Quick decision at a MVC

[systemet]

We can run this out as a scenario if you guys want, but I am just looking to see who chooses which patient.

After your choice, give me your initial stabilizaton treatments and level of cert, I am interested in all level's opinions.

(....)

So the question is: who goes ALS, who goes BLS?

This is obviously a difficult situation. I've already thought about this longer than you would have time to in a real situation. I think this:

* Patient 3 is dead, and gets a blanket.

* Patient 1 gets RSI'd, goes ALS.

* Patient 2 goes BLS, w/ a 20ml/kg crystalloid bolus (if physical exam reveals an absence of significant chest / abdo. trauma). BLS can give entonox in the absence of contraindications.

* BLS gets instructions to call ALS if the patient becomes unconscious. In that situation we double up, and start thinking about airway and dopamine.

Rationale:

- We don't have enough hands to work a code in the presence of other criticals (reference: every triage system out there)

- Initial therapy for patient 2 is a large fluid bolus and analgesia. BLS can take care of one of these, and attempt to address the other (analgesia) with entonox in the absence of contraindications.

- Patient 3 needs to be intubated. They need to be sedated, therefore they can't go BLS.

Observations:

- In a real world situation you're unlikely to know vital signs prior to transport, unless the BLS unit is coming from a way out.

- If you're a medic in a system this rural, it's likely that for the early part of this call you have triage responsibility, unless you have some very sharp EMTs, and aren't going to be doing anything ALS beyond a needle decompression or a 'cric.

- The biggest impact you can probably make in this situation is picking up the phone / radio, calling the ER, convincing them to have an MD there when you get there, preferably one that's competent with trauma, then getting the MD's cell number, waking them up, and suggesting they call the critical care line and arrange 2 x fixed wing now instead of waiting for you to arrive. Depending on local politics this may not be possible.

- You can motivate transporting either patient ALS. Especially in the fog of EMS at 0-dark.-30. Unfortunately whether you made the correct choice will likely be determined after the event by someone who has access to a lot of information that is unobtainable in the initial minutes of this call. They will have the benefit of hindsight, and may crucify you despite your best intentions.

[DFIB]

I would like you guys to help me a little with this.

My rationale for the BLS transporting the decorticate patient is that his prognosis is poor in survival and quality of life, If he is stable the BLS should be able to handle bagging him without a tube and CPR if needed. If the ambulances are traveling in close proximity ALS would be available if necessary. This guy is not going to do well regardless of the transport decision. If the medics protocol allow him to load some meds to help with edema he should have additional advantages.

Patient two on the other hand has the possibility of surviving and having a decent recovery. I would place the most experienced care with him.

If I could only transport one patient, patient one would be out of luck.

[Happiness]

^{I wanted to answer this without reading any response first. My Answer is}

^{#1 is going BLS as his vitals are stable, the airway is managed, he would still be going code 3 but with the snoring that is telling me there is probably severe ICP and his survival is going to be low. He will be c-spine packaged, bagged, O2 and monitored to the hospital}

^{#2 is ALS his viatals are unstable, with possible internal injuries and needs to get to the operating room. I picked him as he has a higher chance of survival. He will be c-spine packaged, O2 Non rebreather at 15 ltrs,.I will have all airway equip ready, and monitored.}

^{#3 toe tagged}

^{I am a PCP, And here is my reality they are both with me #1 on the bench and #2 on the strecher. Both of these pts are going to be going to the same hospital, will probably have the same medical team and possibly the same ER room. They will then be sent to the nearest operating room in rupert but Im not thinking #1 is going to make it. I luv rural EMS also but I am considered Isolated EMS.}

[Bernhard]

^{And here is my reality they are both with me #1 on the bench and #2 on the strecher.}

Why not using the BLS ambulance for one of them (#1, as you said)? Just trying to understand the system.

[mobey]

I agree both could go in the ALS unit. Logistically though, it would have been hard to have 2 criticals in one rig.

The main concern was that these two were found "spooning" so-to-speak. Immobilization was done one at a time since we had severe neuro deficits with Pt #2.

That said, Pt #1 was packaged and ready to go, as Patient #2 was just getting rolled onto his board.

[rock_shoes]

Patient #1 21 y/o male, lying approx 10ft from car, UnCx snoring resps. Accepts OPA. Possible Fx left wrist. Vitals normal. Sp02 99, EtC02 33 (sidestream)

No other injuries to report

This patient should be going with the ALS crew. This patient has zero ability to protect their own airway with clear signs of increasing ICP. The most critical management requirements this patient has are beyond the scope of EMT crews.

Patient #2 19 y/o male lying directly beside Patient #1 (nearly spooning). A&O x4 though lethergic. Complain of parastesia from waist down and severe mid-back pain. No loss conciousness, no resp difficulties.

Vitals BP 84/42 HR70

Negative babinski reflex, No pain responce at any level in his legs.

Basing my evaluation on the Alberta EMT SOP, this patient can be managed reasonably well by the BLS crew. If possible prior to transport an anti-emetic from the ALS crew would be warranted (no-one likes managing a vomiting spinal patient). IV’s with fluid boluses as indicated are within EMT scope as is entonox for analgesia (provided it’s not contraindicated of course).

Patient #3 DOA

So the question is: who goes ALS, who goes BLS?

Left with the police on scene. This individual is now the coroners to manage.

I’m the first to advocate that in an ideal world both of these patients would be in receipt of ALS care but situations like you’ve described are a daily occurrence in rural areas.

In consultation with OLMC, orders to administer high dose corticosteroids and or therapeutic hypothermia could potentially be in patient #2’s future. Patient #1 is all about airway management and rapid transport to the closest neurosurgeon.

Just to add to the discussion. What are the transport capabilities of the fixed wing unit mentioned. Can they take 2 patients? Is the aircraft pressurised or non-pressurised? If the aircraft is pressurised is it possible to run higher than normal cabin pressures to reduce the effective cabin altitude? What is the transport time to appropriate care by air? What would the transport time to appropriate care be by ground?

[Happiness]

Why not using the BLS ambulance for one of them (#1, as you said)? Just trying to understand the system.

I guess depending where the accident occurs, I will be the only one available at the time. The next station is approx 30-40 minutes away, most of the time they are out of service so then the next after that is 1.5 hrs away and by the sounds of it neither pt can wait that long. Our station has done training with other first responders, we work together and I am confident that if I have to take first responders with me they will follow my instructions, im very lucky. I tried to answer as if I had ALS available but I dont

[island emt]

When you work in a rural area, it will happen that both pt's will be transported together in the same truck with as much help as you have on scene to assist with bagging and providing care. Both Pt's would be packaged up and loaded for the long trip to the trauma center with both ALS & Bls providers on board.

Ever tried to bag for a couple hours while bumping down the road? Your hands and forearms will cramp up something wicked. If one or the other tanks then you still have some crew to deal with the other PT. while your energies are occupied with the pt circling the drain.

Rural EMS is WAAAAY different than ten minute transports to your choice of five hospitals. You can spend hours with a critical PT before getting them to a trauma center or even a level 2 hospital.

[Asysin2leads]

The patient with the potential for airway compromise and seizure activity goes ALS. The other guy gets driven fast to the hospital with some EMTs administering rapid infusion of apologies for him being in agonizing pain strapped to a backboard.

[Bernhard]

When you work in a rural area, it will happen that both pt's will be transported together in the same truck with as much help as you have on scene to assist with bagging and providing care. Both Pt's would be packaged up and loaded for the long trip to the trauma center with both ALS & Bls providers on board.

Fully packed ALS ambulance and the BLS unit is left standing alone on scene? Okaaaay...(see below)

Ever tried to bag for a couple hours while bumping down the road?

No need to, we have automatic respirators on our ALS units.

Rural EMS is WAAAAY different than ten minute transports to your choice of five hospitals. You can spend hours with a critical PT before getting them to a trauma center or even a level 2 hospital.

Yes, I'm aware. I grew up in a time in EMS, where hospitals could deny patients. So all the fancy high level trauma centers 30-60 minutes away just closed their doors and let us drive hours to the next big city. Night choppers weren't available then as well. I'm very glad the law has changed and every trauma center now is obliged to take just one more even if fully occupied (assisted by several organizational aids) plus we have usually at least one night flight available, if really needed.

However, I wouldn't let the BLS unit just park on the scene without staff, because they're all in the ALS unit working on two patients in confined space. That sounds like a waste of ressources, in my eyes the BLS ambulance would be perfectly able to transport one of the patients. But I understand, that legal restrictions may arise, if BLS staff is not allowed to work under expanded authorization with rendering/supervising ALS treatments as i.v. drops and else. That's what I asked for to understand. Thank you for explanation! Again, I'm glad to not have those restrictions here (which makes it not better here, just may be easier in this special case).