Don't Dawdle With Trauma

I recall watching EMS students over the course of training sessions start enthusiastically, then dwindle down to "just going through the motions" and eventually gathering in small groups to talk the night away. It seemed their attention span was that of a child's: 15 minutes tops. I would urge them to take their training seriously, reminding them that "you play how you practice." Numerous times I was told, "I know how to start an IV." To which I responded, "Here it is easy. Out in the field with a real patient it is different."

The same was true when teaching the "yawn" subjects like command, triage and mass casualties. It appeared they were interested in only the "glory" topics, with an attitude of "I know how to do this. Why do we have to keep going over it?"

Command, triage, treatment and transport (CTTT) are the mainstays of any major incident with multiple victims. Remove any one of them from the equation and instead of a smoothly run operation where patients receive treatment based on their injuries, you get a situation where the left hand doesn't know what the right hand is doing.

THE INCIDENT

Let's examine a recent incident where two of the four CTTT were missing.

It was Labor Day. The weather was sunny with temperatures in the upper 90s. Around 1:30 p.m., our local fire department, which provides first responder service, and EMS were dispatched to a head-on collision on the overpass on a major highway. En route reports indicated victims were trapped in the vehicles, and one vehicle might be on fire. Based on information gained through numerous 9-1-1 calls, EMS made the decision to launch two medical helicopters.

The fire chief was first on the scene. He reported no fire, three vehicles involved (two cars and one motorcycle), three victims, with one trapped in each vehicle, and the motorcycle driver lying in the roadway. The vehicles crashed at highway speed (at least 55 mph) and each had major front end damage. The fire chief established command of fire department rescue operations and two landing zones (LZs).

The first EMS unit on scene attended to the injured motorcycle driver, Pt.No.1, who was unconscious with a visible tib/fib fracture. They quickly packaged him in a C-collar, secured him to a backboard and loaded him into the back of their ambulance.

The fire department engine and rescue units arrived and quickly went to work with the Jaws of Life rescue tool to extricate the two trapped victims. Pt. No.2, was a young man partially ejected out the driver's side window. He was conscious and screaming in pain. A second EMS crew applied a C-collar. He was rapidly extricated, secured on a backboard and placed on a stretcher. A secondary exam revealed he suffered a fractured femur.

The foot of the third victim, Pt. No. 3, was trapped by the crushed dashboard, and she was screaming in pain. A C-collar was applied and a firefighter crawled into the vehicle to provide support and guide extrication. The Jaws of Life were used to pry open the door and lift the dashboard. She was secured to a backboard, removed from the vehicle and placed on the edge of the roadway. In the initial exam, fire department first responders identified a large, jagged four-inch laceration over her right eye that exposed the skull, a fractured left foot and numerous cuts and abrasions. Fire department personnel splinted her fractured foot.

Considering the mechanism of injury, all three patients were in serious condition.

Pt. No. 1 was in the back of an ambulance while Pt. No. 2 was on the edge of the roadway. Both were being treated by paramedics and EMTs. Pt. No. 3 was being treated at the edge of the roadway by fire department personnel who were ECA qualified (including two firefighter/paramedics, both retired, with advanced medical training and 30 years experience between them).

A secondary exam on Pt. No. 3 revealed the following: B/P 110/60, P-120 and R-25. Her abdomen was palpated and found to be painful and rigid. Her pupils were equal and responsive, although her right eyelid was drooping. Minimal bleeding was noted from the laceration and a closed head injury was suspected.