Case Review: Special Delivery

The weather forecasters couldn’t have been in greater agreement: There was not going to be a big snowfall, just a lot of wind. But the wind was worry enough for the EMS and emergency department leaders in the region, so the chief asked the Attack One crew assigned to work the day the “wind event” would move through to prepare a plan for a potential severe winter weather event.

The crew members reviewed their department’s major weather incident plan and sent a few notes to friends in cities to the north that had seen notable winter events over the years. They talked with the managers of the emergency departments they saw on their usual rounds, and found they were all preparing storm plans. The crew met two days before the front was due, updated their weather plan and briefed department leadership, then called a meeting for the ED leaders. They prepared a briefing for all crew members who would work the weather day. That day the forecast was modified to include “maybe an inch or two of snow.”

A day later, the forecast was “too close to call—maybe more snow, but clearly a very windy day.” The fire, EMS, police and emergency management leaders met, and all agreed they would institute their severe weather incident action plan at 0700 the next day. All departments would staff up, and the jurisdiction’s small fleet of snow removal equipment would be prepared, with backup plans for private contractors and agencies with heavy removal equipment. They would announce their plans to the public on the evening news. They would establish a joint information center, and all department public information officers (PIOs) would work through it.

Fire, EMS and hospital leaders met that afternoon, and the hospitals were prepared to announce they were canceling all elective operations, bringing in and housing extra staff, and discharging all patients who could safely leave. The Attack One crew leader was asked to chair the meeting, be responsible for ensuring emergency plans were not in conflict, and cover the necessary elements of emergency medical response and patient removal. About midway through the meeting, the group realized they would need support from the regional 9-1-1 call center, so a representative was asked to report. One of the hospitals agreed to serve as a regional coordinating center for emergency medical and hospital operations, and one of its employees would be present at the emergency operations center, should it be stood up.

By the time the evening news aired, meteorologists had upgraded their expectations to “blizzard-like conditions for a short period, with 4–6 inches of precipitation and high winds for 6–8 hours.” By the 11 o’clock broadcast, the forecast was worse.

The precipitation started with a light snow at 0600 hours, by which time the Attack One crew was already in the station, briefing the crews from both shifts that would be on duty. Fortunately, schools and businesses closed in preparation for the storm, so traffic on the roads was light. By 0900 hours, it was a solid shield of wind-driven snow, and by 1000 hours it was officially a blizzard. Wind howled around the stations, and crews were having trouble keeping the doorways clear for equipment. Power lines began falling, and calls came in for persons blown over by winds, arcing power lines, and other, more routine medical calls. By 1900 there were many large drifts, and it was difficult to drive on many streets. Road maintenance crews could not keep the roadways clear, but did their best to keep critical areas open to traffic near hospitals, fire stations, utility stations and police headquarters. The public was advised to stay off the roads. After sundown, conditions worsened, and the blizzard continued.

The Call

After dinner Attack One is dispatched to a peripheral area on the north side of the city for a woman in labor, with additional information that she is near term, and the apartment building where she’s located is at the top of a hill and snowed in. The dispatcher advises that a fire engine and snowplow are being dispatched to assist access.

The drive is difficult even with snow chains in place. Drifts and poor visibility turn what is usually a six-minute response into 15 minutes, and the fire engine crew reports they can only get within two blocks of the address. The snowplow can’t get any closer, and is working to clear a path near the engine that will eventually allow the ambulance to remove the patient to a nearby hospital.

Three blocks from the apartment, Attack One can progress no farther. The ambulance crews struggle to load equipment onto a stretcher and carry it the three remaining blocks to the patient’s address. The fire engine lieutenant reports his crew has finally arrived at the apartment and found a young woman in active labor.

When all crew members arrive, they indeed find a 27-year-old female with abdominal cramping and contractions consistent with delivering a baby soon. She is on a couch, with her mother nearby. She has a cast on her right leg due to an ankle fracture that occurred on a patch of ice about a week prior, and she can’t bear any weight on that leg. She is in no distress, and reports she’s at 39 weeks with this, her second pregnancy. Her first baby had been delivered quickly. She had eaten dinner with her mother earlier, and her contractions began about 30 minutes ago. Her amniotic membranes ruptured about 15 minutes prior to calling. She’s passed no blood.

The woman says she was checked by her obstetrician about two days ago to make sure she and her baby were doing well after her fall. The doctor advised her then that she still appeared to be about two weeks from delivery. That obstetrician had asked expectant moms to check into the hospital ahead of the incoming weather if they were close to delivery, but this young lady felt that since she was two weeks away, there would be no problems. She had arranged to stay at her mother’s apartment, since her leg fracture forced her to stay off her feet.

Now she’s having contractions about every five minutes, but does not feel like pushing. She says her obstetrician and preferred hospital are on the south side of the city, where she lives. She requests transport to that hospital. With a smile, the Attack One paramedic tells her, “There’s not much chance of that, but let me make sure.”

After a quick check with the 9-1-1 center and a call to the labor and delivery unit of that hospital, he confirms there is no safe way to take her there. “Ma’am, we make every possible attempt to get pregnant patients to their preferred hospitals,” he tells the woman. “Tonight we’re going to have to carry you three blocks to the ambulance. It took us 15 minutes to drive the mile and a half to your address, and street crews are saying the major roads to get to your preferred hospital are probably not passable. It will be at least an hour to take you there, if we can get there at all. With your contractions and history of rapid delivery, it is unlikely we have that time. We’ve asked your preferred hospital to share your records with a hospital that is two miles away from us. Their labor and delivery unit is open and ready, and it is really the only safe alternative.”

Between the next set of contractions, the young woman agrees.

“To care for you, we’re going to bundle you up, and it will take all nine of us to carry you on the stretcher to the ambulance,” the medic tells her. “We will not start an intravenous line or do any other interventions now, but please let us know how we can keep you warm and comfortable until we get you in the ambulance. Your mother can walk safely with us and travel in the ambulance, because she will never be able to drive out of your parking lot.”

The crews struggle to carry the patient through drifting snow and howling winds across uneven surfaces they can’t see. They have to stop once as the patient has another contraction, and one of the crew members reaches through the blankets to hold her hand as she completes it. “You don’t feel like pushing yet, do you?” he asks.

“Not yet, but probably soon.”

They place the patient in the ambulance and warm the cabin as much as possible. The paramedic feels the cabin will not get warm enough to hang intravenous fluids, so he lets the patient get comfortable on her left side, places her on oxygen, and has the delivery kit ready on the passenger bench.

At the Hospital

The trip to the hospital is tedious. The snowplow leads, then the fire engine, then the ambulance. The nearby hospital is contacted, and the labor and delivery staff advises the crew to deliver the patient to the emergency department, as its entrance is still open, while the L&D entrance is now snow-blocked. The crew shares the patient history with the ED staff by radio; at the same time the patient continues her contractions, and reports that she feels she is going to be pushing soon.

As they pull up to the ED, the patient says she needs to push. The crews collaborate to rapidly get the stretcher out of the ambulance and the patient into the ED, and there the L&D staff delivers the baby on the ambulance stretcher as she is wheeled into the resuscitation bay.

Five minutes later, mother and baby are doing fine. The baby cries, the mother cries with joy, and the grandmother cries as well. The L&D staff put the baby in the warmer, which is somehow appropriate on this freezing night. Mother and baby are eventually taken to the women’s services unit, and both do well.

The crews have a lot of cleanup to do, and even the street plow crew is asked to come for a quick meeting in the ED to celebrate the child’s safe delivery. Then everyone is back into the blizzard for a busy next 24 hours.

Case Discussion

Major winter weather events will require EMS systems to alter their routine parameters of care. When faced with the likelihood of a severe winter weather event with lots of snow or ice, regional EMS and emergency department leaders will need to communicate to ensure the integrity of the emergency system. Together, emergency planners should develop incident action plans that address community needs and resources. Depending on community resources, a variety of agencies may need to be involved. At a minimum, the EMS plan should incorporate an expanded role for fire department and law enforcement resources. If there are plans to make major changes in response patterns, the agencies should collaborate with the media to communicate the necessary information to the public.

Planned alterations may begin at public safety answering points (PSAPs) and include changes in 9-1-1 protocols and prearrival instructions. Interviews of 9-1-1 callers may need to encompass additional information regarding barriers to access for responders, and some additional medical information. Callers may need to be notified of anticipated delays in response, and may need to receive additional prearrival instructions—e.g., “please assist the responders in identifying your home, since they cannot see address markers.” EMS action plans developed with hospitals may include removing patients to their closest EDs; identifying hospitals that may be difficult to access; and stocking larger supplies of sheets, towels and blankets to replace those used in patient care. Between the public safety agencies, there may be different patterns of equipment dispatch, with more use of fire equipment to gain access to addresses and potential collaboration with police and other agencies to use snowmobiles and snowplows to access patients away from cleared roads. Air ambulance and other special transportation resources typically won’t be in service.

To prepare the public, the jurisdiction’s public information office will need to fashion appropriate messages when operations will be significantly altered. If a storm pulls down power lines, it is critical to deliver important warnings before there are large numbers of citizens who cannot access communications. As in this incident, the message to the public may include elements such as weather-related delays in responding to calls, reduced ability to transport to hospitals of choice, and some necessary changes to patient care.

Hospitals and emergency departments will face altered operations as well. They will be holding and managing patients who cannot leave. The problems referred to as “boarding” often are aggravated by severe winter weather. Hospitals may also need to house staff members who cannot travel safely to or from their homes. Many hospitals will shut down elective services to preserve resources for the crisis. If major power outages occur, there will be even more stress on hospital resources.

Overall, the incident action plan for a severe winter weather event allows the emergency system to prioritize the emergency needs of its community and use all available resources to meet them. Elements may include:

  • A modified response plan, embraced by all public safety agencies and private transportation providers;
  • Modified use of PSAPs and centralized communication centers;
  • Cooperation between hospitals, home care and extended care facilities to reduce patient loads on the emergency system;
  • Plans for transportation to the closest ED, regardless of patient type;
  • Increased need for supplies to protect patients from the cold and weather;
  • Cold stresses and an increased chance of injury for first responders;
  • Likely changes in patient load, including more patients with carbon monoxide exposure, cold injuries and burns.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and a member of EMS World’s editorial advisory board. Contact him at jaugustine@emp.com.

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