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Fatality Study: EMS Is a Dangerous Profession

Fatality Study:EMS Is a Dangerous Profession

By Kim Oriole, JEMS InfoMail Reporter
More EMS providers die on the job than anyone suspected, making the occupation nearly as dangerous as police officer or firefighter, according to the first-ever national study of EMS fatalities. The study, “Occupational Fatalities in Emergency Medical Services: A Hidden Crisis,” is detailed in the December issue of Annals of Emergency Medicine, the peer-reviewed journal of the American College of Emergency Physicians. (Click here to view the full report.) Between 1992 and 1997, the study finds 114 EMTs and paramedics were killed on the job, more than half of them in ambulance crashes. That’s an estimated 12.7 fatalities per 100,000 EMS workers, making it close to the death rates for police (14.2) and firefighters (16.5) in the same time period, the study says. And it’s more than twice the national average for all workers (5.0).”The profession is much more dangerous than most people realized,” says Brian Maguire, MSA, EMT-P, chief researcher and study author. “I don’t think people know this is almost as dangerous as firefighting or police work.” He says even EMTs and paramedics who respond to emergencies every day don’t realize the toll their job could take.
The dangers include ambulance crashes, assaults, hazardous materials exposures, infectious diseases, lower back injuries, hearing loss, stress, long working hours and exposure to extreme temperatures.
The study finds that although EMS providers respond to car crashes, shootings, large-scale disasters, hazardous materials incidents and other medical emergencies, little was known about the risks of their occupation. Maguire, the associate director of the University of Maryland Department of Emergency Health Services, got the idea for the study in 1998, but had no idea how difficult it would prove. “This became a four-year project,” he says. “It took a lot, lot longer than I ever expected. It was very challenging. We have a very poor reporting system—no national database,” Maguire says. “We need to have a better tracking system.” He and volunteer researchers pored over hundreds of studies, reports and documents, looking at federal and local numbers, trying to come up with an exact number of EMS deaths. But in the end they had only an estimate—114. “I think it’s a conservative number,” Maguire says. “It’s actually probably higher. I tried to get at only those people who died performing EMS functions, working on an ambulance.” Of the 114 deaths, 67 were from ground transportation accidents; 19 from air ambulance crashes; 13 from heart attacks, strokes and other cardiovascular problems; 10 from homicides, most of them shootings; and five from other causes, such as needlesticks, electrocution and drowning.
Data sources
The researchers used three independent databases to try to find every death, and at the same time, not count repeated reports of the same death. They used the federal Census of Fatal Occupational Injuries (CFOI), the Fatality Analysis Reporting System (FARS) and the National Emergency Medical Services Memorial Service (NEMSMS)—to check and crosscheck the reports. They relied mainly on federal data from the Bureau of Labor Statistics’ CFOI, but had to use their judgment to decide which of the deaths were EMS providers, because there were no unique occupational or industrial codes used for EMS, EMT or paramedic deaths. Instead, the deaths were listed under several different medical headings in that report—physician assistants, licensed practical nurses, health technologists and technicians and nursing aides and attendants—and the researchers had to ferret out which were deaths from EMS work. The size of the EMS population is an important factor in the study’s conclusions. The National Association of Emergency Medical Technicians (NAEMT) estimates there are 870,000 paramedics and EMTs in the United States. However, to calculate the rate of deaths, this study relied on the figure provided by the Bureau of Labor Statistics, which lists 150,000 working paramedics. Maguire reasoned BLS numbers were also used to come up with the death rates for police and
firefighters, “so we’d be comparing apples with apples,” he says. Maguire hopes the study will open the eyes of EMTs and paramedics—”to get the people working out there to take steps to reduce their own risk.”
Ambulance crashes killed the most responders, yet ambulances are exempt from Federal Motor Vehicle Safety Standards. The National Transportation Safety Board has recommended vehicle design safety standards, occupant protection and driver training for ambulances, but its recommendations have never had the force of law. Maguire says new safety regulations are important, but lowering the EMS fatality rate can start with each EMS provider being more safety-conscious on the job.
The study says the patient compartment may be the most dangerous place for EMS providers. Another study found that less than 50% of providers wear seatbelts in the patient compartment. “They can’t take care of the patient if they’re seatbelted in,” Maguire says. “Though they’ll still need to be unbelted at times to work on the patient, if they pay attention, there can be more times that they can wear the seatbelt. The other thing is recognizing the dangerous items in the ambulance—oxygen ports sticking out from the walls, IV poles that hang from ceiling, sharp corners, loose things that need [to be] strapped down.” The other vehicular danger is being hit by passing cars while working on the side of a road or highway, and Maguire says providers might need to wear brighter, more reflective colors.
The report says other changes need to come from the institutional or administrative level—improved vehicle maintenance, better screening of drivers, more driver training, changes in policies on running lights and sirens and reduction of long work hours. Maguire and the other volunteer researchers are now working to study EMS injuries, but he says he originally planned to spend 10 years doing both death and injury studies and laying out plans for interventions and experiments to correct the problems he found. But he’s discouraged now. When they started the fatality study, the volunteers applied to dozens of government agencies, foundations and groups for grants, but got nothing. “On a national basis, there needs to be funding,” Maguire says. “There’s no money for research or interventions. The future of this kind of work is bleak


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Doctors on board – Medical system works for steeplechasing

Steeplechase News – By Joe Clancy - May 13, 2009
 The horse falls. The radio call goes out. “Jockey down at Fence 12. Unit 2 respond.” A specially outfitted John Deere Gator, Unit 2 races to the scene with two paramedics, a backboard and a host of equipment packaged specifically to deal with traumatic injuries.
Once on the scene, the paramedics go to work. They assess the injured jockey, stabilize his injuries, prepare him for transport, place him on the backboard and on the Gator. Slowly, safely, surely, the Gator transports the jockey to the ambulance stationed in an area designed to speed exit from the property. The ambulance then transports the jockey to the hospital.That’s the plan anyway.A customized, step-by-step medical protocol for a steeplechase meet looks something like the above – especially in Maryland. The Grand National, Maryland Hunt Cup, Shawan Downs and several point-to-points work with Special Events Medical Systems, a Baltimore-based company that specializes in emergency services for events and mass gatherings. Working with Dr. Jeff Sternlicht, chairman of emergency medicine at Greater Baltimore Medical Center, and other doctors, SEMS crafted a steeplechase plan several years ago and continues to hone the services offered.

“How do we get care to the jockeys? That’s the big question and it underlies everything we do,” said Clay Richmond, president and owner of SEMS. “Most ambulance services have a hard and fast rule that you don’t take ambulances off a hard surface. They just aren’t made for it, they could flip, they could get stuck, it’s not a good idea.”
And that’s where the Gators come in. No ordinary farm utility vehicle, the SEMS Gators have special suspensions and are customized to carry an injured person in the most efficient way possible.

The NFL, NASCAR, motocross races and college sporting events all use Gators or other small vehicles to transport injured participants.

Richmond’s company began by servicing 5K road races and walkathons and moved on to equestrian events, motorcycle events, monster-truck races and more. Started in 1997, SEMS will provide medical services for 1,000 events this year and now offers a steeplechase certification program – including helmet and boot removal, the potential injuries involved, a site tour – for paramedics planning to work a race meet.

“The biggest thing we’ve learned is the value of pre-planning,” Richmond said. “We have a plan, we work that plan and we continue to improve that plan. We can’t predict where an injury will happen or when, but we are prepared for it all.”

Doctors such as Sternlicht are part of the equation. The course physician at the Grand National for the past seven years, he has studied steeplechasing like any other cause of an emergency situation. The sport brings with it inherent risks, but also carries a subset of issues centering on location, space, weather, animals, spectators and more.

Sternlicht considers jump racing full of unique situations for medical personnel and remembered his first impression.

“It was very intimidating and it still is intimidating,” he said. “You never know what’s going to happen. The courses are spread out, the terrain is rough, you’re doing medical care in a field . . . it’s much simpler to be in my controlled emergency department at the hospital.”

Considering GBMC sees tens of thousands of emergency patients per year, that statement carries some weight.

The third link in the equation involves the Baltimore County Emergency Medical Services program. The Maryland meets often call on Baltimore County ambulances to transport injured jockeys to the hospital, leaving the on-course ambulances in place to serve later races in the day. Part of SEMS’ work also involves notifying hospitals of race meets and the potential for injuries.

Perception isn’t reality
Maryland timber meets have faced their share of medical emergencies – Irv Naylor at the Grand National in 1999, Blair Waterman and Polly Gundry at the Maryland Hunt Cup in 2002, Ellen Horner at the Grand National in 2007, Stewart Strawbridge at the 2008 Grand National and others.

Under the current system, expertly trained emergency personnel respond in Gators and treat injured jockeys in the field. Older systems may not have been as equipped, as trained, as organized, as ready.

To anyone not versed in emergency response, the actions still might look rushed and risky when in reality they are rehearsed and rational.

“We’ve been criticized for not bringing the ambulance on to the field, but there is a clear cut reason not to do that and it’s safety,” said Sternlicht. “You risk having a problem with the ambulance, you risk hurting your own people and you risk putting the patient in more danger.”

The Gators – which aren’t mere Gators – serve as field ambulances with the express purpose of safely moving injured jockeys to the full-size ambulances for transport to the hospital if necessary.

This year Sternlicht, Richmond and race organizers at the Grand National will take the added step of creating a medical tent as “home base” for medical personnel and for evaluation.
Injured jockeys can be brought to the tent where medical personnel can work in a more controlled situation. The tent will also be used to evaluate jockeys who fall and need to be cleared to ride in a later race on the day.

“Sometimes concerned people are a real challenge,” said Sternlicht. “They want to be involved, but my advice would be to let the medical people evaluate, assess and make treatment decisions.”

Sternlicht and others compared steeplechase medical response to that of a ski patrol at a ski resort, where medics respond, stabilize the patient, get the patient to a first-aid center, make a proper assessment in a controlled area and then have the patient transported to a hospital (if necessary).

Sternlicht and Richmond (whose work includes two pending books on emergency procedures at events) see their protocol as a potential national model for steeplechase meets. Both serve on the National Steeplechase Association Medical Advisory Board headed by NSA senior steward and medical professional Gregg Morris.

“The perception in the past may have been that there was no plan, but that’s not the case at all,” said Morris, a physician’s assistant and former jockey. “There are very good, talented people involved and a great process. I’m hoping this tent idea gets off the ground. It might be something that gets recommended to all meets someday. It’s another step, another level of procedure that improves care.”

The Grand National overhauled its medical protocol eight years ago under the direction of Dr. Mark Wheeler, another GBMC physician with emergency experience. The system comes with a pricetag – Richmond and his Gators do not work for free – but the race meet sees it as a worthwhile expense. Sternlicht and the other on-site doctors (between five and eight) donate their services.

“(SEMS) charges us, but the expense isn’t so much,” said Grand National race director Peter Fenwick. “The time, thought, planning and volunteer efforts are pretty substantial and these guys are very qualified for the job. It’s a lot of work on their part and on our part, but it’s worth it and we are very happy with the system we have in place.”


Baltimore Grand Prix Saga Continues

Mid Night July 31

A Bleacher Collapse ?

July 17

Monday’s meeting went well. I arrived at the BGP office about a half hour early to talk to the GM and Race Director. I brought them up to speed on the discussions I had with the Fire Department EMS Chief.

Indy Car Preparation Part 1

Great News !


The next several weeks we will be working with Indy Car preparing for the Memorial Day Race. I think this is an excellent opportunity to give everyone some insight into planning and deploying for a high profile event. Along the way we will be producing a show about the entire experience and talking to every expert we can our hands on.

I will be keeping a diary style blog of my adventures. I am going to give you the good, the bad and ugly of what goes into a venture of this magnitude from having to navigate the maze of bureaucratic red tape to meshing public and private services to the inevitable clash of personalities.


After This Post This Series Will Only Be Available to Members.

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Will Receive a Free Life Time Gold Membership.


Enjoy and Welcome



Sometime in June

Received and email that the Grand Prix would be discussing our contract proposal with the City Manager. We proposed to allow our service to work on behalf of the race to help coordinate a reasonable response and control cost. Last years response was so costly it bankrupted the previous event. The previous year’s race had no one on their staff that knew anything about EMS or Event Medicine. The City Department also didn’t have any experience developing these types of responses. In the absence of experience they got a colossal response that no one could afford to pay for.

July 1, 2012

I spoke with the GM and he informed me that we where hired with only one sticking point. The City Manager wants all on track transports done by the City. I understand what is happening here and like I always tell people life is just a series of never ending negotiations. The race wants me to devise , and over see the implementation an EMS & Safety plan. Wanna know what all that means ? If things go well everyone will get credit and take victory laps and if something goes wrong , yup you guessed it will be all my fault.

During my extensive travels I have observed that the most difficult part of implementing a reasonable event EMS plan is convincing public safety agencies that you can safely cover events with less than everything in their arsenal. This industry is dominated by dogmas. Since 9-11 the dogma has been “be ready for a MCI”. The government has spent billions and most departments got every tool they ever wanted. Since that awful day no attacks, there is no great amount of MCI incidents. After twelve years of funding and conditioning Department Heads have been programed to see the MCI Boogie man behind every concert speaker or goal post.

Treating every mass gathering of people as a potential MCI is expensive. I acknowledge that there is always the potential for a MCI , the same as I acknowledge there is always the potential of an airplane crash. It’s omnipresent but we still do what is reasonable when we fly. We need that same measure of restraint when we plan responses for events.

How many mass gathering or events do you think take place everyday in this country ? I’m talking about fairs, festivals, conventions and concerts ? I don’t know the exact number but I would wager it is in the hundreds of thousands. Excluding the Indiana State Fair stage collapse and the June 17, 2012 stage collapse in Toronto, Canada where one person died ,how many special events have turned into MCI ?

I kinda understand the pressure public officials are under because if something goes wrong in this 24 hour news world they will be roasted and crucified for even the smallest perceived error in judgment. That fears of being held responsible and the consequences that follow is something all leaders face and and accept as a condition of their position.

Instead of treating each event as a potential MCI, develop a responsible response. In EMS change comes very slowly and this will be no exception. EMS manager are constantly playing a game of musical chairs and they don’t want to take the risk of being without a chair when the music stops.  Evidence is mounting that mammoth responses are a thing of the past. As the California cities of Stockton, Mammoth Lakes and, most recently, San Bernardino file for Bankruptcy protection, the city of Detroit announced the lay off 164 firefighters but 2 days later got a temporary reprieve with a grant from the Federal Government, not to mention the fiscal crisis Camden New Jersey is facing and the closure of 3 Baltimore City Fire Companies, no one can afford unreasonably large responses and the public is growing weary demanding proof that the money out lay for our services is justified.

This isn’t a matter of political parties but a matter of more people drawing from a shrinking resources pool. A $30,000 a day response is not acceptable when it could have and should have cost $3000.00 a day. Going forward I believe you will see more of these type of partnerships between public and private.
July 3

Met briefly with the EMS chief he is an awesome guy and easy to work with. We are very close on our vision for the race. I now need to touch base with two hospitals and Indy Race Medical Director early next week. Next meeting scheduled for Monday. We are discussing the budget.

Meeting with the camera crew tomorrow to discuss a shoot schedule for the show and how we can develop around the Grand Prix.

 Reference Material:


For Times They Are Changing


Change is Upon Us Will We Be FedEx or USPS ?


Providing EMS at the 2011 Baltimore Grand Prix

By Erik P. Steciak, NREMT-P

*As SEMSNation begin preparation for the Baltimore Grand Prix 2012 let take a minute an relive the event through the eyes of Paramedic Steciak -Enjoy


Erik P. Steciak has been involved in EMS since 2003, and is currently a Lead ALS provider for Special Events Medical Services.

U2 Concert: 22 June 2011, Medical Standby

U2 Concert Baltimore Maryland- Medical Stand-byU2 Concert: 22 June 2011, Medical Standby

John F. Oliveira, NREMT-P, CCEMT-P, FP-C

The city of Baltimore hosted a major concert last week, and I had the opportunity to be part of the team of Emergency Medical Service providers assigned to the event. The Irish rock group U2 played at M&T Bank Stadium, home of the Baltimore Ravens.  My company, Lifestar Response of Maryland, partners with Medstar Health to provide medical services at all M&T Bank Stadium events. When assigning staff to stadium events, we often refer to “game day” coverage, to quickly determine the amount of personnel we will need, and what they will be expected to do.  The U2 concert received a slightly larger response than a Ravens home game.

For a standard football game, we staff a transport Medic Unit at each ordinal gate, and one Medic Unit on the field which is designated for the players. We also have roving solo EMTs and Paramedics stationed throughout the stadium. Medstar Health provides physicians and nurses to staff first aid stations that are situated throughout the stadium. Each transport Medic Unit is assigned to a specific first aid station. There is a centralized Communication Center in the basement of the stadium where we have supervisors and dispatchers in the same room as every municipal public safety agency present, as well as the stadium’s own safety and custodial staff. Everyone is in the communications loop. Communication and scene awareness are critical in providing excellent medical services in a large scale environment, such as a stadium event.

The U2 concert required additional personnel since the field had been covered with temporary flooring to accommodate roughly 8,000 general admission fans that would be present, instead of the usual 300 or so players, coaches, and staff. There was also an enormous 162 foot tall behemoth of a stage taking up the entire neighborhood of the east end zone. Once the thrill of being in this new environment wore off, we returned to our usual game day preparedness.  Regardless of the size of the event, EMS providers must adhere to the basic tenets of their training. An initial scene survey must be performed. You have to know where you are at all times. You have to know where you are supposed to be at all times. You have to know where your fellow EMS providers are if you need help. For a large stadium-style event, this scene survey is a dynamic assessment as the crowds, and in some cases the service area, waxes and wanes.  Next on the check down list, but just as important, is communications. You need to have constant access to a controlling element of the standby. During your initial scene survey, you will have to identify who will be calling you for service, and who you will be calling for direction and/or assistance.  Finally, you will have to have some sort of plan to deal with whatever medical request or transport you may receive.

My partner and I were honored to be chosen to be the medical team assigned to the band and stage crew. We arrived at the stadium with our colleagues and performed our scene survey. We normally are a transport Medic Unit and have had the same post assignment for several years. For the concert, we would be in close proximity to the band at all times, and would be moving accordingly. We had to navigate around the enormous stage and re-familiarize ourselves with an alien environment.  We had the standard communications equipment and personnel in place, however, we had the addition of a designated band representative who would contact us directly if we were needed.  We had to be in constant visual contact with this representative, so we had to quickly establish our posts, and remain there as needed. During the event, this band representative changed three times. For every personnel change, someone assigned to the band would contact the central communication center and request a supervisor. Our supervisor would then come out and introduce us to the new band representative, and we would go over any signals that would be used. The additional layer of communication, in addition to the added security personnel only caused only minor problems; most everyone there was familiar with the standard game day operations, and used that as a common reference base.

As a whole, the concert required an average response from our combined medical services, with approximately fifty patient contacts, and seven transports to an Emergency Department. The Baltimore Ravens do an outstanding job ensuring that the right people are in the right place and that everyone can talk to each other for every event held at their stadium. This continuity of excellence allowed us to overcome our worst condition at the concert – noise.  While 70,000 cheering football can make quite a loud noise, radio communications are still possible with ear pieces. U2 was much louder. It became quickly apparent during the band’s sound check that our existing radio equipment would be useless out in the bowl of the stadium while music was playing. Since the stadium security personnel were familiar with both the Lifestar and Medstar staff, security would either locate us by recognizing our uniforms to bring us to a patient, or bring a patient to our known locations. This became most beneficial during the end of the concert when those 8.000 or so fans on the field were beginning to press against the security wall in front of the stage and had to be pulled out as they became weak or sick.

Since we work in conjunction with Medstar physicians and nurses, we have a ready-made transport plan in place. We triage our patients and they either get treated in a stadium first aid room or get sent to an appropriate Emergency Department. If we transport to a Medstar hospital, we have the luxury of a Medstar health professional calling ahead for us in lieu of a standard medical consultation. In some cases, we pick up a patient and take them directly to the hospital without making contact with Medstar staff at the stadium. In these instances, we follow Maryland protocol for treatment and medical consultation.  The majority of patient contacts and transports at the U2 concert were for the expected heat and alcohol related injury.  Lacerations and bruises from assaults and falls were also commonplace.  I had the opportunity to perform my first tooth extraction as a paramedic, which gave me the added joy of watching my dispatcher figure out how to code that entry into the event database. As to my partner’s and my responsibilities, we quickly determined that while we were there for the band and crew, the crew was far more likely to provide us with a patient.  Our primary post was directly behind the stage, and the amount of people running around, moving large items, changing electrical equipment, and generally moving in a frenetic pace kept us in a constant state of wariness. On our initial arrival and interview with the first of three band contacts, we asked what type of responses were needed before, how many crewmembers were we responsible for, were there any crew with medical conditions that we should know about, and what, if any, were any other special needs that we should be aware of. These were legitimate and responsible questions that were answered with a shoulder shrug and a terse, “just stand there and wait for me to call you.”  As an EMT, this indifference to our job is common, and with experience, becomes less annoying. We know we’ll figure out what we have to in order to get our job done. Last Wednesday night, among 81,000 people, we did just that.


Out at Home

Updated: January 12th, 2011 10:18 AM CDT
From the May 2009 Issue of EMS World

An injury to a young athlete poses very public care issues

By James J. Augustine, MD, FACEP

As the Attack One crew runs onto the field, it’s so quiet, they can hear every whisper in the crowd. The young baseball player lies motionless on home plate. A coach crouches next to him, but most everyone else is trying to look away. The reason becomes obvious as the lead paramedic crosses first base: The player’s right ankle is grossly broken, and blood is staining his sock and shoe.

The player is pale and groggy. The coach tells the crew the player slid into home, colliding with the catcher, and his ankle snapped. He was in so much pain he was screaming, then looked at his bloody ankle and passed out. The coach is also getting a little pale as he tries to care for the young man without looking at the ankle.

The patient is 15 years old and has a slow, regular pulse. His only injury is the ankle, which has a very unusual angulation, and actually has a piece of fibula sticking through the sock. There is a moderate amount of blood on the sock and the surrounding ground. As the crew moves to immobilize the boy’s ankle and remove his athletic cleats, he wakes up and complains of severe pain. The crew recognizes that the severe deformity of the ankle is causing a great deal of distress for bystanders, so they strategically cover the ankle with a sheet as they work. Any movement of the ankle causes exquisite pain, so the crew moves rapidly to remove the shoe, cut off the sock, and rest the ankle and foot in a splint. With the grossly deformed ankle, the boy has a weak pulse in his foot and poor capillary refill in his toes.

The player lies directly on home plate. Players from both teams are providing support from their dugouts, so one of the EMTs asks if either team can provide some ice to help reduce the pain of the injury. A person in the crowd offers to go to the concession stand to get a bag of ice. The crew decides it will be best to make a quick removal to the medic unit, because staying in front of the other players and spectators won’t be good for anyone.

The coach accompanies the player as they wheel him to the ambulance. The young man’s parents are not present at the game, and attempts to contact them have been unsuccessful. After the crew places the patient in the vehicle, he complains of more severe pain, and the paramedic notices his foot is even paler than it was on the field. The splint is maintaining the ankle in the position it was found, but the circulation to the foot has been compromised. A pulse oximeter placed on the great toe of the right foot cannot find a pulse.

The coach asks, “You can’t treat him, can you? I don’t have a permission form from his parents for medical care, and I probably should.”

“Yes, sir, we can,” the paramedic tells him. “We will provide care to anyone, including a minor, who requests it. We evaluate the patient, and if we find an emergency condition, we treat the emergency. We cannot withhold needed treatment for a young person who needs it, like this young man does.”

Without a pulse, they will have to reposition the ankle to get it more in alignment. The crew contacts medical control as they start an intravenous line, then loosen the splint. They report the injury to the emergency physician, as well as the need for pain medication and putting the ankle into a better position. The physician asks if the boy’s parents are present, and is told they aren’t. But given the report from the paramedic and the young man’s pain, he gives an order for administration of morphine and attempting to get the ankle back grossly into position, so as to restore blood flow to the foot.

The crew starts an IV line, and administers morphine 2 mg at a time until the patient’s pain is under better control. The medic tells the young man and his coach that he’s going to have to pull very gently on the ankle to get it back to its normal position and restore blood flow. At that point the paramedic gently applies traction on the ankle and returns it to a more normal position. The bone sticking through the skin is not going to go back into place, but getting the joint back to a better place restores the pulse in the foot, reduces pain, and decreases the bleeding from the end of the bone. The splint is reapplied, the leg is elevated and the bag of ice from the person in the crowd is placed on the splint. The patient is much more comfortable as they start the 20-minute trip to the hospital.

Before they leave an assistant coach, who had been waiting outside the ambulance, is asked to talk to the player and the coach inside. They agree that the other players and the crowd will be notified that the player’s broken ankle has been put back into better position, and he has been treated with pain medication and is in good condition going to the hospital. They also agree that the assistant coach and some other players’ parents will continue to attempt to contact the injured boy’s parents. Whether they show up at the game or are contacted by phone, they will be directed to the hospital where he is being transported.

Initial Assessment

A 15-year-old male with an open fracture of the right ankle due to a baseball accident. He then had a syncopal episode after seeing the injury.

Airway: Intact.

Breathing: No distress.

Circulation: Patient was originally pale, but on return of normal heart rate, had normal capillary refill and pink skin.

Disability: Fractured ankle, but no distal neurologic deficits. Exposure of Other Major Problems: Open fracture and dislocation of the right ankle. No other injuries present.

Vital Signs





Pulse Ox.



Not palp.













AMPLE Assessment

Allergies: None.

Medications: None.

Past Medical History: No medical problems.

Last Intake: No food intake since breakfast around 0800.

Event: Open fracture and dislocation of the ankle, with bone penetrating through the sock and mild active bleeding. Patient passed out after seeing the injury.

Hospital Management

The ED staff is prepared for the patient’s arrival. During the 20-minute transport, the assistant coach finally reaches the parents, who call the emergency department to say they’re on their way. The ankle is still deformed, but the patient has a good pulse in his foot, and pink skin with good capillary refill in his toes. The elevation, ice and morphine have made him much more comfortable.

X-rays show fractures of both the tibia and fibula, and a dislocation of the joint. The boy will require surgery. The parents arrive and, after talking with their son and his coach, place a call to the EMS service to express their appreciation for the prompt care the Attack One crew provided.

After surgery and extensive rehabilitation, the patient returns to baseball. When he visits the EMS crew during his recovery, he is proud to tell them: “Before I was ‘out’ at home, the umpire had called me safe!”

Customer Service Opportunity

Athletic injuries in front of crowds put EMS personnel in the position of providing care in a very public arena. Events that happen in major crowd venues require special management. Crowd concerns about the patient should be acknowledged, and when possible, spectators and bystanders should be reassured that the athlete will be OK.

Case Discussion

Athletic injuries in front of crowds put EMS personnel in the position of providing care in a very public arena. EMTs should be comfortable in performing their usual medical role, but should be flexible enough to know when interventions should take place. Taking the athlete out of the public eye before doing any procedures and minimizing the athlete’s discomfort are important elements for the patient, their teammates and bystanders.

The management of teenage patients can present issues related to legal aspects of consent for care. These situations are managed by understanding the consent rules outlined by agency medical direction and legal counsel, and generally by providing the best evaluation and emergency medical treatment available to the patient. Teenagers are often involved in activities that take them away from their parents, and may need evaluation, treatment and transportation before parents can be contacted. The teenager requesting care should be evaluated and treated promptly, and transported to the appropriate emergency department. EMS crews should be helpful in providing information to parents that will allow them to meet their child at the best location and understand their child is receiving excellent care. If the patient has an illness or injury that is not life-threatening, it should be made clear to the parents that the child is stable and receiving care, so they do not feel the need to drive inappropriately fast to the hospital, or assume their child is suffering until they arrive.

Learning Point

Teenage athletes can be injured in a variety of ways, and EMS care should include adequate evaluation and managing any emergency medical condition found. This is a good discussion item for EMS providers and their legal counsel and medical direction. Dramatic injuries occurring in front of crowds, often including parents and friends, require EMTs to modify procedures to consider what’s best for all involved.

James J. Augustine, MD, FACEP, is deputy chief-assistant medical director for Washington, DC, Fire and EMS and a member of EMS Magazine’s editorial advisory board. Contact him at jaugustine@emp.com

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