Scene Control

[Timmy]

I’m just after some advice on how you guys manage a chaotic scene.

I had an incident last night involving multiple patients, I was single officer, upon arriving I found about 40 bystanders (family, friends & event officials) in mass panic, some of which were hysterical, people swamped the ambulance as I pulled up, demanding my attention, while I’m trying to assess the patients a bystander shoves a phone to my ear having already called 000, I had the clinician on the phone wanting a situation report re ALS cars/choppers, while I’m half talking to the clinician half talking to the patient I hear “I’m a Paramedic, your doing everything wrong, get collars on these people” paramedic man stands there abusing me and offering his opinion rather than assessing the other patients or helping, I had family tugging at my shoulder to come over and help there family members. Triage was difficult because there were so many people standing around I could barley move or see the other patients in the sea of panicing people.

Despite all the mayhem there was actually no one seriously injured and in the end it all worked out, we got everyone that needed transported to a hospital and everything was fine.

I’m very nursing orientated, its so easy to push the red button on the wall and have a gaggle of medical personal with me within 20 seconds, we have security officers, we can lock people in the waiting room ect. A world apart from the uncontrolled situation I had last night.

I admit, I did a crap job of scene control and there were things I defiantly could have improved on. I wasn’t panicing myself but it was so hard to get around and get a good overview of what was actually happening. I’ve dealt with anxious people and high pressure situations before but never with so many people running around in such an uncontrolled manner with no backup.

How do you guys (being experienced pre hospital clinicians) walk in, click your fingers and have everything under controlled within minutes?

[crotchitymedic1986]

First of all, you have to be in Command, which you were not. You should have politely hung up the phone, explaining you would contact Medical Control once you assessed the scene. One thing that is useful, is to put the "on-scene medical bystanders" to work. If they are busy working, they have less time to standback and critique you. Give them easy jobs: Give me a head count of how many injured, move the walking wounded over there and start triage, set up my triage areas, anything to get them working. If you look like you are in command, and have a plan, they will listen. If you look lost and scared, and have no plan, they will eat you up and get in your way.

Edited January 9, 2011 by crotchitymedic1986

[Richard B the EMT]

Timmy, what was the initial incident to which you responded? Also, for good, bad or indifferent, hindsight is always a bitch, as you will question yourself for some time, no matter how much good you did, as to what you couldn't do. It's human nature to do so. For the time being, concentrate on what went right.

On an unrelated, how are you, and your agency, dealing with the flooding I've been hearing about on the news?

[Bieber]

I'm a brand new paramedic myself, so taking and keeping control of my scene is still a challenge for me and I can sympathize with you. I haven't ever had to deal with a situation like that before, but I have been on scene and felt like I was losing control. You need to be loud, have a plan, and really step up and BE in charge and let it be known that you're in charge by doing those two things: having a plan, and being loud in your implementation of it.

One quote from my AMLS book that always stuck with me throughout my internship was this: "If you don't take charge of your scene, someone else will." And during my internship, my preceptors actually told me that they were going to try to take control of my scene and I had to dominate them and maintain my control because they were going to be actively trying to seize it from me.

[mobey]

This is one of the hardest situations we are faced with, and it takes years to master (I have yet too).

The problem is, when people are dealing with an unfamiliar stressful situation, they often resort to anger or confrentation very quickly. People do not know what to expect from us, so they let thier "Fight or flight" take over and mistake our calm demenour for nonchalant carelessness. The public sees an ambulance at an MCI and thinks "Quick... load everyone up".

I am not one to give too much advice on this, but I'll tell you what works for me.

As above; Start your triage. Get all non-involved parties to one area, assign the "green" people to an area near them and anyone with first aid can keep busy comforting them.

The reality is, you just have to do a few of these to get a good handle on how to react, and handle the scene.

[fiznat]

I'll agree with what Mobey said: this is probably the most difficult job paramedics face in the field. It isn't rhythm analysis, or drip calculations, or assessment, it's making sense out of chaos and getting these scenes under control. It takes a LONG time to get good at this, and even then there will always be calls that throw you for a loop. It's part of what I think makes this job fresh and exciting.

There isn't going to be a single set of advice that will tell you "how to do this," but some general pointers from my experience:

1. It's not your emergency. Stay calm and relaxed. I usually try to establish scene control by being the coolest head in the room. On scenes where everyone is freaking out, it's the guy who's not yelling that stands out.

2. Realize that you don't need to have all the answers in the first few minutes. It's easy to feel overwhelmed with everyone trying to give you tons of details and requests at once. None of that matters. The only things you should care about when you first arrive on scene is (1) whether the scene is safe, (2) how many patients there are, and (3) what other resources you will need. Thats it.

3. Utilize your resources as best you can. Clinician on the phone can go bye-bye, paramedic interfering on scene can be helpful or he's out. Use the police for crowd control, and your partner (EMT?) to get a head count/quick triage numbers. If the fire department is on scene, find their leadership (white hat?) and get on the same page with him. Try to leave yourself free to take in the scene and make sure big things don't get overlooked. It is not your job to treat or assess patients right away.

4. Talk about the call afterwards and discuss things that you could have done better. Find out if everyone else really was on the same page as you, and brainstorm about ways you could have better communicated. Don't expect everything to be perfect, because that never ever ever happens.

Hope some of that helps.

[Eydawn]

When you first get on scene holler for anyone with first aid training to come to you. Give them jobs as described above my personal favorite being moving anyone not injured to another area. If you have more helping hands one helper to each patient and tell them to start getting a history from their person and just keep them talking. THEN you can do triage and then call medical control. You have to be loud and confident.

Sometimes your first phrase needs to be EVERYBODY FREEZE! THIS IS THE AMBULANCE! LISTEN UP! You would be surprised at how well that works. Be firm but polite. It isn't easy to settle out a fustercluck like that one!

So what was the actual scene?

Wendy

CO EMT-B

[mobey]

Just had another thought: When at a call, I usually pick out the person who is dealing with the stress the worst and give them a chore.

"Can you please get me the patients medications", "Do you have a towel I can use" Stuff like that to get them out of the moment, and give them a task so they don't feel so helpless which usually comes out as agression.

On a bigger scene, I use the same theory.

[HERBIE1]

All good ideas. I will reiterate some of them.

You do not mention the type of call- I assume the scene was safe.

Prioritize.

Simple questions need to be answered first:

What exactly do I have? ie Nature of call?

Does it match up with what I was told?

How many victims do I have?

How much assistance and what type do I need- LEO's, more ambos, ALS vs BLS?

Do I need a fixed wing or helo?

Will any of the bystanders cause me enough trouble, be disruptive, or cause a danger that it may interfere with my job?

Asking someone to help is crucial- pick the ones who are most agitated. Giving someone a task- notify family, get their medications, if Pt is a minor, find a parent, etc. It gets them out of your hair, and keeps them from spreading more panic. It is difficult to get control of the scene with nutty bystanders and street doctors.

Ask a disrupter- especially a loudmouth tough guy- to act as a bouncer. Say "listen- I need some help. I''m trying to take care of this person but unless you help keep these people back, I cannot do my job." Ask a calmer female to take a hysterical female away. Generally these folks end up recruiting friends to help them accomplish whatever task you ask of them.

Be polite, but above all, be FIRM. You need to project an air of confidence and show that you are in charge. That's why they called for help- they wanted someone to take over.

There is no magic formula to this, each scene is different, each area you respond to presents challenges that may be unique to that area.

This is a situation that requires experience. You need to be confident in your abilities and be able to project that confidence to others. We are called because someone cannot handle the situation they are in. If they do not think that you can handle the problem, you simply add to the chaos, and depending on the situation, may also jeopardize your safety.

Forget medical control until you have a handle on the situation. You have far more important things to worry about. They will be of zero help in such cases, and often times they can make things worse. Many hospital based folks have no idea what these situations are like. As you say, they make a call, hit a button, and have all the assistance they could want. Their focus and expertise is on MEDICAL issues, not scene safety and control or utilization of assets.

Sadly, you need to experience a few of these before you start to get confidence in your abilities to handle such things. It will happen, just analyze later what went wrong, what went right, and how you could do things better next time.

[Richard B the EMT]

From the FDNY EMS Command Operations guide, circa 2006, and probably updated after. I offer it as a guideline only, Timmy.

1. PURPOSE

1.1 To set forth guidelines for EMS Command operations at public safety incidents.

2. SCOPE

2.1 This procedure applies to all members of the FDNY EMS Command and to employees of voluntary hospitals who provide pre-hospital emergency medical care through the New York City 911 system.

3. DEFINITIONS

3.1 Public Safety Incident - Any active fire or police incident involving an on-going violent threat or hazards to members of the general public or emergency service personnel.

4. POLICY

4.1 The primary mission of the EMS Command is to provide pre-hospital emergency care and transportation to those in need. Where conditions at an incident interfere with this, members shall make every effort to refrain from placing themselves in clear and present danger without compromising their primary mission.

4.2 If FDNY Operations and/or police resources are not on the scene, and if the incident/situation has produced no patients, and poses no threat to civilians at the scene, members shall remain in, or retreat to, a position of safety until the hostile circumstances have been resolved. However, if any civilian at the scene is in need of medical attention prior to the arrival of FDNY Operations resources or the police, members shall take reasonable and prudent actions dictated by the situation.

4.3 Mayoral directive Direction and Control of Emergencies in New York City designates the appropriate agency as Incident Commander for specific types of emergencies. See Appendix 7.1.

4.4 The first-arriving EMS Command officer shall assume command of the EMS branch, including responsibility for all pre-hospital emergency care and transportation resources operating at the incident.

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4.5 A public safety incident may also be a crime scene, and shall be treated as such. In the event that members must enter a secured area (crime scene), every effort shall be made to avoid disturbing any physical aspect of the scene (e.g., moving furniture, or debris, rolling or disturbing deceased victims, etc.) until authorization is received from the responsible ranking FDNY/Police Department Officer at the scene. There shall be no smoking or eating and no disposal of garbage at a crime scene.

5. PROCEDURE

5.1 Dispatchers shall:

5.1.1 Upon receipt of information indicating that a specific situation may be a public safety incident

A. Enter a CAD assignment, if one is not already in the system, with the appropriate call type, furnish a CAD number and time of assignment to all responding units, and advise units of available information concerning the assignment.

B. Ensure that an EMS Command officer is assigned to the incident.

C. Establish direct contact via land-line or CAD with the appropriate Police or Bureau of Fire Communications dispatcher to confirm the incident, ascertain the location of the Police and/or FDNY Command Post, best access, and any other available information concerning the assignment. Immediately relay this information to the units concerned.

D. Direct responding units to the location of the FDNY, Police, or Interagency Command Post, until an EMS staging area is established.

E. At all incidents where FDNY is the lead agency, upon notification that an EMS Command unit is transporting a patient prior to the arrival of Fire Operations resources, notify the respective FDNY Bureau of Communications dispatcher.

F. Not allow any unit to respond in an available status.

G. Ensure that the Citywide Dispatch Supervisor is kept apprised.

5.2 Members who respond to public safety incidents shall:

5.2.1 Notify the dispatcher immediately upon receipt of information from any source concerning an actual or potential public safety incident.

5.2.2 Refrain from responding unless directed to do so by the dispatcher, and then only after receiving a CAD assignment. Units shall not respond in an available status.

5.2.3 Remain alert to the possibility of scene hazards, including, but not limited to, debris, unstable structures, hazardous materials, secondary explosive devices, and weapons of mass destruction, and utilize appropriate caution as conditions warrant.

5.2.4 On arrival, establish an appropriate staging location without blocking access and egress from the scene. If an EMS Command officer is not on the scene, the member with primary responsibility for patient care shall report to the ranking FDNY/Police Officer on the scene.

5.2.5 Wear issued protective gear at all times while operating at the incident, and observe universal precautions against communicable diseases.

5.2.6 Gather appropriate equipment including the rolling stretcher, long backboard, assorted cervical collars, headbeds, tech bag, (ALS) trauma kit, (2) O₂ cylinders with both regulators, (ALS) intubation kit, triage tags, SAED or (ALS) EKG monitor/defibrillator, (ALS) drug bag, BVM, and suction.

5.2.7 As soon as it is obtained but no later than five minutes after arrival, the senior member of the first responding unit, if there is no EMS officer on the scene, shall transmit a Preliminary report, including the following information:

A. Confirmation, nature, and scope of the incident.

B. Command Post and EMS Staging area locations.

C. Approximate number of victims and an estimate of the patient producing potential.

D. Type and extent of injuries.

E. What hazards are or may be present.

F. Additional resources that are or may be required at the scene.

5.2.8 The following information shall not be included in situation reports:

A. Number and type of exposures.

B. Number of alarms, smoke conditions, progression of fire, or the conducting of searches and the results of searches.

5.2.9 If an incident concerns possible explosives, establish telephone contact with the dispatcher, and ensure that there are no radio, MDT, or cellular phone transmissions from the scene.

5.2.10 Pending the arrival of an EMS Command officer, comply with the directions of any FDNY officer, Police Supervisor, or Emergency Services Unit Police Officer.

5.2.11 Refrain from crossing Police barriers or marker tape, designating a frozen area, without the specific authorization of an EMS Command officer.

5.2.12 Remain with the vehicle, ready to respond immediately at all times, unless performing patient-care functions or directed to do otherwise by the EMS Command officer.

5.2.13 When requesting the response of specialty unit resources from outside the EMS Command, state the condition and reason for the request. Avoid specifying the response agency.

5.3 EMS Command officers shall:

5.3.1 Respond to all confirmed or potential public safety incidents in their area of responsibility as instructed by the dispatcher.

5.3.2 Upon arrival at a public safety incident, assume command of the EMS branch and establish a command post adjacent to the FDNY/Police command post.

A. The officer in command of the EMS branch will be known as the EMS Operations Officer.

B. When operating at incidents where FDNY is the lead agency the ranking Fire Officer will be the Incident Commander (see Appendix 7.1).

C. EMS Command operations at these incidents is a branch of the overall fire incident command system.

NOTE: EMS Command officers shall retain command of all pre-hospital emergency care resources and operations relating to the incident.

5.3.3 Announce the assumption of EMS operations over the radio, using the radio designation Box # _____ Operations or (location) Operations, as appropriate.

5.3.4 Confer with the Inter-Agency Incident Commander to ascertain how EMS Command units may cooperate in the operation.

5.3.5 Transmit a preliminary report within five minutes of arrival. Subsequent situation reports shall be sequentially numbered and transmitted at fifteen minute intervals, or more frequently if necessary.

5.3.6 If Fire Operations units are on the scene, provide the Incident Commander with the information included in the situation report.

5.3.7 When operating at incidents in which Fire Operations is present, provide notification to the Fire Operations Incident Commander regarding EMS Command resources treating and/or transporting patients.

5.3.8 Consistent with criteria for patient confidentiality, the names, ranks, and command of injured public safety personnel shall not be transmitted via radio. Tracking information shall be compiled at the command post and reported by MDT or telephone.

5.3.9 To ensure a prompt response to patients, EMS operations officers may be directed to establish a sector near the Fire Staging area. This sector will function as the Forward Triage Sector, and members will stand by at the location. Prior to establishing this sector, the EMS officers shall verify the location with the Fire Incident Commander, confirming that the environment is safe to enter.

A. For example, during a high rise-fire, the Forward Triage Sector would be established below the fire. During a subway incident, the Forward Triage Sector could be established on a platform near the crash site.

NOTE: An area unsafe for building occupants would not be considered appropriate for a Forward Triage Sector.

B. EMS Command officers shall monitor conditions in the Forward Triage Sector and change location, if necessary. The Incident Commander must be advised of such change(s) in conditions and of the necessity of re-locating the Forward Triage Sector.

5.3.10 Ensure that members do not enter a frozen area.

5.3.11 When explosives are suspected, ensure that radio transmitters, data terminals, and cellular telephones are not used at the scene until authorized by the Police Emergency Services Unit or Bomb Squad.

5.3.12 Escalate or de-escalate the EMS Command response, as conditions warrant.

5.3.9

5.3.13 Secure EMS operations at the incident when the incident has concluded and expedite all units back into service.

6. RELATED PROCEDURES

6.1 OGP 106-18.

7. APPENDIX

7.1 Designation of the Incident Commander

BY ORDER OF THE CHIEF OF OPERATIONS

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APPENDIX 7.1

DESIGNATION OF THE INCIDENT COMMANDER

The following chart designates the Incident Commander for the majority of emergencies:

Fires

FDNY

Civil Disturbances

NYPD

Bomb Threat

NYPD

Suspicious/Actual Devices

NYPD

Hostage Situation

NYPD

Sniper Situations

NYPD

Hazardous Materials

FDNY

Water Rescues

NYPD

Explosions

FDNY

Water Main Breaks

DEP

Structural Collapse

FDNY

Terrorism*

Conventional Weapons

Bomb Threat

Chemical

Biological

Nuclear

NYPD

NYPD

NYPD or FDNY

NYPD or FDNY

NYPD or FDNY

Rail Crash

FDNY

Air Crash

FDNY

Confined Space Rescue

FDNY

Weather Emergencies**

OEM

Power/Telephone Outages**

OEM

Prison Disturbances

DOC

Special Events

NYPD***

*Terrorism: The nature of this type of event is such that the Incident Commander will shift as the event evolves. The handling of a threat of a chemical or biological release or the use of conventional weapons falls to the NYPD. Dealing with the consequences of the explosion or release is the responsibility of FDNY. The investigation that follows, once the consequences of the event have been mitigated, is the responsibility of the NYPD. Any conflicts regarding the issue of Command at these incidents will be resolved by OEM.

**These two types of events involve many different types of emergencies at the same time. Therefore the overall event does not itself require Command, but rather Coordination, which is OEM’s role.

***OEM shall coordinate with the Police Department to ensure that City agencies have emergency response plans in connection with planning the major City events. For routine recurring events such as the marathon, the Mayor will decide whether there is a need for OEM’s involvement.

Emergencies are by nature dynamic and the role of Incident Commander can change as the event unfolds; OEM will help to ensure that any transition in command occurs in a smooth and efficient manner.

BY ORDERS OF THE FIRE COMMISSIONER AND CHIEF OF DEPARTMENT