By Fatskills Exam Guides Team — the exam nerds behind 28,500+ quizzes and 2.1M practice questions across 500+ global exams.
Today, EMT and paramedic students are taught “Scene Safe, BSI” as if it is a protective mantra. What truly makes us safer is having a realistic appreciation of the real risks of our work and placing logical workplace controls. WHAT IS SCENE SAFETY? Are EMS providers taking appropriate precautions and fully aware of potential hazards on every scene? Any scene has a potential for violence, and many have not-so-obvious indicators of danger. Just as we proceed as if all our patients have blood-borne pathogens, we should respect all patients as having the ability to become violent, cause an unsafe situation, or intentionally injure someone. Personal safety should be your primary concern on every call, regardless of the call’s acuity. Our goals on every call are patient compliance and scene control, both of which directly affect safety. Safety awareness is something that should be applied to every aspect of each call, from dispatch through completion. In this chapter, we focus on applying safety awareness to every patient approach and assessment. You should always have at least two ways to call for help. Usually paramedics carry a portable radio and a cell phone. Make sure the dispatcher knows that you arrived on the scene. Ask yourself, are there any known dangers? Have the police arrived yet? Has there been any known violence? Is this address “flagged” as dangerous in the dispatcher system? If you are separated from your partner, what is your “Rally Point?” We exist inside a box of physical space. In normal life, we walk from one safe box to another without really worrying about it, but as a paramedic, it is very easy (if you’re not careful) to walk into dangerous boxes and find yourself in peril.
Self-Control = Scene Control People copy emotions Keep your voice down Control your tone Know your temper level and your partner’s Never run on an emergency scene
Scene Approach: Limit Noise Remove loose objects from pockets Limit “jingling” equipment Do not kick gravel Turn radios down to lowest volume where you can hear Upon arrival, drive past scene Evaluate the scene as you approach When parking the vehicle, make sure you can view three sides of the structure
Do not • Park immediately in front of structures • Park in driveways • Take an unexpected approach • Cross yard rather than walkway
Do not walk next to your partner • Spread out • Create two targets
Knock on the door standing on the doorknob side in line with the door frame Identify yourself Wait for occupant to open the door Note whether there are weapons present—obvious and not so obvious
Vehicle Approach: Look for Danger Signs No one in vehicle turns around Everyone gets out of vehicle, and starts toward you “Unconscious person” in properly parked vehicle
Danger signs • Driver adjusts mirrors • to watch you • to keep lights out of vehicle • Persons in vehicle appear to be grabbing or hiding items • Vehicle occupants are “out of place” • Visible signs of violence—arguing, fighting • Dimly lit area • Limited access, exit • “Gut feeling” something is wrong
You must maintain an acute awareness of the structure that surrounds you, the safety of the environment in that structure, and the danger posed by other creatures that might be lingering in there with you. First, you must be careful about the structures—the boxes—you enter. Let’s take a car accident for instance: Is gas leaking? Were the airbags deployed? Watch out for broken glass and exposed metal because they create more hazards than you might realize. And speaking of cars, it’s easy to become dangerously casual about walking around in traffic. Always be vigilant around moving cars. They’re big and they hurt.
Did You Know? On November 24, 2008, a provision in the Manual on Uniform Traffic Control (MUTCD), administered by the Federal Highway Administration (FHWA), went into effect requiring public safety officers, including volunteer firefighters and EMS personnel responding to an incident on the side of a federal aid highway, to wear a safety vest that meets the Performance Class II or III requirements of the American National Standards Institute/International Safety Equipment Association (ANSI/ISEA) 107-2004 publication. Minimum requirements for ANSI/ISEA-compliant garments include use of fluorescent yellow-green, orange-red, or red background material with 360-degree retroflective visibility. Garments should be labeled as compliant with ANSI/ISEA 107-2004 or ANSI/ISEA 207-2006. Second, you must be careful about the safety of the environment inside any “box” you go into. Fires produce dangerous gasses like carbon monoxide, low-oxygen environments, and cyanide gas. Be careful of temperature and weather extremes. You can dehydrate at fires or freeze in prolonged extrications in the winter, and lightning can strike you just as lethally as anyone else, whether you’re wearing a uniform or not. When I trained as a probationary volunteer firefighter, we had a training scenario in which everyone in the pool was found floating face down. Bystanders told us that it happened at the exact same time. Of course, all of the “probies” (including me) jumped right in to “save” the swimmers. Our instructor immediately ended the scenario and told us we were all dead. Why? Live electricity in the pool!
There’s a basic rule of scene safety that this illustrates: If everyone “in the box” is sick, you will be too if you go in. The consequence to that is that if everyone “in the box” is dead, then you probably will be too if you go in. So, bottom line is don’t go in. Sometimes you will have to make a difficult decision, whether to stand outside that dangerous box watching people suffer inside. It’s tempting to run in and be the hero, but that can prove deadly. There are people that love you and are waiting for you to come home, and people who are going to have an emergency tomorrow who need you to be there on duty for them.
Your responsibility as a paramedic is to ensure your safety, the safety of your partner, the safety of other emergency workers, the safety of your patient, and the safety of any bystanders. In that order! Remember, too, that sometimes “the box” isn’t dangerous when you enter it, but the actions you begin to take in the box can make it become dangerous. Releasing oxygen into an enclosed space or defibrillating in wet environments can create dangers that weren’t there when you walked in. Finally, once you’ve determined that the box you’re about to walk into isn’t filled with dangerous gas or substances, and that nothing you do in that box is going to risk your safety, you have to start thinking about the other creatures who are in the box with you. People can be dangerous—not everyone is happy to see you, and crowds don’t think about who they are hurting. Observe everyone at the scene for body language, be aware of actual or potential weapons that can be used against you, and always keep a clear escape route. Never let yourself become trapped, and always stay with your partner.
Never Let Anyone Get Between You and the Way Out Another basic rule of paramedic scene safety is to consider all family pets have the intent to kill you. Make sure family pets are locked up before you enter. Ideally, the dispatcher will have asked the family to do this, but if it hasn’t been done, make sure it gets done quickly. Ensure your biological safety, ensure the scene safety and then enter ‘the box’ your patient is in.
WHY WAS EMS SUMMONED? Once your biological and physical safety is ensured (to the best of your ability) and you know what your dispatcher has told you the call is for, you’re ready to begin to enter the box and meet your patient. As you do, take note of the scene as you walk in. What’s going on? Is this a car accident? Does the patient look short of breath? How old or young does the patient look? What other clues can you get about the patient just from looking at the environment? Is there home oxygen? Are there asthma inhalers or cigarettes? What can you see? What do you hear? What do you smell? After looking at environmental clues, you then have a decision to make: Is this a trauma or a medical call? Trauma versus medical is the big decision you need to make at this point. There are a few reasons that you will want to figure this out before you go into a call. The first reason is so that you can anticipate and mentally prepare for what you might encounter. The second reason is that you normally don’t carry trauma equipment into medical calls. It’s heavy and bulky, so unless you think you’ll need it, you leave it in the ambulance (backboards are really big). The third reason is that priorities are different for each situation and different questions are asked.
Trauma Calls On trauma calls, you want to find out what happened during the accident; when the accident happened—just now or hours or days ago; who was hit; whether there was more than one person; what they were hit with—a car, stick, or pipe. You get the point.
These types of questions tell us the “mechanism of injury.”
Trauma calls are those that involve accidents. Some examples include the following:
In automobile accidents, there is list of questions you want to know. For example, was the patient the driver or the passenger? Which seat was the patient in? Was the patient wearing a seatbelt? Were there other passengers in the car who were unrestrained (that could have flown into your patient during the accident)? Were airbags deployed? Did the car roll over? Where was the car struck? In which direction were the two vehicles traveling, and how fast were they going? Was their intrusion into the passenger’s compartment? These are all important questions. At the same time, you have to wonder whether the patient might have hurt his or her cervical spine (C-spine).
Medical Calls On the other hand, if it’s a medical call, you need to start thinking about what could have caused the patient to become sick. We call this the “Nature of Illness.” Thus, a call for chest pain could mean a heart attack or collapsed lung. An unconscious patient could be due to a stroke, low blood sugar, or seizures. Shortness of breath could be due to asthma, an allergic reaction, or carbon monoxide poisoning.
Medical calls are those that involve someone getting sick somehow. Some examples include the following:
When we go into a scene, we are usually dealing with one patient at a time. In a pinch, a medic crew can usually handle two patients, as long as they are not both critically ill. However, if you have more than one critically ill patient or more than two patients all together, you have a multicasualty incident. When that’s the case, you have to call for additional help. So knowing how many patients there are, and having a rough idea of how sick they are is an important early step in handling an EMS call. Be aware that there might be more patients than you can initially see when you first walk into the call. In trauma calls, especially in car accidents, be sure to search around the accident for patients that might have been thrown clear of the cars or for pedestrians that might have been struck and thrown. Remember, improperly restrained babies can travel a long way; they can also get jammed under car seats or pinned in the metal of the car. Patients who are confused may wander away from the scene. Be sure to examine scenes for clues that someone might be missing. If there’s a car seat and diaper bag, where’s the baby? If there is a purse, where’s the woman who owns it? Just because there is a purse or car seat doesn’t mean that there has to have been a woman or baby in the car, but it certainly means you should at least check. Bystanders who aren’t used to seeing blood can pass out watching you take care of someone who is horribly injured. So be sure to keep an eye on any “crowd” that gathers around you to make sure you don’t suddenly have further, unexpected patients. Also, it’s not uncommon for people to be so upset by their loved ones getting sick that they start to get sick too. I responded to one call where a man was having a heart attack, and this was so distressing for his wife that she ended up having a stroke while we were there. These things happen, so when you walk into the scene, make sure you know how many patients you are dealing with before taking your next steps.
SOMETIMES THE HELPERS NEED HELP The first thing you need to know before you call for help is where on earth you are. Usually, this isn’t a problem because we call our dispatchers to get help to us, and they should know where we are. However, if you are not where your dispatcher thinks you are, you need to let him or her know that. You also need to let him or her know the best way to get to the scene (access) and the best way to leave the scene (egress). Remember, you can call for help at any time. In fact, medics often ensure that help is requested as soon as we hear the dispatch update (ie, asking for police to attend to a big fight). Sometimes we call for help as soon as we see what we are getting into, and sometimes we only realize half-way through a call that we need some help (ie, when we realize that we are walking into a meth lab). No matter when you realize you need help, as soon as you realize it, call for help immediately.
There are two good rules to remember when it comes to calling for help:1. Stay calm2. Give precise information
The final thing you need to know when you’re calling for help is, what help is out there? The folks you’ll call the most are usually the police, the fire department, and of course, other paramedics. The police help control traffic, they control crime scenes, they are the most credible legal witnesses to what happens on a scene, and they are the wonderful men and women who step up when someone tries to hurt us—often at great risk to themselves. The fire department helps contain hazardous materials, secure unsafe structures, and fight fires, and they often get our patients and bring them to us when the environment is too dangerous for us. Other medics can help us to deliver patient care, especially if they have higher levels of medical training than we do. They can help with lifting or by providing an extra pair of skilled hands.
Calling for helicopter medical evacuation is often a good idea in remote areas where our land transport times are more than an hour or so. Some EMS systems have arrangements with their local hospitals to mobilize on-site physician teams for patients who are trapped but need care beyond the paramedic scope of practice. Don’t forget to call your EMS supervisor when necessary; supervisors are an often overlooked resource. Some patients change their mind and decide that they don’t want your help, yet they won’t sign your refusal form. Other patients just seem like the types that are going to lodge a complaint regardless of what you do. Yet other patients will listen to supervisors more than they will to you, just because they know that they are talking to “the boss.” Your supervisor can also help by providing an authoritative legal witness to ensure that you fulfilled your professional duties and obligations to the best of your ability.
Any dangerous animals should be handled by the experts; call the folks at Animal Control. Patients with needs that go beyond medical needs can be helped by social service agencies. Dangerous environments often require specialty teams.
Some possible sources of help you can call on include the following:
Know which teams are in your area and what their abilities are. If your service doesn’t have a lot of information about these teams, this is a great opportunity to invite them in to do a “show and tell” for you as part of your continuing education. Know how to contact public utility crews as well. Electrical crews, natural gas crews, and water crews are all available to help you if you need them. Know who can help you, and know how to call them. Then, when you are in need, send for help.
TALKING TO THE PATIENT You are about to talk to your patient for the first time and to put your hands on them as well. I’m going to assume that you know all about how paramedics work in teams. As humans, we have a fragile design flaw: We have a huge head, attached by a thin column to the rest of our body—our neck. This means that whenever a strong force pushes our heads or pushes our bodies, there is a danger of our necks being injured or broken. In medical language, we refer to our necks as the “cervical” portion of our spinal column, and we always shorten this to “C-spine.” (We don’t say “necks”; if you do, you’ll sound like a rookie.) The problem with our necks—I mean our C-spine—is that if they are broken and we move them, we risk breaking them more and injuring our spinal cord, which runs in a column inside our cervical spine bones. If we injure our spinal cord too much, we might become paralyzed, even to the point of losing the ability to breathe on our own. This means that as a rescuer, we have to take exceptionally gentle care of anyone who is (as we say) a possible C-spine injury. At this point in the call, for the first time we are actually engaging with the patient and speaking to him or her, so it is quite common for the very first words we say to be “please do not move” or “don’t turn your head” even before we introduce ourselves. If the MOI suggests a possible C-spine injury, then we have to protect the C-spine of the patient. Now what? At this point, we’re getting the first good look at the patient and are trying to get a general impression about who he or she is and how he or she is doing. So now we are ready to form our general impression, which is pretty cool because now we are ready to assess and treat.
If you want to paint a clear picture of an incident in another person’s imagination, you’ll need to include five very specific pieces of information, in the following order:
You have to memorize these points, to learn to look specifically for these pieces of information when you approach a patient, and then to report these points, in order, whenever you are presenting your general impression to another medical professional. For example, imagine that there is another, more advanced paramedic crew responding to back you up and they are asking for the general impression of your patient. Imagine that I tell them that I am on the scene with a person in a car accident. Can you form a picture of that in your head?
You might wonder how you can determine a patient’s level of distress just by looking at him or her. At this point, it’s very, very general. If the patient seems to be fine, is walking around calmly, sitting in a relaxed way, or doesn’t look panicked, you can guess (just for now) that he or she is in mild distress. On the other hand, if the patient is collapsed on the ground, is clearly not responding to the environment, or looks as if he or she is in shock or has been really smashed up, then you can guess that the patient is in severe distress. Unless the patient falls in either extreme, we label them as being in “moderate” distress until we find out more. Make sure you’re still safe! Are there any threats? This reminds you to pick your head up at this point and just make sure that there aren’t any obvious environmental threats to you or your patient that you might have missed or that might have appeared while you were doing your quick assessments. The kinds of threats we worry about are things such as traffic, people, animals, structural damage—almost anything. Basically, you’re taking a quick survey of the scene again to ensure that you’re not in danger. Then take a quick look at your patient to ensure that he or she is still the way you thought he or she was. Again, you’re just performing a quick check to ensure that no new danger is present. After you’ve done that, you’re ready to move on to the ABCs. Oh yeah, did you make sure you’re still safe?
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