Mass refusals

[MasterIntubator]

Does anyone have set protocols/SOGs on mass refusals? Like... bus accidents, or even school bus with 10 year olds? Any special handling of no injury documentation?
We do not have anything specific, but have done paper reports for each person ( not popular ); 1 report with all kids' info, then the superintendant signing responsibility; No reports on no injury... and now back to 1 report to each person involved for no injury refusals to please the lawsuit happy possibilities.

I wanna be first there, transport the only hurt person and not go back ( feel sorry for second due.... ) ...

 

[medicRob]

Does anyone have set protocols/SOGs on mass refusals? Like... bus accidents, or even school bus with 10 year olds? Any special handling of no injury documentation?
We do not have anything specific, but have done paper reports for each person ( not popular ); 1 report with all kids' info, then the superintendant signing responsibility; No reports on no injury... and now back to 1 report to each person involved for no injury refusals to please the lawsuit happy possibilities.

I wanna be first there, transport the only hurt person and not go back ( feel sorry for second due.... ) ...

Like if a bus load of hemophiliac nuns with grave's disease crashes into a glass truck kind of bus accident?

I'll look, brb.

I just checked our protocols and it doesn't say anything about mass refusals. I'll do some more research and see if the state of TN has any guidelines available.

 

[MasterIntubator]

Like if a bus load of hemophiliac nuns with grave's disease crashes into a glass truck kind of bus accident?

LOL... I'd rather not be at that scene unless I can get a pumper loaded with FVIII/FIX and clotisol and deck gun the bus...

 

[abckidsmom]

We've done the one at a time thing, and do not document a refusal on people who state that they are not hurt. Patient refusal=patient. No injuries=/= patient, KWIM?

We split it up to 5 refusals per provider.

And in all the systems I've ever worked in the first crew triages and IDs the sickest ones, and the second crew takes them to the hospital. First in, last off the scene for the most part. I guess it would be a little different if there was a long response time for the second unit, but you still have the abandonment of the other patients to deal with.

 

[akflightmedic]

That is what I was gonna say which is standard mass patient situation...First In, Last to Leave.

First unit in does triage and gets the ones out that need to be transported by incoming units.

When no more are to be transported, guess who handles the remaining patients (refusals)...you do-the First in unit, so all the other units can return to service.

Having said that, we made a refusal form that up to 10 people can sign on. It has the disclaimer info at the top, they read it and sign on the line below. We then scan a copy into the database to be attached to their digital report.

Everyone should have a report was our policy. In all fairness, we did create a "refusal report" which removed certain boxes which didn't need to be checked but it was still a report.

"Refusals are a gold mine" I have been told by various attorneys. I have no factual support for those comments, just their words but it does make sense to me. We treat refusals as nothing, as a pain in the arse instead of what they are...which is a person involved in a crash (usually) who got lucky. We should still do an exam and report our non findings.

 

[Melclin]

Interesting question of technicality. Let me think out loud.

For mass cas issues here we have a pretty well organised system based on SIEVE and SORT triage. First ambulance crew there are Transport officer and Triage Officer and they maintain information on all casualties needing treatment and their whereabouts, as well as Triage Officer assuming the role of Health Commander - co-coordinating all heathcare needs with the incident management team - until another paramedic with lots of gold on their shoulder shows up.

If they don't need treatment then they are moved to a "survivor reception area" where they can receive debriefing, psych first aid etc organised by the agency controlling the incident (coppers or the state emergency service) at the behest of the health commander. Any low priority patient still needing treatment can be discharged from the care of the ambulance service to an appropriate level of care - GP, first aid centre, psych first aid, relief centre etc. Their name, injury/illness and discharge details are on the casualty movement log kept by the Transport officer. However, it does say here in the Emergency Response Plan, that a PCR must be completed for "all patients".

I think in the amount of information you would realistically be required to collect for each patient would be inversely proportional to the size of the event and directly correlated with the severity of injury. Name, CC, contact details and vitals from the SORT triage card seem sufficient. Then whether or not you transport them or discharge them to another more appropriate "care pathway" is entirely up to you just like it would be at any other job.

Certainly in the state's First Aid agency we are taught to collect the details of everyone present, but there is absolutely no issue with many people not going to hospital.

Why would you transport someone who didn't need to be transported in any situation, let alone one where local hospitals are likely to be overwhelmed?

I've just realised that this post isn't entirely relevant because I wrote it thinking I was looking for an answer on information collecting, but I've written it now so you can all read it

 

[LucidResq]

If they don't need treatment then they are moved to a "survivor reception area" where they can receive debriefing, psych first aid etc organised by the agency controlling the incident (coppers or the state emergency service) at the behest of the health commander.

I'm very impressed with this concept of a well-organized area for those who do not require immediate treatment and providing a continuum of care for these people, even if that means psychological help. I might be wrong but I don't believe this is focused on much in the US, or at least not in my area. From what I've seen and been taught... it's mostly assign a few people to "corral" the walking wounded and non-injured, monitor them for any changes (they may be fine now but drop later), and keep them out of trouble.

I know this may be hard to dig up but do you have any case studies describing this kind of plan in action? And I'm curious as to what "psych first aid" means exactly... more information?

 

[Sam Adams]

Medically/ legally, at what point is a pedi capable of telling EMS (in an MCI) that he's (not)ok?

I've never thought about it before ...

 

[medicRob]

Medically/ legally, at what point is a pedi capable of telling EMS (in an MCI) that he's (not)ok?

I've never thought about it before ...

Here is what our protocols say about it:

If the person is not 18, or emancipated they cannot refuse without parental consent.

 

[Sam Adams]

If the person is not 18, or emancipated they cannot refuse without parental consent.

Our protocol here in MA is the same. What my thought process is, is, if most of the "standard" protocols for emergencies get thrown out the window during an MCI, do the refusal guidelines as well?

 

[abckidsmom]

Our protocol here in MA is the same. What my thought process is, is, if most of the "standard" protocols for emergencies get thrown out the window during an MCI, do the refusal guidelines as well?

I don't think they're quite thrown out the window, though, just minimized and hurried along.

At a minimum, you should document demographic info (Name, Address, DOB and maybe SSN if your agency does that), complaints, a cursory exam (Head, Chest, Abd, Extremities, Skin, ABCs) (even visual is better than nothing) and that the patient was Alert and Oriented, stated they did not want transport, understood the potential effects of that decision and what their disposition was (ie, home, to ER POV, to PCP or Urgent Care).

I think this is more so that in 4 days when the insurance people, or the administrators of whoever was at fault or whatever comes counting the people, you have an answer for all the patients you saw.

Is it a royal pain? Sure. But how often are you talking about this happening? It's so rare. Even when we've had bus wrecks with 25-30 people on board, usually less than 10 had a complaint, and less than 5 wanted to be transported. If the ratio of occupant:injury is higher, all the more reason to have more documention, IMO, because the potential for review (either at the system level...using the incident as a teaching case, or at the court level...working out the liability in the accident) is higher.

Sometimes you really don't have the resources to look at every single person and assess them. In those cases, all the people affected (ie, we had a ride accident at a local fair), all the people were hearded into a relatively quiet place and individually denied injury. No injury, not a patient. We told them to make sure they talked to the fair company on the way out of this taped off area, and then finished dealing with the people who had complaints.

 

[abckidsmom]

Medically/ legally, at what point is a pedi capable of telling EMS (in an MCI) that he's (not)ok?

I've never thought about it before ...

In our system, they can't refuse without parental consent either. If they don't have a complaint, though, and we don't have the resources to deal with tracking down a guardian, we let them sit in the taped off area with the nice deputy, who tracks down someone. When the mom is on the phone, he calls an EMS provider back over to talk to her.

It goes like, "Ma'am, Johnny was involved in a bus accident. He was sitting in his seat in the back row, the bus rear ended another car in traffic. He was not thrown from his seat, but says that he bumped his head on the back of the seat in front of him. I see no bruising, he's not complaining of any pain. Do you want to talk to him for a minute? OK."

And when she comes back, we talk about how she's going to get Johnny back. Honestly, I've never had a mom say that we should NOT transport the kid in a situation like this. Plus, the logistics of getting all the parents to the scene are nightmarish. We have usually just ended up running a load of kids to the hospital and they are seen very briefly in the ER.

 

[Akulahawk]

Well, you have patients and you have persons... A person is someone with no complaints. A patient is a person who has some kind of medical/trauma/psych complaint. A person, like the dead, has no need for services...

I'd have them sit with a Deputy and have them release to a parent (if the person is a non-emancipated minor).

 

[Melclin]

I'm very impressed with this concept of a well-organized area for those who do not require immediate treatment and providing a continuum of care for these people, even if that means psychological help. I might be wrong but I don't believe this is focused on much in the US, or at least not in my area. From what I've seen and been taught... it's mostly assign a few people to "corral" the walking wounded and non-injured, monitor them for any changes (they may be fine now but drop later), and keep them out of trouble.

I know this may be hard to dig up but do you have any case studies describing this kind of plan in action? And I'm curious as to what "psych first aid" means exactly... more information?

I don't know how well organized it would be Its something that I imagine would only take place in fairly major mas cas work. Not in a four occupant MVA. The head of department at uni is big into disaster medicine, and he's a higher up in the World Association for Disaster and Emergency Medicine, so he likes to push the issue. Probably also one of the benefits of having a single statewide service, working with a single police force, and, for all intents and purposes a single fire service, and a single state emergency service (I wonder if you have something similar to the SES?).

Psychological first-aid is an increasingly popular idea because the psychological fall out can be more financially and socially damaging and last for much longer than the physical problems. What exactly it involves though, I don't know :blush: I imagine it would be some kind of special debriefing by a mental healthcare professional. I heard something about a core of psychologists who were 'deployed' to help survivors of the nasty bush fires we had a while back. I'll find out more tomorrow in my disaster med lecture if I remember because I'd like to know myself.