CONCEPTS, COMPONENTS & CONFIGURATIONS emergency medical services, rescue, water

The Development of a Water Rescue Unit in an Urban EMS System

A river rescue unit was developed in Pittsburgh in March 1986. From its time o f inception through December 31, I987, the unit responded 572 t imes(325 times in 1987); this included 144 medical calls. Many of the other calls were police related, false alarms, routine patrols, or public ser- vice calls. We present a description of the service, type of training neces- sary, costs involved, and administrative aspects of running a marine emer- gency medical services system and its integration into an urban EMS sys- tem. [Weiss LD, McCaughan R J, Paris PM, Kennedy RA: The development of a water rescue unit in an urban EMS system. Ann Emerg Med August 1989;18:884-888.]

INTRODUCTION A computer search of ten years in the medical literature failed to reveal

any articles dealing with the development, organization, or administration of a water-based emergency medical services (EMS) system. Such a service was inaugurated in Pittsburgh in March 1986. Since that time it has been well integrated with local ground and air EMS systems as well as the po- lice. Other localities have "rescue diver" services that are either free stand- ing or integrated with police or fire departments, t-5 We provide the first description of a diver-paramedic service that has developed as an integral component of an urban ground, air, and water EMS system.

HISTORY AND BACKGROUND The Freedom House Ambulance Service was developed in 1967. In 1975,

the city assumed the responsibility of the EMS program. At that time, it consisted of approximately 40 trained paramedics; the system now em- ploYS 186 paramedics and makes approximately 60,000 runs a year, includ- ing 10,000 advanced life support cases. In 1985, the Department of Public Safety was formed. This department includes the police, fire, EMS, and building inspection bureaus. All four bureaus report to a director of public safety. This reorganization facilitated the cooperation needed to develop a comprehensive river rescue unit.

Before the reorganization of public services in the city, the police depart- ment had a river patrol service that was designed to provide law enforce- ment, evidence retrieval, body recovery, and general patrol services on the rivers. 6 By late 1985, there was a recognized need to extend basic EMS and rescue services to the rivers.

Bridge-jumping has long been a popular method of suicide in Pittsburgh. There are presently 25 bridges that cross the rivers within the city limits. There are 38,6 miles of shoreline within the city and 26,977 pleasure craft registered in the county (1987 figures). 7 There are also four large commer- cial river cruisers that operate on a year-round basis. Pittsburgh is the larg- est inland port in the United States, and handled 26 million tons of cargo in 1986'(183 million tons in i979).8, 9 Because of the extensive river traffic and the large number of people involved, it became desirable to develop a water-based EMS/police unit.

ORGANIZATION AND COST The unit functions as a service of the Rescue Division of the City of

Pittsburgh EMS Bureau and consists of 27 trained master-diver paramedics.

Larry D Weiss, MD* Robert J McCaughan, EMT-Pt Paul M Paris, MD* Robert A Kennedy, EMT-P¢ Pittsburgh, Pennsy(vania

From the Division of Emergency Medicine, University of Pittsburgh School of Medicine;* and the Bureau of EMS, City of Pittsburgh, Department of Public Safety, t Pittsburgh, Pennsylvania.

Received for publication July 22, 1988. Revision received November 17, 1988. Accepted for publication April 10, 1989.

Address for reprints: Larry D Weiss, MD, Center for Emergency Medicine, University of Pittsburgh School of Medicine, 230 McKee PI, Suite 500, Pittsburgh, Pennsylvania 15213.

18:8 August 1989 Annals of Emergency Medicine 884/139

WATER RESCUE UNIT Weiss et al

FIGURE 1. Diver training.

FIGURE 2. Monthly distribution of responses. The service was busiest during the s u m m e r months when recreational use of the rivers was greatest.

Each spends four months a year in the service. Nine paramedics are as- signed to the service each month. Twenty-four policemen have taken a basic boating course as well as a ba- sic water rescue course and are re- sponsible for piloting the rescue craft and providing police support during responses. Three police officers are assigned to the unit each month.

Funding i s provided by the Depart- ment of Public Safety and includes salary support for nine full-t ime- equivalent paramedics and three po- lice officer full-time-equivalents. A base is Centrally located. Six craft are maintained by the unit: two 25-ft boats (Frontier and Guardian series; Boston Whaler, Rockland, Massa- chusetts) for primary rescue and pa- trol operations, a 20-ft airboat for navigation over ice and in shallow waters (Yankee Manufacturing, Bald- win, Maine), a 20-ft V-hull aluminum boat (Starcra~t Industries, Goshen, In- diana) as a backup vessel, a 17-ft in- flatable boat for summer backup, and a 14-ft inflatable on a trailer for rapid scene transport.

Start-up costs were $40,000 for div- ing e q u i p m e n t and $102,870 for training, We did not have to purchase any boats or construct a base station (these Were already in place), and we did fiat create any new paramedic po- sitions. Our system was large enough to allow such flexibility. Twenty complete sets of diving equipment were purchased at approximately $2,000 a set. The cost of maintaining all the diving equipment is approx- imately $2,000 a year. The total esti- mated cost of training each diver was $3,810, including $890 for SCUBA courses and $2,920 in salary support and overtime pay. Other. costs may include an additional premium for health and life insurance policies, al- though our paramedics were covered by. their basic benefit package.

The cost of maintaining the river rescue unit is roughly twice that of maintaining a ground unit. A sum- mary of our annual operating costs is shown (Tabl e 1). Patients who are city residents are not billed for EMS

RESPONSES PER MONTH 1987

70

Swimming tests Physical examination Professional Association of Diving Instructors certifications

Open water diver Advanced open water diver Night diver Search and recovery diver Rescue diver Ice diver Dry suit diver Equipment specialist

6O

50 ¢ -

°o_ 4o ~9 O9 rr 3O *6 d 2O

z

10

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

2

TABLE 1. Annual operating budget, 1987

Item Cost

Pai'amedic salaries and benefits (nine full-time equivalents) $276,936

Police officer salaries and benefits (three full-time equivalents) 105,821 Gear maintenance 1,660 Boat maintenance 24,028 Gasoline 1,800 Miscellaneous equipment 4,300

Overhead, base station 980 Compressed air 0

$415,525

services (the city accepts whatever third-party payment is available). Pa- t i en t s who are n o n r e s i d e n t s are billed the same whether they are transported by ground or water.

Medical backup includes several

Annals of Emergency Medicine

medic command physicians experi- enced in diving medicine. There are currently five monoplace hyperbaric chambers in Pittsburgh; these are ad- equate for initial treatment of most diving accidentsJ °42 A large multi-

140/885 18:8 August 1989

TOTAL RESPONSES (1986-87) (Percentage)

False alarms

Public st ~olice

- Other

Routir

MEDICAL RESPONSES (1986-87) (Percentage)

Body~very ~ ~ ~ /Medical ic

iiiiiiiiii i i i i "' iii!i!ilili!i!i!i i! !ii ! ii

Search/rescu e

place chamber will soon be located within the city, allowing us to pro- vide definitive therapy for all diving accidents.

T R A I N I N G A N D RESPONSIBILITIES

All 27 of our diver-paramedics are master-divers certified through the

Annals of Emergency Medicine

FIGURE 3. Total responses (1986- 1987). The mos t common indication for use of the service was medical, closely followed b y routine patrols:

F I G U R E 4. M e d i c a l r e sponses (1986-I987). True medical emergen- cies accounted for only 27% of the medical responses.

Professional Association of Diving Instructors (PADI)(Figure 1). Master- diver certification requires the com- pletion of the rescue diver course plus at least five other specialty courses. All Candidates must be cur- rently licensed paramedics who have passed timed swimming tests and a rigorous physical examination (in- cluding CBC, urinalysis, stress ECG, chest radiograph, and lumbo-sacral spine films). They must have no physical contraindications to SCUBA diving.

Each diver-paramedic spends at least four months a year on the unit and participates in regular in-service training, which includes low-head darn rescue, helicopter training (entry into the water from a helicopter hov- ering 10 ft above the surface), search and rescue exercises, and boating coursesJ 3 The responsibilities of the diver-paramedic are listed (Table 2).

The crew has been in active service for an average of five hours a day. We have averaged approximately one true response per day (ie, excluding false alarms ) . During sporting events at Three RiVers Stadium and river- front festivals, routine patrols often require several hours per day. During the summer regatta, our crews are on active patrol up to 16 hours a day. When not in active service, the crew is responsible for upkeep of all gear and performing SCUBA and water rescue training exercises. Also, much of the annual continuing education requirement can be fulfilled during the months when our divers are as- signed to the river rescue service.

The police officer is primarily re- sponsible for navigation and piloting of the boat and for performing police- related activities on the water (eg, search and seizure, recovery of evi- dence, maintaining law and order). The officer must complete a basic boating course as well as a basic wa- ter rescue course. Many of our police officers are also certified as first re- sponders (basic life support), al- though this is not a requirement.

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WATER RESCUE UNIT Weiss et al

U N I T OPERATION F r o m the t i m e of i n c e p t i o n in

March 1986 unt i l the end of 1987, the uni t responded 572 t imes . In 1987, the first full year of operation, there were 325 responses ; i n c l u d i n g 144 medical calls (25% of total calls). As expected , the m o s t ac t ive m o n t h s were in the summer (Figure 2). Many of the other calls were police related, false alarms, rout ine patrols, or pub- lic service calls (Figure 3). Dur ing a response, the boat is staffed wi th one a rmed pol ice off icer (operator) and two diver-paramedics. In addi t ion to r e spond ing to m e d i c a l and po l ice- re la ted calls, the uni t provides rou- t ine pat rols dur ing events at Three Rivers Stadium, Point State Park, and riverfront events such as the annual P i t t sburgh Three Rivers Regat ta in August.

Of the med ica l l y re la ted calls, 39 (27%) were medical emergencies in- volving boaters or passengers on river c ru i se r s (24 of t h e s e r e q u i r e d ad- vanced life support), 82 (57%) were for s e a r c h a n d / o r r e s c u e , and 23 (16%) involved body (corpse) recovery (Figure 4).

The uni t has become an integral componen t of our EMS sys t em and c l o se l y i n t e r a c t s w i t h our g r o u n d EMS units. All ci ty EMS communi - cation is handled through the emer- gency opera t ions center. A dec is ion is made by the center on whe ther to dispatch a ground unit, a water unit, or both. In many cases where a river rescue uni t is needed, ground uni t s are also needed. When pat ients are in distress on the surface or in the wa- ter, they can be in i t ia l ly resusci ta ted by a river rescue unit . They can then be t ransferred to a ground un i t for hospi tal transport.

The unit is also closely integrated w i t h the local air a m b u l a n c e ser- v i ces . We have the c a p a b i l i t y of qu ick ly t ranspor t ing dix?ers by heli- copter to the scene of an accident and have t hem d i rec t ly enter the wate r from the hel icopter . Because of the compact size of our city, we do not an t ic ipa te the need for this service wi th in the ci ty l imits . However, we are d e v e l o p i n g m u t u a l a id agree- ments wi th surrounding local i t ies re- gard ing the c o o r d i n a t e d use of our rescue divers and air ambulance sys: terns.

Coord ina t ion wi th the pol ice has been essential to the uni t ' s success. M a n y ca l l s i n v o l v e p o l i c e - r e l a t e d

TABLE 2. Responsibilities of the diver-paramedic

Delivery of emergency medical care

Boaters in distress (medical) Boating accidents (trauma) Suicide victims (bridge jumpers) Riverfront (shore) emergencies

Basic water rescue

Search and recovery Boating difficulties (mechanical) Routine patrol

matters . Having an armed police offi- cer on board also faci l i tates responses invo lv ing in tox ica t ed or uncoopera- t ive boaters; this is a combined EM8/ police uni t in all aspects. We are also a t t empt ing to integrate the uni t wi th the fire bureau. Training and pract ice sess ions regard ing fire supp re s s ion are current ly under way, as both Bos- ton Whalers have 350 ga l lon /min fire pumps on board. This wil l faci l i tate the m a n a g e m e n t of fires and o ther p o t e n t i a l d i sa s t e r s i n v o l v i n g r iver- front industries.

In August 1988, the uni t played a v i t a l role in m a n a g i n g a r ive r f ron t d i sas te r . D u r i n g the annua l Three Rivers Regat ta Formula One speed- boat race, a boat veered out of control and plunged into a crowd of people along the shore. Twenty-four people {including 11 children) were injured. Five pat ients were cr i t ical ly injured, including a 7-year-old child wi th se- vere blunt head t rauma who required in tuba t ion but later died.

At the t ime of the accident, all of our rescue craft were in t he water . One boat was w i t h i n 50 yd of the scene. The f i rs t rescue d iver -para- medics were at the scene wi th in 30 seconds. A total of n ine ground units, all of our water units, and five EMS physic ians were at the scene. All pa- t i e n t s we re s t a b i l i z e d and t r a n s - ported wi th in 24 minu tes of the acci- dent. All five of the cr i t ical ly injured pat ients were t ransported with a phy- sician w i t h i n ten m i n u t e s . Such a rapid and ef f ic ien t r e sponse w o u l d not have been poss ib le w i t h o u t the par t ic ipat ion of our river rescue unit.

D I S C U S S I O N Water rescue has been a neglected

area of EMS development . Over the last 20 years, we have seen the devel- opment of sophis t ica ted ground EMS

sys t ems . More recen t ly , air ambu- l a n c e s y s t e m s have d e v e l o p e d in large urban areas. Water rescue is one of the " last frontiers" of EMS devel- o p m e n t and is c u r r e n t l y in i ts in- fancy in the Uni ted States.

The mos t significant a t t r ibute of a wate r rescue service is the s k i l l of the pe r sonne l invo lved . Our diver- paramedics undergo rigorous evalua- t ion and t ra ining. They m u s t be in superb phys ica l condi t ion . A wate r rescue service should be closely inte- grated wi th other EMS services, en- su r ing rap id responses and s m o o t h c o o r d i n a t i o n w i t h g round and ai r EMS services. The expenses of such a sys t em are cons iderab le but can be m i n i m i z e d t h rough in t eg ra t i on . A c o m b i n e d EMS/pol ice un i t has pro- vided us wi th op t imal staffing.

There is a high s tar t -up cost and opera t ing budget to such a sys tem. The c i ty g o v e r n m e n t dec ided tha t the benefits were wor th the costs. In o ther loca l i t ies where this m a y not be the case, the re are ways to de- crease opera t ing costs. A large pro- por t ion of our operat ing costs (92%) is devo ted to sa la r ies and benef i t s (Table I). An EMT can be subst i tu ted for the second pa ramed ic (our EMS sys t em is an a l l -paramedic service). In s o m e l o c a l i t i e s w h e r e t h e ex- pected vo lume is Very light, the crew can be on call. Another a l ternat ive is to have the d iver -paramedics work on ground uni ts at all t imes and to pull them off the uni ts when a water rescue is needed. Ei ther a l t e rna t ive would result in considerable savings; however, t ime delays would invaria- bly occur. In our sys tem such delays are unacceptable.

Many major US cit ies are located along bodies of water. The develop- men t of a water rescue unit would be a valuable addi t ion to such EMS sys-

142/887 Annals of Emergency Medicine 18:8 August 1989

terns. By devot ing more a t t e n t i o n and resources to this problem, water rescue can rapidly evolve to comple- m e n t our ex i s t i ng g round and air EMS systems.

REFERENCES 1. Anderson M: Launching a dive team. H~zzard Monthly 1985;6:3-6. 2. O'Rourke J: Taking the plunge. Firehouse 1985; 10:46-48. 3. Smith DS: Firetighters in the water - Too late to learn. Fire Chief I986;30:34-36.

4. Murry LS: Rescues in the Potomac. Fire Chief 1986;30:37-38. 5. Moore J: Ocean officers. Police 1988;12: 29-32. 6. Petrucci D: Duties of the police river patiol. City of Pittsburgh, Department of Police mem- orandum, January 22, 1985. 7. Boat Registration, Pennsylvania Fish Com- mission, Bureau of Waterways, 1987.

8. US Army Corps of Engineers, Pittsburgh Dis- trict: Lock Tonnage Reports. 1979. 9. US Army Corps of Engineers, Pittsburgh Dis- trict: Lock Tonnage Reports. I987.

10. Hart GB, Strauss MB, Lennon PA: The treat- merit of decompression sickness and air embo- lism in a monoplace chamber. J Hyperbaric Med 1986;hi-7. 11. Moon RE: Monoplace chamber use in the treatment of diving accidents (editorial). J Hy- perbaric Med 1988;3:i-3. 12. Kindwall EP, Goldmann RW, Thombs PA: Use of the monoplace vs muhiplace chamber in the treatment of diving diseases. [ Hyperbaric Med 1988;3:5-10. 13. McCaughan RJ: Standard Operating Pro- cedures. City of Pittsburgh Department o5 Pub- lic Safety, River Rescue Unit, 1987.

The Canadian Association of Emergency Physicians L'Association Canadienne Des M6decins d'Urgence

ATTENTION: All Past, Present, and Future American-Trained Emergency Medicine Residents

The Canadian Association of Emergency Physicians (CAEP) represents the professional interests of all emergency physicians in Canada. We notify you of a recent change in duration of training requirements that has been approved by the Royal Colleg¢~of Physicians and Surgeons of Canada.

Commenc ing June 1, 1989, in order to be eligible for Royal College certification and fellowship standing in emergency medicine in Canada, all incoming residents will require four years (presently three years) of postintemship training under the auspices of an approved Royal College training program in emergency medicine. Those who have past, present, or future training in an approved US emergency medicine residency program and who desire Royal College certification will be required to demonstrate that the training has been of a s imi lar durat ion and nature to approved Royal College programs.

Specific requests for eligibility consideration should be sent to: The Credentials Section Specialty in Emergency Medicine The Royal College of Physicians & Surgeons of Canada 74 Stanley Avenue Ottawa, Ontario, Canada K1M 1P4 (613/746-8177)

A short-answer essay writ ten examination is held annually in September, with successful candidates being invited to sit for an oral examination held annual ly in November/December. Applications for the writ ten examination must be returned in completed form no less than 18 months prior to the date of the upcoming wri t ten examination in order to allow the Credentials Commit tee t ime to review the training qualifications of foreign-trained candidates.

Address requests for further information to: Ronald D Lindzon, MD, FRCP(C) Chairman, Specialist Section, CAEP PO Box 2881, Station A' London, Ontario, Canada N6A 4H9 (519/432-2352)

18:8 August 1989 Annals of Emergency Medicine 888/143