Mci

[emt4life]

I went to a training on MCIs tonight and a question came up that got us thinking, so I thought I would put to all of you: During an MCI and you are the 1st truck on scene, do you stay until all pts are transported or if you have multiple critical pts, do you take the most critical and split if you know there is another truck not far behind? (assuming you have multiple first responders on scene doing triage, other pt care, etc.)

The other thing that makes this more complicated is we have only 1 ALS truck (medic/emtb). If the ALS truck is on scene first, does this still apply or would it constitute abandonment?

just curious what other services policies are saying.

 

[JJR512]

If you are an EMT-P and the first one on the scene, and everyone else who's shown up so far are first responders (going by what you said, assuming you meant that literally), then from what I understood from my class, that makes you the incident commander, and you don't leave until you're relieved. But I'm just in EMT-B training with no prior experience, so I wouldn't be suprised if I'm wrong...

 

[Stevo]

some MCI instructors would have the first truck spread tarps (or blankets), dump all it's goodies, start the triage, and plop a green light (or whatever is of different color) on the empty rig as the first established command post

~S~

 

[ma2va92]

no mater what level you are... you can take control and be command.. if you feel that some ones else is better to handle it.. command can be passed.. if you are a EMT B and are first on scene and know how to be IC then you are the one... example .. there was a major event at a nursing home... you can be the IC for the EMS .. and fire has there command....just because a emt P shows up.. has nother to do with you giving up command ... you as commder for EMS... you already know who needs what and were...... and would give the incoming EMS personal jobs to do or pt. to transport......

Step up to the plate
put your hat on straight
it's time to take command
for you are the man
everyone knows your the boss
no need for the coin toss
you don't have to be a P
to be all you can B
you have been in training and your a good planner
the job is yours you are the incident commander

 

[Jon]

First in rig usually becomes the initial CP / triage unit.

If you have 3 or 4 patients, and 1 is critical, the others are "walking wounded" - I'd consider doing a grab and run, or at least package the patient and wait till the next ambulance shows...

If you've got a bus load of Senior Citizens that overturned on the turnpike - you aren't going anywhere. You call for help and start triage. After Triage is done, then you start treatment... this is the part where your rig will no longer have equipment in it....

Jon

 

[natrab]

From what I understand, if you are the only EMT-P on scene of an MCI, you will not be leaving as you are the highest level of medical direction. If you do, you open yourself up to some major lawsuits.

Imaging you triage and take off with the first critical pt you see. 10 yards away someone else is sitting there with a developing tension pneumo right next to their wife who is ok and happens to be a lawyer. No medics show up for another 10 minutes and the guy dies. The wife asks around and finds out that the paramedic left the scene with someone else. In her book, that's pt abandonment because a) you already did a basic assessment when you triaged them b) you left the scene without providing care for them c) by leaving, you caused him to die because you could have easily decompressed his chest and he would have survived.

Now I know that's a bit skewed, but that's what they'll throw at you in court.

Being the son of a lawyer who's done plenty of malpractice/negligence suits, I've had it drilled into my head. Once you talk to or assess a pt, they're your pt until you transfer them to someone else's care. In the case of an MCI, you're not expected to save everyone, but you have to be there to try. Triage tags are your first line of assessment, but they are not a release of care.

Now if your IC structure permits you to leave, and any other "reasonable and prudent" medic in your area would do the same, then you've got a good leg to stand on. Follow your policies, but always remember to "CYA".

 

[Jon]

ALS is a resource on a MCI Scene... I love hearing people say that "the medic has to triage because they are a EMT-P, and they are 'God' "... B.S. - anyone can triage. The medic shouldn't be dedicated to triage, they should treat. And treatment at a MCI scene sometimes means "abandoning" one patient over another... stuff happens. As the great Mr. Spock says on Star Trek - "The needs of the many outweigh the needs of the few, or the one"

~Jon

 

[Stevo]

spock would've done a logic triage....

McCoy woulda just walked around muttering 'He's Dead Jim!"

~S~

 

[coloradoemt]

I have been on 2 MCI's recently. One being 2 adults, 5 children in a mini-van. All were unrestrained but one child. 5 emergent transports to the hospital. The second was a van vs semi, 8 adults, most were restrained. 1 took a chopper ride, 2 emergent transports, 3 routine. On each of these triage was started by the first in TEAM, not just the medic. Then you need to start pt care according to pt needs. No matter how bad a pt condition is, you cannot scoop and go. First onscene unit needs to stay until a hand off report can be given to the individual taking scene command. Then and only then can transport decisions be made.

 

[Jon]

My squad just put the new "SMART Triage system" into place, giving out a bunch of EMS Command bags, and lots of little packs for ambulances.

We had an intresting discussion last night, because it is a "complex" system. The Tags are more versitile, and there seems to be a good, evidence based system behind it (Important when you get sued for not working the Resp. Arrest at the MCI).

Several of the other folks at the Squad refuse to belive this system is better, and just don't want to change.

The line I loved, from our supervisor - "I don't have time to deal with that" - as in he dosen't have time to set up the patient accountability system that comes with the kit.

I'm sorry - you waste more time trying to find patients later, than you will if you just track them all correctly from the start.


Jon

 

[SafetyPro2]

In a true MCI situation, our ambulance personnel would probably end up coordinating medical communications with dispatch for additional units from neighboring departments (we only have two ambulances) and the MAC (Medical Alert Center, a County EMS function), which would coordinate the transport/receiving decisions. We're all BLS, BTW. We'd probably have 5-10 ALS units from neighboring departments on-scene in under 5 minutes in that situation.

The only real MCI we've worked recently was at our 4th of July parade a couple years ago where a float went into gear unexpectedly, injuring (I think) 5 or 6 persons (the most serious of which had a skull fracture). This happened to take place about 20 feet where our entire department and an engine from the neighboring department were staged for the parade, so resources weren't an issue (only 3 patients had to be transported).

Interesting side note, myself and one other firefighter were the only two FD members there who did not see the accident occur. We were in the first-due engine, which was pulling up to the staging area when it happened, and we were both sitting backwards, so all we heard was "Oh #%#%" from the Engineer and Captain followed by "Get the trauma box!"

 

[rural_emtp]

What consitutes a MCI would vary from place to place. In my county, it would not take much to create one. With a population of 20,000 in an area of 452 square miles served typically by 2 ALS units, the number of patients can exceed the number of rescuers easily. Backup units from neighboring counties depends upon availability with response times of over 20 minutes. We can get helicopters faster than that. Closest hospitals are 30 minutes away, since we have none in our county. Level 1 trauma centers are over an hour away by ground under optimum conditions. Few of the few first responders in the county are EMT-B, the rest are just there to help.

The last MCI consisted of 5 patients from a wreck. Four of them were over 70 years of age, with injuries and mechanism of injuries that dictate evacuation by air. For example, symptomatic head injury, extremity amputation, unstable pelvis. We could get only two single patient helicopters to respond. Usually, there are three single patient helicopters and a dual patient helicopter available. Given the time of day and traffic conditions in the major cities where the level one trauma centers are located, two of these patients went by ground to a level II center due to its proximity. The fifth patient had a fractured tib and went with the others.

To handle this call, one ambulance was pulled off of a call with a low priority patient, who was given the choice of going to the hospital via the wreck or not. Another ALS unit responded to the call originally. Another unit was staffed by an off-duty paramedic called from home and a volunteer driver.

The call was in a part of the county with a time to scene of 15 minutes on average. All in all, it went smoothly. The last patient was off the scene within 25 minutes of the arrival of the first unit. The first unit took two patients to the LZ, the other two trucks came from about 15 miles away. Even if the the third truck had not been available, the first unit was on a time schedule that would have allowed it to return to the scene from the LZ for the last patient in the same time frame as the arrival of the third unit. All the patients were gone before law enforcement arrived.

I have run a MCI before where some of the critical patients were left on the scene with a trooper until the sole unit could return to take them. That is tough triage, deciding who will go first and leaving the others until you return.

Rural EMS is different.

 

[RebelRescue]

Our standard protocol for who is IC at an MCI is by senority and highest level of training.

EX. 1st on the scene are 1st reponders with 1 EMT-B-EMT-B assumes IC role- then more basics and a paramedic show up-paramedic assumes IC and stays in command unless a paramedic with more years of experience shows up and assumes command.Whoever is the IC(with highest level of training/senority) remains on scene until all PTs in need of transport have left.At least that's the way it's suppose to go but,as you all know,sh** happens and sometimes the regs get thrown out the window.

 

[JJR512]

We don't have first responders in Anne Arundel County, MD, and whoever is the highest level of the first on scene assumes the IC. That could be an EMT-B. But, just because an EMT-P shows up later, he doesn't automatically become the IC. I believe the paramedic can take command if he feels he needs to, but it's not automatic.

 

[MedicPrincess]

In our system, the first arriving ambulance would have command until our MedCom got on scene. The MedCom is our shift CPT or LT. Then command is given to them once they get on scene. Ultimately, they decide who goes where and when and how. We currently have 2 helicopters that can be to any portion of our county in 10-15 minutes and an additional one that can be to our county in 17-26 minutes at our disposal. The county I work for is parterning with HCA and Life Net Air Medical to bring a helicopter to our county. So we generally have a lot of airevac options.

If it gets to out of hand, our EMS Chief and/or County Director of Public Safety will take over as IC from the MedComs. Of course, that is a blue moon occurance. They save their energy for the Natural Disasters and press opportunities.

 

[Ridryder911]

From working several MCI's (even VERY large ones)... they usually are a cluster no matter what system you have in place. That is why they are called disasters..

Even the ones that was called "successful" and became a model system .. definitely has it problems as well.

The best way is plenty of drills, prepapredness as much as possible and alternatively communications (intragencies). It is the little things that causes problems.

Be sfe,
R/R 911

 

[Jon]

There really is no reason for a Paramedic to be IC or Triage officer. A good EMT or FR can do the same job, and the medic can treat the patients better than an EMT

 

[Ridryder911]

Actually studies have shown that lower level trained individuals perform better at initial triaging. More advanced level the person has the more they want to perform a task or treatment and over triage persons with injuried not compatitable with treatment in disaster settings.

I agree stick the more advanced in the treatment areas where they can perform their level and let the bsic level perform inital triage.

Be safe,
R/R 911

 

[emt4life]

There really is no reason for a Paramedic to be IC or Triage officer. A good EMT or FR can do the same job, and the medic can treat the patients better than an EMT

I totally agree with having an emt being IC or triage. I think that a paramedic may get too wrapped up in things that should be done for a patient, rather than focusing on the scene as a whole. I think emts are wonderful at keeping scenes moving along, especially those that have been emts for a while.

Thanks for all the imput everyone, it really gave me a lot to think about.

 

[JJR512]

The three posts immediately above (17, 18, and 19) are exactly why my county doesn't automatically advance command to the highest "ranked" or skilled person on the scene.