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The emergency response in Tucson: Timeline shows ambulance delays

James Palka / AP

Congressional intern Daniel Hernandez walks with emergency personnel as Rep. Gabrielle Giffords is moved after the shooting in Tuscon, Ariz., on Saturday, Jan. 8.

By Bill Dedman
Investigative reporter
msnbc.com

How fast was the emergency response in Tucson?

It depends on your perspective.

The Pima County Sheriff's Office released on Friday a timeline of the shooting in Tucson, Ariz., of Rep. Gabrielle Giffords and others, appearing to show the first ambulance arriving 20 minutes after the first 911 call came in.

That information seemed to match reports just after last Saturday's shooting, in which witnesses told reporters that ambulances were 10 to 15 minutes behind the first sheriff's deputies.

It turns out that that's not quite what happened. The sheriff's press release was incomplete.

The first fire/rescue medical personnel arrived at a staging area near the Safeway supermarket 8 minutes after the first 911 emergency call came in. The first ambulance for transporting patients arrived a minute later.

But these units and later-arriving ones were held away from the Safeway in a staging area, even several minutes after the gunman's weapon was secured, out of fear there was a second gunman. This is standard operating procedure in emergency services. First responders who become victims can't help anyone.

The first medical units didn't actually reach the Safeway until 11 minutes after the emergency call. Even then, some were held back for safety. During that time, members of the congressional staff and other volunteers provided first aide to the injured.

And it was not until 16 minutes after the first emergency call that the medical response was upgraded to a mass casualty incident, although the initial 911 call reported that there were "multiple shot." The battalion chief said he never makes that call until one of his crew is on the scene to confirm initial reports, which often are misleading.

Perspective matters
Counted as police and firefighters count their response times, the medical units arrived only five or six minutes after they were dispatched.

But counted from the time the 911 call came in, it was 11 minutes or more before patients were being treated.

"Yes, from the perspective of someone on that horrible scene, calling 911, and waiting and waiting and waiting, it would seem like a long time," said Tom Brandhuber, fire chief for the private Rural/Metro Fire Department in Pima County, whose ambulances responded. "The units got there as quickly as possible. They all descended on the scene at once. And they were able to get all the patients off the scene quickly."

Another factor of perspective: Congresswoman Giffords would naturally have been the focus of much of the attention from witnesses waiting for ambulances. The ambulance that took her to the hospital did arrive 20 minutes after the first 911 call, and left for the hospital 10 minutes later. That total time, 30 minutes, makes her survival of a gunshot wound to the head all the more remarkable.

The timeline
Here's a timeline of first responders for last Saturday's events, compiled by msnbc.com by merging information from the Pima County Sheriff's Office, the public Northwest Fire District, and private Southwest Ambulance and Rural/Metro Fire Department. Two cautions: Times were given in whole minutes, and clocks could vary from one computer-aided dispatch center to another.

10:10 a.m.: The shooter opens fire. Nineteen people are shot.

10:11 a.m.: Pima County Sheriff's Department receives the first of many 911 calls about a shooting with multiple victims at Safeway, 7100 N. Oracle Road, Tucson. That call was taken by a general call taker, who determined that this was both a police and medical emergency, and transferred the information to specialists for both types of calls.

10:14 a.m.: First medical units are dispatched. Northwest Fire/Rescue (public) sent a "first alarm medical," a higher level of response than a simple heart attack or single gunshot victim would receive. That included three fire engines with advanced life support capabilities, a battalion chief, and three ambulances. Those ambulances aren't normally used to transport patients to a hospital, so two ambulances were also dispatched by private agencies with contracts with the county, Rural/Metro Fire Department and its sister company Southwest Ambulance, to provide not only treatment but also transport.

10:15 a.m.: Southwest Ambulance dispatches a second ambulance.

10:15 a.m.: Deputy Thomas Audetat is the first sheriff's deputy on scene and detains the suspect.

10:16 a.m.: Deputy Georgina Patino is second on scene and secures the weapon.

10:17 a.m.: Southwest Ambulance dispatches a third ambulance.

10:19 a.m.: The first medical personnel begin arriving, from the county agency, Northwest Fire/Rescue, but are held in a staging area nearby to make sure the situation was secure. Northwest's first responders were six firefighters with medical certification as paramedics or EMTs, on two vehicles, a paramedic fire engine and a paramedic ambulance. These vehicles are fully equipped for medical treatment, but don't transport patients except when no other transport is available.

10:20 a.m.: The first ambulance for transport arrives from Southwest Ambulance, Paramedic 838, and is held for safety. It was Southwest's second ambulance dispatched, and arrived first, five minutes after it was dispatched.

10:22 a.m.: Northwest paramedics and EMTs are allowed to move to the treatment area and start working. Even then, not all the units moved in at first. "Even when they said it was safe to send in, I sent one rescue company and engine company, until I knew it was safe," said Battalion Chief Lane Spalla from Northwest Fire/Rescue. "It's hard for us to sit on the corner while people need help, but we have to make sure it's safe. And we have to make sure we're sending the units to the right place. Those are always good minutes that are needed. I thought law enforcement did a fantastic job clearing the scene in three minutes. We've been on calls for individual gunshot victims that took longer."

10:23 a.m.: Second and third ambulances from Southwest Ambulance and its sister Rural/Metro Fire Department arrive (Paramedic 837 and Rescue 76). They are held at the staging area waiting for the "all clear." They arrived in the staging area six minutes and nine minutes after dispatch.

10:23 a.m.: Six more Northwest firefighters arrive, for a total of 12 medical personnel in the treatment area, with others waiting in the staging area.

10:24 a.m.: The three ambulances from Southwest Ambulance and Rural/Metro Fire are given the all clear, and move to the treatment area by the Safeway.

10:24 a.m.: A neighboring firefighter unit arrives. By now there are 30 or more medical personnel making their way from the staging area to the Safeway.

10:27 a.m.: Northwest Fire/Rescue upgrades the call to a "second alarm medical," indicating mass casualties. This effectively doubles the response, sending three more fire engines, three more ambulances, and other officers.

10:27 a.m.: A fourth ambulance from the private sector, a Rural/Metro Fire Rescue unit, is dispatched.

10:31 a.m.: This entry in the sheriff's public timeline is a source of confusion. The sheriff's office reports that Rural/Metro's Paramedic 831 is the first ambulance on scene, but this turns out not to be correct. It's the fourth ambulance for transport on scene, not the first. This ambulance had not been dispatched until 10:27. The sheriff's timeline for public release may focus on this ambulance because it's the one that will carry the congresswoman.

10:35 a.m.: The first ambulance to leave is Rescue 76 from Rural/Metro. It was on scene for 11 minutes before leaving. It arrived at Northwest hospital at 10:43.

10:36 a.m.: A second ambulance leaves the scene, Paramedic 838, and arrives at a hospital at 10:45.

10:41 a.m.: A third ambulance leaves the scene, Paramedic 831, with Rep. Giffords for University Medical Center, arriving at 10:54. (There were incorrect reports that she was taken by air ambulance. Others were, but the ground ambulances arrived at the Safeway first, and left first.)

10:48 a.m.: A fourth ambulance leaves the scene, Paramedic 837, and arrives at a hospital at 11:06. Other ambulances follow.

Standards for response times
The nationwide standard for arrival times is usually six minutes: one minute to handle a call ("dispatch time"), one minute to gear up and get on the road ("turnout time"), and four minutes to drive ("travel time"). That six-minute standard is used by the National Fire Protection Association.

Time is of the essence in handling gunshot wounds, heart attacks and other life-threatening emergencies. The American Heart Association says that brain death starts between 4 and 6 minutes after cardiac arrest.

These standards are not laws, and municipalities are not bound by them. Communities can adopt those standards, striving for the highest-quality fire and ambulance response, or they can not adopt them. Even when adopted, they are merely guidelines, though sometimes legal contracts between municipalities and ambulance companies set certain response times.

Rural/Metro Corp. and its subsidiary, Southwest Ambulance, have 20 stations in the Tucson area, and more than 75 ambulances. Based in Scottsdale, Ariz., Rural/Metro serves about 400 communities in the U.S.

Southwest Ambulance (Rural/Metro Corp.) said its standard, under its state license or so-called "certificate of necessity" issued by the Arizona Department of Health Services, is for response within 8 minutes in 70 percent of the medical calls. It said it exceeds those, hitting 8 minutes in at least 90 percent of calls.

Calculating 'response times'
Working from that timeline, these are the approximate response times:

Times for the first medical units: three minutes of dispatch time at the central dispatch before the medical units were called, then five minutes of turnout and travel time. "Response time" from the perspective of the medical units: five minutes. Then another three minutes of hold time for safety of the first-responders. "Response time" from the perspective of a person who dialed 911: 11 minutes.

Times for the first ambulance for transport: three minutes of dispatch time, at the central dispatch before the medical units were called, then six minutes of turnout and travel time. "Response time" from the perspective of the medical units: six minutes. Then four minutes of hold time for safety of the first responders. "Response time" from the perspective of a person who dialed 911: 13 minutes.

"These are good times," said Chief Brandhuber from Rural/Metro. "They show multiple agencies working together well on a mass-casualty event."

Delay in upgrading the response?
The first 911 call reported "multiple shot."

"There was a shooting at Safeway at Ina and Oracle where Gabrielle Giffords was, I do believe Gaby Giffords was hit."

Responder: "At the Safeway sir? ... Was somebody shot there sir?"

"It looks like a guy had a semi-automatic pistol, and he went in, he just started firing and then he ran."

"She's hit, she's breathing, she still got a pulse ... we got one dead... there's multiple shot."

Responder: "Oh my God."

Other callers told of "a bunch of people shot" and "a total of 10 people, maybe more."

Sheriff's radio tapes show an early call from an officer, "Start multiple med units. ... People down. ... I'm counting at least 10."

And another officer pleading, "Start every ambulance we have out here."

And a third, "We're really short on medical personnel."

It would be 16 minutes before the incident was upgraded to a mass casualty event.

"According to our records, the incident was upgraded to a second alarm medical at 10:27 a.m. and additional ambulances were dispatched according to protocols," said Jackie Evans, Southwest Ambulance's market general manager for Southern Arizona.

That's 13 minutes after the first medical units were dispatched, and 16 minutes after the 911 call.

Battalian Chief Spalla said he was responsible as the scene commander for calling for an upgrade, which doubled the number of crews responding, and he is always cautious about taking this step. If too many units are sent to a minor incident, that puts them out of position if genuine calls come in.

"We might show up and there's nothing. Stories often change from the first 911 caller to the second, from the time we get on the scene, from the ambulance crews to the ER doctors. We sent a higher level of response from the beginning, more than we would send for chest pains, and until I get units on the scene, until I get eyeballs on bodies, I don't upgrade again."

Did the delays matter?
There were plenty of paramedics and EMTs, pronouncing as deceased five of the victims, and assessing, stabilizing and treating the 13 wounded, preparing them for transport to the hospital, said Capt. Adam Goldberg, who also serves as a spokesman for Northwest Fire/Rescue. (The New York Times describes the scene that a first responder from Capt. Goldberg's company encountered at the Safeway store, and the life-saving choices made by paramedics, EMTs and doctors at the hospital.)

If the ambulances for transport had arrived sooner, the most seriously injured patients might have left sooner for the hospital, Goldberg said. He said he "absolutely" does not think that the wait for an ambulance made a difference between life and death in this case, but one can never be sure.

Two doctors were at the shopping center before the paramedics and EMTs, and the five dead had already been covered. The sixth to die, the 9-year-old girl, was in cardiac arrest with wounds presumed to be fatal, and wouldn't normally have been rushed to the hospital if there weren't enough paramedics to work with her, Goldberg said. After confirming the five deaths, the paramedics and EMTs went to work furiously on the 13 injured.

"As the ambulances arrived, they were given patients out of our treatment for transport," Goldberg said. If the ambulances had arrived sooner, patients would still have needed to be stabilized. "You don't just take a patient and throw them on the ambulance."

So both things are true at once, he said: If the ambulances had arrived earlier, the first patients might have left earlier. And it might not have mattered. "It's a valid question," Goldberg said.

Battalion Chief Spalla said the delays in the staging area were frustrating, but once at the Safeway his crews had all the people they needed.

"I had more than enough resources to treat at the scene," Spalla said. "We were plenty busy. Treatment never asked for an ambulance that we didn't have for them. If there had been 10 ambulances sitting on the corner, I couldn't have used them until I got triage going."

The earliest firefighters and paramedics on the scene recount their frantic first minutes outside the Safeway grocery store. NBC's Lee Cowan reports.