Quick decision at a MVC

[BEorP]

However, I wouldn't let the BLS unit just park on the scene without staff, because they're all in the ALS unit working on two patients in confined space. That sounds like a waste of ressources, in my eyes the BLS ambulance would be perfectly able to transport one of the patients. But I understand, that legal restrictions may arise, if BLS staff is not allowed to work under expanded authorization with rendering/supervising ALS treatments as i.v. drops and else. That's what I asked for to understand. Thank you for explanation! Again, I'm glad to not have those restrictions here (which makes it not better here, just may be easier in this special case).

I agree that leaving an ambulance on scene creates difficulties and that it will be difficult to have three EMS providers and two patients in a single ambulance. That being said, if we're talking about a system where the BLS level can't give fluid (or do much), then transporting both patients in the ALS unit with one BLS provider assisting seems like the best way to get the highest level of care to the patients in this case (the other BLS crew member can take the ambulance and could possibly even continue to cover the area on a first response basis - since in rural areas this will be an important consideration).

There are a number of factors in this scenario that come together nicely to make this a feasible option in my opinion (and we surely won't always be this lucky). If that third patient were viable then there would be another challenging decision to make since someone is going to be taking two patients. The other thing that works out well in this situation is that they are both going to the same hospital without question. The final thing that works out well in this scenario is that the BLS crew on scene cannot just scoop and run with one patient since there are no other EMS providers on scene for the other patient. Another challenge that could have been added is if a supervisor/ERU/RRV/whatever you want to call the single EMS provider vehicle were on scene and then an argument could be made that the BLS providers should have scooped and run with one of the patients while the single EMS provider packaged the other patient and waited for the second ambulance to arrive.

In short, I am saying that I wouldn't always advocate for putting two patients in one ambulance when there is another perfectly good ambulance available, but it seems like a good option here (though other options could easily work as well). As I'm sure we can all see from the discussion, there are so many considerations here for what really does need to be a quick decision on scene so it is great to consider and discuss now while we have the time!

[Bernhard]

Isn't there any concept in your country (as I recall we have at least USA, Canada, Australia, NZ, UK, Netherlands and Mexico here) to occasionally add transport capacity for non-regular emergencies in your area despite mutual aid?

We have rapid response squads specialised in transport, prepared for multi casualty scenarios. Two ambulances per squad can be sent out in 10-30 minutes, volunteer based (mostly EMT level). In our little district we have two of those squads, so I can easily double transport capacity within short time. Additionally we have two volunteer treatment units that each may buffer 25 patients until transport could be set up. All of them have a call volume of about 2 per year (the vollies serve in regular EMS to keep in shape). That is even where we have a lot of ambulances (ground and air) available on mutual aid basis.

Wonder if such things exists and/or are commonly used in your country. If not, and if you encounter such scenarios often, it may be a good idea...what does you hinder?

EDIT: typo

Edited November 1, 2011 by Bernhard

[systemet]

Wonder if such things exists and/or are commonly used in your country. If not, and if you encounter such scenarios often, it may be a good idea...what does you hinder?

EDIT: typo

I think the problem with this relates to scale. Consider Alberta, Canada, where mobey's from -- population 3.7 million, with an area of around 650,000 km2 (255,000 square miles). This is larger than all European nation states except Russia or Kazakhstan. It's twice the area of Germany (~ 80 million). It's about the same size as Texas (pop. 25 million), and larger than every other US state, except Alaska. It has a similar population density to Wyoming, slightly less than New Zealand. And this is considered a relatively populated area within Canada.

The large centers typically have some sort of MCI unit that can haul water and spine boards / supplies / O2 tanks, and then a bus fitted for stretchers for en masse transports of critical patients.

But when you're looking at a region where the next nearest BLS ambulance might be an hour drive hot (if it's available), and the helicopter has to make a refuel stop there and on the way back, it's difficult to add resources. Some of these systems will do a call-in of all off-duty staff and use a mechanical spare, but this takes time and is subject to staff availability.

Another factor that's often an issue in Canada / the US, is that ambulance service is often seen as a municipal service, and may be contracted to private entities, or run through a series of different fire departments or third-service providers. While they may have mutual aid agreements, often the resources end up where the tax dollars are. There have been many instances in such systems where "the last ALS unit in town" has refused to respond out of it's jurisdiction to assist at an MCI, in case a 911 call occurs in their service area. [As I understand it, this is no longer the case in Alberta. Although I may not be fully informed.] Government run systems tend to consider whether it might be strategic to place an ambulance in a low call volume (read: unprofitable) area, because there is no timely assistance. Private providers tend not to do this.

[DFIB]

Wonder if such things exists and/or are commonly used in your country. If not, and if you encounter such scenarios often, it may be a good idea...what does you hinder?

EDIT: typo

In urban areas there are multiple resources. In rural areas it is common for there to be up to 100 km or more that are covered by a single volunteer unit. Not necessarily an ambulance and almost never manned by EMTs.

Quick response units would be very nice.

[HellsBells]

Ill try to respond to this in the spirit it was posted, as if I had to make the decision quickly.

Pt 1. would come with the ALS unit, intubated and treated accordingly, a firefighter driving me and my partner

Pt 2. would go with the BLS crew, fluid bolus's as reqiured, again with a Fire Dept. driver.

Since the trip to definative care is a long one, its hopeful ALS mutual aid could hook up with the BLS crew. There is no way I'd take both pts with the ALS ambulance, there would not be enough room to provide needed care for both pts and they would suffer as a result.

[island emt]

Fully packed ALS ambulance and the BLS unit is left standing alone on scene? Okaaaay...(see below)

However, I wouldn't let the BLS unit just park on the scene without staff, because they're all in the ALS unit working on two patients in confined space. That sounds like a waste of ressources, in my eyes the BLS ambulance would be perfectly able to transport one of the patients. But I understand, that legal restrictions may arise, if BLS staff is not allowed to work under expanded authorization with rendering/supervising ALS treatments as i.v. drops and else. That's what I asked for to understand. Thank you for explanation! Again, I'm glad to not have those restrictions here (which makes it not better here, just may be easier in this special case).

Bernhard: We use large type iii module ambulances which have plenty of room to carry two pt's and several providers. Better to have several crew working together on 2 critical pt's in the ALS truck than passing off the least likely to survive on the BLS crew.

Doing it this way would allow additional crew to be called in from home to pick up and staff the BLS truck while you are off on a several hour trip to the big city hospital.

We don't have auto respirators on board.

Yes in an ideal world they would both be flown out to the trauma center by air, but the reality is helicopters are dangerous and not able to fly in bad weather conditions, which we have a lot of. quite often when they are requested they refuse due to flight minimums caused by weather, fog , snow, heavy rains, are all reasons not to fly.

Hells bells: It depends on the type of ambulances you run. In a vanbulance or a sprinter type, not enough room. in a modular type III, plenty of room ,unless your trying to due thoracic surgery or birthing babies.

Edited November 3, 2011 by island emt

[Bernhard]

We use large type iii module ambulances which have plenty of room to carry two pt's and several providers.

Really? Do you have pictures? I googled for "type III ambulance", but got noone seeming to have more space than our standard EN 1789 Type C Mobile Intensive Care Unit (bavarian 2010 model).

Better to have several crew working together on 2 critical pt's in the ALS truck than passing off the least likely to survive on the BLS crew.

This also depends on the education and legal possibilities of the BLS crews. I would have no problem here (neither legal nor personally) to hand my patient over to a BLS crew if instructed to call me when something goes wrong. At least that whats they're able to (and have to do in everydays BLS business).

EDIT: That's our recent standard BLS non-emergency transport unit: EN 1789 Type A2 Patient Transport Ambulance (EN is the european standard "euro norm"). Website in German, but click on the pictures zoom in.

Edited November 4, 2011 by Bernhard

[island emt]

Bernhard

The unit in your first link is close but still quite a bit smaller. More like what we call mini-modulars, which are often used for city trucks.

Your second link is similar to a type II van based chassis with raised top. Companies like the empire & other privates use these because their cheap to purchase. We have some transport companies using the sprinter based units for their long distance transport, usually hospital to hospital or interstate transfers because of improved fuel economy

.

Here's a link to the truck we use. The photo in the brochure is a Portland Medcu unit , twins to ours and many other services in our area. Plenty of room for the stretcher and another pt on the squad bench.

http://www.plcustom.com/PLShowroomMedESasp.asp

[zippyRN]

patient 1 i'm suspecting a head injury if he tolerates an OP he's probably going to be falt enough for a Supra glottic airway or a tube

patient 2 has a low BP , but from the description given of other signs and symptoms his low BP may well be from Spinal Shock / Spinal cord injury - what are our examination finding head to toe? is there another cause for the hypotension ... 84 systolic in a fresh SCI isn't actually too bad.

patient 3 ROLE at scene - police to organise body recovery at a point the SIO decides that sufficient evidence has been gathered

[Kiwiology]

First bloke is Super Crook^TM so he's going to get a tube, second bloke needs some fluid to fix up his neurogenic shock provided we exclude internal bleeding (as confidently as we can), third bloke is DOA (ROLE)

It's worth a chat on the ambo phone to the local hospital to see if they can accept these patients for initial stabilisation because there's no way in bloody hell that somebody can sit on a bag mask and ventilate the intubated fella for as long as its gonna take for the plane to get up here.

I bet the poor SHO at the little hospital is going to have kittens when we roll up