Andrew Palmer’s brother offers suggestions aimed at reducing fireline fatalities

Andrew Palmer.
Andrew Palmer. From the NPS report.

When Andrew Palmer was killed in a tree felling accident on a fire in northern California July 25, 2008, and especially when the report on the accident was released on November 2, 2009, it shook the wildland firefighter community. Not only was one of our own lost, but after reading the report, a person has to wonder how it would have turned out if Mr. Palmer had been transported to an appropriate medical facility during the “golden hour”, as opposed to the three hours and 20 minutes it took to transport him from the accident site to the Redding, California airport where he was pronounced dead.

The coroner determined the cause of death to be “blood loss due to blunt force trauma to the left leg”. He bled to death.

We offered an opinion about it last November, but we recently discovered that in January, 2009, Andrew Palmer’s brother, Robert, wrote a very well researched and very reasoned paper about the accident and what we could do to reduce the number of  fatalities that occur on the fireline. The first two pages of the eight-page document are excerpted below with his permission; the entire document is HERE.

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2009 National Wildland Fire Reform, “The Palmer Perspective”
January 29, 2009
by Robert Palmer

Short History

My world changed on July 25, 2008. I lost faith in the “fire world’s ability to help one of their own”.

I had just returned from a 14-day wildland fire assignment in Northern California, when my Fire Management Officer meet me in the parking lot to tell me about my younger brother, also a member of a wildland fire staff; “Rob, Andy was hit by a tree this afternoon and isn’t doing well. I’m going to drive you to the airport and fly you back down to California.” I made it to the airport, 15 minutes away, when I received a call informing me that Andy had died en route to the hospital.

He was 18 years old, a recent high school graduate, enrolled in college for the fall, and lived a vigorous life. After a couple of weeks of training, this was his first fire assignment and first day of real work when he died. Andy’s incident provided me with a very raw and a very distinct perspective considering my experiences. I now understand what it means to lose a loved one tragically. I know what it is like to watch a falling tree kill a fellow crewmember and the frustration of not being able to change anything. I also know how Fire Management operates after serving over 10 seasons in fire and as a crew supervisor with the National Park Service (NPS).

Problem

I have protected our national lands, I have lead some of the finest employees in this country, and I have fought for their interests. I now need your support as I fight for my brother’s; we have a National Fire Management Program that cannot provide for the safety of its most important resource, its employees. Several weakness’s and human factors contributed to Andy’s death, but Andy is not alone. One would be naïve to attempt to focus corrective actions on one factor, for we have a much larger problem. We aggressively engage too many fires. We need to ask the questions, “Why are we doing this? and Why are we here?”

Objective: Golden Hour Response

Determine response and engagement based on the capability to deliver any injured fire personnel to an appropriate medical facility in less than 60 minutes. This will:

  • Decrease engagement to SAFELY mitigate risks during response
  • Establish Emergency Medical Standards on an Incident
  • Dramatically decrease costs associated with wildland fire
  • Decrease impacts to the ecosystem

We must decrease our engagement because we do not have the capacity to evacuate injured fire staff safely.

Necessary Actions

Given a lack of rescue and prompt evacuation capacity, we must decrease our engagement until our emergency evacuation capacity complements our engagement. In the short term, we will therefore limit our exposure until we have the capacity to rescue any fire personnel to an appropriate medical facility within 60 minutes, the golden hour. The “golden hour” of trauma defines that if one suffers massive life-threatening injuries reaches an appropriate receiving hospital within 60 minutes, the individual has the greatest survival rate. “Historically, wound data and casualty rates indicate that more than 90% of all casualties die within the first hour of severe wounding without advanced trauma life support.” Instead of reacting and floundering through an emergency within an incident, we will determine future wildland fire response tactics based on the principles of the golden hour, invoking the first radical change in the history of wildland fire.

You can read the rest of the document here.

Author: Bill Gabbert

After working full time in wildland fire for 33 years, he continues to learn, and strives to be a Student of Fire. Google+

5 thoughts on “Andrew Palmer’s brother offers suggestions aimed at reducing fireline fatalities”

  1. A well thought out document. Another pressing need within the fire management community in the US is a standardized Danger Tree Assessment program. Many of fireline injuries and fatalities over the years could have been prevented by implementing a progressive program for the identification and mitigation of the hazards presented by fireline dangerous trees.

  2. This document makes some excellent points, but one concern is the concept of the “Golden Hour”. With nothing but respect for Mr. Palmer and his family’s terrible loss, current trauma theory has debunked the concept that trauma patients have 60 minutes in which to be saved. All have a finite time period, but for some, it may be 10-15 minutes, for some, it may be 3-4 hours. There’s nothing magic or “golden” about one hour. Very sadly, Andy Palmer apparently had slightly less than 3.5 hours…and his case clearly and tragically points out the shortcomings addressed in this document, but to use 60 minutes as the gold standard is no longer valid.

    1. Eric-

      You made some good points, but I don’t think anyone thinks the concept of the golden hour is “magical”. But right now there is no written standard for how quickly an injured firefighter must be transported to an appropriate medical facility. A Medical Unit Leader who writes the Medical Plan may not even address the issue, or consider it when, and if, they specify emergency transport time frames in the plan. And requiring a time standard, may affect what transport systems are in the plan. Certain tactics, or locations of assignments, or time of day or night for assignments, may be affected.

      If a standard time frame for transport is required to be implemented on wildfires, then you can assume that the Medical Plan will be configured to make it possible to transport a seriously injured firefighter in a manner that could save their life.

      What we have now (no standard time frame) does not always work and can increase the chances that firefighters die. We need to have a standard, or a goal to shoot for…. 45 minutes, 60 minutes, 90 minutes, whatever. But something.

      What time frame do YOU suggest?

      1. I agree. At one time, though, the Golden Hour concept was considered a magical time, that if trauma patients got in within 60 minutes, they’d likely make it, after that their chances dropped dramatically. Unfortunately, there is no clear cut optimal time, since it varies so widely between patients. Timely transport is clearly something that needs to be addressed. As an EMTP and MEDL, I wanted to barf reading the report and how long it took to get Andy transported, whether or not it might have changed his outcome. Clear, definitive plans for how treatment and transport will be done must be addressed for every incident. I’d just hate to see us get to the point that one fire can be attacked, because we can evacuate someone in 59 minutes or less, the next fire be let go (to grow more dangerous perhaps) because it would take 62 minutes based on a 60 minute window from 1980’s trauma care.

  3. Eric,
    Thanks for the feedback. I agree that some people will succumb to fireline injuries within the “Golden Hour,” and that some survivors took well more than three hours to reach definitive care. However, those incidents don’t debunk the intent of the “Golden Hour Response.” The intent of the “Golden Hour Response” is to only engage fireline personnel in locations where we have the capability to deliver the injured person to definitive care in an hour. There are some basic assumptions involved:
    1. Any fireline personnel’s life is more valuable than the actual or potential effects of fire.
    2. The faster an injured person receives definitive medical care, the better off the person will be.
    3. The current engagement and evacuation strategies and tactics are insufficient.
    4. We have the ability to decide when and where to engage fireline resources.
    5. And, we also have the ability to change.

    Unlike trying to articulate extremely complex cost, benefit, risk analysis per activity or per location, the “Golden Hour Response” standardizes the risk management approach into a reasonable policy that both fireline personnel and the general public can understand. I am further not concerned with an evacuation time slightly over one hour, but I am extremely concerned with an evacuation time in excess of three hours. I will also agree that when engagement is based upon a “Golden Hour Response,” we will have significant outcomes, but those outcomes will result in significantly fewer fireline deaths and a better allocation of risk.

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