The Three Collision Rule

I imagine it was probably my first Prehospital Trauma Life Support class back in 1990 that I first heard of the three collision rule. Since then, it has remained a useful tool in examining the mechanism of injury after auto accidents. If you haven’t heard of it, please allow me to elaborate.

The three collision rule states that, in any auto accident, there are three collisions that occur and the keen EMT needs to be aware of all three. The next time you walk up to a vehicle accident, instead of imagining two large objects colliding with each other, imagine three separate collisions occurring with each respective vehicle. All of them have implications for the alert EMT.

Collision Number One: The Exterior of The Vehicle Strikes Something

Take a quick walk around the vehicle and consider the elements of Newton’s second law (force is mass times acceleration or deceleration). Ask yourself the questions that apply to that equation. How heavy is the vehicle involved? How fast was it traveling? How fast did it stop? All of these will contribute to the force involved in the initial impact, but speed really is king. Force increases proportionally as the weight of the vehicle increases, but speed has an exponential influence on collision forces.

Several things can give us clues about how fast the car was traveling at impact.

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Understanding Kinetic Energy and Trauma

With every trauma call we run, there are two things that are almost absolute certainties. And I don’t mean that in the tongue-in-cheek sense, like, “We are certain that the elderly fall victim will live on the third floor and the elevator will be broken or nonexistent.” or, ”We are certain that the nursing home C.N.A. will call for that extended inter-facility transfer 12 minutes before the end of our shift.” type of certainty. I mean…even more certain than that.

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When people call us for trauma, these two things are certain.

1.) Two objects collided with each other.

2.) Someone called 911.

When we put these two certainties together, we can make some fair assumptions about trauma calls. Objects colliding with each other aren’t such a big deal. It happens all the time. If my fingers weren’t colliding with the keys on my computer keyboard, you wouldn’t be reading this right now. But nobody’s running off to call 911.

It’s the second certainty that gives us pause. You see, people don’t start activating 911 until things collide in uncontrolled ways. Trauma calls happen when things collide together in unexpected ways and with unexpected velocity. It’s as simple as that. Now that I’ve said that, it sounds so profound that I want to write it down again and put my name under it. Here:

“Trauma calls happen when things collide together in unexpected ways and with unexpected velocity.”

- Steve Whitehead

Doesn’t it sound more profound in quotes? I agree. …Lets move on.

As obvious as it sounds, it bears repeating for one simple reason. If all of our trauma calls originate with two or more objects colliding with each other, doesn’t it make sense to spend a little time learning the nature of how objects in our universe behave when they collide with each other? Regardless of what two objects collide, whether it be Grandma Smiths hip and her linoleum floor or a minivan and an SUV, there are some elements that are always true about the way things collide. When we understand them, we can better predict the potential for damage.

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The Protocol / Skill Breakthrough

Once you understand the protocol / skill connection you might come to see a host of problems with the way we develop, use and teach our protocols. I’d like to tell you about two biggies.

As we explained in the protocol / skill connection, we are dependent on our protocols to different degrees at different levels of skill development. This is defined by the Dreyfus model of skill acquisition. Misunderstanding this concept leads to some predictable problems.

The problem with our protocols is that they were written with the expectation that everyone would use them the same way.

The problem with our field education is that proficient and expert field providers teach novice and advanced beginner students. These two groups think differently about their protocols.

Let’s look at both of these problems a little more closely.

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The Protocol / Skill Connection

Part one of a two part series. (Part two is here.)

If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow.

Such is the nature of growing things.

It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-ha moments. Here’s how it works.

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The EMT Liability Pop Quiz

There really is a dizzying array of stuff we can do to get ourselves in legal hot water in EMS. I was considering a few this afternoon and I got this idea.

Let’s play a game. I’ll give you a whole list of scenarios and you match the legal transgression to the act. OK, that was a really boring and overly technical way to describe my game.

I’ll say what they did; you tell me what they did wrong. Sound like fun? I agree. Let’s begin.

Here are all the possible answers:

• Sounds OK to me
• Negligence
• Battery
• Abandonment
• Assault

Jot your answers down on a scrap of paper. I’ll be back on Thursday with my answers and the rationale behind them.

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Assessment and Scope of Practice

It’s never comfortable to be placed under a microscope. Especially when the dude looking through the microscope is The Rogue Medic, Tim Noonan. Tim’s a great dude, but he’s not the guy you want picking through your knowledge sock drawer. He’s thorough, he’s smart and he’s willing to analyze the details long after you and I have gone to bed.

If you don’t already read Tim’s blog you should. He’s a fantastic EMS blogger. That being said, I wasn’t terribly excited when he posted a comment on my post “I’m Only An EMT Basic” announcing that his comments on the piece could be found over at Rogue Medic headquarters.

For the record, my piece received nothing but kind handling by Tim. The question he chose to focus his lens on? Are lung sounds a part of the EMT scope of practice?

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The Illussion of Control

Part two of a two part series on scene presence. Part one is here.

While we’re talking about scene presence, I think it’s important to bring this one up. I’ve hesitated to talk about the illusion of control on the blog even though it’s a learning point that I invariably discuss with new students on the rig in the first one or two shifts. The illusion of control is deeply applicable to learning scene presence, but, quite frankly, it contradicts something I’ve preached here on The Spot for some time.

It contradicts my advice to always be authentic. When it comes to authenticity, the illusion of control is the exception to the rule. I suspect that some of my regular readers may have take issue with that. It’s OK, I’m a big boy. I can handle it.

In the world of scene management and scene control, the illusion of control is a metaphor for how we should respond when things don’t go the way we planned.

There is an awkward and embarrassing moment that we all have to deal with while running calls. It helps to think it over before it happens. If you’ve been in EMS for any length of time, it’s already happened to you. So let’s talk about it now. How do you react when you make a mistake during a call? What do you do when things don’t go as planned? How do you respond when you make an outright flub, guffaw or blatant error right there for everyone to see?

My answer, “The illusion of control.” Allow me to explain.

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The Med List: ACE Inhibitors

Today I’m starting a new series called The Med List. Once or twice a month, I’d like take a closer look at a single class of home medications and explore the medical implications for our patients who take these meds.

The patient’s medications list holds a wealth of information. Prescribed medications tell us about the patient’s medical history. They also give us clues to the patient’s possible current condition and presentation. Some medicines can better explain the clinical picture in front of us and others can be red flags regarding treatment options and the patients likely response.

Let’s kick off by looking a little closer at a class of medicines called Angiotensin Converting Enzyme Inhibitors. These meds are more commonly called ACE Inhibitors. Everyone calls ACE inhibitors ACE inhibitors in much the same way that  everyone calls International Business Machines IBM and everyone calls American Telephone and Telegraph AT&T.

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L.C.E.S. For EMT’s

Some of you who are familiar with wildland firefighting are already well versed in the safety acronym L.C.E.S. It was developed in 1981 and continues to be taught in wildland firefighting curriculum as a handy checklist of things we should have in place when operating in dangerous environments where conditions can change fast.

L.C.E.S. came about when retired U.S. Forest Service Superintendent Paul Gleason looked at fatal fires over the previous 20 years and identified the four elements most likely to save your butt when stuff goes really wrong. The acronym he created is simple and it works.

In wildland firefighting changes in weather and fuel sources can mean that the operating conditions can go from good to “everybody run” in the blink on an eye, so L.C.E.S. is practiced pretty religiously.  One area of EMS where I feel is has tremendous application is when we’re working in traffic on accident scenes. I’d like to see us EMS folks adopt the L.C.E.S. mindset any time we’re working in the street or on the roadside.

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To Walk or Not To Walk?

The Happy Medic (THM) recently posted a fantastic topic on his blog. I love diving into controversial decisions that we have to make every shift. Here’s one of those questions that we need to answer on just about every call. Should we walk the patient to the pram or carry them?

This is one of those things that we have no choice but to address in every system on just about every call. How to we get the patient to the pram? When is it OK to walk them?

It seems like this subject got rolling on Justin’s (THM) blog when EMS types from around the country started sending him feedback about his role in the documentary film, The Chronicles of EMS. He was surprised by the volume of comments about him choosing to walk patients to the ambulance.

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