We all have our good calls and our bad calls. Don’t we? Sometimes things just flow. Sometimes the patient, the bystanders, the crew members, everyone just clicks. And it’s beautiful. It’s like that perfect drive off the tee box that keeps you coming back for another round. The three point jumper that makes you wonder if you should have tried to play college ball.
Unfortunately (perhaps) it is the rare scene that runs flawlessly. More often than not we look back on our calls and think about the things we could have, and should have done better. Of course, that’s how it should be. Without those moments we don’t grow or become better. Some EMT’s carry the philosophy that we should emerge from our field instruction with flawless medicine. Nothing could be further from the truth.
Here is my list of five common trauma scene mistakes I have encountered frequently in my career. I am guilty of doing all of these, some with painful frequency. In those moments of personal scene review, I rank these as my top five, “I wish we had done that differently.” items.
#1 Failing to manage the scene.
We learn a lot about patient care in school. Unfortunately our education regarding management of the scene may be limited to being taught to blindly recite the words, “Scene safe, BSI” as we enter our skills stations. Scene management can be hard. Especially management of big scenes with multiple priorities like calling for more resources, assessing hazards, protecting bystanders, interacting with family and friends of the injured and triaging multiple patients.
On these scenes, patient care suddenly becomes a warm comforting blanket. Caring for one patient seems so much more manageable. Patient care priorities like holding c-spine and doing an assessment call to us like a sirens song. Don’t do it! It seems obvious but, when it’s your job to manage the scene, manage the scene.
Trauma scenes devolve rapidly when the person who should be in charge gets tied up doing patient care. I remember one new student who had such a hard time with his scene management skills that he preceptor forced him to work whole shifts running calls with one hand in his pocket and the other hand on his radio. Everything he wanted to accomplish needed to be done through communication and delegation. For him, scene control and delegation was a hard lesson, but he learned it well.
#2 Delaying transport for lesser priorities.
Control the airway, immobilize the spine, package the patient and go. We don’t fix critical trauma patients, neither does the ER. Surgeons fix critical trauma patients. This means we need to rethink our approach to trauma scenes.
We don’t need trauma patients to wait on scene for really pretty packaging jobs with straps nicely organized, tape folded over so it doesn’t touch the eyebrows and limbs neatly splinted. Packaging should be effective and fast … that’s it. Critical trauma patients shouldn’t look pretty and they shouldn’t be waiting on scene while we start IVs and check their pulse oximetry. Load and GO.
#3 Neglecting the Airway
Sometimes it seems like we emphasize the airway ad-nauseum and I wonder if it isn’t overkill. That is, until I walk on to a trauma scene and see a group of providers focusing on c-spine and packaging while the patient has snoring respiration’s at a rate of six. I’ll look at this group of trained EMTs and say, “Hey guys, someone needs to establish airway control here.” and everyone will look at me like, “Isn’t that your job?”
Well, yes and no. BLS before ALS. A paramedic on scene does not relieve you of responsibility for establishing airway control and assisting ventilations. The patients airway is not something you take over after the patient is intubated. get your BLS tools out, drop an OPA, drop an NPA, even better, drop two, and start breathing for that patient. The BLS airway is your bread and butter skill. Don’t be afraid to use it aggressively when the patient is failing to breath.
#4 Focusing on the loudest patient first
I remember the call like it was yesterday. Four teenagers in a Toyota Carola on a rural road. The car was torn almost completely in half. When I arrived on scene two girls remained “in” the vehicle. One girl was trapped in the front seat. She was screaming like a banshee, “Get me out of here!” Her friend lay face down between the two former halves of the vehicle. She was unresponsive and laying across the hot exhaust pipe in a large pool of gasoline. At the time of my arrival, five responders were tending to the front seat patient, none had assessed the face down girl.
We see this all the time. It’s not to say that loud patients don’t warrant our attention. They certainly do. But on this scene perhaps two rescuers up front and three in the back would have been a more appropriate division of labor.
Loud patients call to us. They compel us to abandon our training and focus on them. Resist this urge. when you walk on to a multi-patient trauma scene don’t pay attention to where everyone else is looking. Look for the quiet patient and approach them first. Odds are that you’ll find your most critical injury right there.
#5 Forgetting about scene safety
I’ve noticed that I have several regular readers in Germany and a few in Israel, Saudi Arabia and Iran. I’m sure my views on scene safety issues might ring naive to some of my international readers, but one thing I’d bet remains universal is this, the longer we remain on scene, the less we think about scene safety.
We all learn some version of the windshield assessment. We take a good look before we get out and approach with caution. But bad things don’t just happen in the first two minutes. On every scene things evolve and conditions change. Make it a habit to reassess your safety.
Start deciding to look up and reassess your surroundings each time you take a pulse or load a patient on the pram. Pay as much attention to safety in second half of your scene time as you did in the first. I can’t wait to see you in the ER and talk about how well your call went.