MVA Scenario Discussion

[skyraider]

Setting the scene: 7 cars & a semi on the highway. Crash consists of 1 semi (upright) on the right shoulder w/ a fuel leak; then on the left shoulder are 2 totalled cars; 100 ft behind them are 2 more crashed cars; 100 ft behind them are 2 more crashed cars; then 1 more behind them. All passengers are out of the vehicles and walking around appearing alert & oriented (no rollovers). Hazmat's called. Everyone rolls on scene one right after the other: engine, medic, BLS, 2nd due engine, & 2nd due BLS.

Not sure this constitutes a mass casualty. Can someone walk me through how they handle MVAs when there are several (let's say 5 or more vehicles involved) with multiple engines & medics/ambos on scene.
Questions:

1. How does the medic and the ambo crew know who is checking out who? Assume units don't park near each other and each OIC headed for different cars/patients.

2. When you have a mechanism such as a medium-high speed traffic accident and people are out of the car, how much of an assessment do you do on the people that say they're fine? They're supposed to get a PCR once touched or sign a refusal....but if no assessment is done, no PCR. If you ask someone if they're ok, they say yes, do you just ask a few questions, and if ok, then move on to the next "patient?"

3. Are there times when a driver & an OIC would be separated to check out different patients?

4. Someone says they hurt and wants to go to the hospital....you see their car is totalled, but they're walking around, oriented, appear fine. Don't you backboard just because of mechanism?

5. Someone has minor cuts & bleeding (possibly from glass) but doesn't want to be assessed, treated or transported...says they're fine. Do you document? If so, where? (Same question as #2, I suppose)

Appreciate the feedback.

[RyanEMVFD]

First off you should have protocols for all this. Initially triage should go look over all patients and be tagged with a color. Also mass casualty is considered anything that overtaxes the local system, or in my system anything over 20 patients. So if you have one ambulance and there are 5 patients that could be considered an MCI.

Something like this example Incident Command is a must. Under our protocols, the medic becomes IC while the EMT becomes triage officer. The rest is run as per our MCI plan with an IC working with the FD and PD.

[skyraider]

I understand your point (and agree w/) the protocols & triage issue. I've just never seen them implemented properly...that's why I was asking. Resources have rarely been the problem...scene's are just chaotic. Being the ambo BLS crew (answering to and coordinating w/ the Medics & Engine) is sometimes confusing. Thanks, though!

[mitllesmertz1]

Setting the scene:
1 semi (upright) on the right shoulder w/ a fuel leak;
2 totalled cars;
2 more crashed cars;
2 more crashed cars;
1 more behind them.
So the initial "worse case" size up is a minimum of 8 critical patients (if only 1 per car), and a possible fire/haz -mat from the semi. Could be an MCI, but we'll investigate further.

engine, medic, BLS, 2nd due engine, & 2nd due BLS.
-First in Engine Officer establishes command (IC). Shut down freeway/block traffic/talk to PD. Have crew pull a charged line to the semi, foam as needed. Assuming 3 person Engine crew, they are now used up :(
Have all other units stage behind First due Engine.

-First due Medic: senior medic assumes Medical Command(MC), driver is Triage Leader. MC meets up with IC, starts making plan, and allocating resources. Contact local trauma center about possible MCI per protocols. MC asks IC for second ALS unit. MC has cell phone and radio, and NEVER TOUCHES A PT.

-IC assigns First Due BLS, Second Due Engine, and Second BLS to MC. MC assign units to Triage.

Triage gets MCI kit from rig and passes out supplies to EMT's.
Medic driver(Triage Leader) directs 2-man triage teams to do START triage, come back to him with patient count (ie 2red,2yellow,6 green,etc)

-After START triage, Triage gives patient update to MC, MC requests additional units from IC as needed.

-Triage now becomes Treatment Leader. Directs triage teams (now treatment teams) to start getting patients packaged and ready for transport according to severity.
Treatment Leader establishes Treatment area.

-MC can request an officer to become Transport Leader, or assign it to the ALS unit that has arrived on second alarm (glad you asked for them!)

-MC and Transport start working with trauma center by phone to figure out who's going where.
-Patients are packaged, or examined and released, according to injury and protocol.

-Treatment and Transport advise MC when all patients are transported or cleared. MC advises IC that scene is cleared of patients.

-IC clears MC from scene, first ALS is in service.
-IC controls scene until PD takes over/hazards are mitigated.

If ya treat the scene like it's an MCI from the beginning, you won't get caught "behind the ball". Ask for help early.


Not sure this constitutes a mass casualty.
A simple definition of an MCI is "more patients than you have resources on scene to treat". If they all turn out to be non-injured, greta. But if only 1 was critical and 2 need to be boarded/collared and transported, you will need more help.

Questions:

1. How does the medic and the ambo crew know who is checking out who? Assume units don't park near each other and each OIC headed for different cars/patients.

That's why a command presence it so important!! Without it, everyone will just jump out of their rigs and start grabbing patients, with no order. 8 people will start working on freeing a trapped patient while 3 other patients need help.
They know what to do because the IC established command and delegated patient care to the first in Medic (Medical Command).


2. When you have a mechanism such as a medium-high speed traffic accident and people are out of the car, how much of an assessment do you do on the people that say they're fine? They're supposed to get a PCR once touched or sign a refusal....but if no assessment is done, no PCR. If you ask someone if they're ok, they say yes, do you just ask a few questions, and if ok, then move on to the next "patient?"
Obviously depends on your protocols, and the amount of patients vs resources. With limited resources and multiple patients, a quick triage of EVERBODY will seperate the critical from the "Pemco Pain" patients. Medical Command can then delegate the appropriate resources to care for the pt. Ideally, every pt involved will be examined and treated or cleared by the end of the call. You don't want to have a critical pt that was ignored by the triage teams. You mus trust your EMT's to do a good rapid assessment of all patients.



3. Are there times when a driver & an OIC would be separated to check out different patients?
Yess!!! See my example.
Your medics should have more knowledge of protocols and available resources for treatment/transport. The most senior medic should be Medical Command, the next senior should be Triage Leader. With a typical MCI, the Medical Command will never even touch a pt!
The Triage Leader shouldn't be doing pt care initally either.


4. Someone says they hurt and wants to go to the hospital....you see their car is totalled, but they're walking around, oriented, appear fine. Don't you backboard just because of mechanism?
Again, depends on your protocols and available resources. Anyone with a high mechanism needs to be examined.


5. Someone has minor cuts & bleeding (possibly from glass) but doesn't want to be assessed, treated or transported...says they're fine. Do you document? If so, where? (Same question as #2, I suppose)
Sorry to repeat myself, but your protocols dictate what to do with patients with possible injuries that refuse care.

The most important thing to remember in an MCI is to stop!!! Take a deep breath, and start doing triage. Fight the urge to start treating the bloodiest person you see.
Do a systematic triage of ALL patients, then make a plan, then start treating in order of severity!

[skyraider]

Thank you for the analysis, Mertz. I'm not sure why I've never seen the triage procedures actually implemented at my station. You answered the most important question, to me, which is that as the BLS crew, I should be looking for MC (first medic) and taking direction from them instead of going staight to a patient. As the BLS driver, I pretty much follow my OIC's lead and the OIC typically just jumps right in, making it awkward for me...enhancing the confusion.

Interesting that you say everyone should stage behind the first due engine. Our protocols state the EMS units pretty much pull in front of the incident. Do you say that in this case because of the fuel leak or is that standard for you?

Your point comes clear when you mention that if you treat are large incident as an MCI up front, you'll be prepared. I was looking at this from an "after the fact" point of view....we only had 2 patients requiring transport, both BLS. So, in hindsight...we had enough resources on scene. BUT...we didn't know that arriving on scene. While it's not uncommon for us to transport two trauma patients in the unit, we would not have been prepared if we had a number of transport patients.

You wrote: "Without it, everyone will just jump out of their rigs and start grabbing patients, with no order." That's exactly what happened (from my observation).

I wonder if some folks don't do full rapid assessments on "patients" out of vehicles & walking around because they don't want to fill out the paperwork. If they don't touch a patient, then they don't need to do a PCR or a refusal. I need to start listening to my head instead of listening to others. Thanks! (One of my OICs will most definitely disagree w/ me assessing all patients).

After your & Ryan's responses, I'm going to make sure I go back and re-read our protocols (unfortunately they're not available to us on line from home). Very much appreciate your feedback.

[mitllesmertz1]

Interesting that you say everyone should stage behind the first due engine. Our protocols state the EMS units pretty much pull in front of the incident. Do you say that in this case because of the fuel leak or is that standard for you?
A couple reasons, of course there's no set-in-stone answer.
1. By keeping the rigs "upstream" of the MVA, you can use the rigs as a barrier between you and the people trying to kill you (other cars).
2. Keeps all rigs out of the scene, which helps IC control who goes where and does what. We have people stay in there rigs until told otherwise!
3. Makes more room for rigs to pull thru and pick up pts later.

Your point comes clear when you mention that if you treat are large incident as an MCI up front, you'll be prepared. I was looking at this from an "after the fact" point of view....we only had 2 patients requiring transport, both BLS. So, in hindsight...we had enough resources on scene. BUT...we didn't know that arriving on scene. While it's not uncommon for us to transport two trauma patients in the unit, we would not have been prepared if we had a number of transport patients.


You wrote: "Without it, everyone will just jump out of their rigs and start grabbing patients, with no order." That's exactly what happened (from my observation).
Not just you,sir. Everyone does it at their first MCI, unless they are controlled by strong leadership.

[DrParasite]

I would agree with mittles on everything he said except for this part

First due Medic: senior medic assumes Medical Command(MC), driver is Triage Leader. MC meets up with IC, starts making plan, and allocating resources. Contact local trauma center about possible MCI per protocols. MC asks IC for second ALS unit. MC has cell phone and radio, and NEVER TOUCHES A PT.It's more of a terminology issue, but there is no such thing as medical command. there is ONE incident commander. if it becomes a big incident, you may have a unified command at a command post, but in this situation, I doubt that will be the case. You will have the fire officer be the incident commander, while the Lead medic will be in charge of Medical Operations. in the Full ICS system, you will also end up having a HazMat Operations too, and both operations groups leaders would report to the IC (the head fire guy). but everything else he said is 100% dead on

To reiterate what Mittles said, it is easier to size up and triage the scene when you can control who you go. that means stage the other EMS resources until you need them. then once ambulances start arriving, your Medical Operations officer can contact them (or go through the Staging officer if you have one) and direct them which patient to treat, and more importantly, transport them off the scene (out of sight, out of mind is a good thing in this regard). but the Med Ops officer needs to keep track of all the patients and make they they are all transported (well, that's the job of the transport officer, but if there isnt' one, it falls only him).

It is better to call for more resources early and cancel them if not needed, then to scream for them late in the game because you need them here NOW.

As a general rule, you can transport 2 BLS patients in one rig, but each ALS patient gets their own truck.

[mitllesmertz1]

Thanks Dr P, absolutely right, my terminology was off.
Medical is a group, not a command.

[rolandthunder]

I agree with everything that has been said so far. But the one differance is that the area I am in doesnt have the resources locally. So we would be calling for more EMS units as soon as we are paged. We can always turn them around if we get there and dont need them. We would have 2 birds in the air if they are available and at least on truck from another town enrout. Fire doesnt have a lot to do on this scene so we would put anyone with medical training to work.

[CH47Doc]

So the initial "worse case" size up is a minimum of 8 critical patients (if only 1 per car), and a possible fire/haz -mat from the semi. Could be an MCI, but we'll investigate further.

-First in Engine Officer establishes command (IC). Shut down freeway/block traffic/talk to PD. Have crew pull a charged line to the semi, foam as needed. Assuming 3 person Engine crew, they are now used up :(
Have all other units stage behind First due Engine.

-First due Medic: senior medic assumes Medical Command(MC), driver is Triage Leader. MC meets up with IC, starts making plan, and allocating resources. Contact local trauma center about possible MCI per protocols. MC asks IC for second ALS unit. MC has cell phone and radio, and NEVER TOUCHES A PT.

-IC assigns First Due BLS, Second Due Engine, and Second BLS to MC. MC assign units to Triage.

Triage gets MCI kit from rig and passes out supplies to EMT's.
Medic driver(Triage Leader) directs 2-man triage teams to do START triage, come back to him with patient count (ie 2red,2yellow,6 green,etc)

-After START triage, Triage gives patient update to MC, MC requests additional units from IC as needed.

-Triage now becomes Treatment Leader. Directs triage teams (now treatment teams) to start getting patients packaged and ready for transport according to severity.
Treatment Leader establishes Treatment area.

-MC can request an officer to become Transport Leader, or assign it to the ALS unit that has arrived on second alarm (glad you asked for them!)

-MC and Transport start working with trauma center by phone to figure out who's going where.
-Patients are packaged, or examined and released, according to injury and protocol.

-Treatment and Transport advise MC when all patients are transported or cleared. MC advises IC that scene is cleared of patients.

-IC clears MC from scene, first ALS is in service.
-IC controls scene until PD takes over/hazards are mitigated.

If ya treat the scene like it's an MCI from the beginning, you won't get caught "behind the ball". Ask for help early.


A simple definition of an MCI is "more patients than you have resources on scene to treat". If they all turn out to be non-injured, greta. But if only 1 was critical and 2 need to be boarded/collared and transported, you will need more help.


That's why a command presence it so important!! Without it, everyone will just jump out of their rigs and start grabbing patients, with no order. 8 people will start working on freeing a trapped patient while 3 other patients need help.
They know what to do because the IC established command and delegated patient care to the first in Medic (Medical Command).


Obviously depends on your protocols, and the amount of patients vs resources. With limited resources and multiple patients, a quick triage of EVERBODY will seperate the critical from the "Pemco Pain" patients. Medical Command can then delegate the appropriate resources to care for the pt. Ideally, every pt involved will be examined and treated or cleared by the end of the call. You don't want to have a critical pt that was ignored by the triage teams. You mus trust your EMT's to do a good rapid assessment of all patients.



Yess!!! See my example.
Your medics should have more knowledge of protocols and available resources for treatment/transport. The most senior medic should be Medical Command, the next senior should be Triage Leader. With a typical MCI, the Medical Command will never even touch a pt!
The Triage Leader shouldn't be doing pt care initally either.


Again, depends on your protocols and available resources. Anyone with a high mechanism needs to be examined.


Sorry to repeat myself, but your protocols dictate what to do with patients with possible injuries that refuse care.

The most important thing to remember in an MCI is to stop!!! Take a deep breath, and start doing triage. Fight the urge to start treating the bloodiest person you see.
Do a systematic triage of ALL patients, then make a plan, then start treating in order of severity!

Great post, EXACTLY how it should be done.

as a side note, we have NEVER used triage tags. we tried to one time but it was a big cluster fuQ. had a 40pak schoolbus rollover on a country road. had 3 helicopters there in addition to 3 ems agencies including my own. the 2 other EMS providers were from 2 different counties. total goat skrew but it got done and all turned out ok.

[RyanEMVFD]

Hey Doc, have ya'll trained using the tags, kinda like we don't do?

[mitllesmertz1]

Yeah, we had a BC that made us use them on every wreck with more than 5 pts being transported.
Thought it was dumb at the time.
But when we had a real MCI a few months later, we were well practiced at using them, it was second nature.
Use every wreck with multiple pts to practice setting up the MCI protocols.

[sleepyemt]

http://www.montgomerycountymd.gov/firtmpl.asp?url=/content/firerescue/psta/stp/triage/index.asp

something my county implemented...all the hospitals in my county do it too...

[CH47Doc]

Hey Doc, have ya'll trained using the tags, kinda like we don't do?

my triage tags are covered in grime and axle grease underneath my vehicle jack in an outside compartment. TDH requires we carry em...so we do..:)
we triage like the stock market bids. only thing missing is a dude that talks 100mph. luckily we're in a rural area of texas. my ems director REFUSES to move into this decade. guy still practices johnny and roy medicine. hes a TOTAL pain in the ass on calls. hes been a medic since like 1990 or so and hes in charge of medics comming right out of school. the curriculums have changed 50 times since then and he has not a clue whats being taught and what we know now days. (sorry for the boss rant) to answer your question, we train just like you:P

[38ffems]

I agree with the way mitllesmertz1 set it up, one question though, you dont actually have anyone starting triage until late in the game, initially unless fire/hazmat is preventing this from happening you should be doing an initial triage as soon as first ambulance is there. Essentially running through opening airways and getting a basic count. This would happen well before tags are passed out and MCI kit is set up. Basically just to make sure its even necessary. We have had 10+ car pile ups without any significant injuries. If you dont do the initial size up by simply checking cars and people and you just declare an MCI because of the possibility of multiple injuries you are going to cause a cluster at the hospital, the dispatch, and of course the scene because you are going to set the MCI protocol in motion when its unwarranted. Now it may not be a bad idea to request at least a couple ambulances right off the bat just as a precaution but declaring an MCI essentially changes everything. During an MCI your legal responsibility changes. Patients that you dont believe are going to make it can be written off if treating them means a patient who might have a chance of living wont get the care due to lack of resources. You really really really need to learn the protocol because if you jump the gun or simply declare an MCI cause you sorta kinda think its one, then you open yourself to all kinds of litegation and asschewing.

[Dave1983]

-First due Medic: senior medic assumes Medical Command(MC),

Just a question. If the first in engine officer establishes IC, why are crews on other units "assumimg" anything? Once IC is established, shouldnt all tasks be assigned by the IC? I know thats what I was tought in IC class. ;)

[38ffems]

Well thats only initially, the IC has command of everything until they are either overwhelmed and span of control cannot be maintained or if say procedure says otherwise. At any major fire or incident there is only one IC, there can be many sub-divisions off of that individual. This is how unified command works, the are EMS chiefs, Police chiefs, DOT people, etc.... If your SOP says that the first medic has medical control than i would imagine the reasoning behind that is that the engine either is staffed with individuals that are not trained to have medical command. In reality the IC runs the overall scene but rarely on anything such as an MCI will he be on his own. What it comes down to is your policies, and what your trained in.

[Dave1983]

Well thats only initially, the IC has command of everything until they are either overwhelmed and span of control cannot be maintained or if say procedure says otherwise. At any major fire or incident there is only one IC, there can be many sub-divisions off of that individual. This is how unified command works, the are EMS chiefs, Police chiefs, DOT people, etc.... If your SOP says that the first medic has medical control than i would imagine the reasoning behind that is that the engine either is staffed with individuals that are not trained to have medical command. In reality the IC runs the overall scene but rarely on anything such as an MCI will he be on his own. What it comes down to is your policies, and what your trained in.

Thanks, but Im certified by my state in IC, so I think I know how it works, including in MCIs.

And what I know is, the IC is responsible for assigning tasks untill such time he/she designates sector officers to oversee individual tasks. What I read from his post is the first in ambo crew just assumes medical, regardless of how many units are on scene, or if the IC is still maintaining "span of control".

The way I know IC this would be called "freelancing", unless dictated by SOG. If its dictated by SOG, pehaps the people that write said SOGs need to reconsider, because they are circumventing the proper implimentation of IC.

[mitllesmertz1]

What I read from his post is the first in ambo crew just assumes medical, regardless of how many units are on scene, or if the IC is still maintaining "span of control".

The way I know IC this would be called "freelancing", unless dictated by SOG. If its dictated by SOG, pehaps the people that write said SOGs need to reconsider, because they are circumventing the proper implimentation of IC.
Interesting thoughts; I am not sure if my wording was proper or not, because frankly I don't get all excited about wording differences.
According to our SOP, the first arriving medic unit (2 medics) at an MCI will split crew. The in-charge medic shall become Medical, the driver shall become Triage.
I guess the IC could change that, and have us go get ice cream, but I've never heard of it happening.
Call it assumed or assigned, whatever fits into your view of how ICS runs. But that's how we do it.

[Dave1983]

Interesting thoughts; I am not sure if my wording was proper or not, because frankly I don't get all excited about wording differences.
According to our SOP, the first arriving medic unit (2 medics) at an MCI will split crew. The in-charge medic shall become Medical, the driver shall become Triage.
I guess the IC could change that, and have us go get ice cream, but I've never heard of it happening.
Call it assumed or assigned, whatever fits into your view of how ICS runs. But that's how we do it.


OK, that makes sense. I read it as they just assume it on thier own. Maybe I read too much into it. ;)

[mcfd45]

anyone think to see what the semi is leaking? the biggest priority on scene is my safety 2nd is everyone elses. do it rightand look for a placard.

[38ffems]

I agree with the way mitllesmertz1 set it up, one question though, you dont actually have anyone starting triage until later in the game, initially unless fire/hazmat is preventing this from happening you should be doing an initial triage as soon as first ambulance is there....

Yes, I covered that awile ago, the entire scene should/would come to a screaching halt if there is even the most remote suspicion that there is a leak or spill.