I'm a first responder and good at it. I trained as a firefighter and came up through the ranks to become a company officer. I can fight fire and direct others who fight fires. Like you, I know how to put water on the red stuff and make it go away. I have learned Chief Alan Brunacini's "Fire Ground Command" and the incident command system (ICS). I can take command of a fire scene, section it, branch it, sector it and put the fire fight into manageable functions for success."
Photo by Jack Jordan Emergency vehicles should be positioned so that emergency workers can do their jobs safely.
However, almost 80% of all emergency incidents are now EMS as opposed to fire. Let's use our valuable ICS knowledge toward EMS incidents and manage those scenes for successful patient outcome as well as we do fire scenes. No reinventing the wheel, no new management skills. Just effectively using ICS to enhance the positive outcomes of our patients.
We will give you, in these articles, EMS scenarios for a first responder firefighter. You may be an EMT. You might be an IV-sticking, medication-pushing, heart-zapping, pull-them-back-from-the-dead fire paramedic. You may have just started responding to EMS calls after having responded to fire calls for years. The purpose of these articles is to help the first responder, unaccustomed to EMS incidents, realize their basic life support (BLS) responsibilities and manage them with the skills learned in ICS training.
Alarm Room: "Channel 4, EMS assignment, truck into a van with fire and trapped people. National Highway and Martha Boulevard. Engine 1, Engine 2, Ladder 3, Ambulance 4, chief 5."
You are the captain on Engine 1 and the first emergency unit on the scene. The maxim to remember is really quite simple. We may risk our lives a lot to protect savable lives. We may risk our lives a little to protect savable property. We will not risk our lives at all to save what is already lost. Now follow ICS with EMS factors in mind.
Your role as the command officer on the scene is to direct both the fire fight and patient care. As other resources arrive, command may be passed, other crews assigned to various tasks. Stabilization is the key objective.
You want to stabilize any patients you encounter. But first, you must stabilize the scene. Patients can't be stabilized until they are in an environment which has been stabilized. This includes an environment which is safe for the patient and safe for the emergency providers.
Your situation is a truck into a van with fire and trapped people on a busy highway. There's no sense in having your crew members working on a highway if their lives are unnecessarily endangered. One thing you don't want is more patients. Park your emergency vehicles in such a way they provide a defense for your crew members. Spot your rig across the traffic lanes so that oncoming traffic are impeded from hitting anybody. Firefighters need to be turned out in full protective clothing. Those emergency providers who will not be fighting the fire need to be wearing bright vests.
Photo by Jack Jordan Note how the rigs are parked across the lanes of traffic to protect the firefighters.
"This is Engine 1 on the scene. We have a truck into a van with the van on fire. We are taking a handline to extinguish the fire. Engine 1 will be Martha Command."
What may appear to be obvious still needs to be approached in a systematic, chronological way. You've got patients trapped in a burning vehicle. But you can't start treating them until their environment is stabilized either the fire is extinguished or they are removed from the danger of the fire.
The firefighters on your engine are taking a handline to the burning vehicle to put out the fire. As they do this, Engine 2 and Ladder 3 arrive on the scene. Let's say in your scenario you won't have any advanced life support (ALS) providers until Ambulance 4 arrives on the scene. Using your ICS training, it's pretty basic. Once the fire has been extinguished, the ladder crew goes in for extrication and you have assigned Engine 2 as the treatment sector.
The scene has been stabilized; your emergency vehicles have been spotted such that emergency workers can do their jobs safely and the fire has been extinguished. Now you can start with the next step, which is stabilization of any patients. Taking a closer look, there are three. One patient trapped in the truck has an open femur fracture but is otherwise conscious, alert and letting the world know he wants out of that truck. While your firefighters are extricating him, he needs to have a dressing put on the open fracture. He is losing a lot of blood otherwise. Be sure your crews are using C-spine precautions as they work with him and the other patients as well.
There were two other patients in this vehicle, ages 25 and 4, who got out or were taken out by bystanders prior to your arrival. The 4-year-old is unconscious and bleeding from the ears. The 25-year-old is awake and screaming that she hurts badly. She has 20% second-degree burns to the chest and face area.
As a BLS provider, all of your checkpoints have, so far, been covered. All patients have their ABCs (clear Airway, Breathing and blood Circulation). Now you need to collect as much information as you can for the ALS providers whom you know are on their way. And you must start any treatment necessary within your realm as a BLS provider.
The first thing you need to do is continue your radio report and let them know how many patients you have and what their status is. This helps in providing transport to a care facility.
Crew members should be getting vitals on the patients. There are five: heart rate (pulse), breathing rate, pupil reaction, skin condition (temperature, color, etc.) and blood pressure. This information must be recorded and a new set repeated at least every five minutes on a patient who isn't stable. With a patient who is stable, get a set of vitals every 15 minutes. Always use C-spine precautions.
The 4-year-old has blood coming from her ears and a dilated left pupil. This should tell you something is very wrong. One of her vitals is not good. Relay this information immediately. If your system has a medical airlift helicopter, it should now start chopping. If not, your coming ambulance knows they pretty much have a "scoop and run."
At last, your screaming patient in the truck has been extricated. Keep getting sets of his vitals. That open femur won't kill him. Right away. But with so much blood loss, his vitals could change real fast.
One of the best standbys for BLS providers is oxygen; full-blown, 15 liters by mask assuming the airway is clear. Continue getting the set of vitals on all patients. Have someone closely watching the 4-year-old and the fractured femur patient. Their situation could change real fast. Keep the patients still, comfortable and warm. Talk with the patients. Reassure them. Put yourself in their place injured and in pain, unsure of what has happened, frightened, strangers buzzing around them. Talk with them in a reassuring manner. Continue making your radio reports so that any ALS units en route know what to expect.
When the ALS units get there, they are somewhat aware of what they've got. Give them your written report with the sets of vitals and your oral report. With your professional handling of the situation, the paramedics can hit the ground running and you've met your responsibilities as a BLS provider to give the victims their best chance for survival.
Decker Williams, a Firehouse® contributing editor, is a 27-year veteran of the Phoenix Fire Department currently serving as a battalion chief. One of Arizona's original paramedics, he teaches the incident management system at medical incidents for firefighter safety and is a staunch supporter of the dual role of fire service first responders. Tim Simmons has been with the Phoenix Fire Department for 12 years and currently is assigned to the Division of Corporate Communications. He is also a volunteer captain in the Nogales, Mexico, Fire Department.
