MCI Question

[JohnnyOV 2]

I may be wrong, so maybe someone can clarify: I was under the impression that MOI can be used without any other information to qualify a patient as a major trauma (under the Adult/Peds major trauma protocol), thus qualifying the patient for ALS response and transport to a trauma center. The reason for this, I assumed, was that internal injuries don't always manifest themselves in predictable ways and in the field it may be impossible to determine the extent of someone's injuries. So

if someone falls 20', for example, even if they have what I think is just a broken bone, I still call ALS and take them to the med center (not the closest hospital).

If the PD/FD is a licensed first response agency, then I don't see a problem with leaving patients on scene with them and taking the (more) criticals. But if they're not, how is this different from abandonment (provided you don't RMA)?

Quoted from NYS DOH EMS BLS Protocols - it classifies the patient as a "major trauma" patient, and to contact ALS if availble

http://www.health.state.ny.us/nysdoh/ems/p...majortrauma.pdf

(Including Traumatic Cardiac Arrest)

Note:

Request Advanced Life Support if available.

Consider Air Medical Transport per regional protocol.

Do not delay transport to the appropriate hospital.

For the purpose of this protocol, major trauma is present if the patient’s physical

findings or the mechanism of injury meets any one of the following criteria:

PHYSICAL FINDINGS

1. Glasgow Coma Scale is less than or equal to 13

2. Respiratory rate is less than 10 or more than 29 breaths per minute

3. Pulse rate is less than 50 or more than 120 beats per minute

4. Systolic blood pressure is less than 90 mmHg

5. Penetrating injuries to head, neck, torso or proximal extremities

6. Two or more suspected proximal long bone fractures

7. Suspected flail chest

8. Suspected spinal cord injury or limb paralysis

9. Amputation (except digits)

10. Suspected pelvic fracture

11. Open or depressed skull fracture

MECHANISM OF INJURY

1. Ejection or partial ejection from an automobile

2. Death in the same passenger compartment

3. Extrication time in excess of 20 minutes

4. Vehicle collision resulting in 12 inches of intrusion in to the passenger compartment

5. Motorcycle crash >20 MPH or with separation of rider from motorcycle

6. Falls from greater than 20 feet

7. Vehicle rollover (90 degree vehicle rotation or more) with unrestrained passenger

8. Vehicle vs pedestrian or bicycle collision above 5 MPH

HIGH RISK PATIENTS

If a patient does not meet the above criteria for Major Trauma, but has sustained an

injury and has one or more of the following criteria, they are considered a “High Risk

Patient”. Consider transportation to a Trauma Center.

Consider contacting medical control.

1. Bleeding disorders or patients who are on anticoagulant medications

2. Cardiac disease and/or respiratory disease

3. Insulin dependent diabetes, cirrhosis, or morbid obesity

4. Immunosuppressed patients (HIV disease, transplant patients and patients on

chemotherapy treatment)

5. Age >55

[Guest alsfirefighter]

In my opinion, MCIs are a huge weakness of the EMS system that we have in northern westchester. I've never had to deal with a large incident, and although we have periodic drills and whatnot, I really hope the day never comes.

The problem is that we don't need a plane crash at the airport to overtax our system. Here's an example:

Imagine a 3 car MVA with 6 patients on one of the highways in Northern Westchester. Let's say 3 of them are ALS. I get on scene with my BLS ambulance and medic intercept. I'm already in trouble for the following reasons:

1) Chances are, due to MOI, all of these patients could be considered "major trauma" and should be taken to the medical center by ALS. We can fit two patients in a rig, but each medic only has one set of ALS gear (monitor, etc., as far as I know), so a case can be made that I need to call and ask for 5 more ambulances and 5 more medics. I have no idea where these ambulances and medics would be coming from, but given the location, I think that the 5th patient could easily be waiting 30-45 minutes.

2) Let's say I approach the scene from an MCI mentality and start the whole green/yellow/red business. I call for more ambulances and ALS units. Given response times in the area, it might be 15 minutes before the most critical patient gets transported. A more likely manifestation of this problem is the following, and I have had this happen: 2 car MVA with 4 patients, big SUV vs. little honda. The two SUV patients are RMAs, the two in the little honda need to get to WCMC ASAP. I call for another ambulance mutual aid, but I can get the two little honda patients packaged and ready to go 10 minutes before someone shows up to RMA my SUV pts. In an ideal world there'd be a bunch of EMTs on scene to RMA the SUV guys while I'm packaging the hondas, but that never happens. Now I'm sitting on scene with 2 possibly critical patients who are waiting for me to either RMA the other two or for another rig to show up and do it. I've mentioned this scenario before and people have thrown around the idea of leaving an EMT on scene if there's an extra with some equipment, but I'd be awful uncomfortable doing this.

3) The recently-posted stat-flight dispatch protocol says that a helicopter should be called when an MCI threatens to overload local resources. It also says to notify dispatch if I'm going to need more than one. Getting back to the original scenario, according to that protocol, how am I supposed to know if I should call none or one or two birds? Theoretically, and this seems unrealistic, I would know how long it will take each of the next 5 (most likely VAC) rigs to show up, and if the times are high enough I'd call for the helicopter. Is that realistic, though?

Chris already pointed out most of what I was going to say but I wanted to add on a couple of things.

If its a weakness, its due to lack of planning, training, policy and operational awareness. It may sound harsh, but often it always comes down to that level. How many agencies are out there pushing for more MCI resources, such as MCI trailers and common sense training that works at the lone provider level not just a "disaster drill." Disaster drills are great, but its the everyday stuff that could lead to a MCI and they're not going to occur at 10 am on a Saturday morning with just about every bus staffed with 3 or 4 people in a 20 mile radius.

1) While the chance that they may all be ALS is ever present, statistically its probably not going to be the case. 1 set of gear or not, an ALS unit should have a minimum to treat 2 persons between first in gear and the truck/bus. Doesn't mean you want to jamb 2 severly critical patients into the bus, but 1 severe critical and another who is deemed another ALS patient by other findings might work well. Additionally any Paramedic worth their salt is going to review all the patients, determine or re-determine their status, direct the resources on scene as to what is needed and where and get additional resources as needed.

2) Textbook abandonment? If I wanted to follow textbooks for the rest of my life I would have went to the culinary institute instead of college to be a Paramedic. Decisions made when things are "interesting and challenging" are when good critical decision makers shine and with common sense litigation is avoided. To me nothing is interesting...it may be challenging but interesting comes after the call is completed. If I ask the 2 in the SUV if they are injured or have any complaints and they say "no" then they get no further attention from me other then the comment "if anything changes or you wish to be taken to the hospital please let one of the EMS personnel or the police officer know." A RMA is "Refusal of Medical Attention" if they are not injured or do not wish to be "checked out" as people I love always ask, they are not in need of medical attention in the first place and therefore aren't refusing anything. Communicate, communicate, communicate. If all else fails I'd find a trusted colleague or another apparatus crew member who can handle an RMA for me.

As far as not being comfortable with leaving a member on the scene...I can't see why either...as a Medic I do it on a daily basis when turfing a call BLS.

3) If using STAT Flight for an MCI..again they should be used for critical patients. If none are left or none are critical get on the phone and contact the 3 closest hospitals, see what they can handle, let them know what's coming and coordinate.

As Chris stated MOI is a component of trauma criteria and then there is those specifically listed which are a good rule to live by. Understand that with motor vehicles the game is constantly changing...at low speeds cars look awful with crumple zones and with air bag location and technology getting better and better, vehicular damage is not as good of an indicator as it use to be.

Nothing beats good solid physical assessment, a quick primary when first there to identify immediate life threats to treat and then a solid head to toe and detailed once the person is in the bus.

[Guest emtb23]

If I ask the 2 in the SUV if they are injured or have any complaints and they say "no" then they get no further attention from me other then the comment "if anything changes or you wish to be taken to the hospital please let one of the EMS personnel or the police officer know." A RMA is "Refusal of Medical Attention" if they are not injured or do not wish to be "checked out" as people I love always ask, they are not in need of medical attention in the first place and therefore aren't refusing anything. Communicate, communicate, communicate.

Is that legal? I was under the impression that if we're called to an MVA, for example, every person involved in the accident is part of the call, so they're all either going to sign an RMA or come to the hospital.

It doesn't make much sense to me that a person can... refuse RMA, essentially, by saying that they "don't want to be checked out." The RMA protocol has a bunch of safeguards: attempting vitals, evaluating history for psych. disorders, ETOH/drug use, Alzherimer's, abuse, etc. If the people who make these protocols think it's important that we look into all of these things before letting someone RMA, I can't imagine they'd also be ok with us skipping all of these criteria and being fine with an "I'd rather not get checked out." Not to mention minors - would you walk away without documenting anything if one of the two cars was full of 16 year olds? In other words, are patients who can't RMA to begin with eligible to refuse being "checked out"? And if not, how's that any different than patients who are drunk, a danger to themselves, (insert other things we check during an RMA here), etc.? I'm guessing that it's not, but then I don't see why you wouldn't document all of these refusals to get checked out.

[helicopper 1,050]

Is that legal? I was under the impression that if we're called to an MVA, for example, every person involved in the accident is part of the call, so they're all either going to sign an RMA or come to the hospital.

It doesn't make much sense to me that a person can... refuse RMA, essentially, by saying that they "don't want to be checked out." The RMA protocol has a bunch of safeguards: attempting vitals, evaluating history for psych. disorders, ETOH/drug use, Alzherimer's, abuse, etc. If the people who make these protocols think it's important that we look into all of these things before letting someone RMA, I can't imagine they'd also be ok with us skipping all of these criteria and being fine with an "I'd rather not get checked out." Not to mention minors - would you walk away without documenting anything if one of the two cars was full of 16 year olds? In other words, are patients who can't RMA to begin with eligible to refuse being "checked out"? And if not, how's that any different than patients who are drunk, a danger to themselves, (insert other things we check during an RMA here), etc.? I'm guessing that it's not, but then I don't see why you wouldn't document all of these refusals to get checked out.

I was under the impression that the trauma protocol had been updated to make MOI a component in the process but not a sole criteria for designation as a "major trauma" - is 2004 really the latest update to that protocol?

Using your rationale shouldn't you respond to EVERY auto accident to obtain a refusal then? If there's a six car rear end accident during rush hour because one car got slammed injuring the person in that car and the other four got "bumped" are you really going to get RMA's from everyone else involved? I gotta agree with ALS and there've been threads about this in the past - if I'm not injured I'm not refusing anything. 16 year olds are a different situation - let's stick to one problem at a time. If I complain of pain/injury then I do have to refuse.

Back to the MCI question... don't confuse your one on one decision making with the triage and multiple patient decision making. As ALS and BNechis have said in the past, without training, policies, and practice, we're never going to resolve this!

Prior threads on refusals: http://www.emtbravo.net/index.php?s=&s...st&p=103840

http://www.emtbravo.net/index.php?s=&s...st&p=103370

[ny10570 745]

Throughout Westchester outside of a few extraordinary circumstances you really aren't going to need statflight. Unless the helicopter can be on the ground at the scene before the pt is extricated the ambulance is almost always going to win the race. Special circumstances are where flying becomes an asset in this area. With your scenario with 5 or 6 critical pts all who NEED a medic and a Trauma or other specialty referral center, statflight would be an excellent resource to help take some pressure off of WMC by running a pt out to a further facility. Croton's motorcycle accident is another example, a pt with probable spinal trauma that would either take too or long or be to rough to drive to WMC so they elected to go for the helicopter.

Remember protocols are a guideline. While MOI may qualify a pt for ALS assesment, think about what a medic is going to do for this patient. The protocol is just trying to cover for people who can't think on their own. They figure that odds are a pt meeting such and such criteria might need ALS and the EMT's reading this may not be able to figure this out so well just tell them to call for ALS. I've been on several accidents where to has taken more than 20 minutes to extricate or the vehicle has rolled where the patient was fine and truely needed no treatment or were who's injuries were so minor that ALS was clearly not needed. You as a competent EMT should be able to asses your patient and justify why you do or do not need ALS for your patient. Same goes for medical calls, if the pt is responding to BLS interventions then you do not need ALS.

Judgment judgment judgment, I can't stress it enough. The car with a scuffed bumper and no complaints is pretty much a no brainer "EMS not needed". When you start getting into more significant MOI its once again falls on your judgment. The RMA is a statement that you as the health care provider believe that the person should go to the hospital and is potentially placing themselves at risk for further injury or death as result of their refusal.

It is important to understand what it takes make a case involving patient care. First they have to prove that you had a duty to act, second that the care provided was below the standard of care, third that the patient suffered harm, and lastly that your actions caused or made worse that harm. The RMA is just to document that you fulfilled your duty to act at the recognized standard of care. If in your judgment the patient stands to suffer no harm from refusing treatment then you have no duty to act and can send them on their way. It is also important to understand that unless the person has a complaint or there is something to indicate to you that they may not be aware of the extent of their illness or injury they are not your patient no matter how old they are or what their mental status may be.

[Guest alsfirefighter]

Is that legal? I was under the impression that if we're called to an MVA, for example, every person involved in the accident is part of the call, so they're all either going to sign an RMA or come to the hospital.

It doesn't make much sense to me that a person can... refuse RMA, essentially, by saying that they "don't want to be checked out." The RMA protocol has a bunch of safeguards: attempting vitals, evaluating history for psych. disorders, ETOH/drug use, Alzherimer's, abuse, etc. If the people who make these protocols think it's important that we look into all of these things before letting someone RMA, I can't imagine they'd also be ok with us skipping all of these criteria and being fine with an "I'd rather not get checked out." Not to mention minors - would you walk away without documenting anything if one of the two cars was full of 16 year olds? In other words, are patients who can't RMA to begin with eligible to refuse being "checked out"? And if not, how's that any different than patients who are drunk, a danger to themselves, (insert other things we check during an RMA here), etc.? I'm guessing that it's not, but then I don't see why you wouldn't document all of these refusals to get checked out.

First you can what if any call all day long. Having "minors" changes the ball game and I would attempt to contact a parent and speak to them directly, that's the one wonderful thing about the cell phone world today. If they tell me and tell their parents they are not injured and I conference with the parents about the situation, the fact they appear fine and the context of the MOI, they are not injured so why would they need to sign a refusal of medical attention? What do you also do then if the parents are not readily available to sign the RMA...wait on scene? Bring 2 extra patients to jam up the hallways of the ER anymore then they already are? Also realize I never said anyone "refused" an RMA, if they deny injury or complaint and they say they are fine, they are not medical patients. Therefore they are not refusing medical attention. Which on a side note...I've had people refuse to sign an RMA...for whatever reason that was. Needless to say I explained it...they still denied, and I wasn't going to have an RMA standoff.

Also, the "RMA protocol" which I'm not overly familiar with except for my own common sense checks for non of the above..the provider does. I make my first impression by looking at what is going on when I arrive, approach the party(ies) and then while talking to them. Im' not sure you mean by "they'd be ok with us skipping these criteria", with a little common sense, good sound judgement as my colleague NY10570 pointed out, there is nothing to skip. Its called "no medical needed."

If you feel you need to RMA...by all means RMA. But as I've pointed out I'm not a chef, so I do not open the "cookbook" to gear my treatment, etc.

Would you RMA someone if you got a call via 3rd party of someone with any disposition, SOB, syncope, etc, and when you get there, they open the door looking like a deer in headlights because they had no clue you were coming, you explain the situation so you have some dialogue with them (CAOx3, no ETOH to the best of your ability) and so on? I certainly wouldn't waste my time or any additional resources. Many of us are working in busy systems where this delayed time is worthless.

Additionally the safeguards mentioned really do not provide much safeguard against anything...vitals? If they are walking around when you get there, you can assume they have a stable BP to begin with.

ETOH? While we can have opinions on whether that is there or not, we are not "experts" to say the lease and even if they did admit they had a few, would you "force" them to go? Unless their arms are hanging off or they have a very obvious problem, or they are really intoxicated and not totally oriented, I will watch them for a few while checking on everyone else to see if any conditions arrive. Otherwise, they can get an RMA.

This isn't a pit with lawyers with fangs...

[ckroll 101]

Excellent thread. I feel for the EMT who wants to live by protocols. The newer any provider is, the closer they should hew to the letter. That said, even the protocols open with the admonition that nothing in the protocols is intended to replace good clinical judgment. And that said, a wonderful quote from aviation..."Good judgment comes from experience... and experience comes from bad judgment."

What an MCI allows, is for the provider to take a different perspective on evaluation/triage. What is best for 'the patient' is supplanted by how can we do the most good for the most people. Part of that is the provider not working past his or her abilities. Be it fire fighting, high angle,or EMS, we all need to be aware of what we are allowed to do and also to be aware of what we are capable of doing. Big picture/small picture, global/local, call it what you will, the challenge is to see both while not losing focus of either and still respond appropriately. Cooking is a great analogy. Dinner for two is done differently than dinner for 12. The standard we want may be nutritionally balanced and 3 courses, but the best we can do may be snacks for everyone and a hamburger for the fellows who need it.

What one calls the event is not so important. How one responds to it is. Assessments change, needs change, so communicate early and often. The person who can get you resources can't help if they don't know what you need. Manage people's expectations and revisit the big picture as often as possible. What individual providers need to do is think hard about how each of us will manage, not necessarily to a plane crash, but a six patient MVA. We never have the resources we want exactly when we need them. We should all know what we will do with what we get.

The last one of these I responded to was 6 pts, rollover, some gruesome injuries, walking wounded, a trauma center just over the horizon, one ambulance, one medic, one EMT and a language barrier, so we really couldn't tell how badly everyone was hurt. ETA for a second ambulance, no EMT, was 15 minutes. You work with what you have and keep it basic. A medic ought to be able to manage 2 major trauma patients [without airway issues] with bystander assistance to package and alone to transport. It's not ideal, but yeah, genuine multiple system trauma needs a trauma center sooner rather than later. I'd rather have to explain why I left a broken wrist with a fire chief than explain why I left a skull fracture on scene waiting for more help to arrive. If one has done their job, the person with broken wrist will understand this and you will leave with his blessing.