The ABCs of Scene Size-Up

Attack One responds to a report of a motor vehicle crash. Arriving at the freeway scene, the crew finds one automobile off the road with significant damage, and three stretch vans and a large SUV piled into each other. There are a large number of bystanders already congregated. Traffic is moving around the vehicles.

Organization of the Incident

Command is established over the radio. The Attack One crew needs to deliver a rapid size-up.

Essentially all EMS and fire agencies in the U.S. have implemented the Incident Command System for incidents involving two or more vehicles or crews. Using this system on a daily basis familiarizes operations personnel with it, making scaling up to large incidents comfortable and routine.

The approach to scene size-up and initial communications can be organized using the familiar ABCDEF format.

A - Anticipate victims and injuries
B - Breathing: Is this possibly a toxic environment?
C - Cars/crowds
D - Disability: What further threatens victims and rescuers?
E - Electricity
F - Fuel/fire

A stands for anticipation of victims and their injuries. A responder at the scene of an automobile accident will be able to anticipate victims and distinct injuries that differ from those of, say, a hazmat spill or a building fire. The responding crew can then anticipate a triage operation.

B, for breathing, reminds personnel that many different types of incidents can result in toxic spills or releases that can pose a further threat to victims and rescuers. Responders are taught not to enter a scene without appropriate protection if there's a possibility that a toxic environment is present.

C is for cars/crowds. Many emergencies occur in or along roadways, presenting hazards from oncoming traffic, nearby electrical wires and fuel spills. Additionally, personnel must note the behavior of bystanders and the size of a growing crowd. A crowd can represent a useful source of untrained ancillary personnel, but it can also make a scene more dangerous. If there's a fuel spill, for example, members of the crowd smoking cigarettes or lighting flares can create further scene hazards. In a barroom situation, a hostile crowd can produce an unstable environment in which to work. In some circumstances crowds can even hinder access to emergency vehicles. Emergency personnel can utilize some people as ancillary help in lifting and moving certain victims, and the remainder of the crowd can be managed by responding law enforcement personnel.

The next component of the scene size-up is searching for further scene hazards, which represent the D, or disability factors. These can include such things as unfriendly animals, a hostile crowd, inclement weather or unsafe structures. E, electrical, and F, fuel or fire hazards, are other immediate threats to victims and rescuers.

Scene Size-Up and Initial Communication

There are multiple vehicles involved on a busy interstate, with a large number of bystanders. The vehicles are recognizable as passenger-carrying vehicles commonly used for children. The smell of spilled fuel is obvious through the open windows as the Attack One crew approaches. No wires are present in the area.

The crew communicates an effective scene size-up with these observations, all before leaving their vehicle: "Dispatch, Attack One is on the scene. We have a five-vehicle crash, with four multiple-passenger vehicles. Please prepare for a multiple-casualty incident declaration. We have fuel down and one vehicle, which may require victim extrication. We have blocked traffic in three right lanes and a large crowd of bystanders. Please expedite police and the highway incident responders. Attack One will be Command."

The crew's next steps are to place the vehicle correctly, based on department protocol and defensive-driving education, then perform a walk-around size-up, triage and initial Incident Command duties.

There are no immediate threats to life identified. The passenger vehicles contained 50 children from a local child-care center, returning from a visit to a local zoo. All were restrained in seat belts. Of these, 27 complain of injuries. The vehicle off the road has a single driver with moderate injuries who requires extrication. Three adult passengers in the vans have moderate injuries; the other injuries are relatively minor.

Organizing Triage

Many fire and EMS organizations use triage systems that result in patients being numbered in sequential fashion. The Emergency Assessment box on page 36 represents the results of that process here. The crews triaged 28 patients, and categorized them by compromise of the ABCDE body systems.

Victim Outcome

The red-triaged patient had a ruptured spleen, and required emergency surgery and repair of the leg fracture. She had a good outcome.

The yellow-triaged patients had laceration repairs and observation for closed head injuries. All had good outcomes.

The green-triaged patients had minor neck strains, contusions and abrasions. No significant injuries were found on ED evaluation.

The triage system had effectively classified patients by their need for care and allowed timely transportation decisions.

Case Discussion

An actual or potential major medical emergency will require an approach using the Incident Command System. Just as the ABCs can be an easily recalled reminder for our emergency victim care, a set of ABCs has been constructed for scene size-up and initial scene management. This allows first-arriving responders to organize their initial approach, and identify hazards and communicate them efficiently. Many times this system can be applied before the crew leaves the response vehicle. In the February issue, I will discuss the organization of initial incident command actions in an ABC format.