Case of the Month
August 2008

Multi-patient - motor vehicle accident

Dispatch
Your BLS unit is dispatched to a motor vehicle accident. While en route the dispatcher notifies you that the call is being upgraded to a rescue response. A fire engine that was responding to a medical emergency has rolled over and four firefighters have been injured. Added to the response are: an engine, a ladder truck, an ALS unit, two BLS ambulances, a battalion chief and police.

En route your crew discusses the following considerations:

• Patient triage
• Extrication
• Potential scene hazards
• Need for additional resources

Scene Size-up
As you roll up to the scene you see a fire engine resting on its side. There is steam rising from the engine compartment and the smell of anti-freeze fills the air. One of your team members dons a triage vest as you perform a scene survey.

You find two firefighters in the cab: one is unconscious and bleeding from a cut to the head, the second is conscious and has released himself from his seatbelt and is tending to his colleague. There are books and various firefighting equipment strewn about the cab. Two SCBA are dislodged and lying next to an axe and some binders of reference material.

You find a third firefighter pinned under the apparatus—he is motionless. A fourth firefighter is found leaning against the undercarriage. He is conscious but lethargic and can not follow commands.

As you establish command and update the incoming units your partner puts triage tags on the patients: two Red, one Green, and one Black—the firefighter pinned under the apparatus had no pulses, no breathing and massive head injuries. The engine is judged to be secure in the position it is resting and there are no other scene hazards. You request an additional ALS unit and notify the local trauma center.

Triage Results:

• 2 Red – unconscious, unable to follow commands
• 1 Green – walking wounded
• 1 Black – no pulse and no respirations

Initial Assessment
Your partner moves the walking green patient to an area a few feet away. You work up the unconscious Red patient who is trapped in the cab. She is pale, mildly diaphoretic and seems to be having difficulty breathing. A cut on her right temple is bleeding profusely, but is controlled with direct pressure. 

Initial Treatment
Your partner quickly rejoins you as the truck company arrives. As you and your partner treat the Red patient in the cab, the truck company sets up for an extrication. Due to the positioning of the Red patient and difficulty of breathing, you will perform a rapid extrication. As she is being removed from the cab you note an angulated fracture of the right femur and the same of the right lower leg. During the extrication the engine and the first ALS unit arrives. The battalion chief arrives and assumes incident command. 

Vital Signs

• Respirations                        28
• Pulse                                 Radial at 136
• Mental status                      Unconscious
• Blood pressure                     96/P

Further Evaluation and Treatment
The Red patient is extricated, placed on a backboard and moved to the ground. A quick blood pat down reveals no other evidence of obvious bleeding. A rapid trauma assessment reveals instability in the left forearm and no other injuries.  The team secures the patient to the backboard and moves her to the back of the second arriving ALS unit. The patient is transported to the local trauma center without incident. The other two patients are back boarded and transported to the trauma center.

Aftermath
Under START triage procedures, the four patients were classified for the following reasons:

The patient in the cab who was secured by a seat belt with a cut to the head was considered Red because of mental status. The other firefighter in the cab was classified as Green because he was able to walk and did not have immediate, life-threatening injuries. The firefighter found pinned under the cab was listed as Black due to being unconscious with a lack of pulses and an absence of breathing. The fourth firefighter, found leaning against the undercarriage was considered RED because she was not able to follow commands.

An investigation of the accident reveals several contributing factors to the injuries and death. The primary cause of the accident was operator error. The vehicle was traveling too fast to negotiate a turn resulting in the crash. Two of the firefighters were not wearing seat belts—one was ejected during the roll.

Several other injuries occurred secondary to unsecured flying objects (UFOs) in the cab during the rollover including breathing apparatus, first aid equipment, resource books and a pick head axe. An accident review board deems that the accident and all injuries were avoidable.

Safety First
The emergency services are inherently dangerous to those who provide aid and assistance. Unfortunately as emergency workers we often add hazards to our work environment. There are several steps to avoiding injuries when responding to emergencies.

Surprisingly, we create a problem by placing equipment on the apparatus. As our role as rescuers evolves we must fit more tools into a tighter space—“ten pounds of stuff in a five pound sack.” When you add another tool to the apparatus you must look at how the item is stored and what would happen in the event of an accident. All equipment that is not fully secured in the cab of vehicle can become a lethal projectile in a collision.

Another important step mimics the first. As you enter the cab you must remember to utilize your seat belt. Seat belts drastically reduce injuries in vehicular collisions. You must strap down your tools and you must strap down yourself.
 
Safe driving skills also are paramount. You want to arrive quickly at the scene, but this does not justify reckless speeds and dangerous maneuvers. Whether you are driving a fire engine or an ambulance, the physics involved are much different than the passenger vehicle. If you drive an emergency apparatus without a full appreciation of how it differs from your personal vehicle you are putting yourself and your colleagues in mortal peril. 

You should review your apparatus and defensive driving policies on a regular basis. Wear your seat belts and arrive alive!

Cab safety issues
Fire Apparatus Magazine (external Web site)

NIOSH Firefighter Fatality Investigation Reports (MVAs)
CDC/NIOSH (external Web site)

Video “Buckle Up!”
Google - Houston Fire Dept (external Web site)