It’s 9am on a Saturday. You and your crew are at the gas station filling the tank for the next shift when two calls come in simultaneously. The first, a pregnant woman 5 minutes away; the second, a single vehicle accident with four victims, possible fatalities and life threatening injuries 20 minutes away. You are the nearest ambulance for both calls and the next closest ambulance is 30 minutes from your current location. Which do you take?
There is no right or wrong answer to the above question. Just like in triage, you do as much good as you can with whatever information you have for the most people you can. Sometimes you hit yourself over the head for years to come and sometimes you go home completely sure about yourself and the choices you took. This call was the latter.
We took the vehicular accident which was located on the highway between Mexico City and next biggest city, Toluca. Being an ambulance service located on the edge of the city we usually got called to rural calls such as these where the arrival time is over 20 minutes and usually transport to the nearest hospital can be over an hour.
First let me explain a little about how things work in Mexico City, as they are very different from Canada and, I imagine, most places from where you might be reading this.
Here in Mexico we have three types of transport patients. Those with private healthcare, those with government healthcare and those without healthcare. This determines to what hospital we can take the patient and let me tell you it changes dramatically the speed at which your patient can be cared for. The law, however, states that you can take a critical patient to any hospital regardless of his or her healthcare situation. This usually helps us in rural cases because just on the edge of the highway we have one of the best private healthcare hospitals in Mexico; so if the patient is critically injured, we have where to go. Otherwise, strap-on and hold tight because it’s going to be a long transport.
For most people this is what defines a rural call. One that takes place far from a tertiary hospital, at least an hour away, and where resources can take a lot longer than usual to arrive. Resources such as search and rescue, ambulances, firetrucks and patrol vehicles.
In this case, the nearest ambulance was us at 20 minutes from the scene, rescue services at 30 minutes, additional units at 50 minutes and aerial medical evacuation at 10 minutes, however no landing zone available nearby.
We race towards the accident scene with limited information and unsure as to what exactly we will be needing on the scene. Despite having been told that there are multiple victims with possible fatalities we are not told how many or the state of them. There are no first responders on scene and the patrol vehicle on scene does not have direct communication to us.
That’s another important thing to mention about paramedicine in Mexico back then (2009); emergency services were not coordinated by one entity, but rather work independently. This usually meant arriving at scenes with no clear information of what we were walking into. Thankfully this has changed in the past two years.
Back to the accident… At arriving we notice that the vehicle had been speeding, lost control on a slope, spun off the highway and impacted laterally against a rock wall on the side of the road. The car was bent in half, engine still running, and grim silence all around the scene.
There were four victims. The driver, who perished on impact, the side passenger, who was ejected from the driver’s window and had life threating injuries, and two little girls in the back. One, sadly, without vital signs and the other trapped with multiple traumatic injuries. It was clear that we needed rescue on scene as soon as possible and an additional ambulance.
The fire rescue engine took twenty additional minutes to arrive on scene. Meanwhile one of us took to treating the ejected passenger and loading her to the ambulance, two more to treating the girl in the back of the vehicle, and one of us coordinated the arrival of the remaining resources needed to properly treat this incident. (And yes, sometimes we are five paramedics per ambulance here).
When the trapped victim was liberated and the second ambulance arrived, our first victim fell into cardiac arrest. Our protocols back then for rural cases were to load and go to the nearest hospital (remember that nice private hospital I was telling you about?).
We loaded our patient, began CPR and drove to the aforementioned private hospital where two trauma teams were waiting for both ambulances to arrive.
Sadly our patient didn’t come out of cardiac arrest, but the little girl survived and was discharged many months later from her insurance hospital.
What we learned on that call was simple. Time matters and patient care is key. We frequently revisited the site, re traced our steps, analyzed the situation with co-workers and other companies and every time we came to the same conclusion: the accident happened just too far away from any emergency services to have been handled any differently.
Things have changed since that fatal car accident all those years ago. The highway patrol units have better response times to accidents, the fire department is kept in the loop and has a new ambulance for highway accidents, more ambulances have been deployed nearer to the highway and out medivac helicopters have been authorized to extend their coverage zone to reach those remote sections.
There are hundreds if not thousands of stories like this one all over the world pertaining to how long an ambulance took to arrive or how long it took for emergency services to be called in. Slowly but surely different countries, provinces and states have improved their response time and now employ statistics to determine what area is the most likely to have accidents or require faster response times during certain months of the year.
Since 2017 there has been important headway in community paramedicine to avoid unnecessary patient transports, emergency department presentations and hospital admissions (1).
In New Zealand, for instance, the model for Extended Care Paramedics has been adopted. The role of these ECP’s is similar to that of a Community Paramedic in Canada in that they both aim to analyze, diagnose and treat patients in their home, so long as the illness allows it. (2)
Extended Care Paramedics and Community Paramedics have special training in stabilizing patients on scene while waiting for prolonged hours for the nearest ambulance to arrive and transport if needed.
These models have not yet been adopted in Mexico and there is still a long way to go before this happens. However, more ambulances are being deployed to remote areas to help prevent these delays in transport and help save lives.
- Bennett KJ, Yuen MW, Merrell MA. Community paramedicine applied in a rural community. The Journal of Rural Health 2018; 34(Supplement 1): 39-47.
- Hoyle S, Swain A, Fake P, Larsen P. Introduction of an extended care paramedic model in New Zealand [Internet]. National Library of Medicine. 2012 [cited 2 September 2020]. Available from: https://pubmed.ncbi.nlm.nih.gov/23216727/