Your Truck And Your Patient Crashes....................

[romneyfor2012]

You are called to the residence of a 39 year old asthmatic at 3am, who is having respiratory distress that is unrelieved by her inhaler.  You hear moderate wheezing, but nothing to be concerned about, seems to be your average every day asthma call.  You get the patient to the truck and begin your first nebulizer treatment, and head to the hospital non-emergency (a 20 minute trip on backroads).  Your patient starts to get more "tired", and sats are not improving, so you go to the next level in your protocol (whatever that is), about 2-3 miles from the hospital the patient goes into respiratory arrest, you pull over and intubate the patient, reassess vital signs, all is stable, and sats are improving.  You know the closest engine company is a bout 5 miles away, and it is 3am, so you have to wait a little longer for them at this hour of the morning (in bed, got to throw on some turn-out gear, so you decide you will go to the ER instead of waiting on assistance from them.  Your partner drives lights and siren, and as he is turning on to the road the hospital is on, he makes a right hand turn in front of a car he thought had stopped, but it had not, and plows in to the side of your box.  Partner gets out, other driver is not injured (nor are anyone in the ambulance), it was low enough speed that the box is damaged but the truck is driveable, and you are literally 1/4-1/2 mile from the hospital. The patient's vitals are good except for respiratory rate, you do not believe the patient will go into cardiac arrest, but she is intubated. So do you:

1.  Call radio and ask for PD, then instruct the other driver to sit tight, that you are going to take the patient to the ER, then your partner will immediately return to the scene to fill out paperwork. Realizing you are leaving the scene of an accident.

2.  Or do you call for backup, wait there for the other ambulance to arrive, and let them transport (we will assume that ambulance is less than 10 minutes away).

3.  Or do you do something totally different.  

This scenario is more about the risk benefit of leaving and getting the patient to a hospital, versus waiting and then being blamed because you delayed transport, so do not get bogged down in trying to figure out why the patient arrested, it happened, so now you have to make a quick decision, and for this exercise, your supervisor is not answering his/her radio or cell at 3am, so you have to make the call.

Edited December 19, 2011 by romneyfor2012

[Vorenus]

Call dispatch and police, report the situation - as long as the other driver`s not injured/not severly injured, don`t delay transport.

[Just Plain Ruff]

No injuries to the other driver, then no stay.

But I wouldn't be surprised if that driver you leave at the scene doesn't miraculously come down with some neck pain or something.

At the time you have no injuries to the driver of the car but that can easily change.

I would still leave the patient and head to the hospital. As a matter of fact, both of you, not just your partner can return to the accident scene. Then you can transport that suspicious neck pain that the driver will develop by the time you return.

I would not delay transport of this critical patient if you don't have any injuries to the other car's driver. That's bad juju.

[Richard B the EMT]

Local protocols will be observed.

Mine are, radio in that your unit is in an accident, using specification of "My unit is involved", and give location, injuries sustained by you, your partner(s), the patient(s), the folks from the other vehicle, and damage to both vehicles.

Then, you will await the arrival of additional ambulances to take over patient care from you, and take care of you and your partner. You will also await the arrival of the "Conditions Boss" (nearest field supervisor, usually a lieutenant), and the LEOs, which in my area is the NYPD. At discretion of your dispatcher, you might also get a "Box Pull", consisting of 2 FDNY Engine and 1 Truck Companies, and the nearest FDNY Battalion Chief.

When transported to the hospital, or back at the station, an MVA (Motor Vehicle Accident) "Package", with all the paperwork in multiple copies, will be completed, sent to HQ, with copies to the Personnel Files, and one to take home by the department members involved.

I note that we have reasonably close backup here in NYC, so help is never too far away. Such is NOT the case in all areas of the country, or the world.

[HERBIE1]

Depends on local protocols, but in our case, your first priority is with the patient in your apparatus. Our policies dictate that if there is someone injured on the scene, then we must wait for help to arrive before we can leave the scene.

In this case, I would be calling dispatch, advising them of what happened, that there are no injuries but to send additional units to the scene to verify nobody needs EMS and to properly document refusals of service, instructing dispatch to send law enforcement to the scene and for them to meet us at the hospital to complete the paperwork, advising the base station of what happened and that there would be a slight delay, and I would have proceeded to transport with my patient.

[Bernhard]

Legal and local protocol question. Here we have several possibilities, including all of your given answers. In exactly that scenario I would:

• notify dispatch, request another ambulance, request notifying supervisor and PD
  
• secure scene (done)
  
• carefully assess other driver (done), if in any doubt that he may be injured: do NOT leave the scene (we may rule out minor bruises, we're allowed to rule out C-spine injuries).
  
• carefully assess own ambulance, really able to drive on?
  
• check with dispatch for other ambulance's ETA (in this scenario: still far too long), decide if patient is time critical (in this scenario: yes, vitally challenged)
  
• leave written information about our side (license number, driver name) to the other driver
  
• explain situation to the other driver and ensure that he knows others are on the way
  
• take a picture of the situation (see other thread! one of the rare exceptions i would take a picture), maybe do some marks on the street (german mandatory car first aid kits actually have crayons in it for that purpose)
  
• leave the scene and deliver critically patient
  
• return to scene afterwards as "out of service"
  

Normally we have the option to wait for another ambulance, it should be there within minutes and thus during the whole initial scene assessment (if requested early!), but this may be not the case in any situation (dispatch information/decision). Supervisor normally is on scene within 10-20 minutes, same for PD. Could be far too long for the patient (my decision).

Again: here the critical part is to request assistant as soon as immedeately after crash. Then backup should be available just when it comes to the decision to drive on or not, instantly making this decision needless. Had several such situations, thankfully not as involved ambulance but as backup or as supervisor (even some when ambulance actually left scene with a critical patient).

Carefully check your local protocols! There should be a policy about this. And as always in EMS: know your options.

[DwayneEMTP]

Excellent scenario...I'm screwed no matter what. If your local protocols say that you stay and she deteriorates, the parents are going to sue. If they don't and you leave, CK's scenario is likely to occur and they will sue. But either way, I have no idea what my protocols would say addressing such an incident.

What is the staffing of the truck? M/B? M/M?

Though it sounds bad, we're really talking little more than a fender bender here. If the situation is M/B then there's not much of a call. I've got an intubated patient that has/is deteriorating at a rate that I believe dictated intubating...I'm going to the hospital.

Depending on the number of people in the car I'll likely call dispatch, tell them I'm in a cluster fuck, load the vehicle occupants in the truck with me, if they'll come, and continue to the hospital.

I really love this scenario, as it's a true moral/ethical/legal dilemma in the U.S. Take the patients and everyone is safe but the vehicle is left unattended and the drivers '$20,000 diamond necklace' disappears (from her 1974 rusted out El Dorado), leave them and there's no mysterious necklace but a complaint of "I told them my back was killing me and they just drove away!", or wait and the pts family, justifiably in my opinion, claims 'We called for help but instead of helping they sat on the side of the road until my baby nearly died!"

So my answer, of course based on actual patient presentation, is that I take all and go to the hospital. If I can't easily convince them to come with me then I leave them for PD, transfer my patient and then go back if the backup ambulance hasn't arrived yet...

Dwayne

[romneyfor2012]

In this real-life scenario, both were medics, the senior medic made the decision to transport to the ER and let his partner (the driver) return while he completed his report at the ER. He was suspended for 16 hours for doing so, but as he stated he would do it all again because if he got fired from this employer he could work elsewhere, if he lost his license, he could not work for anyone.

[akflightmedic]

I applaud your scenario as it is outside the box and presenting those who choose to participate with many different issues to consider prior to taking action...HOWEVER, this will NEVER have happened to me as you presented.

You are called to the residence of a 39 year old asthmatic at 3am, who is having respiratory distress that is unrelieved by her inhaler. You hear moderate wheezing, but nothing to be concerned about, seems to be your average every day asthma call. You get the patient to the truck and begin your first nebulizer treatment, and head to the hospital non-emergency (a 20 minute trip on backroads).

There is no average asthma call, especially one not slightly relieved by an inhaler. Knowing that I have an adult asthma patient who has felt bad enough to call 911 probably after taking 20 shots of the inhaler in past 20 minutes despite probably only telling us "4"....knowing it is just me and my partner and knowing the distance to the ER...I would already be on high alert and considering activating my resources (FD). Note I said considering... Additionally, the first nebulizer treatment would have happened wherever the patient is because once you start moving them, no matter how much you move them, they are still exerting themselves and exacerbating their condition. Also, once you go through that front door, it is either gonna be too hot or too cold for them to breathe which further worsens their condition before that first treatment has time to work.

Your patient starts to get more "tired", and sats are not improving, so you go to the next level in your protocol (whatever that is), about 2-3 miles from the hospital the patient goes into respiratory arrest, you pull over and intubate the patient, reassess vital signs, all is stable, and sats are improving. You know the closest engine company is a bout 5 miles away, and it is 3am, so you have to wait a little longer for them at this hour of the morning (in bed, got to throw on some turn-out gear, so you decide you will go to the ER instead of waiting on assistance from them.

Whoa! Hold up....I am making the decision to intubate and NOT calling for extra hands?? See, this is why the scenario would never work. The few minutes of sitting on side of the road waiting for extra resources is time well spent. Because even after intubating, I now have to hook up a ventilator, so I have time to kill...unless you plan on me only bagging and not doing anything else for the remaining of the trip....and if I plan on a respiratory arrest patient remaining intubated who is showing improvement, then I better be pushing some drugs as well.

This is why this scenario will NEVER be an issue for me, cause once I have help on scene assisting...if I were to get in a crash--I now have enough resources to deal with all the other hypotheticals.

[Just Plain Ruff]

I applaud your scenario as it is outside the box and presenting those who choose to participate with many different issues to consider prior to taking action...HOWEVER, this will NEVER have happened to me as you presented.

There is no average asthma call, especially one not slightly relieved by an inhaler. Knowing that I have an adult asthma patient who has felt bad enough to call 911 probably after taking 20 shots of the inhaler in past 20 minutes despite probably only telling us "4"....knowing it is just me and my partner and knowing the distance to the ER...I would already be on high alert and considering activating my resources (FD). Note I said considering... Additionally, the first nebulizer treatment would have happened wherever the patient is because once you start moving them, no matter how much you move them, they are still exerting themselves and exacerbating their condition. Also, once you go through that front door, it is either gonna be too hot or too cold for them to breathe which further worsens their condition before that first treatment has time to work.

Whoa! Hold up....I am making the decision to intubate and NOT calling for extra hands?? See, this is why the scenario would never work. The few minutes of sitting on side of the road waiting for extra resources is time well spent. Because even after intubating, I now have to hook up a ventilator, so I have time to kill...unless you plan on me only bagging and not doing anything else for the remaining of the trip....and if I plan on a respiratory arrest patient remaining intubated who is showing improvement, then I better be pushing some drugs as well.

This is why this scenario will NEVER be an issue for me, cause once I have help on scene assisting...if I were to get in a crash--I now have enough resources to deal with all the other hypotheticals.

But see AK, you have the help. Some people only have what they arrived to the house with no matter how hard they ask for more help.

I also would have been calling for either first responders, fire, or another ambulance. I think that if I got to the decision point of intubating the patient without calling for additional help is where we fail the patient. Now if the patient crashes on the way and it's just you then you go with it but you call for help at that moment.

Plus, I have the ventilator so that does free up a pair of hands but you still in the end have a critical patient that would benefit from the extra hands.

I loved the scenario, it was a outside the paradigm (para dig em) scenario.