispatched until 10:27. The
sheriff's timeline for public release may focus on this ambulance
because it's the one that will carry the congresswoman.
10:35 a.m.: The first ambulance to leave is Rescue 76 from Rural/Metro.
It was on scene for 11 minutes before leaving. It arrived at Northwest
hospital at 10:43.
10:36 a.m.: A second ambulance leaves the scene, Paramedic 838, and
arrives at a hospital at 10:45.
10:41 a.m.: A third ambulance leaves the scene, Paramedic 831, with
Rep. Giffords for University Medical Center, arriving at 10:54. (There
were incorrect reports that she was taken by air ambulance. Others
were, but the ground ambulances arrived at the Safeway first, and left
first.)
10:48 a.m.: A fourth ambulance leaves the scene, Paramedic 837, and
arrives at a hospital at 11:06. Other ambulances follow.
Standards for response
times
The nationwide standard for arrival times is usually six minutes: one
minute to handle a call ("dispatch time"), one minute to gear up and
get on the road ("turnout time"), and four minutes to drive ("travel
time"). That six-minute standard is used by the National Fire
Protection Association.
Time is of the essence in handling gunshot wounds, heart attacks and
other life-threatening emergencies. The American Heart Association says
that brain death starts between 4 and 6 minutes after cardiac arrest.
These standards are not laws, and municipalities are not bound by them.
Communities can adopt those standards, striving for the highest-quality
fire and ambulance response, or they can not adopt them. Even when
adopted, they are merely guidelines, though sometimes legal contracts
between municipalities and ambulance companies set certain response
times.
Rural/Metro Corp. and its subsidiary, Southwest Ambulance, have 20
stations in the Tucson area, and more than 75 ambulances. Based in
Scottsdale, Ariz., Rural/Metro serves about 400 communities in the U.S.
Southwest Ambulance (Rural/Metro Corp.) said its standard, under its
state license or so-called "certificate of necessity" issued by the
Arizona Department of Health Services, is for response within 8 minutes
in 70 percent of the medical calls. It said it exceeds those, hitting 8
minutes in at least 90 percent of calls.
Calculating 'response
times'
Working from that timeline, these are the approximate response times:
Times for the first medical units: three minutes of dispatch time at
the central dispatch before the medical units were called, then five
minutes of turnout and travel time. "Response time" from the
perspective of the medical units: five minutes. Then another three
minutes of hold time for safety of the first-responders. "Response
time" from the perspective of a person who dialed 911: 11 minutes.
Times for the first ambulance for transport: three minutes of dispatch
time, at the central dispatch before the medical units were called,
then six minutes of turnout and travel time. "Response time" from the
perspective of the medical units: six minutes. Then four minutes of
hold time for safety of the first responders. "Response time" from the
perspective of a person who dialed 911: 13 minutes.
"These are good times," said Chief Brandhuber from Rural/Metro. "They
show multiple agencies working together well on a mass-casualty event."
Delay in upgrading the
response?
The first 911 call reported "multiple shot."
"There was a shooting at Safeway at Ina and Oracle where Gabrielle
Giffords was, I do believe Gaby Giffords was hit."
Responder: "At the Safeway sir? ... Was somebody shot there sir?"
"It looks like a guy had a semi-automatic pistol, and he went in, he
just started firing and then he ran."
"She's hit, she's breathing, she still got a pulse ... we got one
dead... there's multiple shot."
Responder: "Oh my God."
Other callers told of "a bunch of people shot" and "a total of 10
people, maybe more."
It would be 16 minutes before the incident was upgraded to a mass
casualty event.
"According to our records, the incident was upgraded to a second alarm
medical at 10:27 a.m. and additional ambulances were dispatched
according to protocols," said Jackie Evans, Southwest Ambulance's
market general manager for Southern Arizona.
That's 13 minutes after the first medical units were dispatched, and 16
minutes after the 911 call.
Battalian Chief Spalla said he was responsible as the scene commander
for calling for an upgrade, which doubled the number of crews
responding, and he is always cautious about taking this step. If too
many units are sent to a minor incident, that puts them out of position
if genuine calls come in.
"We might show up and there's nothing. Stories often change from the
first 911 caller to the second, from the time we get on the scene, from
the ambulance crews to the ER doctors. We sent a higher level of
response from the beginning, more than we would send for chest pains,
and until I get units on the scene, until I get eyeballs on bodies, I
don't upgrade again."
Did the delays matter?
There were plenty of paramedics and EMTs, pronouncing as deceased five
of the victims, and assessing, stabilizing and treating the 13 wounded,
preparing them for transport to the hospital, said Capt. Adam Goldberg,
who also serves as a spokesman for Northwest Fire/Rescue. (The New York
Times describes the scene that a first responder from Capt. Goldberg's
company encountered at the Safeway store, and the life-saving choices
made by paramedics, EMTs and doctors at the hospital.)
If the ambulances for transport had arrived sooner, the most seriously
injured patients might have left sooner for the hospital, Goldberg
said. He said he "absolutely" does not think that the wait for an
ambulance made a difference between life and death in this case, but
one can never be sure.
Two doctors were at the shopping center before the paramedics and EMTs,
and the five dead had already been covered. The sixth to die, the
9-year-old girl, was in cardiac arrest with wounds presumed to be
fatal, and wouldn't normally have been rushed to the hospital if there
weren't enough paramedics to work with her, Goldberg said. After
confirming the five deaths, the paramedics and EMTs went to work
furiously on the 13 injured.
"As the ambulances arrived, they were given patients out of our
treatment for transport," Goldberg said. If the ambulances had arrived
sooner, patients would still have needed to be stabilized. "You don't
just take a patient and throw them on the ambulance."
So both things are true at once, he said: If the ambulances had arrived
earlier, the first patients might have left earlier. And it might not
have mattered. "It's a valid question," Goldberg said.
Battalion Chief Spalla said the delays in the staging area were
frustrating, but once at the Safeway his crews had all the people they
needed.
"I had more than enough resources to treat at the scene," Spalla said.
"We were plenty busy. Treatment never asked for an ambulance that we
didn't have for them. If there had been 10 ambulances sitting on the
corner, I couldn't have used them until I got triage going."
Source msnbc.com
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