Scene Control

[Timmy]

Thanks very much for the feedback, much appreciated. Apologies with the delayed response, things have been a little busy.

[NYCEMS9115]

You have to remain calm. Composure is your ally. Sometimes taking 10 seconds to play it out in your head can have you make the right decision(s). Guides are just that, guides. It doesn't portray all events you may be involved in. You must be confident but show humility. Lets face it, Multiple Casuality Incidents (MCI) link up many people from many backgrounds; so there will be head butting but as long as you go through assessing for the priorities and triage all accordingly then you will have no real issues. After this incident; since it is fresh in everyone's mind. All involved in the rescue effort should sit in a room and open things out with a moderator who had no involvement at the event. CSID (Crtical Stress Incident Debreifing) will help all involved and make the next incident to go better. Good Luck....

[tniuqs]

Well just me but I love this stuff and the bigger the better, yup a bit warped I guess.

just 2 tiny piece's of advice as others have pretty much covered the main points.

It is THEIR emergency not MINE, and WALK by the noisy ones as they are moving air.

If a so called medic is giving me helpful ? advice ... ie Ah your right no collars can you get them on for me and what was your reg number again (ie accountability) You will find lots of weekend Paramedics out there but good ones will size things up walking in and actually help out or ask what they can do to help .. sounds like you found a prick, one in every crowd.

My 3 questions of triage:

1- Take a deep breath ... (airway and breathing)

2- Where does it hurt ... (chief complaint)

3- What happened .... (LOC)

cheers

[Bernhard]

Just read this thread, sorry for warming up an semi-old one.

I know those situations well, from a on-scene-commander's as well as from a first responder's view. Meanwhile I'm considering me pretty experienced at those types of calls ("less than 50 patients are still fun"), but there always is something new to learn, even if I teach this stuff now. There already were a lot of good tips mentioned in the postings above, I just want to add some basic principles I find helpful:

1. Call for help early! A common mistake for first responders is to work and work and work (and sink in chaos) but letting dispatch not know whats happening. The later you call for additional help, the later you'll get it.
2. Smile! At least don't get visually angry. A calm and friendly appearance may offend some, but in general I have found out, it employs an area of calmness around oneself. Speaking loud and clear isn't contrary to this, yelling and beeing rude is (adding more aggressivity and emotions to a scene always is a bad idea). However, don't overact - an oversized grinning face may look more dumb than cool...maybe you have to train this in front of a mirror.
3. Establish a clear command post! You don't at first need a fancy command truck for this, just take what you have: yourself and a paper notebook or clipboard. This does not only include to be available as meeting point for following crews but having them know your position (radio advise). Colored vests help, if available. Tell others (and yourself) clearly, that you assume command until maybe a higher rank arrives.
4. Focus! ignore things, which aren't helpful at the moment. Get back to them (minutes?) later, if they have importance -> handle one problem after another (again: this may change within minutes, but be sure, you are the one who is deciding what and when). With more and more experience I have got a kind of selective hearing. My wife doesn't love this...
5. Follow the circle of command! Assess/identify needs, plan actions, act/give order, check - and start from the beginning again. If somehow lost (most common: trying to get more and more information while forgetting to really act), interrupt and start again. This needs some sort of watching himself, not easy. Taking frequent short rests help, see below.
6. Take a short rest! Common for inexperienced ad-hoc-commanders is tunnel vision. You will get out of this if you actively "take you out of the scene" for a moment. Take a deep breath, ignore all around you for a moment and look around. Those splits of a second are enough, for you it will seem like minutes and you have the possibility to re-evaluate the scene, think over your actions and starting the command process again.
7. Train! Take part in (good) drills, set up your own drills, get hands on scene reports from other calls (EMS magazines, internet, news) and imagine what you've had done, make up scenarios in your head and try to solve them.
8. You can't control everything! If some detail doesn't run the way you would do it (i.e. some "medic" applying any sort of strange medicine) but isn't yet totally out of control, let it go, before you loose control over the rest of the scene.

And a lot more ("10 commandments of EMS tactics" would be a good number, but I have no time left...). I strongly suggest the "training" point, to have all the things available and your adrenaline under control (well, sort of), when things go bad. Good luck!

[Bernhard]

Just two more to make the magical number of 10 complete (unfortunately can't edit my prior posting?):

• Take a piece of paper with you! Write down anything you might need afterwards: number of patients, injuries (briefly), special problems to be solved (mark, if solved), names/call signs of following units and much more. You will get too much information to remember correctly. Another issue is, if you note it, the other party will see that you take him seriously (and maybe doesn't bother you any more). Plus, you get time to think while writing or looking on your writing, looking busy. A prepared form may help, but a blank sheet of paper does it as well for the first phase. Note: A pencil may even write in wet conditions where a ball pen gives up.
• Re-evaluate yourself afterwards! If noone else does an investigation of the scene work, do it yourself, and if it's just for your own education. Be sure to include a summary with at least one topic which was very good, one which wasn't, something you want to point out, one event you feel uncomfortable with and at least one suggestion to improve something. There always is at least one each - but if you don't have to improve anything, then you don't need to remember those 10 points anymore, because most probably you're living them. Congrats.

Hope, that helps.

Edited May 5, 2011 by Bernhard

[Richard B the EMT]

[*]Call for help early! A common mistake for first responders is to work and work and work (and sink in chaos) but letting dispatch not know whats happening. The later you call for additional help, the later you'll get it

This is a "Must Do" item. It is always easier to stop a response, if the additional specialty or regular help turns out not to be needed, than to start it out in the first place.

[HERBIE1]

This is a "Must Do" item. It is always easier to stop a response, if the additional specialty or regular help turns out not to be needed, than to start it out in the first place.

Very true, Richard. Problem is, unless you are going into an area that is high crime, and known for issues, it may be hard to foresee a problem. As anyone who has been around for awhile knows, some of the worst problems come at the times when you least expect it: A domestic breaks out at the scene of a medical call, you get caught up in some peripheral issue that has nothing to do with your call, or a family member/friend/bystander decides that messing with you is on their to-do list for today. In a "safe" area, we tend to become more complacent, and not as aware of our surroundings. SItuational awareness- ALWAYS important.

Experience also helps you develop a sixth sense about things. You get a gut feeling- maybe based on attitudes of the bystanders, a sudden change in the affect of a patient, a general feeling about what is happening in the area, the specific circumstances of the call, or simply a little voice in your head tells you something is not right. You ALWAYS need to listen to that voice and like you said, get that help at the first sign of trouble. LEO's are always happy to help, and they would much rather be cancelled, than to show up and be put in the middle of chaos.

The other day we had a guy who the fire company dismissed as a drunk. Yes, he admitted to drinking, but was not really unsteady, not slurring his words, but he claimed he did not know his name, nor how he got there. Something was not right about this guy. He allowed us to check him briefly and get vitals- all normal, and he allowed us to transport him. He vehemently denied doing drugs, and I saw no evidence of it. Upon questioning, he admitted he was bipolar, and was noncompliant with his meds. Problem is, he just had this look in his eyes- like I am just waiting for an opportunity to go off on you. As we were enroute to the ER, he began to get agitated and threatening, and I immediately called for police. He began making threats, telling us we better let him go or we would be sorry. No amount of TLC was going to talk this guy down. Thankfully psych patients seem to have problems with seat belts, so it bought me some time. I got out, and he was still fumbling with the belt when PD arrived. They cuffed him and escorted him to their car. Problem solved. In my younger days, I may have tried to restrain this guy, but with age comes wisdom. He could have trashed the rig for all I cared- stuff can be replaced, but we cannot.

[Richard B the EMT]

Timmy, what was the initial action on this call here? What eventually happened?

[TXpmed]

Timmy,

First off thanks for sharing this call with everyone, also don't beat yourself up too much about it. Here is my take on scene control.

In the crowd find someone you think can help calm everyone down. Sometimes you can find someone that the crowd / family / etc... can relate to and they may listen to them before thye listen to you. This has helped me on a few scenes over the years.

Remember "scene control" means many different things and each situation is different. Often the tough guy Cop approch only pisses people off more and makes the situation that much more intense and stressful.

Anything else I say will just be repeating what's been said already. Again, don't beat yourself up, learn from it and move on. Some day when you are a crusty seasoned medic you can tell your rookie this story.

[Timmy]

Hi Guys. Thanks for taking the time to respond. To sum the situation up a couple of people refused treatment, even though I highly suggested they be checked over by the paramedics, which they did but still refused treatment and a couple went to hospital in spinal precautions, I haven’t heard anything more…

I followed up the so called ‘paramedic’ but from the information I received I couldn’t find anything to suggest he was in fact a paramedic.

Just a bad day I guess!