Saving Philly gunshot victims starts outside the hospital door — with a heavy lift

Someone with big muscles was always on hand to lift the gunshot victims out of police cruisers when they sped to the emergency entrance at Penn Presbyterian Medical Center.

An athletic nurse or two, perhaps with an assist from a brawny technician or security guard.

Until the bloody Friday night of Sept. 16, 2016.

Nurses lifted the first victim onto a stretcher and into the trauma bay, and stayed inside to help save the person’s life. Then came another victim, slippery with blood. And another. Within minutes, six shooting victims would arrive at the West Philadelphia hospital, some of whom had to be wrestled from cars by staffers of slender build.

With mass shootings on the rise, trauma team veterans realized they needed a better way.

Penn now has a five-point plan to streamline patient extrication from police or private cars, which the trauma team described in May in the Journal of Emergency Nursing. Among the key features: When the patient is heavy, two nurses first pull the person down to a backboard on the ground, then lift it up to a waiting stretcher.

Other city trauma centers use slightly different methods, but all acknowledge a grim fact in one of America’s deadliest big cities. Before the intubations, the pricey lifesaving drugs, and the high-tech machines that take over the heart’s job of pumping blood, the lives of Philly shooting victims depend on overcoming a very low-tech challenge: getting them through the door of the hospital.

That’s because unlike in most cities, the bulk of Philly shooting victims don’t come to the hospital in an ambulance. Instead, they come by police cruiser — a long-standing practice nicknamed “scoop and run” — or by private vehicle. Studies suggest the practice can save lives when police arrive first on the scene of a shooting. A trip to the hospital via police cruiser can shave minutes off transit time, allowing trauma teams to get to work before it’s too late.

But extracting a patient from a sedan or other low-riding vehicle is hard for several reasons, said Penn Presbyterian emergency nurse James Glatts, the lead author of the study. They are not designed to have a stretcher jammed against the passenger door. The doors are much smaller than those at the back of an ambulance, making it hard for the lifters — many of them women with smaller physiques — to gain sufficient leverage.

And because patients are not strapped down as in an ambulance, sometimes they slide down into the well where passengers place their feet, Glatts said.

“It’s very challenging to pull out somebody who is a full-sized grown male, unresponsive and covered in blood and sweat,” he said.

Glatts and colleagues started developing the new patient extrication plan soon after the September 2016 shooting, and the final version has been in place for several years. The reason they publicized it this year is because they recently conducted timed simulations, determining that the practice shaves 9 seconds off the typical 60-second extraction time. That may not sound like much, but when someone is bleeding from a major artery, every second helps, Glatts said.

The five improvements are as follows:

Other trauma centers in the city do not use backboards to remove shooting victims from cars, but otherwise their processes are similar.

Temple University Hospital collaborated with police to identify the best drop-off area, and it deploys nurses and patient-care assistants to transfer victims to stretchers, spokesman Jeremy Walter said.

At Thomas Jefferson University Hospital, which received 10 of the 14 victims in June’s South Street shooting, up to four nurses and emergency technicians help extract patients as needed, trauma surgeon George Koenig said. The process isn’t spelled out as formally as Penn’s, but everyone knows the drill, he said.

A guard watches the security camera so as to alert others the instant a police car turn into the driveway on 10th Street — giving patient extricators an extra 10 seconds to get ready.

“It’s not, car pulls up and chaos happens, and a person is ripped out of the car,” he said. “There truly is a process.”

And unlike in most hospitals, an operating room is located inside Jefferson’s emergency department, just 15 feet from the entrance, saving still more time, Koenig said.

Penn Presbyterian’s vehicle-extrication process might, in addition to saving time, be easier on the joints of the lifters, Glatts said.

That ergonomic issue is often on the mind of Angel Estep, a veteran trauma nurse at Crozer-Chester Medical Center in Upland, Delaware County. While area police do not practice “scoop and run,” many gunshot victims arrive by private vehicle, meaning she has to lift them out — on occasion, all by herself.

So far, her body has held up during seven years in the emergency department, but she worries about the strain for her and other nurses, most of whom are women.

“While we’re very strong, we’re more petite, and it’s sometimes hard to get them out,” she said. “But adrenaline is an amazing thing.”

With gunshot victims, the main reason for speed is to stop the bleeding. When someone is minutes from death, nurses lifting the person from a car can’t worry too much about other injuries, even to the spinal cord, Glatts said.

Studies have found that when health-care providers immobilize the spines of shooting or stabbing victims, the practice does not lower the risk of death or neurologic injury, Glatts and his Penn coauthors wrote.

To be absolutely sure, Glatts consulted with Jeremy Cannon — Penn Medicine’s trauma section chief and a former Air Force surgeon, who served in Iraq and Afghanistan — and he agreed.

“When it comes to penetrating trauma, the incidence of spinal injury is very low on the things-that-can-kill-you list,” Glatts said. “You’re most concerned about somebody’s who’s hemorrhaging or bleeding out.”