# Car Accident



## BecomingaBetterEMT (Jan 28, 2015)

Hello guys. About two weeks ago I was in a multiple patient car accident. There were patients. 

Upon arrival to the scene there was a crew accessing the patient in critical condition and another ambulance arrives on scene (we were the 3rd ambulance). One member of the second crew commands that he is the incident commander on the radio.

When I get out of scene he doesn't tell me what is going on (what patient I should be attending to) do I have to go up and ask the other emts from the first crew what is going on. I feel like the incident commander should be able to tell me this information.

Also as I was approaching I could here the first crew talking to the police officer whether or not they need a  medivac. They honestly were a little bit flustered and couldn't answer the question definitely. Should that be a responsibility on the incident commander?

I'm going to go back and see what my textbook has to say.

Also one last thing. Is the incident commander not allowed to leave the scene? Since we only ride 2 people at a time on a crew it rendered one ambluance out of service so we needed an additional 4th ambluance for only 3 patients. His help was truly needed but he was just standing here ultimately useless.


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## teedubbyaw (Jan 28, 2015)

Incident commander should stay on scene and be last person on scene. Not really sure what your questions are beyond that.


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## luke_31 (Jan 28, 2015)

When you get on scene you would need to report to the IC, he may not know you are there until you are physically in front of him. Were you all BLS or was the second ambulance a higher level. I only ask this because on that scene if it needed a formal command, the first ambulance on scene should have had one of them establish command and the second person starts triaging the patients.  The incident commander should have been the one coordinating with all other agencies. From how you are presenting this scenario I would have to saw your company should use it as an example of how a scene turns to chaos without having a good plan going in  a debrief discussing what went wrong and what went right would help to create a good learning experience for all.


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## DesertMedic66 (Jan 28, 2015)

MCIS are always a different breed. How they are handled will depend on how your company/area is set up. Do you have protocols on who should be IC? (Highest ranking? Highest medical certs?).

Generally speaking the first crew on scene should be the IC until a more qualified or higher ranking crew member gets on scen. They should then have a face to face to hand over command. 

As an IC he may not even realize you are on scene. If he doesn't give you a task over the radio then you need to have a face to face with him to establish you are on scene, what resources you have, and to get a task. 

During the initial triage the IC doesn't yet know how many people are injured (other than an estimate) or who is critically injured. The crew members who are doing the triage need to relay that information to the IC So he can call out the correct resources.

The IC should make the decision on what resources are called however the IC may not know if there are any critical patients yet. Once the triage crews give the IC the needed information he is better able to call out resources. 

The IC is always the last person to leave the scene. Even if he is on a transporting unit. The IC will either transport the last patient himself or have the last unit aside from him transport the last patient. That is one of the problems with having a transport unit be IC. 

With the information given it is very hard to tell anything. Also in some areas PD/LEO is in charge of calling for air resources.


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## BecomingaBetterEMT (Jan 28, 2015)

luke_31 said:


> When you get on scene you would need to report to the IC, he may not know you are there until you are physically in front of him. Were you all BLS or was the second ambulance a higher level. I only ask this because on that scene if it needed a formal command, the first ambulance on scene should have had one of them establish command and the second person starts triaging the patients.  The incident commander should have been the one coordinating with all other agencies. From how you are presenting this scenario I would have to saw your company should use it as an example of how a scene turns to chaos without having a good plan going in  a debrief discussing what went wrong and what went right would help to create a good learning experience for all.



All ambulances were BLS but from different agencies. I think the failure was the fact that no one triaged any of the patients. This delayed the nesscary ALS units and also from finding information from each patient.

I'm definitely going to talk to my supervisor even though it was awhile ago.


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## OnceAnEMT (Jan 28, 2015)

BecomingaBetterEMT said:


> All ambulances were BLS but from different agencies. I think the failure was the fact that no one triaged any of the patients. This delayed the nesscary ALS units and also from finding information from each patient.
> 
> I'm definitely going to talk to my supervisor even though it was awhile ago.



Doesn't hurt to talk to your supervisor even just for clarification, like you were asking. Don't go in looking to pin someone, go in looking to learn and make yourself better.

Sounds like ICS gone wrong either way, with what information was given.


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## EMDispatch (Jan 29, 2015)

Do what Grimes said.

Many of the issues with that call are going to be at a state or local level. It sounds like many communication and inter-operational issues. It shouldn't be a witch hunt or a blame game, but a learning experience for all involved. I will say the states I'm familiar with have specific protocols for MCI's, HEMS, etc. ICS wise it sounds like an all too very common misapplication. People get title happy and start filling charts that don't need to be filled in, and unfortunately have no idea what title they just gave themselves implies.


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## Tigger (Jan 29, 2015)

BecomingaBetterEMT said:


> Hello guys. About two weeks ago I was in a multiple patient car accident. There were patients.


Indeed, there were patients. 



> Upon arrival to the scene there was a crew accessing the patient in critical condition and another ambulance arrives on scene (we were the 3rd ambulance). One member of the second crew commands that he is the incident commander on the radio.


I don't know how things work in your area and it would be a good idea to check to see if you're area or agency has MCI plans in place and what that calls for in terms of command structure. That said everywhere I have worked the first unit on scene takes command and responsibility for triage. On these calls you cannot devote the first crew to a critical patient without doing at least some cursory triage. It's fine if the IC starts helping with patient care if he's from the only ambulance on scene and triage is complete, but as soon as more resources arrive (that he requested immediately I'd hope), it's time to step back. 



> When I get out of scene he doesn't tell me what is going on (what patient I should be attending to) do I have to go up and ask the other emts from the first crew what is going on. I feel like the incident commander should be able to tell me this information.


If you didn't announce your arrival to him, it's tough to blame him. Also depending on your arrival time, triage may not have yet been complete. 



> Also as I was approaching I could here the first crew talking to the police officer whether or not they need a  medivac. They honestly were a little bit flustered and couldn't answer the question definitely. Should that be a responsibility on the incident commander?


In an ideal world when a crew recognizes that their patient requires air-medical, they should advise command of that so the IC can get that going. 



> I'm going to go back and see what my textbook has to say.


A better use of time would be to see what your area has for MCI planning in place.



> Also one last thing. Is the incident commander not allowed to leave the scene? Since we only ride 2 people at a time on a crew it rendered one ambluance out of service so we needed an additional 4th ambluance for only 3 patients. His help was truly needed but he was just standing here ultimately useless.



The IC should say until the completion of the incident or until he turns command over to someone else. Perhaps with enough ambulances on scene and no more patients he could have turned it over to someone else if there were no other ambulances, but it's not the end of the world.


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## Ewok Jerky (Jan 29, 2015)

Welcome to mass casualty incidents. Always easy to Monday Morning QB these.

I would look up your agency/local policies and take ICS and NIMS, they are free online


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## Trauma Queen (Jan 30, 2015)

The first crew on scene of a major incident should, ideally, take responsibility of triage and incident command. In many areas, the highest ranking fire officer is responsible for IC, and an experienced EMS provider assists in EMS command, organizing resources and keeping track of patients and where they're being transported. The EMS command or crew in charge of all IC should not, under any circumstances, make contact with patients. Ideally their partner would begin the triage process, get a rough idea of resources required, and contact dispatch and request those resources. If s/he makes patient contact, s/he is now devoted to that patient. 

As other units come onto the scene, they should either alert IC on a designated channel of their impending arrival, or upon arrival find command, identify themselves as ALS or BLS, and ask where they're wanted. Then, in order of triage, you will be assigned 1 or 2 patients, or another job. Be sure to notify command and dispatch of the number you're transporting, and your destination facility. Ensuring dispatch is notified is crucial, as they can then notify the hospital of a possible influx of patients so they can be ready. 

Some great courses to look at are any of the NIMS courses. Discuss questions with your supervisors or chief of service. Review any protocols on MCI's. Familiarize yourself with triage practices. Discuss with your training officer the possibility for an MCI drill. And most importantly, learn from your mistakes.


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## Tigger (Jan 30, 2015)

Trauma Queen said:


> The EMS command or crew in charge of all IC should not, under any circumstances, make contact with patients. Ideally their partner would begin the triage process, get a rough idea of resources required, and contact dispatch and request those resources. If s/he makes patient contact, s/he is now devoted to that patient.



Ideally, perhaps. Meanwhile in rural America, that is not an effective use of resources. If my partner and I arrive on scene along with three volly FF/EMRs, you can bet we will both start patient care once one of us has completed triage and the other has "established command" and gotten more resources rolling. 

If you make patient contact, you don't have to be dedicated to that patient once another ambulance arrives. As soon as the next unit arrives, have them come to you, give them the scoop, and go back to playing IC. 

Multitasking. It's a thing.


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## Trauma Queen (Jan 30, 2015)

Yes, but if you're IC, and dealing with a patient, then how are you going to command the incident? Yes, there's five of you and ten patients, some critical, so that's where triage plays in. 

As IC, rural or urban, paid or volly, there needs to be someone available with 100% knowledge of the scene, so there is someone to direct incoming resources. Because if you're doing patient care, and you have firefighters and ambulances pouring into the scene, no one knows who is who, and that's when the confusion sets in. Ask any fire officer. If they're IC, they're not on the hose. They're not on the tools. They're standing back, watching the units on scene, and delegating, communicating with dispatch, and making sure all the cogs of the machine are working properly.


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## Nightmare (Feb 4, 2015)

Did you have FD on scene? i wouldn't really consider 3 patients an MCI when you have 3 ambulances there, the first rig on scene should have decided what resources were needed, in your case 3 ambulances. They decide which one is most critical and then one provider assumes care of that patient while the other directs FD to the other patients and assists the FD in their care until the other rigs arrive. As rigs arrive critical patients are passed off to the rigs until you get to the green patients. 

Any time you have a thought about a medivac it wouldn't hurt to at least request one unless your transport time is a short one.

By the sounds of it your "IC" doesn't know how to operate as an IC. Typically between me and my partner, he would assume command and i would go through and triage then report it back to him as he was requesting ambulances and more personnel. In a small incident like the one you handled, the incident commander would usually transport the last patient unless he could get another rig there.


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## OnceAnEMT (Feb 4, 2015)

Nightmare said:


> Did you have FD on scene? i wouldn't really consider 3 patients an MCI when you have 3 ambulances there, the first rig on scene should have decided what resources were needed, in your case 3 ambulances.



For the most part MCI declaration varies by system, defined as a strain on resources. And if a number is needed, I think the magic number is actually 3 or more. That said, sure they have the 3 ambulances, but that also means there are 3 zones now without a truck. MCIs effect a system; they are not an isolated event.


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## DesertMedic66 (Feb 4, 2015)

Grimes said:


> For the most part MCI declaration varies by system, defined as a strain on resources. And if a number is needed, I think the magic number is actually 3 or more. That said, sure they have the 3 ambulances, but that also means there are 3 zones now without a truck. MCIs effect a system; they are not an isolated event.


3 patients is an MCI? Welcome to every car accident. 5 is the magic number in our area. 

It is extremely common for us to transport 2-4 patients from calls without incident. My last MCI (9 patients) we used only 3 ambulances.


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## Trauma Queen (Feb 4, 2015)

DesertEMT66 said:


> 3 patients is an MCI? Welcome to every car accident. 5 is the magic number in our area.
> 
> It is extremely common for us to transport 2-4 patients from calls without incident. My last MCI (9 patients) we used only 3 ambulances.


I think it really depends on the particular service. Sure, bigger commercial companies and volly towns with multiple ambulances can handle 3 patients. _Technically, _an MCI is anything that you would need to call an outside agency for assistance if it strains your system. I definitely think calling a three patient MVA an MCI is a bit of a stretch, but someone still needs to make the call to call for additional resources as needed. And, if I have a small-scale multiple patient scenario, as a rule I try to only transport multiple patients in the same rig if they're from the same vehicle, or else you run into people arguing about fault and who's wrong in an 8' by 4' box while you're trying to provide care. (Plus possible HIPAA issues.) If you run into a large scale multiple patient scenario, all bets are off and I'm taking two stable patients no matter what. 

In a situation like this one, I certainly think its fair to do a super quick triage, call for two additional ambulances (assuming that there's 3 vehicles involved,) and once they arrive, assume patient care and transport the final patient. 

How to handle an MCI largely depends on the number of patients, and criticality of the situation.


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## DesertMedic66 (Feb 4, 2015)

Trauma Queen said:


> I think it really depends on the particular service. Sure, bigger commercial companies and volly towns with multiple ambulances can handle 3 patients. _Technically, _an MCI is anything that you would need to call an outside agency for assistance if it strains your system. I definitely think calling a three patient MVA an MCI is a bit of a stretch, but someone still needs to make the call to call for additional resources as needed. And, if I have a small-scale multiple patient scenario, as a rule I try to only transport multiple patients in the same rig if they're from the same vehicle, or else you run into people arguing about fault and who's wrong in an 8' by 4' box while you're trying to provide care. (Plus possible HIPAA issues.) If you run into a large scale multiple patient scenario, all bets are off and I'm taking two stable patients no matter what.
> 
> In a situation like this one, I certainly think its fair to do a super quick triage, call for two additional ambulances (assuming that there's 3 vehicles involved,) and once they arrive, assume patient care and transport the final patient.
> 
> How to handle an MCI largely depends on the number of patients, and criticality of the situation.


Definations of MCIs change on the area. A MCI here technically is any incident where the initial resources are out numbered by patients. So if I arrive on a TC first and there are 3 patients, it's a MCI. Now if the fire department and I arrive on a TC with 4 patients it is not a MCI. 

In my area an outside agency may not be required until we need more than 100 ambulances.


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## Tigger (Feb 5, 2015)

DesertEMT66 said:


> 3 patients is an MCI? Welcome to every car accident. 5 is the magic number in our area.
> 
> It is extremely common for us to transport 2-4 patients from calls without incident. My last MCI (9 patients) we used only 3 ambulances.



If I have three critical patients and one ambulance and a bunch of non-medical firefighers...that's an MCI here without a doubt. Especially since the second in unit is a helicopter half the time.


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## DesertMedic66 (Feb 5, 2015)

Tigger said:


> If I have three critical patients and one ambulance and a bunch of non-medical firefighers...that's an MCI here without a doubt. Especially since the second in unit is a helicopter half the time.


I am aware of that. That's why I said in my next post that while some areas have numbers to declare a MCI it really depends on the amount of resources initially on scene. In some cases if a solo provider arrives on scene first with 2 patients then the incident may be declared.


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## Ewok Jerky (Feb 14, 2015)

ICS by definition is fluid with dynamic definitions depending on circumstances. 5 patients today might be a simple call for a second unit while 5 patients tomorrow is an MCI.  

This why all EMS personnel need to be adequately trained in ICS. It really isn't that difficult of a concept as long it doesn't start into a pissing match.  It falls apart when peeps don't understand/respect their role.


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## Noncreative (Jul 2, 2015)

DesertEMT66 said:


> 3 patients is an MCI? Welcome to every car accident. 5 is the magic number in our area.
> 
> It is extremely common for us to transport 2-4 patients from calls without incident. My last MCI (9 patients) we used only 3 ambulances.


Textbook MCI is anything that immediately overwhelms your resources, so in a rural or poorly equipped area, 2 could be an MCI


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