EMS, Crash Site Responsibility

Article Author:
Stephen Clark
Article Editor:
Rachel Meeks
Updated:
1/16/2019 11:50:07 PM
PubMed Link:
EMS, Crash Site Responsibility

Introduction

Emergency Medical Services (EMS) have several responsibilities at the scene of a crash site whether it be an automobile, aircraft, boat, or any other vehicular crash.  Proper training and preparation for these unique scenarios protects EMS responders and improves outcomes for the victims they are rescuing.  The EMS responsibilities covered in this article include the following:

  1. Scene safety evaluation
  2. Triage coordination
  3. Prehospital medical treatment
  4. Crash site investigation

Issues of Concern

SCENE SAFETY

When EMS personnel respond to a crash site, they assess scene safety before they proceed onto the scene.  This scene safety survey determines if it is safe for EMS responders to proceed on scene and what safety equipment is required.  Additionally, crash sites are highly dynamic environments and may change from safe to unsafe.  EMS responders continuously monitor scene safety and if the situation becomes unsafe, its personnel are withdrawn.

Crash sites often contain a combination of hazards, including: wreckage, hazardous material, fire, and noxious fumes.  Depending on the location, season, and time of day there may also be environmental hazards present (I.e. urban, marine, mountain, desert, winter, nighttime, etc.).  Most modern EMS agencies have access to the gear required to keep personnel safe in all but the most extreme environments.  Knowing when to don this gear reduces the risk to lives of both the rescuers and victims.

The most basic safety equipment includes personal protective equipment (PPE) which is common for most EMS response scenarios. However, each crash site is different in its scope and severity.  For instance, if the crash site spans a large area, as is typical for an aircraft crash site, EMS personnel may also require radio communication, fire suppression, construction machinery, and casualty collection transport for safe and efficient response. 

EMS manage the safety and medical treatment of all personnel at a crash site which may include firefighters, law enforcement, bystanders, and media. Injuries to these crash site personnel would divert time and resources away from crash victims resulting in further injury and/or loss of life.[1]  

TRIAGE

Most crash sites are mass casualty incidents (MCI) with a range from uninjured to deceased crash victims.  Therefore, EMS providers are required to triage patients quickly and efficiently to prevent local resources from becoming overwhelmed. A common mistake seen in past MCI responses is for uninjured patients to receive priority transport while critical patients remain in the field.[2] 

There is no universally accepted triage system and triage procedures may vary from hospital to hospital within the same region.[3]  While no data shows one triage system is better than another, it is clear that when different triage systems are in use at the same MCI, the resulting confusion and disorder delays patient care.[4][5] Therefore, it is vital that each EMS agency train their respective responders to understand their local triage system and provide a unified response to an MCI.  Each MCI will be different in its scope and cater to what resources are available, but at as a general guideline, a triage system will include triage categories and category collection points. 

EMS personnel assign MCI victims to a triage category upon initial presentation. Each triage protocol may vary in how triage categories are determined.  Category metrics may include: Glasgow Coma Score (GCS), vital signs, visible injuries, etc. This initial evaluation is efficient to minimize delay for the patient to receive definitive treatment and also to allow the EMS responder to move to the next victim.  Triage categories are clearly marked and highly visible to aid appropriate transportation and patient care.  These category designations can be a system of color coding, numbering, lettering, or by transporting the patient to a designated category collection point.  As part of their survey and planning EMS leaders will designate collection points that are accessible from the crash site and accessible for transport to medical facilities.  Compounding the challenge of MCI triage logistics is the potential for a victim to deteriorate from one category to another as time goes on.  EMS duties therefore include the continuous monitoring of patients during triage and transport.

Study of real-world examples show that without prior training or a unified triage protocol, responders will transport patients on a first-come, first-serve manner and critical patients will encounter delays in treatment. It is the on-scene EMS’s responsibility to administer and maintain a uniform triage plan for each MCI and to manage the crash site in a way that maximizes the survivability of the most victims possible.[6]

MEDICAL TREATMENT 

Concurrent to triage, EMS personnel are responsible for the pre-hospital medical care for all crash survivors.  As in all other EMS scenarios, this medical care will begin at the initial encounter and will continue throughout the patient’s transport to the medical facility.  Per Advanced Trauma Life Support (ATLS) protocol, responders treat life-threatening injuries first prior to victim transport from the crash site to a collection point. Less severe injuries will be treated at appropriate stages of patient evacuation per the triage system in place.

Specific to aircraft crash victims, data from post crash analysis shows that lower extremity fractures are the most common injury of hospitalized aircraft crash survivors.  Also common were head injuries, open wounds, upper extremity fractures, internal organ damage, and burns.[7]  Specific to rotary aircraft is the high potential for spinal column injuries.[8] These results show the need for all transport decisions to consider the need for C-spine stabilization.[6]  It is common for trauma victims to have multiple distracting injuries which is why EMS providers are trained to do a thorough assessment and to stabilize these injuries for the purpose of transport to a center of definitive care.

INVESTIGATION

In the case of an aircraft crash, investigators consider the events as far back as years prior to the crash but will also research the events immediately following the crash.  This includes the eyewitness accounts of EMS first responders on the scene.  As part of the triage process, the deceased are left where found, being careful to only move the deceased victim enough to perform an evaluation.   The investigation that follows will be able to evaluate the passengers' positions in relation to the crash and extrapolate the cause of injury or death. By this same token, investigators may ask that EMS responders recall the location of debris moved or altered by necessity to get to potential survivors. The result of these crash site investigations have resulted in changes to processes, materials, and training which have subsequently prevented future loss of life.[9]

Clinical Significance

Emergency Medical Services (EMS) have several responsibilities at the scene of a crash site, which if properly executed will result in the saving of lives and reducing morbidity.


References

[1] Neely KA, Scene control in prehospital care. Topics in emergency medicine. 1987 Apr     [PubMed PMID: 10281997]
[2] Lee WH,Chiu TF,Ng CJ,Chen JC, Emergency medical preparedness and response to a Singapore airliner crash. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2002 Mar     [PubMed PMID: 11874774]
[3] Tinkoff GH,O'Connor RE, Validation of new trauma triage rules for trauma attending response to the emergency department. The Journal of trauma. 2002 Jun     [PubMed PMID: 12045646]
[4] Garner A,Lee A,Harrison K,Schultz CH, Comparative analysis of multiple-casualty incident triage algorithms. Annals of emergency medicine. 2001 Nov     [PubMed PMID: 11679866]
[5] Shah AA,Rehman A,Sayyed RH,Haider AH,Bawa A,Zafar SN,Zia-Ur-Rehman,Ali K,Zafar H, Impact of a predefined hospital mass casualty response plan in a limited resource setting with no pre-hospital care system. Injury. 2015 Jan     [PubMed PMID: 25225172]
[6] Postma IL,Winkelhagen J,Bijlsma TS,Bloemers FW,Heetveld MJ,Goslings JC, Delayed diagnosis of injury in survivors of the February 2009 crash of flight TK 1951. Injury. 2012 Dec     [PubMed PMID: 22005153]
[7] Baker SP,Brady JE,Shanahan DF,Li G, Aviation-related injury morbidity and mortality: data from U.S. health information systems. Aviation, space, and environmental medicine. 2009 Dec     [PubMed PMID: 20027845]
[8] Scullion JE,Heys SD,Page G, Pattern of injuries in survivors of a helicopter crash. Injury. 1987 Jan     [PubMed PMID: 3440607]
[9] Sahiar F,Garrison R,Lehman LD,Véronneau SJ,Canfield DV, The value of experienced medical personnel during the investigation of general aviation accidents. Aviation, space, and environmental medicine. 2002 Sep     [PubMed PMID: 12234039]