The call came in as a vehicle accident with no details. I have handled literally thousands of these calls in my 28 years in”žEMS. Many end up as non-transports; most involve only minor injuries. But when I pulled up on scene, I knew this was not going to be your normal, everyday vehicle accident. Traffic on the four-lane freeway was at a standstill in both directions. The first vehicle I encountered was a small sedan that looked like someone had attacked it with a giant can opener. About 100 yards down the road was a full-size pickup truck sitting on a sports car like a giant red chicken trying to hatch an egg. As the first medic on the scene, I took a deep breath, thought of a few colorful phrases, and waded into the chaos.
These types of calls are what I call routine Æ’ or everyday Æ’ disasters. They are not big enough to be declared an MCI, but can be overwhelming to the first units on the scene. The keys to success in these situations, just as in large disasters, are good organization and communications. The difference is that there is usually only one person in charge of the medical decisions who must handle all the ICS functions normally occupied by many people in a larger incident.
The following suggestions and guidelines have proved vital during Ë™routineà“ multiple-casualty incidents. There are very few hard and fast rules Æ’there are just too many variables. The ability to remain flexible is a great asset when dealing with multiple patients, because, as sure as the sun is going to rise tomorrow, things are going to happen that will force you to change your plan.
Who_s in Charge?
“ž It may be stating the obvious, but someone has to be in charge. So many times, I have arrived at a scene with multiple patients where no one is in charge. Or, more correctly, there are several people in charge, each with their own plan. Someone has to be in charge! There must be one person who controls the medical and transportation decisions. I like to call that person the Triage Officer. Often, it is the person with the highest level of medical training. But it can also be someone with a lower level of training who is experienced in handling multiple-patient scenes. Everyone will have ideas and suggestions. Use the good ones to modify your plan and communicate the new plan to everyone. But, only the person in charge of the medical decisions should change the plan.
In agencies that handle both first responder and ambulance responsibilities, it is much easier to designate the medical leader. When the first responders and the ambulances are from different agencies, things can get a bit more complicated. If the crews have the same level of certification, it may be best to let a first responder be in charge. This would allow the first ambulance to leave as soon as possible with the most critical patient without disrupting the management of the scene.
If the transport agency has the highest level of training, it may be best to let the first ambulance crew be in charge, as they cannot leave before another ambulance arrives. Of course, an incident like this may result in response from several agencies, greatly multiplying the confusion. The best time to work out these issues is before they come up on scene by meeting with all interested parties that are likely to respond together to a multiple-patient scene.
Duties of the Triage Officer
Once someone is designated the Triage Officer, there a few initial steps that are critical to managing a scene well. As soon as that person arrives, they need about 30-60 seconds to take in the whole scene and begin to devise a plan. They need to be able to concentrate without interruption. When I look back on the multiple patient calls where I was in charge and things didn_t go well I most often didn_t get that uninterrupted 30-second size-up.
The next important step is to communicate early and often with the Incident Commander (IC). If your plan is going to work, the IC must be your partner.
The Triage Officer should try to stay detached from patient care to allow a broader perspective as the situation changes. He or she can help out and fill in where necessary without having to concentrate on just one patient. I like to constantly roam around the scene to check the progress of every patient, see what resources are needed, and communicate the plan to everyone. This type of oversight also allows the Triage officer to identify safety hazards that others might have missed.
Next, the Triage Officer should find every patient and get a general impression of their injuries. Doing so will dictate what other resources will be needed. Only one person should have this job to avoid a patient being overlooked. Every patient must be found. I cannot emphasize this enough. There have been many successful lawsuits against”žEMS agencies where patients were overlooked on scene and later found dead. Someone may have been ejected. Some may be in other vehicles or in a nearby home, taken in by a concerned citizen.
I don_t know how many times I have arrived on the scene of a vehicle accident and been told I had one or two patients. Further investigation revealed there were eight people in the involved vehicles, but only one or two had obvious injuries. Every person involved in an incident is a patient until a thorough history and physical is performed and the necessary paperwork is completed on those refusing transport. Another ambulance or supervisor may need to respond to complete the paperwork on those not being transported.
Another key step in managing the scene is to gather all the patients together as soon as possible. With the patients concentrated in one place, communication is much easier. You also need fewer people for treatment. In addition, equipment can be used more efficiently. Even a minor incident with two patients can become two separate scenes if they are separated by distance (or are on opposite sides of a vehicle). Located next to each other, family members can comfort and calm each other. Of course, this can backfire on you if you put two antagonistic people next to each other.
Communications”ž
As previously stated, good communications is a key element in handling any multi-patient call. That seems rather obvious, but communications often break down or are nonexistent in these situations. This is another reason for the Triage Officer to be constantly on the move and checking on all the patients. Doing so provides opportunities to constantly reinforce the plan and see if any changes need to be made. Good communication needs to go beyond the public safety agencies on scene. Your dispatch center needs to know what is happening so they can send additional resources and ensure all other response areas are adequately covered.
If helicopters respond, you need to know how many patients they can take. A helicopter capable of transporting two patients, may only be able to transport one patient due to weather or fuel considerations. You need to find that out early so you can request other transport resources. If more than one helicopter responds to the scene, you must also ensure each one knows about the other. They can then talk to each other to avoid any safety conflicts.
Incoming units need to be briefed as they arrive. I try to meet them as they arrive, so they don_t start doing things on their own that conflict with the plan. This is another good reason to stay detached. Don_t let them wander around. Tell them exactly which patients are theirs and where they are to take them.
The patients are an important group often overlooked in regards to communication. They need to know, briefly, what is going on, what you are going to do, and where they are going. This is especially important if relatives are patients as well. In today_s cell phone world, it is not unusual for family members to show up on scene. You need to deal with them. Ignore them, and you will regret it. I try to tell them what hospital their relative is going to and that they can meet the patient there. This information usually gets them off the scene fairly quickly.
Bystanders are another group to contend with. In the best-case scenario, law enforcement will handle them. However, you may arrive before law enforcement. When a crowd is too close, I don_t just ask them to stand back. I tell them to stand beyond a specific spot, such as a light pole or vehicle well away from the scene. There are situations where you have to use bystanders to help you, or they are already doing something with a patient. You may have non-EMS medical personnel that want to help. I usually have them do something like hold c-spine precautions. Giving them something to do forces them to stay put and not wander around the scene. Bystanders can be put to good use as crowd controllers and translators. In the initial moments, when trained personnel are in short supply, they can be used for simple things like controlling bleeding, c-spine precautions and comforting children, until more help arrives.
Treatment
You want to get the patients packaged for transport as soon as possible so they can leave the scene as soon as transport units arrive. Those still waiting can receive other treatment after they are packaged.
Patients who require extrication add another dimension to your plan. You may need two ambulances for two patients if one is trapped and will take time to extricate. How much treatment will you provide while the patient is trapped? That is a difficult judgment call. Treating a patient who is trapped may delay efforts to extricate them. Use of oxygen may create a hazard for the patient and rescuers. At the very least, someone needs monitor the patient_s medical condition during extrication. If the patient begins to deteriorate, the leader of the rescue effort needs to know so other options can be explored to remove the patient as soon as possible.
Environmental hazards must be addressed for both patients and rescuers. In cold and/or wet conditions, it_s critical that trauma patients are protected from hypothermia. If your area has very cold winters, consider carrying disposable aluminized space blankets to keep patients warm and dry. Bystanders can be used to hold up tarps or umbrellas to protect patients from sun or rain. The ambulance can also be prepared by turning on the heater or air conditioning as soon as they arrive. Heat is not as big a concern for patients as it is for rescuers. During long extrications, firefighters wearing full turnout gear working with heavy tools can experience heat exhaustion or even heat stroke.
Transport
Vehicle access and staging is not usually considered on smaller incidents, but it can become a problem if it_s not well thought out. To keep scene time to a minimum, ensure there is a clear route for the ambulances to enter and exit. Patient loading should only occur once all the patients that are going in a particular unit are packaged. Otherwise, there is the danger of a patient being loaded into an ambulance and left unattended. If environmental or other factors demand loading as soon as possible, someone must stay with each patient.
As with large MCIs, you don_t want to move the disaster to a hospital by overloading them with patients. If you have more than one trauma center in your area, send the lowest priority patients who meet trauma criteria to the furthest one. If you are using helicopters, send them to the furthest as well. If you have families with children involved, I try to send at least one adult family member to each hospital where a child goes. This can help with identification, medical history, treatment permission and emotional comfort.
Finally, it_s important for the Triage Officer to keep track of who goes where. I usually track patients on the basis of which vehicle they were found in. This can also be used as a double check to ensure everyone is accounted for and no one is missed.
Other Considerations
A general precept of these calls is that the first ambulance in is always the last one out. In certain circumstances, I don_t think this is necessarily true. Specifically, when you need two ambulances and there is only one critical patient, it may be better for the first ambulance to leave with the critical patient as soon as the second unit arrives on scene. The first crew would not have to do a hand-off to the second crew, saving valuable time. Additionally, the first crew would be more familiar with the patient_s condition and treatment needs. This would only happen if the first crew had completed a scene size-up and was certain all patients had been located and were stable. The first ambulance wouldn_t leave until they provided a brief report to the second crew.
Another method that has served me well involves splitting crews on calls that require two ambulances. The crewmembers of the second unit are used as drivers, and the crew from the first unit act as attendants. This allows a very quick turnaround and good continuity of care.
Multiple patient calls are some of the most difficult you will handle. Very little training is provided on this topic. But, by following a few basic principles, you can bring organization out of chaos. Make sure you find everyone involved in the incident. Bring them together as soon as possible. And always, always, communicate clearly and often with all the players. You may not agree with all my ideas, and I may have failed to mention others. Regardless, I hope these suggestions prompt you to discuss this topic with your co-workers and fellow public safety agencies.
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Barry Smith, EMT-P, has been a paramedic for more than 20 years and currently works for the Regional EMS Authority,”žReno,”žNev. He has also worked as a volunteer firefighter and as a member of SAR and Civil Air Patrol rescue teams. He has published numerous”žEMS articles and books and is a frequent contributor to JEMS.
