Multiple patient, single ambulance transport scenario..

[DwayneEMTP]

So, I was surprised by the bariatric patient thread when there were several, (if memory serves), that said that they have never, nor would ever transport a patient on the bench seat.

I've done this a gazillion times (Not sure exactly how many a gazillion is, but it sounds like a lot).

At my last service, my partner and I were the only ALS unit at night in a rural county, also the 3rd largest county in the U.S. We had a 2 minute chute time (From dispatch to running lights and sirens.) If we knew we were going out of the City then we notified the backup unit and they had 15 minutes to cover our position from the time of dispatch.

The outside edges of our response zone were approx. 30 miles to the north and south, and if we went east and west were almost immediately into the mountain country where a response could be an hour or more.

Fire and law enforcement are under strict orders to not operate ambulances and others responding are nearly completely untrained first responders that have a near perfect record of freaking out and being a danger to themselves and others on most calls. So there's the setting, as I expect that it exists in many, many rural places around the country.

Ok, so here is an actual call....

Called for four wheeler accident with a child involved. That is all the information we are able to get before arrival on scene. I'm going to give the scenario in gross terms as that hopefully will be all that's necessary to allow you to make your transport decisions.

Upon arrival we find two children in the back of a p/u truck. a 5 year old boy and a 4 year old girl.

Looking at the scene I see a big hole in the apron running around the bottom of a jacked up mobile home. And, I swear to God, about 20 first responders running frantically around, many of them crying.

While getting a history I find that the boy was puttering around and the little girl tried to climb up behind him. While doing so she grabbed his throttle arm causing him to rocket off, dumping her and running over her head/neck with the rear tire.

He continued on hitting the home at a near perfect angle to mash the handle bars down and smash him between the bike and the bottom of the trailer. He was stuck there with the edge of the trailer settled on his chest with some witnesses claiming that he was unable to breath until they pulled him out. Witness one through 4 claim that took about 10 seconds. Witnesses 5-8 claim about 7 minutes, witnesses 9-12 claim that this accident happened last week some time.

The girl is screaming her brains out, blood is coming from her nose, left eye, left ear, the one that was mashed to the ground. Her tears are running down both sides of her face so it's hard to tell if the blood is diluted due to tears or CSF. She is breathing about 30/min between screams, though she stares straight ahead up (immobilized per first responders) and when I touch her eyelid one blinks about half way with the other not appearing to move at all. PERRL, all other vitals within acceptable limits for this situation when all things are considering. But of course it's one set of values only.

The boy is laying quietly, both knees are abraded and swollen ,I assume from hitting the bottom of the trailer, Both hands are a mess, his fingers mangled, he has deep scrapes running from his pubis, across his chest, and it appears that his chin may have stopped his forward progress as it's split wide, to the bone, and bleeding freely. His eyes are open and he is breathing upon first view on his own approx. 6-8/min with depth somewhere near normal.

I can't activate flight to scene due to weather, though I do start them to the closes hospital available to them. I can activate the unit at quarters and send them my way, but they will have a minimum of an hour response.

Again, for all of course, but for those of you that claim that you have never, and would never transport a patient on the bench seat, how would you handle this call?

Though it may appear to be a trap, it's truly not. I'm fully aware that there are many, in fact most, here more intelligence and deeper in experience than myself. I only saw one realistic way to deal with this issue...I'm curious of the thoughts of others...

Thanks all...

Dwayne

[BushyFromOz]

well mate, my decision is made for me bcause my vehicle only has one stretcher and no bench seat, so my dilemma becomes;

1: down triage one and leave it on scene to die

2: split the crew and take a patient each and wait for a second vehicle

3. pinch a "driver" and ferry the most critical patient to the chopper then go back and ground transport the second patient

How close is the nearest viable landing site for the chopper?

Edited October 19, 2011 by BushyFromOz

[DwayneEMTP]

Right near the quarters I responded from, if they can get in there...about an hour, probably an hour and a half now, with patients on board due to the bumpy road and weather conditions...

And Bushy, thanks for participating in the spirit intended. Many of these calls look cut and dried until you see them through the eyes of others.

Dwayne

[Kaisu]

Ya gotta take 'em Dwayne... I had a T-bone at the intersection of an interstate and a state highway. People are supposed to slow down when they approach the ramps. There are the usual gas station/sub shop/trucker supply places and always people leaving them to go onto the state highway to access the interstate. Long story short, I took the husband and his wife. The next available rig was 40 minutes away, I was 25 minutes (lights and sirens) from an ER. The husband was stable on scene, started deteriorating during extrication. I saw the big bubble of subQ air and had just decided I wasn't needling him unless his sats started to deteriorate. No sooner was the thought in my head, when his sats deteriorated. He was also bradying down on me. I ended up sticking 2 needles into his chest.

Patient's wife was on the gurney. She was stable. I didn't want to take the monitor off him, so I did manual BPs on the wife. She was talking to me and on the cel phone throughout the transport. She had a fractured pelvis.

Got them to the ER. He was knocked down and I ended up taking him CCT ground (vented) 2 1/2 hours lights and sirens because choppers weren't flying.

I got reamed out by the ER doc for taking two patients. My medical director backed me 100%. He said I was in the middle of nowhere and did the right thing.

[nypamedic43]

I would have the helicopter land at the closest landing zone and take both patients. Drop the most critical patient with the flight crew and then ground transport the second to the closest ED or interface with the other ground crew somewhere along the line.

Now, she may die enroute, but at least I will have her traveling in the direction of definitive care.

I've taken 2 patients dozens of times. It's hectic and nerve wracking with 2 bad patients. Maybe I shouldn't have but it was better than choosing which one lives and which one dies there on scene. Especially with family watching.

[island emt]

Of course there are times when you end up with more than one pt in the back of the bus if you are in a rural service.

City dwellers have zero concept of the fact that NO the rotary wing is not flying today due to weather, and the next nearest bus is also loaded with multiple pt's.

We went mutual aid to a crash a few years ago in our neighbors coverage area. Rented Lincoln towncar had not made the turn at Knights corner while doing 65-70 mph.

That big old 200 year old maple tree never loses the argument.

Problem was there were 9- 20 somethings returning home from a wedding rehearsal dinner in the car. None of them were from the area except the bride in the back seat.

We arrived on scene as the second due truck, and walked up on a carnage of twisted metal and bodies in the Lincoln which was twisted halfway around the big ole tree.

Several had been thrown clear on impact.

Triage had been started and incoming trucks were assigned to transport as soon as the pt's were removed from the wreckage.

Of the three thrown clear they had injuries ranging from a broken humerous and lacs, to a near amputation below the knee.

We loaded the three of them and headed south for the trauma center. near amputation on the stretcher boarded & collared, humerous FX splinted and strapped in the captains seat. Abdominal injuries boarded and strapped down on the squad bench. All were properly assessed and treated enroute by two of us working in the back.

Was it the ideal solution?

Probably not, but the remaining Pt's all had serious crush injuries & multi systems trauma, and would need to be transported alone once they were extricated.

[WelshMedic]

I would have the same problem as Bushy as I only have one stretcher and no other options. If my back were to the wall (but it's not likely, Holland is so small that there's always a second truck within 15 mins away) then I may consider transporting both children on one backboard by top and taling them. No, it would not be ideal, but the alternative would,effectively, to let one of the kids die.

However, this is all very theoretical to me. I sincerely hope I never have to face the said situation.

WM

[ERDoc]

I was one that said never. I didn't come from a rural system. I am from one of the largest, most well funded volley systems in the country. In a situation like this we could have over 20 ambulances, 40 first responders/chiefs and quite a few memebers who happened to be "drivng by" on scene in less than 20 minutes. I see your point, Dwayne and agree with you. In your situation you have 1, potentially 2, unstable pts who cannot wait an hour for another unit. You do what you have to do, risk vs. benefit, life over limb,or whatever other phrase you want to throw on.

This is the whole idea behind an MCI. An MCI has to exceed local resources, so what constiutes an MCI in one place will not in another. In Dwayne's case, it is clearly an MCI. Where I'm from it is just another call.

[Chief1C]

It's common to take two per rig here, the one that's worse off goes on the cot. I've had more than that in an ambulance, but I won't share that story. It was a matter of do, or someone dies. They weren't trauma patients though.

[akflightmedic]

I have taken 4 patients in one ambulance...have also taken 3 on several occasions. Taking 2 was quite common and routine where I worked. As ERDoc said, most have no concept of the necessity of those situations until they live/work in an area where it demands such. It is never black/white.