scenario-vehicle crash

[PRPGfirerescuetech]

Dispatched via county for BLS mva with injuries.

Your the EMT on a limited MIC ambulance, dumped for the call, in your moderately rural district. While enroute, call gets upgraded from BLS to ALS, from ALS to rescue, and from one vehicle to two, to three, to four, with multiple ejections and entrapments.

Its -10deg, middle of a blizzard, on Christmas day, and many of your local services are off status for lack of staffing. Your closest ALS next due is roughly 20 minutes drive away, your 20 miles from a trauma center, and suddenly, you feel like going home.

But your not even there yet...

Lets take this one conservative. What do you want to know so far?

[JPINFV]

I want an easy button.

Coming up to the scene I want to know what resources I DO have. Police, fire, aeromed, etc and where is the nearest hospital. If I can't get a helicopter, ohh well. If I can't get the number of units or medics that the scene needs, ohh well. No sense dwelling on what you can't have. If worse comes to worse, you can always get an ALS or RN staffed CCT unit in route to the nearest PRC and start shuttling the patients to it. The serious patients can get transferred via the CCT unit to the trauma center (the ER doc at the local hospital *should* be able to do basic stabilization). This should keep you available if you need to return.

Considering the conditions, I would also want the local highway agency (CalTrans in my state) on the way. Get those nice little message boards set up leading up to the accident since it sounds like you're going to be there a while. Start warning

drivers and start getting them to slow down as far away as possible.

Scene safety (Were you able to get around the accident and able to park past the accident? Are there cars still running into the pile up? The last thing I want to do is become a victim, which just slightly more worse then working in temperatures below 60 degrees)?

Number of cars? Number of patients you can reach broken down by START triage (Go Hoag Hospital. +5 if you get the reference)? Number of patients that you can transport, even if its by a passing POV that you put an EMT into (with the temperature, I want to transport everyone ASAP to prevent hypothermia. Just getting the minor patients off the scene will help. Fire and police can drive the ambulance).

[AnthonyM83]

I'd like to know my resources (air support, other first responders, cops). I wouldn't know much about working in such cold weather, so I'm not sure what special considerations I'd need to have with eqiuipment or patient care other than trying to keep warm myself (how do you keep a trapped person warm for example... portable heater? heat packs? thermal blankets? hand rubbing?)

Can I have CHP close off the freeway one entrance prior, so we have space to work and easy access for responding units? How far is the trauma center or appropriate hospital? If we have limited resources, can the ambulance go in two rounds (probably wouldn't want this, but just a thought)

And of course the nature of the injuries, vehicles, extraction times, and tools needed (do we have them?).

[PRPGfirerescuetech]

Good start fellas.

Somethings to keep in mind

1.) Rural road, one community hospital with no trauma 10 minutes away. One community hospital 15 minutes away. All further hospitals are more than 30 minutes away.

2.) Flight services have declined scene flights. You do have a working runway with illuminated helipad and running strip about ten minutes away.

3.) Its a rarely traveled roadway, 30-35 mph.

Now, time for the arrival details.

You arrive to an intersection, and all vehicles are in the snowly embankment on the southwest side of the intersection. You pull up to the scene at the corner, and see this.

A pickup truck, split in 2 pieces, with the nose of the front in the dirt, and cab in the air. The tail of the pickup truck bed in also in the dirt, up in the air. You can see markings in the snow where the rollovers took place, too many to count. There is a bleeding man with the vehicle. The vehicle and man are 75 yards from the corner of where the roads meet.

There is a blood trail in the snow, drips initially, then a sliding trail lasting approximately 60 yards from the truck, and 15 yards from you. There is a unconcious female at the end of it.

There is a moaning coming from a bush about 50 yards from you. Unsure why the bush is moaning.

Off to the left of the corner, there is a late model jeep cherokee rolled over into what is the beginning of a sewer basin. It had rained before the massive snowfall, and the car was flipped into 4 feet deep of icy water.

There is a gentleman with blood on his face, walking around the scene, screaming "theres people in the jeep" "help them!"

A few notes.

This is a state police area. With the traffic, your ETA for any police help is 45 minutes+

First due rescue company is committed on a rescue on the turnpike (you didnt hear it, you were busy sleeping). 2nd due service is 15 minutes away, clearing a hospital fire alarm at the 2nd closest community hospital.

Next thoughts?

Oh, and yes, this actually did happen. Prior to the easy button.

[JPINFV]

4 patients (bloody drag girl, moaning bush, truck boy, and the walker). I would check on the jeep, but if the patients heads are in the water, then they are dead with rescue 15+ minutes out. Send anyone into that water without gear (i.e. police or EMS) and they are done for the night on account of the cold.

Are these "rescue" units ambulances or fire trucks (we don't call them "rescues" out here). Do the community hospitals have a helipad? Is the helipad on the way to the hospital (a map would be nice here, are the hospitals, for example, in the same direction?)? Are there ambulances 20-30 minutes away from the closest community (again, RN or P staffed)? This is going to be more about moving meat then treatment. As a basic I can treat A (suction) and B (NRB or BVM), but I can't do anything for C past bleed control.

(ok, half of my dispatchers are idiots and what I'm doing is a little off the wall). Based off of the current resource info, I would TELL dispatch to start getting distant CCT/ALS units (i.e. 20 minutes from the far side of the hospital from me) to the community hospital. I'll have enough time to spend chatting about it later.

Ok, patient impressions right now. Bush is alive and moving air. Is truck boy and bloody drag girl breathing following head tilt? If not, then they are dead. I can't C-spine alone. How many LSBs, scoops, and KEDs do I have? Is Jeep boy entrapped, or can we get him out?

If I have a KED, then the walker gets it and a seat in the front of my ambulance. He also gets the spare O2 tank and a NRB if I have an extra regulator. I really don't care about V/S on him, he is the least injured. Taking a BP is going to just delay me from getting on the road and treating the other patients.

Next move depends on the condition of jeep boy, bloody drag girl, and (maybe) the water people.

End plan right now is transport everyone that is alive and that I can remove to either the community hospital (the ER doc should, at the very least, be able to start blood products, intubate, chest tubes, etc short of surgery) or to the landing strip. The CCT teams can take it from there. Hopefully I can get a few RN units there. This would keep the paramedic units in service instead of running them to the trauma center.

[strippel]

No easy button. Damn.

I guess then you can't thank them for playing, and send them all home with a years supply of Turtle Wax, and remind them to spay/neuter.

Are there helipads at either community hospital? When you tell your dispatcher to send you "everyone", you could have the further away services report to which ever hospital does not have a helipad, or to the landing strip. Have the dispatcher notify the community hospitals to consider extra help in the ER. Have them call the landing strip, and leave the light on for you. If they decide to close, and you have resources going there....

Besides that, you are screwed no matter what. If you are a paid service MICU, you have 2 providers. If you had a third, you would be livin' large.

I like the idea of putting the walking wounded guy in a KED, and in the front seat. Take your LBBs (hopefully you have more than 1, and the off going crew did @$%^ you) and scoop/reeves, and take the 3 remaining "accessible", and currently living patients, immobilize them, and throw them into your warm truck.

After that, you are damned if you do, damned if you don't. I'd start driving, probably toward either the hospital (with a helipad), or to the landing strip. I would have to know there was someone there, and helicopters on the way.

[ReD]

go poke your head in the jeep if you can, at least go to the edge of the water and shine your flashlight over there to see if you can see anything. get a look at everyone first before you start assigning anyone a priority. also run over to the bush and see whats up, they have at least somewhat of an airway since theyre making noise so from what i know now, id be worried about bloody trail girl and jeep occupant(s).

i dont know how your boxes are, but with truck boy in the front seat, i could fit 3boarded pts in my box, and one in the captains chair if possible.

stop worrying about if the hospital has a helipad or not, the way this scene seems to be going, our main goal is going to get the pts transported to the local ER to get stabilized enough to where they can live long enough to stick around until troops can be ralleyed up to transport these people to a trauma center.

I really don't care about V/S on him, he is the least injured. Taking a BP is going to just delay me from getting on the road and treating the other patients.

Dont take a BP, palpate pulses, if he has a radial, then you're ok. at least get SOMETHING on him, you can palpate the radial for 5secs and at least tell if he's tachy as hell or not, or if theres even a pulse present.

[JPINFV]

The guy walking around has a strong enough pulse to walk. Thats good enough for me.

Lets say we ignore the airfield and it happens to be open. We load up everyone and go to the community hospital that doesn't have a heliport. ER doc (who's last major trauma might have been during residency) manages to do chest tubes, RSI's, etc PRN. He still lackes the ability to operate, so the injured are still bleeding out and all. Now you've delayed significatly PCT to OR. The possibility to lose some more people then you should have is now running a lot higher.

[MedicNorth]

I would not give up on the patients in the jeep, if at all possible. Even if they have been submerged for 15 minutes plus, the extremely cold water might be enough to trigger their Mammalian Diving Reflex, which might make for viable resucitation up to 60 minutes after immersion, especially in children.

We had a case up here about two years ago with a child trapped under 2 meters of meltwater for over 25 minutes befiore rescue. He recovered completely, and was home within three days.

Mammalian dive reflex: Drowning suffocation causes a lack of oxygen, resulting in death in only a few minutes. An exception to this rule appears in victims who have been suddenly and rapidly submerged into ice-cold water. Some of these people have survived up to an hour underwater without any physical damage resulting. This phenomenon is known as the mammalian dive reflex, which is activated when the face and body plunge into ice-cold water, resulting in the slowing of body metabolism as well as diverting blood only to the heart, lungs, and brain. If someone gradually becomes hypothermic (gradual lowering of body temperature), then this reflex does not apply. With the slowing of body metabolism as the body cools, the body uses less oxygen to survive. The goal is to rescue these victims before their oxygen is used up.

http://www.emedicinehealth.com/drowning/article_em.htm

[Dustdevil]

Dont take a BP, palpate pulses, if he has a radial, then you're ok. at least get SOMETHING on him, you can palpate the radial for 5secs and at least tell if he's tachy as hell or not, or if theres even a pulse present.

Every patient has a pulse... right up to the point they lose it. It's mere presence tells you very little of value.

And the old theory of estimating BP by palpating a pulse was disproven quite awhile back. It's old school and is being thrown out of ATLS.