# Lightning Strike



## FireDog19 (Sep 13, 2017)

First scenario, constructive criticism welcome.

Medic Units 2, 4 & 5 respond to 111 Party Ln. on a lightning strike, multiple patients. No further information at this time. [@19:30]

You (unit 2) arrive on scene to find 4 patients, all have been drinking. Units 4 & 5 are 7 minutes out, here is your triage info: [@19:40]

Pt. 1) 35yo male conscious and A&Ox2 doesn't know where he is our what he was doing prior. Pt. 2 states the gash on his head is from falling against the grille during the strike.

Pt. 2) 34yo female conscious, breathing 9/min. tripod position and A&Ox3. Seated in chair by the porch with pt. 3.

Pt. 3) 20yo male conscious, A&Ox4 complaining only of a migraine.

Pt. 4) 56yo male not conscious, not breathing after head tilt chin lift, and pulseless, face down in grass, where the lightning stuck.

Who is your priority patient? Why? What's their treatment?


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## MonkeyArrow (Sep 13, 2017)

Is this a real scenario? If so, why would pt. 2 be tripoding but only have a RR of 9?

Nevertheless, see if pt. 1 gash has life-threatening hemmorage. If so, control the bleeding. If not, move straight to compressions for pt. 4. Wait for help


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## FireDog19 (Sep 13, 2017)

It was real but I couldn't remember all info but yes, I was looking for someone to stick to the standard triage but I'm glad somebody actually thought to use reverse triage


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## DesertMedic66 (Sep 13, 2017)

Triage the patients as I come up to them. Patient 1 will likely be triaged as minor during intial assessment, Pt 2 will either be an immediate or minor during primary (depends on how she is doing with that resp rate). Patient 3 is minor/walking wounded. Patient 4 would be marked morgue if I am the only unit on scene.

Control the bleeding and obtaining baseline vitals until additional units get on scene.


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## Summit (Sep 13, 2017)

DesertMedic66 said:


> Triage the patients as I come up to them. Patient 1 will likely be triaged as minor during intial assessment, Pt 2 will either be an immediate or minor during primary (depends on how she is doing with that resp rate). Patient 3 is minor/walking wounded. Patient 4 would be marked morgue if I am the only unit on scene.
> 
> Control the bleeding and obtaining baseline vitals until additional units get on scene.



Unless you triaged someone as immediate and confirm that they truly are immediate, then you should be treating your apneic patients as your priority patients in a lightning MCI.

ETA: http://www.wemjournal.org/article/S1080-6032(14)00274-9/pdf


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## DesertMedic66 (Sep 13, 2017)

Summit said:


> Unless you triaged someone as immediate and confirm that they truly are immediate, then you should be treating your apneic patients as your priority patients in a lightning MCI.
> 
> ETA: http://www.wemjournal.org/article/S1080-6032(14)00274-9/pdf


This patient is apneic and pulseless which in the case of a MCI or when one could argue you have more patients than providers on scene they are black tagged. If I have extra resources on scene then sure


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## MonkeyArrow (Sep 13, 2017)

DesertMedic66 said:


> This patient is apneic and pulseless which in the case of a MCI or when one could argue you have more patients than providers on scene they are black tagged. If I have extra resources on scene then sure


But you have to look at the reason behind why we would black tag them. We black tag them because in an MCI, do the most good for the most people. So, that means don't overcommit multiple resources to a person with a high risk of mortality (traumatic arrest) if that means that other potentially salvageable people could be saved. For instance, you come across a scene with 3 patients with arm amputations with arterial bleeding and one pulseless patient as the sole unit. Sure, black tag them and move on because you spending resources on the pulseless patients means that you can't put TQs on the other 3 causing them to die. But in this case, with no other identified immediate injuries (i.e. nothing life threatening), no one is going to suffer significant harm by you treating the pulseless patient, since they definitely will die without intervention, might survive with intervention while no one else dies as a result of intervention.


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## Summit (Sep 13, 2017)

DesertMedic66 said:


> This patient is apneic and pulseless which in the case of a MCI or when one could argue you have more patients than providers on scene they are black tagged. If I have extra resources on scene then sure



START is not the best traige algorithmn in all situations. START was developed for trauma MCIs in an urban/suburban prehospital environment. In these situations, you prioritize stabilization and transport of traumas for surgical intervention before they deteriorate to save the most patients when you don't have enough resources. In these patient populations, assisted ventilation/defib/compressions are highly resource intensive while being minimally effective. This works well for the typical MCI patient profiles in a bus vs semi, driveby shooting, bleacher collapse, pipe bomb, or house fire 

Lightning is a "special case" MCI where START works poorly because the pathophysiology and injury profile of the patients is totally different than a.

Read the article I linked to.

What would be an expectant patient according to START becomes an immediate patient in a lightning MCI.

I can tell you about several other MCI types where START is a crappy algorithm.


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## DesertMedic66 (Sep 13, 2017)

However my system only recognizes the START process with no reverse triage as an option. Sadly in my system all I have is a hammer so everything looks like a nail...


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## Summit (Sep 13, 2017)

DesertMedic66 said:


> However my system only recognizes the START process with no reverse triage as an option. Sadly in my system all I have is a hammer so everything looks like a nail...


Have a golf course in your district? Baseball field? Highschool football? Swimming pool?

The evidence on this is clear as a bell. START does the exact opposite of its intended purpose for a lightning MCIs.

Maybe you should talk to your medical director. I wouldn't want you to get in trouble, but you might literally being leaving viable patients to die in the name of protocol. That is the worst type of practice you can do.

Be aware that lighting strike patients often require extended assisted ventilation after ROSC (or even if they didn't suffer cardiac arrest).


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## CALEMT (Sep 13, 2017)

Summit said:


> Have a golf course in your district? Baseball field? Highschool football? Swimming pool?
> 
> The evidence on this is clear as a bell.
> 
> ...



I don't see the protocol changing in the area that we work in that only gets maybe 2 inches of rain per year and has approximately 340 days of sunshine per year.


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## StCEMT (Sep 13, 2017)

Nothing about the first three make me think they will be dead before that 7 minute mark. Start with pt 4 IMO.


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## DesertMedic66 (Sep 13, 2017)

Summit said:


> Have a golf course in your district? Baseball field? Highschool football? Swimming pool?
> 
> The evidence on this is clear as a bell. START does the exact opposite of its intended purpose for a lightning MCIs.
> 
> ...


In a 9 year time frame there were only an estimated number of 300 people struck by lightning with 30 of those being fatalities. It’s not high on our counties list of protocols/policies to create.


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## Summit (Sep 13, 2017)

Well I live in a semi-arid region, and lightening doesn't require rain. We get a couple lightening strikes every few years for the last 15 years, including arrest-saves and including a 20 person MCI (golfers).

We don't have a lightening MCI protocol. But we also don't have to mindlessly follow a stupid protocol if it is going to seriously harm the patient (failure to rescue falls into that).


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## DesertMedic66 (Sep 13, 2017)

Summit said:


> Well I live in a semi-arid region, and lightening doesn't require rain. We get a couple lightening strikes every few years for the last 15 years, including arrest-saves and including a 20 person MCI (golfers).
> 
> We don't have a lightening MCI protocol. But we also don't have to mindlessly follow a stupid protocol if it is going to seriously harm the patient (failure to rescue falls into that).


I haven’t ran on nor have I heard anyone in our county running on a lightening strike. For MCI the fire department is in charge and things run smoother for them when everything is done one way (and even then it doesn’t run smooth).


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## Summit (Sep 13, 2017)

@DesertMedic66 So now that you know better, if you get called out tomorrow the park nearest your station for a lightning strike, what will you do when you have three dazed people walking around complaining about headaches and pain with two people on the ground apneic?


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## DesertMedic66 (Sep 13, 2017)

Summit said:


> @DesertMedic66 So now that you know better, if you get called out tomorrow the park nearest your station for a lightning strike, what will you do when you have three dazed people walking around complaining about headaches and pain with two people on the ground apneic?


Honestly the odds are that the fire department would arrive on scene before I did. I would still be bound by protocol and county policy that states we must follow any legal order that the IC gives us. If I breech that and start free-lancing that is going to result in company and county troubles which I would rather avoid.


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## Summit (Sep 13, 2017)

DesertMedic66 said:


> Honestly the odds are that the fire department would arrive on scene before I did. I would still be bound by protocol and county policy that states we must follow any legal order that the IC gives us. If I breech that and start free-lancing that is going to result in company and county troubles which I would rather avoid.


Since when does The Incident Commander have authority over medical treatment? Going to let an EMT FF tell you (paramedic) how to treat your patients? Do you think they have the legal authority to order you to do something harmful to a patient? Wouldn't you advocate for your patients? Are your protocols truly written like (and does your medical director expect to execute them like)  a computer program without any thought? Have you worked MCI before? Don't you feel like, of all the different types of calls you could run, that a MCI is the ultimate example of "each call is unique" where the protocol is a guideline aiming to achieve the goal of the best outcome for the most patients?


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## DesertMedic66 (Sep 13, 2017)

Summit said:


> Since when does The Incident Commander have authority over medical treatment? Going to let an EMT FF tell you (paramedic) how to treat your patients? Do you think they have the legal authority to order you to do something harmful to a patient? Wouldn't you advocate for your patients? Are your protocols truly written like (and does your medical director expect to execute them like)  a computer program without any thought? Have you worked MCI before? Don't you feel like, of all the different types of calls you could run, that a MCI is the ultimate example of "each call is unique" where the protocol is a guideline aiming to achieve the goal of the best outcome for the most patients?


On a medical call the highest trained provider on scene is in charge. On a traffic collision technically PD is in charge. On an MCI who ever is the most qualified is in charge which is going to be the fire captain or the BC. 

If it is a large incident then they will not be worried about our treatments and who we treat but on the smaller incidents they will get involved and as long as what they are asking us to do is legal, we have to follow it. Trying to be a patient advocate on scene during a MCI and pretty much telling the IC to **** off will not get anything accomplished and will instead result in you looking like an idiot and write ups from the company and the county. 

When it comes to a MCI our protocol pretty much sums it up as “use START and follow all directions of the IC”. 

I have been on a couple of MCIs with the biggest being only 8 patients where I was first on scene for approx 10 minutes before the next unit got on scene.


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## CALEMT (Sep 13, 2017)

Disclaimer this is the system we work in, in CA: 



Summit said:


> Since when does The Incident Commander have authority over medical treatment?



The investigative agency has authority. Either PD or FD. (MCI will initially be a company officer aka engineer or captain then transferred over to a BC). 



Summit said:


> Going to let an EMT FF tell you (paramedic) how to treat your patients?



This rarely exists in CA anymore. 



Summit said:


> Are your protocols truly written like (and does your medical director expect to execute them like) a computer program without any thought?



http://www.remsa.us/policy/ 3304 if you want to take a look.


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## VentMonkey (Sep 13, 2017)

FF-EMT is still very much prevalent in a large portion of Central California.

What's your guys' magic MCI number? Ours is 5 or more patients. The OP's post wouldn't constitute an MCI in Kern County.


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## CALEMT (Sep 13, 2017)

VentMonkey said:


> FF-EMT is still very much prevalent in a large portion of Central California.
> 
> What's your guys' magic MCI number? Ours is 5 or more patients. The OP's post wouldn't constitute an MCI in Kern County.



The county states 10 or more patients requiring transport OR if deemed necessary.


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## DesertMedic66 (Sep 13, 2017)

VentMonkey said:


> FF-EMT is still very much prevalent in a large portion of Central California.
> 
> What's your guys' magic MCI number? Ours is 5 or more patients. The OP's post wouldn't constitute an MCI in Kern County.



This for right now. However it seems to change every year. It goes from 5 or more patients or when the number of patients out numbers the providers on scene. 


CALEMT said:


> The county states 10 or more patients requiring transport OR if deemed necessary.


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## Tigger (Sep 13, 2017)

If you are the only resource on scene, there is one patient. The other two have complaints but based on the (admittedly sketchy) info in the OP, it is very apparent that the other three need minimal if any medical attention immediately. That would leave you with an arrest patient that you have a very good chance of resuscitating. But no, we aren't going to do that because we only triage one way? 

Jesus. Do the right thing.


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## Summit (Sep 14, 2017)

Our regional protocol explicitly says: "Mass casualty incidents are not covered in detail by these guidelines" and "No protocol can anticipate every scenario and providers must use best judgment."

This one is just blowing my freakin' mind... let me paint darkly in a hypothetical AAR:



			
				My Medical Director said:
			
		

> So when the IC gave an ignorant order that you correctly understood to mean, "Don't try to save your patient's life. Waste your effort!" you responded, "Well, that is what the protocol says to do... and you're the boss!"
> 
> Really?
> 
> [censored] you [censored][censored] in  the [censored][censored][censored] because you [censored][censored][censored] so bad that [censored][censored] from your [censored][censored][censored]



This is not solely an EMS problem. I'm also reminded of some RNs I worked with (and despised) who loved following policies so much that they'd follow them to the detriment of their patients even though a core tenet of nursing educational philosophy is to question harmful prerogatives. It was easier to disengage the brain and follow the policy.

Protocols cannot cover all eventualities and being an avowed slave to them falls somewhere between ignorance and ethical laziness. That is a much kinder description than I would apply to the system that demands/allows such mindsets.

"I'm sorry, I wouldn't advocate for my patient because I might get in trouble for it even though I'm 100% right and it could have saved a life," describes a systemic problem so deep and broad, the mind fairly boggles.


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## StCEMT (Sep 14, 2017)

Realistically, I don't think it matters. At least here, I don't know any Capt or BC that wouldn't follow my lead on a medical scene with just 4 patients. No fire? No extrication? Cool, this is my area of knowledge and this is my suggestion on what to do. Done.


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## johnrsemt (Sep 28, 2017)

MCI is not a set number and doesn't depend on where you work:   Major City:  LA, NYC, Chicago, Salt Lake, etc.  MCI could be 3 patients if you are the first on scene with you and your partner;  until you get help.
Where I work FT with 3 ambulance crews 4 days a week and 2 crews on weekends:  with shuttle vans with 12 people in them,  if we have an accident it would always be a MCI for us;  Fire is right there with us, but 2nd and 3rd ambulance and more than 6 FF are 20 minutes away,  (if we are lucky).
PT job has 2 or 3 crews on duty/on call.  But 2 hours from closest hospital and 90+ minutes from help (40 minutes from helicopter help) makes life interesting:  especially since we have 5 large hotels/casino's  MCI is a real threat.

On the lightening strike scenario you need to be cautious when you are that far from help:   My only lightening strike had 2 patients,  and the one walking around confused but with good vital signs almost died where the one that wasn't breathing on his own, and bystanders were doing CPR when we got there did fine.
So if you and your partner start doing CPR on the pulseless/apneic patient who is going to watch the other 3 until help gets there?


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