Breaking the Rules to Save Lives

by Joseph Cahill

In the New York City Fire Department Emergency Medical Services (EMS), patient contacts are documented by using an Ambulance Call Report – a frequently time-consuming but nonetheless valuable process used in gathering important information. During and after a mass casualty incident, this process is sometimes truncated by allowing the use of triage tags to be hung on a victim’s neck, wrist, or ankle. The information required to complete a triage tag is significantly less than that needed for an Ambulance Call Report, but the tag still provides enough data to effectively track patients.

Triaging & Medications Although it is certainly important to track patients through the typical and officially approved response and recovery processes, a valuable lesson can be learned from the makeshift triage procedures used at the scene of the World Trade Center terrorist attacks in September 2001. The first responders on the scene were ordered to stop using triage tags and, if a patient could walk, point him or her east “and keep them moving” away from the destruction and toward possible safety. In short, no documentation or contact was to be offered unless a survivor obviously required significant treatment and/or transportation to the nearest available hospital or other healthcare facility. This single order, “keep them moving,” may well have saved hundreds, and perhaps thousands, of lives when the north tower collapsed on and around the triage area that had been originally established.

Medication manufacturers are required by law to assign expiration dates in order to safeguard patients from medications that, over a certain period of time, are or may be: (a) losing potency; (b) breaking down into harmful compounds; and/or (c) becoming contaminated with bacteria. In early 2012, the Texas Medical Board was alerted that some EMS units had been using expired medications when they were unable to obtain the same medications with unexpired dates. In general, the expired medications were used only during life-threatening conditions when there was no readily available substitute.

Outside the Box, But Within the Law In the first example of intentional rule-breaking cited above, the enormity of the event precluded following the usual prescribed procedure to the letter. The totally unexpected and enormously dangerous conditions that had been created by outside causes took away the responder agency’s usual control of the situation. In both of the situations cited, the decision maker was a senior officer of the agency who had the legal authority needed to accept, on behalf of the agency, the increased level of risk involved in departing from previously established, and officially approved, processes and procedures.

In the case of EMS agencies using expired medications, consideration must be given to the federal and state agencies that regulate the use of such medications. Most regulatory agencies may and usually do have an “exception” process available to allow violation of the rules, under certain circumstances (but usually mandate additional oversight requirements as well). For example, in situations calling for the use of expired medications, there may be another path, within the overall structure of the rules that could achieve the same goals. However, technical expertise still is needed in such situations to determine any possible medical ramifications.

In other words, it is not enough for officials on the scene to simply assert that the risk of a negative outcome is outweighed by the likely positive outcome – or even to say before and/or after the fact that the positive outcome is more likely than the negative. Breaking the rules in emergency response situations is an extremely serious business, with significant ramifications. It is certainly not the time for the strategic sergeant on the scene to take control of the situation and make the call. Rather, it is a time to implement a predetermined “plan” designed specifically to cope with a scenario that does not quite fit “within the box.”


For additional information on: American Society of Health-System Pharmacists’ list of current drug shortages, visit

FDA Drug Shortage Page

Texas drug shortage information, visit

The U.S. Food and Drug Administration’s Current Drug Shortages Index, visit

________________________ Joseph Cahill is a medicolegal investigator for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as the citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Prior to that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s Paramedic Program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.