For Fire Officers: Shifting Gears in EMS Operations
DEPARTMENTS
EMS
Fire fighters are frequently faced with the problem of treating multiple patients injured in transportation accidents. But before actual treatment can begin, you must determine the order of treatment of the patients so that emergency medical equipment and personnel can be properly utilized.
The name that has been given to this process of setting priorities for patient treatment is triage. As used in emergency medical situations, triage is the sorting of injured patients according to the seriousness of their injuries.
Triage begins with a rapid initial assessment of all persons involved in the accident. Generally, the initial patient assessment will be a rapid hands-on, head-to-toe survey done on each patient to correct the immediate life-threatening injuries and to locate other injuries.
However, in serious situations and with the limited amount of manpower that first arrives on accident scenes, this initial assessment may have to be limited to a rapid visual count of the total number of injured and an estimation of the severity of their injuries.
As an example of a fire officer using this technique in the initial assessment of an accident: an engine company has been dispatched as part of the initial response to a reported commercial bus accident. After arriving on the scene, assuming command of the incident and confirming that there is a commercial bus accident, the engine s crew makes a rapid walk-around of the incident, counting the number of patients and visually estimating the severity of the injuries. They report their findings back to the engine officer.
The officer then makes a more complete situation report: “This is a major accident involving a commercial passenger bus that has rolled down the Interstate embankment. There are approximately 35 patients, 20 with minor injuries and 15 with major injuries. There are persons trapped. Extrication equipment and heavy wreckers will be needed. Seven ambulances are requested at this time. This is a major accident and I am requesting that the county mutual aid and medical disaster plans be implemented.”
This first-arriving engine should not become involved in the treatment of patients at this time in this accident. Why not? In most places, with either paid or volunteer departments, this engine will have a crew of two or three fire fighters (including the officer). Since these fire fighters have already made an initial assessment of the accident, they should have the best understanding of where and how the responding equipment and manpower can be utilized in this accident.
They must “shift gears” and become managers of the rescue team in order to deploy the correct resources to the correct portion of the accident. Many things need to be done: scene protection, hazard mitigation, triage areas established, treatment areas established, lighting (if the accident is at night), vehicle stabilization, etc.
These, and many other such activities, are certainly not direct patient care activities, but they are the essential logistical and support activities that will allow the additional rescue resources to be effectively and efficiently utilized upon their arrival at the scene.
In effect, the engine officer must make the decision that, given his present resources at the scene (three fire fighters), he will utilize those resources to give the maximum benefit to the accident. This benefit is in the organizing of the management of the responding rescue team to put their resources to maximum use and effectiveness.
If the three fire fighters on the first engine immediately begin treating patients and ignore these management responsibilities, the soon-to-arrive additional equipment and personnel will probably not be organized and resources and time will be wasted through the duplication of effort, false starts, poor techniques and poor utilization of resources.
A common error made by many first-arriving units on serious accidents of this type is to make sweeping calls for assistance, such as, “Send all available help!” or “Send everything that you’ve got!” While these statements accurately reflect everyone’s general emotions, they are of little value and are disruptive to organizing an effective response.
In studying many different types of multiple or mass casualty situations, it has been found that most patients can be divided into three general groupings. A rule of thumb in most serious accidents, 60 percent of the total number of patients will be lightly injured or uninjured; 20 percent of the patients will have moderate injuries; and 20 percent of the patients will have serious injuries.
Therefore, count or accurately estimate the total number of patients involved in the accident, divide by five and request that initial number of ambulances.
This formula provides an initial starting point for ambulance requests and is considerably more accurate than, “Send everything you’ve got!” Of course, a more accurate estimation of injuries and resources will have to be made as soon as time permits.
When faced with serious situations such as a bus accident, most rescuers will do what they do everyday and attempt to treat patients. In fact, these situations require that we consciously move away from the direct provision of emergency care for patients to the overall management of the incident. Training in the initial evaluation and initial management of serious multi or mass casualty situations is essential if we are going to make the required “gear change” as smooth as possible.
The use of an incident command system that can be established by the first-arriving unit; making use of this incident command system routine; and training on the essential management aspects of multi or mass casualty situations are the essential elements in the management “transmission” that allows for a smooth change in operations.
In fact, your system should be able to switch from normal operations into expanded operations as smoothly as an automatic transmission changes from low to drive to overdrive.