# MVA scenario



## Foxbat (Aug 14, 2008)

You are the only EMS unit on scene of an MVA. You have 2 patients: one with minor injuries (but not refusing treatment) and another one with symptoms of shock. The second one, obviously, needs to go to a hospital, preferrably trauma center, fast. The problem is, the next available unit is 20-30 minutes away (rural area), and you are on one of those ambulances that do not allow you to transport more than 1 immobilized pt.
Would transporting the shock pt. and leaving the other one wait for the next truck be abandonment?
PA protocols say there is an exception to having to wait for equal or higher level personnel when "patient care needs outnumber EMS personnel resources at scene and waiting for an equivalent or higher level of practitioner will delay patient treatment or transport". Does it apply in this scenario or I am interpreting it wrong?


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## firecoins (Aug 14, 2008)

If you stay, you are abandoning the first patient.  You need to transport patient 1 now.  You can do a quick turnaround.  

If the 2nd patient is minor, you could skip immobilization and throw him in the up front passenger seat.  Maybe put a KED on him.  Backboard him in the hospital parking lot.


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## KEVD18 (Aug 14, 2008)

if your protocols allow you to leave a green patient at the scene to await a second rescue, then thats certainly an option.

i wouldnt personally ked them and then put them in the cab. they either need cspine or they dont. half assing it obly opens you up to very expensive litigation.


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## Jon (Aug 14, 2008)

Foxbat.... To meet KKK specs, the vehicle needs to be able to transport 2 patients.

Can you post a picture of one of these hypothetical vehicles?


Hypothetically... if it was my patient... crew would likely work on load-and-go, while 1st patient is perhaps immobilized and left with SOMEONE onscene - like a Firefighter with FR training.


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## traumateam1 (Aug 14, 2008)

Is there anyone on scene (police, bystanders with First Aid, etc) that can babysit the patient with minor injuries? In any account I would fully package the shock patient. Load n go with him, put the other patient with minor injures in the jump seat. While keeping the shock patient in a compensating state, I would keep reassesing the minor injuries patient for signs of shock, slow developing pneumothorax, small hole in the liver, etc. And then of course, depeding on injuries, you can also request for another car to meet you enroute to the hospital to give him the minor wounds patient.


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## EMT192229 (Aug 14, 2008)

If your first pt needs advanced care that you are unable to perform in the field then you are required to transport rapidly, keep in mind you have the golden hour working against you. For the second PT I would perform a rapid head to toe assessment,Place them in a collar and short board or KED vest them and place them in the captains chair where you are able to revaluate them.You still have to maintain PT care for them and re-evaluate them every 15 minutes. The person that is going into shock you need to re-evaluate every 5 minutes. As per the span of control an EMT-B should be able to manage PT care effectively and efficiently for both Pt's. 

This is my opinion and nothing else.


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## BEorP (Aug 14, 2008)

EMT192229 said:


> If your first pt needs advanced care that you are unable to perform in the field then you are required to transport rapidly, keep in mind you have the golden hour working against you. For the second PT I would perform a rapid head to toe assessment,Place them in a collar and short board or KED vest them and place them in the captains chair where you are able to revaluate them.You still have to maintain PT care for them and re-evaluate them every 15 minutes. The person that is going into shock you need to re-evaluate every 5 minutes. As per the span of control an EMT-B should be able to manage PT care effectively and efficiently for both Pt's.
> 
> This is my opinion and nothing else.



Golden what?



> Our search into the background of this term
> yielded little scientific evidence to support it. It is
> crucial for medical researchers to critically exam-
> ine concepts such as the golden hour that are
> ...


http://www3.interscience.wiley.com/cgi-bin/fulltext/119825956/PDFSTART


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## mycrofft (Aug 14, 2008)

*Jumping in...here I go again...*

"Golden Hour" is the concept that you have one hour to get the pt *into the OR *after which imporvement is much less likely, and survival less certain. If I'm right, this was based on empirical observation dating from the Korean and Vietnam conflicts and brought to the then-newly blossoming emergency "room " scene. Many interventions are now available which can work if applied in much less than one hour in certain cases, and it has been demonstrated in the Iraq scenario some things like TK's can be more freely used if the time to "second echelon care" (first echelon is "buddy care") is very short. (Read "On Call In Hell").

This scenario has been brought up and up and up over the decades. How about "What if an ambulance is about to leave the scene and is already packed"? You have just encountered the mass-cas world, no matter how few pts, as long as they outstrip resources. If the situation is in an over-all disaster scenario, you can tapdance more. If not, you cannot relinquish care to a less-qualified person. Says so right here on the wrapper.

As always, cut to the chase. Care for the more-critical case first, and do what will save the most lives. You may end up fired and ruined, but you do what is right and then press on, that's part of the ethic. Maybe Pt #2 doesn't really NEED spine board? 

Firecoins, I laughed out loud at the picture of longboarding someone in the parking lot! Faced away so you could emerge from the back unobserved?

PS: Wiki "GOLDEN HOUR TRAUMA":
http://en.wikipedia.org/wiki/Golden_hour_(medicine)


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## mycrofft (Aug 14, 2008)

*PS: This is a good wakeup call.*

Go out and inspect your rig. Does it have the correct litters, with straps, to fit in those ceiling hangers? A spine board for each? Ever try to actually put a person up there? Are the hangers actually there? Can you fasten a litter to the bench? If not, you just made your ambulance a one-litter ambulance as described.


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## BossyCow (Aug 14, 2008)

Why would you KED a pt for transport? KED is an extrication device only. Not C-spine. While it can be used for splinting a hip, I would soooooo get my posterior masticated if I brought a pt in as described. 

If the lesser injured pt is not needing BLS transport, why not release that pt for transport in a POV, family or friend that the pt calls? You can document the bajeeesus out of the incident, informing them to seek emergency evaluation. If its an MVA then to leave an uninjured pt, or pt that has mere bumps and bruises with Law Enforcement or firefighters isn't abandonment, its assessment and triage.


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## Foxbat (Aug 14, 2008)

Jon said:


> Foxbat.... To meet KKK specs, the vehicle needs to be able to transport 2 patients.
> Can you post a picture of one of these hypothetical vehicles?


There are plenty of such ambulances abroad, but I have never seen one in the US. Now I know why  Thanks.


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## firecoins (Aug 14, 2008)

mycrofft said:


> Firecoins, I laughed out loud at the picture of longboarding someone in the parking lot! Faced away so you could emerge from the back unobserved?



You do what you got to do. I wouldn't necessarily try and keep it secret.  I would just document, document and document some more.  Sometimes you need to improvise with what you have.


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## Bosco578 (Aug 14, 2008)

BossyCow said:


> Why would you KED a pt for transport? KED is an extrication device only. Not C-spine. While it can be used for splinting a hip, I would soooooo get my posterior masticated if I brought a pt in as described.
> 
> If the lesser injured pt is not needing BLS transport, why not release that pt for transport in a POV, family or friend that the pt calls? You can document the bajeeesus out of the incident, informing them to seek emergency evaluation. If its an MVA then to leave an uninjured pt, or pt that has mere bumps and bruises with Law Enforcement or firefighters isn't abandonment, its assessment and triage.



Actually you can use a ked for Immobilization / C-Spine. Might not be the first choice,but it works just fine.


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## KEVD18 (Aug 15, 2008)

Bosco578 said:


> Actually you can use a ked for Immobilization / C-Spine. Might not be the first choice,but it works just fine.



you're partially correct. the ked is a SECONDARY immobilizer. you still need a primary.


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## Tiberius (Aug 15, 2008)

Well, I always carry 2 LSB's on my truck...the patient with minor injuries will be fully immobilized, then secured to the bench, whilt the critical pt. gets the stretcher, as it's easier to load and unload the critical pt. I'm assuming that in this scenario, the local FD is either on scene or responding. The volunteer FD's in my area usually, (the key word is USUALLY, as it doesn't always work that way) carry LSB's on their trucks (some might not, but I've never been faced with a situation of having 2 pts. and 1 LSB; even if I had  just one as a result of using my other one on my last run which was, say, another MVA, the local FD would have the patient(s) fully immobilized by the time I got there)...but anyway....if there is only 1 LSB available, you can use the KED and/or shortboard and document, document, and document...or, the pt. with minor injuries may even refuse full C-spine immobilization (but still wants to ride to the hospital for evaluation), in which case you get him to sign the RMA and he can sit on the bench.

As I was saying, we'll assume that the critical pt. would need to be extricated. one crew member stays with each patient and utilizes the FD personnel for implementing C-spine immobilization with the non-critical pt....once you get the critical patient out and fully immobilized and secured to the stretcher...vitals, high-flow O2 (if ALS, IV access and administration of LR. run a strip, etc.) and hammer down. Note: you can even utilize FD personnel to drive the truck in while both crew members work on the patient in the back.

Of course, being that this scenario takes place in a rural area, upon receiving the call, I'd have dispatch get a helicopter on standby, then upon arrival and initial assessment, call for the chopper and set up a LZ, handle business, load and go, transport to the LZ, unless the chopper can land right on scene, then continue onto the hospital with my non-critical pt.


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## BossyCow (Aug 15, 2008)

Bosco578 said:


> Actually you can use a ked for Immobilization / C-Spine. Might not be the first choice,but it works just fine.



The KED doesn't immobilize the lower spine sufficiently in my opinion. It would stabilize the upper spine but I don't know about the mechanics of putting someone in a KED into a seated position inside a rig. Sounds like it would negatively impact the spine to me.


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## Foxbat (Sep 15, 2008)

Jon said:


> Foxbat.... To meet KKK specs, the vehicle needs to be able to transport 2 patients.
> 
> Can you post a picture of one of these hypothetical vehicles?


Well, now I can  New KKK-1982 (effective 2009) no longer requires ability to transport 2 pts, so here it is...


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## Flight-LP (Sep 15, 2008)

Foxbat said:


> Well, now I can  New KKK-1982 (effective 2009) no longer requires ability to transport 2 pts, so here it is...



So my kids always tell me that I need to "catch up with the times". It is still 2008 correct???

So the new KKK-1982 would not yet apply?


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## Flight-LP (Sep 15, 2008)

So you have an ambulance that transports one patient. If the MVA has 2 known occupants, information that would be gathered almost immediately on the part of the 911 dispatcher, then why wasn't the second ambulance dispatched from the initial call? Leaving a patient on the scene is abandonment, period. Leaving that pt. in the hands of a first responder is still abandonment as you are turning over care to a lower level. It is not delegation as you cannot delegate anything if you are not there. You say that the pt. has minor injuries. Are you sure? Can you effectively make that factual statement with your limited assessment ability and lack of diagnostic resources? Remaining on the scene may not be the optimal idea, but it the ethical one and the one that will cause you the least amount of legal headaches. Both pts. require your care. Unfortunately, a small amount of Darwinism will have to apply. Living in a rural environment places you at a higher risk of death secondary to illness or injury due to a lack of effective resources.

Placing a pt. in only a KED and not competely immobilizing them is maleficent and completely half arsed. It leaves you wide open for litigaiton.

Leaving a patient behind with Bubba Joe first responder is abandonment. Again, leaves you open to litigation.

Wait on scene with your patients, then litigation is possible, but it will have to be against the agency, county, or the State. Its hard to name you individually if you are treating both patients.

Yeah life sucks all around when it comes to these conundrums, but you just do what you can...................


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## marineman (Sep 16, 2008)

In WI per trans 309, the DOT list of requirements for an ambulance any in-service ambulance must carry at least 2 long spine boards as well as a cot and a full bench with three buckles on it, alas we must have the ability to transport 2 immobilized patients in WI. While we were extricating the critical patient I'd have a partner go start an assessment on the green tag. I posted before but the paramedics I ride with have the ability to check off c-spine in the field and I've actually seen the medical director go off his rocker when they brought in a fully immobilized patient that was up and moving around before we arrived. With that depending on the initial assessment of the good 'ole green tag he'd probably end up sitting in the captains chair so he's not in the way on the bench while we're working the other patient. I'd keep him out of the cab in case he does crash then we have to stop and move him in back for care.


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## jrm818 (Sep 16, 2008)

Flight-LP said:


> So you have an ambulance that transports one patient. If the MVA has 2 known occupants, information that would be gathered almost immediately on the part of the 911 dispatcher, then why wasn't the second ambulance dispatched from the initial call? Leaving a patient on the scene is abandonment, period. Leaving that pt. in the hands of a first responder is still abandonment as you are turning over care to a lower level. It is not delegation as you cannot delegate anything if you are not there. You say that the pt. has minor injuries. Are you sure? Can you effectively make that factual statement with your limited assessment ability and lack of diagnostic resources? Remaining on the scene may not be the optimal idea, but it the ethical one and the one that will cause you the least amount of legal headaches. Both pts. require your care. Unfortunately, a small amount of Darwinism will have to apply. Living in a rural environment places you at a higher risk of death secondary to illness or injury due to a lack of effective resources.
> 
> Placing a pt. in only a KED and not competely immobilizing them is maleficent and completely half arsed. It leaves you wide open for litigaiton.
> 
> ...





He said the other ambulance was 20 minutes out.  Guess this is rural territory.

Regardless there are almost defiantly other resources available - the green pt. can be left with a FR, EMT on scene not with the ambulance, etc.  In this scenario you didn't really specify the exact status of the "green" pt., but assuming they were properly trialed as green but needed to be c-spined, put them on a board, leave them in the care of a FR/FF or FR/PD or whatever is there.  

This is an MCI (2 pts, one ambulance = pt. outnumber resources = MCI) and triage rules apply.  Red -->yellow--> green--> black.  Get the critical patient out of there, there's no problem with turning over care to a lesser trained individual in an MCI/ triage situation.

I would hope fear of litigation wouldn't override good clinical judgment in this case.  The golden hour may be a myth, but that doesn't make it irrelivent how long you take to get to the hospital.  Major trauma = rapid transport is required.  Load and go.

I agree with not transporting in a KED.  I did that once due to special circumstances (pt. unable to lie down, best methods of spinal precautions tolerable), but in general, if they need a spinal precautions, they get full spinal precautions.  Just find somebody to watch them.

short answer is yes, the PA exemption does apply in this case.


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## Flight-LP (Sep 16, 2008)

What about air resources, where they considered? that would have eliminated the problem right there....................

I'm sorry, but there are two trained medical professionals on an ambulance (I'll use the term professional loosely). 2 EMT's + 2 patients fails to equal an MCI. This wasn't a lack of medical resources, it was an inappropriate utilization of available resources. If this call was back in the sticks and it is known that one unit can only transport one patient, then a second unit should have been dispatched from the word go. Or, as previously stated, alternate forms of transport (i.e. air medical) arranged. 

I find it hipocritical that people come on her arguing a BLS unit is capable of running primary 911 and then calling a simple 2 patient MVA an MCI. Maybe its the different geographic locations, but I would never call an MCI for only 2 people. Besides, if you are going to truly play the MCI card, then just put the green tag in the front seat or even another vehicle for that matter as they are now "walking wounded". I still don't see this scenerio constituting an MCI.....................


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## BEorP (Sep 16, 2008)

mycrofft said:


> "Golden Hour" is the concept that you have one hour to get the pt *into the OR *after which imporvement is much less likely, and survival less certain. If I'm right, this was based on empirical observation dating from the Korean and Vietnam conflicts and brought to the then-newly blossoming emergency "room " scene.




Did you read my post?


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## jrm818 (Sep 16, 2008)

I'll agree that this scenario is a bit contrived...unrealistic limitations.

That said, what if air resources are unavailable (eg its a blizzard, which caused the accident).  Even if the 2nd ambulance were dispatched from go, depending on the location, it may be 20 minutes out upon arrival of the first.  

The number of EMT's may = the number of patients, but in this hypothetical scenario only one can go in the ambulance with spinal precautions.  Mechanism alone is almost certainly going to require spinal precautions on the 2nd patient, even if they are completely stable.  Thus only one patient can be transported at this time.  May be a small number of pt's for an MCI, but the decision is not based on raw number, but number compared to resources.  

There's no question in my mind that sitting on scene with a trauma patient for 20 minutes is not an acceptable decision.  If there isn't a way to adequately provide care for every patient with the resources you have, you are dealing with an MCI, regardless of actual patient number.

Leave one EMT behind with the stable backboarded patient (yellow by our triage rules, but I suppose he could be "green" by some...i guess), have a FF drive the ambulance, and get going (the obvious solution now that I think about it more).


EDIT:

I forgot about the BLS/ALS cheap shot.  This scenario has the same outcome if its an ALS rig that can only transport one patient: MCI.  BLS/ALS has absolutely nothing to do with it.  Only possible difference is if medics can give whole blood where you are, might make sitting on scene a few minutes more acceptable.  That's not the case in most places, and even if it is, I'd still call that decision poor.


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## YouthCorps1 (Nov 13, 2008)

ok i want body substance isolation and scene safety...have a lower-trained partner attend to patient 1...if patient 2 is in shock...i want to do a rapid extrication...spinal injy is not my concern...i will have PD grab neck collars, a backboard, and a stretcher along with o2 and a trauma bag. i also need towels to do a rare extrication technique. first i will throw on the collar, and then wrap a thick towel once around the patients front neck, then overlap them in the back...then go under the arms. now you have complete control and can move them with preventing spinal movement. put the patient on the backboard. throw him into the truck. depending on where he is bleeding from, grab some 4x4's, 5x9's and dress all injs...splint all fractures..take a set of vitals...have some fluids going through this guy,,,start him on oxygen depending on how well or how bad his breathing is at...preferably an NRFM (non-rebreather face mask) . is possible get your suction ready...also if possible...get ready to transport patient in trendelenburg pos...while attending to patient 2, get the partner to go get personal info, check for blood, hair, or anything in that catagory near the winsheild, dash, or airbag deployment...get damage to car sample...and have PD wait with patient 1 and treat him for minor injs with supplies their SUPPOSED to have in their car...rapid transport


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## JPINFV (Nov 13, 2008)

YouthCorps1 said:


> i also need towels to do a rare extrication technique. first i will throw on the collar, and then wrap a thick towel once around the patients front neck, then overlap them in the back...then go under the arms. now you have complete control and can move them with preventing spinal movement. put the patient on the backboard.


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## EMTinNEPA (Nov 14, 2008)

JPINFV said:


>



I lol'd for a minute and a half straight, and hard enough that my face actually hurts :lol: x 9999999999999999


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