- Email: [email protected]
Nonfatal Sniper Attack of a Pediatric Patient: Prehospital Response in a Regionalized Trauma System
Nonfatal Sniper Attack of a Pediatric Patient: Prehospital Response in a Regionalized Trauma System Joseph L. Wright, MD, MPH,*yz§ Michael G. Holder, MDO The unusual circumstances surrounding the prehospital response to a highly publicized sniper attack upon a pediatric patient are detailed. Examination of this case from a systems perspective within a highly developed statewide regionalized trauma care network highlights essential system features. The unique aspects of the response are also critically examined and discussed. Clin Ped Emerg Med 7:71 - 75 ª 2006 Published by Elsevier Inc. KEYWORDS emergency health services, emergency medical services, emergency medicine, pediatrics, prehospital emergency care
F
or a 3-week period in October of 2002, the Washington, DC, metropolitan was terrorized by a series of random sniper attacks. The string of shootings, primarily focused in the Maryland suburbs, resulted in 13 victims who sustained single shot, high-velocity penetrating injuries. The only pediatric victim of the sniper attacks was among the 3 survivors. The following report details the prehospital phase of this patient’s care in the context of a regionalized, pediatric-specific system response.
System Background Over the last 30 years, trauma system development in this country has evolved dramatically. By definition, region*Office of the State Medical Director, Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, MD 21201, USA. yEmergency Medicine and Prevention and Community Health, George Washington University Schools of Medicine and Public Health, Washington, DC 20037, USA. zChild Health Advocacy Institute, Children’s National Medical Center, Washington, DC 20010, USA. §Center for Hospital Based Specialties, Children’s National Medical Center, Washington, DC 20010, USA. ODivision of Pediatric Emergency Medicine, Akron Children’s Hospital, Akron, OH 44308, USA. Reprint requests and correspondence: Joseph L. Wright, MD, MPH, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010. (E-mail: [email protected])
1522-8401/$ - see front matter ª 2006 Published by Elsevier Inc. doi:10.1016/j.cpem.2006.03.002
alization of trauma care refers to a geographic organization of services that ensures access to trauma care at a level appropriate to patient needs while maintaining the efficient use of available resources [1]. Despite a paucity of population-based evidence, it appears that trauma regionalization confers statistically significant benefit to those communities served by systems in which essential system components have been established [2,3]. In fact, in motor vehicle crash–related mortality, the effect of trauma system presence seems to be most beneficial in the 1-14 age group [4]. Since 1973, the Maryland Institute for Emergency Medical Services Systems (MIEMSS) has been the lead organization responsible for coordinating Maryland’s statewide emergency medical services (EMS) system [5]. MIEMSS was one of the earliest systems to incorporate the essential components of regionalized trauma care and is currently 1 of 34 designated statewide trauma systems in the United States [6-8]. Over the last 30 years, the Maryland system has grown to encompass 11 trauma centers, including the R Adams Cowley Shock Trauma Center in Baltimore, which serves as the system’s primary adult resource center. Statewide communications and transportation systems are also overseen by the agency, including a fleet of 12 high-speed state police helicopters that are operated by the Maryland State Police (MSP) Aviation Command. They perform a triple function of 71
J.L. Wright, M.G. Holder
72
Figure 1 MSP medevac helicopter bases.
medevac, search and rescue, and law enforcement and are strategically stationed at 8 operational bases across the state to enable rapid response to field trauma (see Figure 1). Within the regionalized system, MIEMSS has identified 2 specialty centers as pediatric trauma centers. For the last 2 decades, the Emergency Medicine and Trauma Center (EMTC) at Children’s National Medical Center (CNMC) in Washington, DC, and the Pediatric Trauma Center at the Johns Hopkins Children’s Center in Baltimore have essentially bisected the state, each serving a major population center within its catchment area (see Figure 2). Both centers are American College of Surgeons verified level I pediatric trauma centers and also serve the system as pediatric base stations.
Case Report Incident Scene The Benjamin Tasker Middle School is the only public middle school in Bowie, a city with a population of
Figure 3 Overhead of Benjamin Tasker Middle School campus.
50,000, located 16 miles east of the District of Columbia (DC) in Prince George’s County, Maryland. The school is on a wooded park-school campus situated along a welltraveled county thoroughfare less than a mile from a major interstate highway. Entrance to the school is accessed from a sidewalk that rims a semicircular driveway at the front of the building (see Figure 3). Students being dropped off to school by private vehicles typically pull up to the curb close to the school entrance. On the morning of October 7, 2002, shortly after 8:00 am, a 13-year-old eighth grade student was dropped off to school early by his aunt and was waiting on the sidewalk out front for the school doors to be opened.
The Shooting
Figure 2 MIEMSS: pediatric trauma centers.
At 8:08 am, the student was struck by a single-round .223 caliber bullet fired from a high-powered semiautomatic weapon, subsequently identified by law enforcement as a Bushmaster XM-15 assault rifle. The projectile was fired from an area estimated to be 150 yd in front of the boy. The bullet struck the victim just below the left costal margin; there was an entrance wound but no exit wound. Bullet fragmentation produced penetrating shrapnel injuries to organs in both the thoracic and abdominal cavities including the left lung, diaphragm, stomach, pancreas, spleen, and liver (see Figure 4). A rib was also shattered by the bullet’s impact. The pericardium, great vessels, and kidneys were spared.
Nonfatal sniper attack of a pediatric patient
Prehospital Response Bystander Care The victim’s aunt, ironically an experienced inpatient surgical nurse at CNMC, was still in the school driveway when the shot was fired and heard the discharge. The boy, who had been initially felled, was able to get to his feet and, with his aunt’s assistance, walk to her vehicle. She immediately called 911 via mobile telephone reaching a dispatcher who advised her to stay at the school and await a first response unit. By that time, however, she was already driving the mile and a half distance to the nearest medical facility, the Bowie Health Center, arriving there in just a few minutes.
Resuscitation The Bowie Health Center is a busy, freestanding urgent care facility not attached to a hospital or inpatient facility. An outpatient day surgery facility, connected by a hallway, operates next door. The center is staffed by emergency medicine physicians and is open daily from 8:00 am to midnight. The shooting victim was the first patient of the day. A resuscitation team composed of the Bowie Health Center emergency medicine physician on duty that morning, a surgeon, and anesthesiologist summoned from the day surgery facility, and several nurses was quickly assembled. Beginning at 8:18 am, the ad hoc team conducted a primary trauma assessment and initiated appropriate interventions. Rapid sequence intubation and a left tube thoracostomy were performed, and large bore peripheral intravenous access was established. Volume resuscitation was initiated including the infusion of 2 units of O-negative packed red blood cells. The patient was stabilized in a state of compensated hemorrhagic shock.
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Trauma System Activation The initial 911 activation had resulted in advanced life support (ALS) response by Prince George’s County Fire and EMS, and a medic unit was standing by at the Bowie Health Center. In accordance with the trauma decision algorithm of the statewide Maryland EMS protocols, the regionalized trauma transport system was also activated [9]. At 8:28 am, System Communications in Baltimore informed the Emergency Communications and Information Center at CNMC that an MSP helicopter was being dispatched to respond to the Bowie Health Center for a penetrating trauma victim. Additional MSP aviation assets were being sent to assist in the law enforcement response. The mission objective was medevac of the victim to the designated pediatric trauma center at CNMC. At 8:31 am, MSP helicopter Trooper 2 lifted from Andrews AFB for the 6-minute flight to Bowie.
Transport to Definitive Care The Bowie Health Center does not have a structured helipad, and at 8:37 am, Trooper 2 touched down in a nearby, nonadjacent, landing zone. Care of the victim was transitioned from the makeshift resuscitation bay inside the Bowie Health Center to the awaiting Prince George’s County Fire and EMS medic unit for the short ground transport to the helicopter. Care was then transitioned from the ground unit to the flight paramedics, and at 8:52 am, Trooper 2 lifted for the 7-minute flight into Washington, DC, and the EMTC at CNMC. Medical control for this phase of care was transitioned at that point to the base station at CNMC. Trooper 2 was met on the CNMC rooftop helipad by an attending pediatric emergency physician who accompanied the patient and flight medics to the resuscitation bay and the assembled trauma team in the EMTC 4 flights below. Reassessment in the trauma bay determined only the need for more volume, and a liter of isotonic fluid was rapidly infused. At 9:09 am, care was transitioned from the trauma team to the awaiting surgical team in the operating room. Several hours of surgery followed, which included hemostasis, total splenectomy, partial pancreactectomy, and primary diaphragmatic, gastric, and hepatic repairs. The patient was discharged after a 35-day critical care and inpatient course.
Discussion
Figure 4 Portable chest radiograph of pediatric sniper victim with multiple bullet fragments in left hemithorax.
Trauma surgeon and EMS systems innovator, R Adams Cowley is credited with coining the phrase the bgolden hourQ [10]. He implemented the principles of a rapid response, rapid transport approach in the development of the Maryland EMS and trauma systems [11,12]. In the 61-minute golden hour that transpired from penetrating injury to definitive surgical care for this pediatric trauma
J.L. Wright, M.G. Holder
74 victim, several highly choreographed, sequential phases of prehospital care were successfully performed. Although regionalized trauma systems are designed with just this type of rapid response in mind, there are several interesting aspects of this dramatic case that highlight the value of adaptation as a necessary operational element within an EMS and trauma system construct: 1. Bystander care—The patient’s aunt appropriately activated the 911 system immediately upon realizing what had occurred. She then took the unusual step of initiating citizen transport by privately operated vehicle to the Bowie Health Center. This action occupied the first 10 minutes of this child’s golden hour. In a subsequent interview, the aunt stated that the primary influencing factor in her decision was concern that the school campus was not secure and that the snipers would strike again [13]. Certainly, scene safety is the foremost adage of first responding EMS personnel and it is impossible to know what role the physical security of the response environment would have been played vis-a-vis the response timeline had the victim remained on scene. 2. Field response—Despite that the initial resuscitation took place in a health care facility, this facility was clearly not a trauma center or emergency department and, from the Maryland trauma system perspective, represented an out-of-hospital event requiring a primary field response. With the exception of the bystander-mediated transport from the scene to the urgent care facility, the sequence of communications and the response cascade were indistinguishable from that associated with any penetrating trauma victim in the field. 3. Multiple transitions of prehospital care—Although it is not unusual for transition of prehospital trauma care to occur between basic life support and ALS units at the scene, this case involved several rapid transitions of ALS care involving a tenuous patient. From the urgent care center to the expeditiously established landing zone and the Trooper 2 flight paramedic team to the trauma team awaiting at CNMC, the number of physical hand-offs of this unstable patient, all occurring within 25 minutes, is a testament to system readiness and flexibility. 4. A series of fortunate events—Initial transport from the scene via privately operated vehicle notwithstanding, the confluence of several fortuitous circumstances optimized the seamless continuity of this victim’s care within the trauma system. Had the sniper struck 10 minutes earlier, the Bowie Health Center would not have yet been open for business; had they struck 10 minutes later, the emergency medicine physician on duty may not have had the assistance of the anesthesiologist and
surgeon from the day surgery center as they would have already been scrubbed into their first case. Furthermore, trauma response activation through System Communications found Trooper 2 on the ground at Andrews AFB, the closest possible location in the system from which to launch a medevac mission to this particular scene. Trooper 2 could just as easily have been on another mission requiring dispatch of a helicopter from a more distant location.
Summary The global capability of a regionalized trauma system to impact survivability can only be as robust as the strength of its component parts. The unusual circumstances surrounding the prehospital response to the pediatric sniper victim underscores the necessity of standby resource readiness in a regionalized system of care. Although EMS and trauma system maturity has been identified as an evidence-based element related to performance, the value of case-to-case adaptability by providers within the system cannot be overemphasized as an equally important contributor to positive patient outcomes.
Acknowledgments The authors acknowledge the editorial input of Dr Robert Bass, executive director of MIEMSS, as well as the review commentary of Drs Richard Alcorta, Douglas Floccare, Allen Walker, and Ms Cynthia Wright-Johnson, all of MIEMSS. On behalf of the entire agency, we acknowledge the outstanding collective effort on the part of all the providers who contributed to the care, transport, and ultimate survival of this child. Above all, we thank the family who has graciously granted permission for us to share their story for the purposes of teaching and knowledge expansion.
References 1. American Academy of Pediatrics. American College of Critical Medicine, Society of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Pediatrics 2000;105:15225. 2. Mann NC. Assessing the effectiveness and optimal structure of trauma systems: a consensus among experts. J Trauma 1999; 47(suppl):S69-S74. 3. Nathens AB, Jukovich GJ, Cummings P, et al. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA 2000;283:199024. 4. Nathens AB, Jukovich GJ, Rivara FP, et al. Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation. J Trauma 2000;48:25230. 5. Wright J, Klein B. Regionalized pediatric trauma care systems. Clin Pediatr Emerg Med 2001;2:3212. 6. West JG, Williams MJ, Trunkey DD, et al. Trauma systems: current status-future challenges. JAMA 1988;259:35972600. 7. Bass RR, Gainer PS, Carlini AR. Update on trauma system development in the United States. J Trauma 1999;47(Suppl):S152S21.
Nonfatal sniper attack of a pediatric patient 8. A 2002 National Assessment of State Trauma System Development, Emergency Medical Services Readiness, and Disaster Readiness for Mass Casualty Events. U.S. Department of Health and Human Services, Health Resources and Services Administration, TraumaEMS Systems Program, Rockville, MD, 2003. 9. Maryland Institute for Emergency Medical Services Systems (MIEMSS). The Maryland medical protocols for EMS providers. Baltimore, MD: MIEMSS; 2005.
75 10. Lerner EB, Moscati RM. The golden hour: scientific fact or medical burban legendQ? Acad Emerg Med 2001;8:758260. 11. Cowley RA, Hudson F., Scanlan E, et al. An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. J Trauma 1973;13:1029238. 12. Cowley RA. A total emergency medical system for the state of Maryland. Md State Med J 1975;24:37245. 13. Jones T. Speed and skill saved boy. The Washington Post; 2002.
F
or a 3-week period in October of 2002, the Washington, DC, metropolitan was terrorized by a series of random sniper attacks. The string of shootings, primarily focused in the Maryland suburbs, resulted in 13 victims who sustained single shot, high-velocity penetrating injuries. The only pediatric victim of the sniper attacks was among the 3 survivors. The following report details the prehospital phase of this patient’s care in the context of a regionalized, pediatric-specific system response.
System Background Over the last 30 years, trauma system development in this country has evolved dramatically. By definition, region*Office of the State Medical Director, Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, MD 21201, USA. yEmergency Medicine and Prevention and Community Health, George Washington University Schools of Medicine and Public Health, Washington, DC 20037, USA. zChild Health Advocacy Institute, Children’s National Medical Center, Washington, DC 20010, USA. §Center for Hospital Based Specialties, Children’s National Medical Center, Washington, DC 20010, USA. ODivision of Pediatric Emergency Medicine, Akron Children’s Hospital, Akron, OH 44308, USA. Reprint requests and correspondence: Joseph L. Wright, MD, MPH, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010. (E-mail: [email protected])
1522-8401/$ - see front matter ª 2006 Published by Elsevier Inc. doi:10.1016/j.cpem.2006.03.002
alization of trauma care refers to a geographic organization of services that ensures access to trauma care at a level appropriate to patient needs while maintaining the efficient use of available resources [1]. Despite a paucity of population-based evidence, it appears that trauma regionalization confers statistically significant benefit to those communities served by systems in which essential system components have been established [2,3]. In fact, in motor vehicle crash–related mortality, the effect of trauma system presence seems to be most beneficial in the 1-14 age group [4]. Since 1973, the Maryland Institute for Emergency Medical Services Systems (MIEMSS) has been the lead organization responsible for coordinating Maryland’s statewide emergency medical services (EMS) system [5]. MIEMSS was one of the earliest systems to incorporate the essential components of regionalized trauma care and is currently 1 of 34 designated statewide trauma systems in the United States [6-8]. Over the last 30 years, the Maryland system has grown to encompass 11 trauma centers, including the R Adams Cowley Shock Trauma Center in Baltimore, which serves as the system’s primary adult resource center. Statewide communications and transportation systems are also overseen by the agency, including a fleet of 12 high-speed state police helicopters that are operated by the Maryland State Police (MSP) Aviation Command. They perform a triple function of 71
J.L. Wright, M.G. Holder
72
Figure 1 MSP medevac helicopter bases.
medevac, search and rescue, and law enforcement and are strategically stationed at 8 operational bases across the state to enable rapid response to field trauma (see Figure 1). Within the regionalized system, MIEMSS has identified 2 specialty centers as pediatric trauma centers. For the last 2 decades, the Emergency Medicine and Trauma Center (EMTC) at Children’s National Medical Center (CNMC) in Washington, DC, and the Pediatric Trauma Center at the Johns Hopkins Children’s Center in Baltimore have essentially bisected the state, each serving a major population center within its catchment area (see Figure 2). Both centers are American College of Surgeons verified level I pediatric trauma centers and also serve the system as pediatric base stations.
Case Report Incident Scene The Benjamin Tasker Middle School is the only public middle school in Bowie, a city with a population of
Figure 3 Overhead of Benjamin Tasker Middle School campus.
50,000, located 16 miles east of the District of Columbia (DC) in Prince George’s County, Maryland. The school is on a wooded park-school campus situated along a welltraveled county thoroughfare less than a mile from a major interstate highway. Entrance to the school is accessed from a sidewalk that rims a semicircular driveway at the front of the building (see Figure 3). Students being dropped off to school by private vehicles typically pull up to the curb close to the school entrance. On the morning of October 7, 2002, shortly after 8:00 am, a 13-year-old eighth grade student was dropped off to school early by his aunt and was waiting on the sidewalk out front for the school doors to be opened.
The Shooting
Figure 2 MIEMSS: pediatric trauma centers.
At 8:08 am, the student was struck by a single-round .223 caliber bullet fired from a high-powered semiautomatic weapon, subsequently identified by law enforcement as a Bushmaster XM-15 assault rifle. The projectile was fired from an area estimated to be 150 yd in front of the boy. The bullet struck the victim just below the left costal margin; there was an entrance wound but no exit wound. Bullet fragmentation produced penetrating shrapnel injuries to organs in both the thoracic and abdominal cavities including the left lung, diaphragm, stomach, pancreas, spleen, and liver (see Figure 4). A rib was also shattered by the bullet’s impact. The pericardium, great vessels, and kidneys were spared.
Nonfatal sniper attack of a pediatric patient
Prehospital Response Bystander Care The victim’s aunt, ironically an experienced inpatient surgical nurse at CNMC, was still in the school driveway when the shot was fired and heard the discharge. The boy, who had been initially felled, was able to get to his feet and, with his aunt’s assistance, walk to her vehicle. She immediately called 911 via mobile telephone reaching a dispatcher who advised her to stay at the school and await a first response unit. By that time, however, she was already driving the mile and a half distance to the nearest medical facility, the Bowie Health Center, arriving there in just a few minutes.
Resuscitation The Bowie Health Center is a busy, freestanding urgent care facility not attached to a hospital or inpatient facility. An outpatient day surgery facility, connected by a hallway, operates next door. The center is staffed by emergency medicine physicians and is open daily from 8:00 am to midnight. The shooting victim was the first patient of the day. A resuscitation team composed of the Bowie Health Center emergency medicine physician on duty that morning, a surgeon, and anesthesiologist summoned from the day surgery facility, and several nurses was quickly assembled. Beginning at 8:18 am, the ad hoc team conducted a primary trauma assessment and initiated appropriate interventions. Rapid sequence intubation and a left tube thoracostomy were performed, and large bore peripheral intravenous access was established. Volume resuscitation was initiated including the infusion of 2 units of O-negative packed red blood cells. The patient was stabilized in a state of compensated hemorrhagic shock.
73
Trauma System Activation The initial 911 activation had resulted in advanced life support (ALS) response by Prince George’s County Fire and EMS, and a medic unit was standing by at the Bowie Health Center. In accordance with the trauma decision algorithm of the statewide Maryland EMS protocols, the regionalized trauma transport system was also activated [9]. At 8:28 am, System Communications in Baltimore informed the Emergency Communications and Information Center at CNMC that an MSP helicopter was being dispatched to respond to the Bowie Health Center for a penetrating trauma victim. Additional MSP aviation assets were being sent to assist in the law enforcement response. The mission objective was medevac of the victim to the designated pediatric trauma center at CNMC. At 8:31 am, MSP helicopter Trooper 2 lifted from Andrews AFB for the 6-minute flight to Bowie.
Transport to Definitive Care The Bowie Health Center does not have a structured helipad, and at 8:37 am, Trooper 2 touched down in a nearby, nonadjacent, landing zone. Care of the victim was transitioned from the makeshift resuscitation bay inside the Bowie Health Center to the awaiting Prince George’s County Fire and EMS medic unit for the short ground transport to the helicopter. Care was then transitioned from the ground unit to the flight paramedics, and at 8:52 am, Trooper 2 lifted for the 7-minute flight into Washington, DC, and the EMTC at CNMC. Medical control for this phase of care was transitioned at that point to the base station at CNMC. Trooper 2 was met on the CNMC rooftop helipad by an attending pediatric emergency physician who accompanied the patient and flight medics to the resuscitation bay and the assembled trauma team in the EMTC 4 flights below. Reassessment in the trauma bay determined only the need for more volume, and a liter of isotonic fluid was rapidly infused. At 9:09 am, care was transitioned from the trauma team to the awaiting surgical team in the operating room. Several hours of surgery followed, which included hemostasis, total splenectomy, partial pancreactectomy, and primary diaphragmatic, gastric, and hepatic repairs. The patient was discharged after a 35-day critical care and inpatient course.
Discussion
Figure 4 Portable chest radiograph of pediatric sniper victim with multiple bullet fragments in left hemithorax.
Trauma surgeon and EMS systems innovator, R Adams Cowley is credited with coining the phrase the bgolden hourQ [10]. He implemented the principles of a rapid response, rapid transport approach in the development of the Maryland EMS and trauma systems [11,12]. In the 61-minute golden hour that transpired from penetrating injury to definitive surgical care for this pediatric trauma
J.L. Wright, M.G. Holder
74 victim, several highly choreographed, sequential phases of prehospital care were successfully performed. Although regionalized trauma systems are designed with just this type of rapid response in mind, there are several interesting aspects of this dramatic case that highlight the value of adaptation as a necessary operational element within an EMS and trauma system construct: 1. Bystander care—The patient’s aunt appropriately activated the 911 system immediately upon realizing what had occurred. She then took the unusual step of initiating citizen transport by privately operated vehicle to the Bowie Health Center. This action occupied the first 10 minutes of this child’s golden hour. In a subsequent interview, the aunt stated that the primary influencing factor in her decision was concern that the school campus was not secure and that the snipers would strike again [13]. Certainly, scene safety is the foremost adage of first responding EMS personnel and it is impossible to know what role the physical security of the response environment would have been played vis-a-vis the response timeline had the victim remained on scene. 2. Field response—Despite that the initial resuscitation took place in a health care facility, this facility was clearly not a trauma center or emergency department and, from the Maryland trauma system perspective, represented an out-of-hospital event requiring a primary field response. With the exception of the bystander-mediated transport from the scene to the urgent care facility, the sequence of communications and the response cascade were indistinguishable from that associated with any penetrating trauma victim in the field. 3. Multiple transitions of prehospital care—Although it is not unusual for transition of prehospital trauma care to occur between basic life support and ALS units at the scene, this case involved several rapid transitions of ALS care involving a tenuous patient. From the urgent care center to the expeditiously established landing zone and the Trooper 2 flight paramedic team to the trauma team awaiting at CNMC, the number of physical hand-offs of this unstable patient, all occurring within 25 minutes, is a testament to system readiness and flexibility. 4. A series of fortunate events—Initial transport from the scene via privately operated vehicle notwithstanding, the confluence of several fortuitous circumstances optimized the seamless continuity of this victim’s care within the trauma system. Had the sniper struck 10 minutes earlier, the Bowie Health Center would not have yet been open for business; had they struck 10 minutes later, the emergency medicine physician on duty may not have had the assistance of the anesthesiologist and
surgeon from the day surgery center as they would have already been scrubbed into their first case. Furthermore, trauma response activation through System Communications found Trooper 2 on the ground at Andrews AFB, the closest possible location in the system from which to launch a medevac mission to this particular scene. Trooper 2 could just as easily have been on another mission requiring dispatch of a helicopter from a more distant location.
Summary The global capability of a regionalized trauma system to impact survivability can only be as robust as the strength of its component parts. The unusual circumstances surrounding the prehospital response to the pediatric sniper victim underscores the necessity of standby resource readiness in a regionalized system of care. Although EMS and trauma system maturity has been identified as an evidence-based element related to performance, the value of case-to-case adaptability by providers within the system cannot be overemphasized as an equally important contributor to positive patient outcomes.
Acknowledgments The authors acknowledge the editorial input of Dr Robert Bass, executive director of MIEMSS, as well as the review commentary of Drs Richard Alcorta, Douglas Floccare, Allen Walker, and Ms Cynthia Wright-Johnson, all of MIEMSS. On behalf of the entire agency, we acknowledge the outstanding collective effort on the part of all the providers who contributed to the care, transport, and ultimate survival of this child. Above all, we thank the family who has graciously granted permission for us to share their story for the purposes of teaching and knowledge expansion.
References 1. American Academy of Pediatrics. American College of Critical Medicine, Society of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Pediatrics 2000;105:15225. 2. Mann NC. Assessing the effectiveness and optimal structure of trauma systems: a consensus among experts. J Trauma 1999; 47(suppl):S69-S74. 3. Nathens AB, Jukovich GJ, Cummings P, et al. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA 2000;283:199024. 4. Nathens AB, Jukovich GJ, Rivara FP, et al. Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation. J Trauma 2000;48:25230. 5. Wright J, Klein B. Regionalized pediatric trauma care systems. Clin Pediatr Emerg Med 2001;2:3212. 6. West JG, Williams MJ, Trunkey DD, et al. Trauma systems: current status-future challenges. JAMA 1988;259:35972600. 7. Bass RR, Gainer PS, Carlini AR. Update on trauma system development in the United States. J Trauma 1999;47(Suppl):S152S21.
Nonfatal sniper attack of a pediatric patient 8. A 2002 National Assessment of State Trauma System Development, Emergency Medical Services Readiness, and Disaster Readiness for Mass Casualty Events. U.S. Department of Health and Human Services, Health Resources and Services Administration, TraumaEMS Systems Program, Rockville, MD, 2003. 9. Maryland Institute for Emergency Medical Services Systems (MIEMSS). The Maryland medical protocols for EMS providers. Baltimore, MD: MIEMSS; 2005.
75 10. Lerner EB, Moscati RM. The golden hour: scientific fact or medical burban legendQ? Acad Emerg Med 2001;8:758260. 11. Cowley RA, Hudson F., Scanlan E, et al. An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. J Trauma 1973;13:1029238. 12. Cowley RA. A total emergency medical system for the state of Maryland. Md State Med J 1975;24:37245. 13. Jones T. Speed and skill saved boy. The Washington Post; 2002.