When the “Factual Report” (huge 21Mb file) about the death of firefighter Andrew Palmer was released on November 3, we posted a summary of the report and the findings. But beyond those facts and findings, which were developed by a government panel investigating the death of Mr. Palmer, who died in a tree felling accident on a fire in northern California July 25, 2008, I have not written anything else about the incident. In part, because to anyone who has taken the time to read the 115-page report, the issues that contributed to the unfortunate death of Mr. Palmer are very obvious. And, because there were so MANY, uh, “issues,” that led up to and contributed to the death, that it is rather sickening to think about the many examples of poor judgment that screamed out at me as I read the report. Sickening.
To write about those mistakes, in one respect, is like picking low-hanging fruit. They are obvious to anyone with a background in wildland fire suppression and some emergency medical training.
Oddly, perhaps, I am reminded of a portion of Abraham Lincoln’s Gettysburg Address.
… It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us — that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion — that we highly resolve that these dead shall not have died in vain…
He was talking about soldiers, but the same sentiment can apply to ensuring that Mr. Palmer did not die in vain.
The first radio report that there had been an accident and medical assistance was needed came over the radio at approximately 1:50 p.m. Mr. Palmer was pronounced dead at 5:10 p.m., five minutes after he arrived via Coast Guard helicopter at the Redding airport. It took three hours and 20 minutes to get him to the airport. From there, if he had still been alive, he would have been transferred to a ground ambulance and transported to a hospital in Redding for treatment.
The coroner determined the cause of death to be blood loss due to blunt force trauma to the left leg.
The report shed light on many poor decisions and others that were not made in a timely manner. After much dithering about which of four helicopters to use to extract the victim, they finally settled on using a Coast Guard helicopter, after ordering it, canceling it, and then ordering it again. But the final request for the ship was not placed until 2:49 p.m., at the end of the “golden hour” during which a severely injured patient needs trauma care to improve their chances for survival.
The Captain of the engine module to which Mr. Palmer was assigned was in Redding attending to the mechanical repair of their engine when he received a phone call about the accident. It took him an hour and 25 minutes to drive from there to the fire and hike up the hill to the location of his injured crew member. This indicates that a ground ambulance would have gotten Mr. Palmer to a trauma center in Redding far more quickly than the procedure chosen by the incident personnel.
Obviously there was no feasible plan in place for that operational period on the fire that would cover how to extract an accident victim and get them to a trauma center within the golden hour. Or within the second hour. Or within the third hour. Mr. Palmer would have arrived at the trauma center about halfway into the fourth hour. Unacceptable.
He bled to death. And a little forethought would have prevented it.
It is sickening.