# MVA Scenario



## sbp7993 (Apr 13, 2010)

What would you do in this situation? 


You are dispatched to an MVA.  Upon arrival you note that 2 cars were involved in a head on.  Car 1 has one DOA  driver(as is confirmed by the medic)  The passenger in the front has no complaints---doesn't realize that the driver is dead, and cannot recall the events.  Car 2 has just a driver---no passengers. Car 2 is screaming of lower arm pain and you note a closed, possible fractured radius, or ulna. Initial exam shows nothing further. vitals are stabile. What do you do?  You are in a van ambulance, and you were the only unit dispatched, with only the 1 medic.


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## EMS_rabbit (Apr 13, 2010)

Well this more than you can handle with one rig so your going to have to call in more resources for sure sounds like everyone is getting c-spined do to the fact that the crash was enough kill an occupant from there follow your ABC's O2 PRN control any major bleeding and so on. Contact trauma centers to make sure there is bed space and follow START.


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## exodus (Apr 14, 2010)

Tx the passenger as a major trauma on the gurney, and the second one as a moderate trauma on the bench...


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## eveningsky339 (Apr 14, 2010)

exodus said:


> Tx the passenger as a major trauma on the gurney, and the second one as a moderate trauma on the bench...



Um, beg your pardon?  Are you implying that you can transport two trauma patients on one ambulance with one EMT in the back?  h34r:


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## exodus (Apr 14, 2010)

eveningsky339 said:


> Um, beg your pardon?  Are you implying that you can transport two trauma patients on one ambulance with one EMT in the back?  h34r:



Uhm, if we're the only available resource, what am I going to do? Stick around on scene with a thumb up my *** with a major trauma? Grab a firefighter or a cop to ride with us in case somebody codes.


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## Shishkabob (Apr 14, 2010)

eveningsky339 said:


> Um, beg your pardon?  Are you implying that you can transport two trauma patients on one ambulance with one EMT in the back?  h34r:



Where's the problem? Can a medic not take care of more than one patient at a time?  

EMT drive, medic in back, or have another responder drive and try to squeeze the EMT in the back too.


Without further details on the 3rd patient, all it seems to be is splint, narcotics and monitor.  But the second patient NEEDS to get to a trauma center asap as there is a high suspicion of major injuries, considering another occupant of their vehicle died.


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## Veneficus (Apr 14, 2010)

I am curious to know what the difference in prehospital treatment for a major and moderate trauma are and how you could possibly make those triage decisions with the information presented?

Did the driver have an MI and code which preceded the impact? Was he/she looking in the back seat? People generally don't just decide to head on somebody.

There could be all kinds of reasons one patient died and the other didn't. Off center hit,body position, unrestrained, preexisting condtions, extremis of age, medications, and/or struck by an object in the car, to name a few.

Likewise the occupant in the 2nd vehicle could have any number of similar comorbidities.


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## Shishkabob (Apr 14, 2010)

Was that directed at me or am I reading it wrong?

If directed at me:

Common teachings are if there are multiple people in a car, and one dies and another lives, the living patient needs to be looked at extremely suspiciously for life threatening trauma even if they have no complaints at that time.

Sure, the other car was subjected to the same accident, but a number of circumstances could have lead to the different outcome, a major one being different vehicles.  They could have been in a big truck and the other vehicle a small compact car... big truck usually wins.

And I was treating based off the VERY limited and basic info provided... ie "no complaints" and "broken arm but 'stable' "


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## Veneficus (Apr 14, 2010)

partly directed at exodus, the rest for just general consideration of the readers.


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## Shishkabob (Apr 14, 2010)

Ah, okie dokie.


Consider my post an extension to my original


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## 8jimi8 (Apr 14, 2010)

Red Patch Linuss is quick on the counter-punch!  I like


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## Dominion (Apr 14, 2010)

Without reading  the rest of the replies.  

Contact dispatch for coroner on confirmed DOA. Fire should be on scene or on their way.  If not quite there yet would also ask dispatch for an ETA on fire and police for crowd control/assistance.  Medic will go to the patient who cannot remember the accident, EMT goes to the closed possible fx.  Fire on scene will assist medic and EMT seperately to board and collar their patient.  

Once all patients are boarded and collared as well as the possible fx splinted (if needed).  Pt with possible fx goes on bench, pt that cannot remember anything goes on strecher.  Transport to nearest trauma center or facility with extensive neuro capabilities.  Radio ahead to let the receiving hospital know we're coming in with two patients and to have a bed ready for us outside, additionally request possible trauma room assessment for a patient with suspected head injury involved in an MVA with one DOA occupant.  EMT and Medic ride in the back, fire drives us in.  

I've done this scenario many many many times at my service.   We only run vanbulances and I've taken two patients in many a time.

Edit: Got my patients backwards on who gets loaded where, whoops.


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## Dominion (Apr 14, 2010)

Also you have plenty of resources for two patients one truck with a medic.  Get a firefighter to drive the ambulance in while the medic and basic work in the back.


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## mycrofft (Apr 14, 2010)

*Person most likely to live is the driver in a highspeed.*

I'm not going into the rest of the inconsistencies. Good brain exercise.

You can move four laydowns if you have enough litters that fit the ceiling hangers.


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## CAOX3 (Apr 14, 2010)

It is quite common for a patient in a MVA not to be able to recall the event.  Now confusion, repetitive questioniong or lethargy thats a different story. With the little info provided its tough to say, was there intrusion into their compartment, broken glass, steering wheel deformity or any indicator of potential underlying injury? 

*Assessment* is the key and as it  was presented in my opinion they would both go the closest facility.  I didnt read anything presented that would require a trauma center, a community hospital with an orthapedic on staff and CT capabilities should be sufficient.

I would never put two people from different vehicles in the same ambulance especially when death resulted.  We dont have a resource problem usually so they go in different ambulances.

If resources are a problem and the last resort is to transport these parties together have a firefighter drive if it makes you more comfortable having two people in the back.


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## mycrofft (Apr 15, 2010)

*Prehospital management of a Major versus Minor category injury...you don't.*

You examine each pt and decide what's wrong (diagnose, if you will) and treat each pt as needed and in order of what needs addressing first for survival. In a mass casualty situation you might need to start categorizing and allowing that to affect transport and treatment. Categories are administrative, not medical.

"Five is four"...the "Single Combat With Death" scenario. It is how we all come to grips with the fear we'll get swamped someday.
But a good execise and discussion. Thanks for posting, OP!


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## reaper (Apr 15, 2010)

Two pt's in one unit is a common occurance. Opposite drivers are a common occurance. If it is during a busy time in your system, why tie up another unit.

If both pt's are fairly stable, there is no reason a medic cannot treat both. It is done all the time. You have to think outside the box on this job. Be prepared to do what is needed.


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## CAOX3 (Apr 15, 2010)

I would assume it could be very uncomfortable for the parties involved to be in the same vehicle especially if serious injury or death has occured.

Just my opinion.


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## Shishkabob (Apr 15, 2010)

8jimi8 said:


> Red Patch Linuss is quick on the counter-punch!  I like



I can has knowledge from red patch!


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## mycrofft (Apr 15, 2010)

*If you search my posts...*

I actually was the guy in the back of a Cadillac and we did that! Family members were saying how they'd crush the guy who did it, and he was lying unconscious within inches of their knees.


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## Melclin (Apr 15, 2010)

reaper said:


> Two pt's in one unit is a common occurance. Opposite drivers are a common occurance. If it is during a busy time in your system, why tie up another unit.
> 
> If both pt's are fairly stable, there is no reason a medic cannot treat both. It is done all the time. You have to think outside the box on this job. Be prepared to do what is needed.



Are there any problems with caring for someone on a bench? I'm not entirely familiar with the layout of those ambulances but things like, "Does the suction reach?", "How many oxygen taps have I got?", "Are there privacy concerns in asking questions of patients?" etc, come to mind.


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## Shishkabob (Apr 15, 2010)

"Does the suction reach?"

In my experience, yes, with a long enough hose.



"How many oxygen taps have I got?"

Most boxes I've seen have 1-2 oxygen taps above the bench seat.




"Are there privacy concerns in asking questions of patients?"

We speaking legally or morally?


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## mycrofft (Apr 15, 2010)

*Bench issues part dux*

IF the pt is on a litter it shold be either just flat to the ground, or it has to have feet that match the detents on the bench. Need to be able to firmly secure litter or it will fall off. And, once secured on, th bench contents are locked in unless your ambo has a side hatch for the bench as well.

Pt is firmly against the starboard side (passenger side is different for different countries).

If sitting, bench pt's do not have the full restraint the would if on a civilian vehicle or up front (heaven forbid). They also have their feet where you will be working.

Maybe smack em down with fentanyl and strap em into the suction station captaion's chair?

Don't even start about the ceiling hangers!


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## mycrofft (Apr 15, 2010)

*Ah, yes there we are...*

http://www.emtlife.com/showthread.php?t=8820&highlight=caddy     Am I a weird magnet or what?

Those old cadillac were not roomy, but could they ever move.


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## exodus (Apr 15, 2010)

Veneficus said:


> I am curious to know what the difference in prehospital treatment for a major and moderate trauma are and how you could possibly make those triage decisions with the information presented?
> 
> Did the driver have an MI and code which preceded the impact? Was he/she looking in the back seat? People generally don't just decide to head on somebody.
> 
> ...



Just as linus said with limited info in the scenario, as far as Triage, anybody in  a vehicle with a death in the same passenger compartment, is considered a major trauma. And the other patient, has a simple eventually stabilized fx, and his vitals are 'stable'. If there was enough energy to kill the driver, there was enough energy to kill the passenger. For all we know, the driver of the other car, was just clipped and happen to have his leg in that one freak position that will break it.


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## CAOX3 (Apr 17, 2010)

exodus said:


> Just as linus said with limited info in the scenario, as far as Triage, anybody in  a vehicle with a death in the same passenger compartment, is considered a major trauma. .



Really?

Interesting, here mechanism of injury is a poor indicator of potential injury.


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## Shishkabob (Apr 17, 2010)

CAOX3 said:


> Really?
> 
> Interesting, here mechanism of injury is a poor indicator of potential injury.



MOI is a great indicator for potential injury.  You are more likely to suffer an injury from a 30 foot fall than a 3 foot fall, correct?  Yes, there are freak accidents, but there's also laws of physics, which are definitely alive and well in trauma.


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## CAOX3 (Apr 17, 2010)

Here is a good article.  

http://www.ems1.com/ems-products/ed...anism-of-Injury-in-Prehospital-Trauma-Triage/

In a 2004 San Francisco study, trauma researchers found MOI a very poor predictor of which patients required trauma team activation. Of the 700 trauma team activations for MOI criteria, only 54 (7.7 percent) patients required ICU or operating room admissions, and none resulted in death in the emergency department. The four least predictive MOI criteria were found to be "motorcycle crash with separation of rider," "pedestrian hit by motor vehicle," "motor vehicle crash with rollover," and "*motor vehicle crash with death of occupant."4 *

While agree with you there are circumstances or exceptions to the rule basing hospital destination on mechanism alone is outdated.

There was also another great article but since Im old now I cant seem to remember where I read it.


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## Shishkabob (Apr 17, 2010)

Oh I wasn't saying a significant MOI should be an instant trauma alert... to the contrary.  But the more significant the force put on the body, the *potential* for injury is greater and more scrutinization of the patient is to be done, even if they have no complaints.

We've all seen someone injured that had no clue they were injured.


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## thinkABC (Apr 26, 2010)

Uhh....

Is this a trick question?  I think I'm concerned with the DOA first.  (I assume that means dead on arrival?)  Unless he's missing a head or something, if this guy has any chance in the world of being revived, I'm loading him up and going.  The arm fracture and the confused, possibly-injured-but-no-apparent-life-threats are waiting on the next responder.  Right?


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## MonkeySquasher (May 2, 2010)

I feel this scenario has much potential, but very little information.  It doesn't mention plenty of key things, such as speed/damage to the vehicle, location/position the occupants were found, extrication required, physical exam or vitals...


But I concur with all the responses though, load both and go.  Make passenger nakkie, full ALS workup, while you provide splinting and pain support for the other driver.  Fire drives, Medic/EMT ride, slow Hot to a trauma center.




.....OR WE CAN USE THE HELICOPTER!


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## Stewart1990 (May 28, 2010)

thinkABC said:


> Uhh....
> 
> Is this a trick question?  I think I'm concerned with the DOA first.  (I assume that means dead on arrival?)  Unless he's missing a head or something, if this guy has any chance in the world of being revived, I'm loading him up and going.  The arm fracture and the confused, possibly-injured-but-no-apparent-life-threats are waiting on the next responder.  Right?



If there is one ambulance, 2 EMS personell and 3 patients, this is considered a mass casualty incident. Mass casualty triage dictates that once someones code black, theres no going back. By all means, if you could diferentiate that the injuries of the moderate trauma weren't 'life threatening', you might be able to rationalize working the code. Otherwise, the two living patients are the ONLY patients....Just what I was taught.


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## Smash (May 28, 2010)

thinkABC said:


> Uhh....
> 
> Is this a trick question?  I think I'm concerned with the DOA first.  (I assume that means dead on arrival?)  Unless he's missing a head or something, if this guy has any chance in the world of being revived, I'm loading him up and going.  The arm fracture and the confused, possibly-injured-but-no-apparent-life-threats are waiting on the next responder.  Right?



I don't like interfering with corpses.  Despite what the plaintiff had to say I... sorry?... oh, my lawyer says I shouldn't talk about that.

Seriously though dead from trauma is dead, they don't come back.

Too little info to do much with this one, I'll just go with 'sick people don't :censored::censored::censored::censored::censored:' and be more concerned about the quiet one.  Arm dude can come for a ride too.

Assuming that road transport time is < 5 minutes, we are in an urban area, there is an electrical storm on the go with strong cross winds and we are right next to a large number of high tension power transmission lines, I say call out all the choppers, cos they gave me a mouse mat once.


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## EMSLaw (May 28, 2010)

CAOX3 said:


> In a 2004 San Francisco study, trauma researchers found MOI a very poor predictor of which patients required trauma team activation. Of the 700 trauma team activations for MOI criteria, only 54 (7.7 percent) patients required ICU or operating room admissions, and none resulted in death in the emergency department. The four least predictive MOI criteria were found to be "motorcycle crash with separation of rider," "pedestrian hit by motor vehicle," "motor vehicle crash with rollover," and "*motor vehicle crash with death of occupant."4 *



The underlined one has always seemed like something of a red herring to me.  Honestly, I've lain a bike down, and I came off it.  I think that separation of the rider from the bike is the sine qua non of a motorcycle crash.  

But then again, it's not a predictive MOI, so my anecdotal experience, for once, matches up with the evidence.  Blind squirrel.  Nut found.


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## usafmedic45 (May 28, 2010)

> motorcycle crash with separation of rider



In the injury epidemiology literature, usually that is referring to a "Evel Knevel style over the handlebars" separation.   The problem is that you can't assume EMS personnel are smart enough to make the distinction since a good number of our colleagues are, in fact, of very questionable intellect.  Case in point:


> Unless he's missing a head or something, if this guy has any chance in the world of being revived, I'm loading him up and going.



To the person I just made an example out of, as Smash said, he's dead.  Please don't flog him because of it.  Remember, descration/abuse of a corpse is a crime in most (all?) jurisdictions.  



> I assume that means dead on arrival?



Nah, in this case it's more like "dead on asphalt".  

Meanwhile, at the Legion of Doom...:



> the confused, possibly-injured-but-no-apparent-life-threats are waiting on the next responder.



...you just increased the likelihood of that patient having a poor outcome. 



> .....OR WE CAN USE THE HELICOPTER!



"What we have here is, failure to communicate...."  :lol:



> MOI is a great indicator for potential injury.



Linuss, I love you man, but seriously, don't intentionally try to confuse the newbies and the folks who simply practice off the "We've always done it this way" principle. 



> We've all seen someone injured that had no clue they were injured.



The ones that really piss me off are the people who know they are seriously hurt, but aren't.  



> "Are there privacy concerns in asking questions of patients?" etc, come to mind.



"Bob meet George.  George, meet Bob.  You'll both be seeing each other naked tonight, but don't worry, if doesn't mean either of you are gay."


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