1. Chapter 12 Scene Size-Up INTRO TO EMS Unit 3: Patient Assessment

2. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview  History of Safety in EMS  Standard Approach  Hazard Identification  Risk Management

3. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 3 History of Safety in EMS  EMTs always faced hazards –Weather, hazardous road conditions, infectious disease  America Burning (1973) –Federal report  drew attention to problem of on-job injury in fire & EMS services  NFPA created to develop standards for safety emergency operations

4. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 4 History of Safety in EMS  Occupational Safety and Health Administration (OSHA): Bloodborne pathogens (BBP) rule –Requires emergency responders to be protected from BBP Includes training & mandated exposure procedures –EMS agencies responsible for employee safety  government enforced Reduction of EMS workers’ exposure to BBP  raised EMS concern w/ serious safety issue

5. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved Scene Size-Up  Scene size-up: overall assessment of the emergency scene –First step in patient assessment plan 1.Take appropriate BSI/standard precautions & assess scene safety 2.Identifying mechanism of injury (MOI) or nature of illness (NOI) 3.Determining and calling for additional/specialized help 5

6. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 6 SCENE SIZE-UP 1. PERSONAL SAFETY includes 2. MECHANISM OF INJURY OR NATURE OF ILLNESS 3. NECESSARY RESOURCES TAKE THE “BIG” PICTURE SCENE SAFETY  IDENTIFY HAZARDS # OF PATIENTS HAZMAT SPECIAL RESCUE

7. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 7 Personal Safety BSI PRECAUTIONS Consists of SCENE SAFETY

8. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 1. Ensuring Personal Safety  First step in scene size –up is to assess & ensure personal safety…. –BSI Precautions –Scene Safety 8

9. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 1. Ensuring Personal Safety  BSI Precautions –Must be taken on every call –Observe scene & patient Don PPE as deemed necessary by what is seen Gloves: wear when there is any chance of coming into contact with blood or body fluids Protective faceware: wear if any chance of blood or body fluids spraying/splashing into eyes, nose or mouth Gown: wear if chance of clothing becoming soiled with blood or body fluids 9

10. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 1. Personal Safety  SCENE SAFETY NOTHING IS MORE IMPORTANT EMERGENCY SCENE THAN PERSONAL SAFETY –Hazards may be obvious  violence, downed power lines, or HAZMAT –Don’t overlook not-so-obvious dangers  unstable vehicles, unsafe surfaces, dangerous pets –3 words to go by: Plan Observe React 10

11. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved STOP & REVIEW  1. Why would you wear protective gloves as a BSI precaution? –Wearing protective gloves when there is any chance of coming in contact with patient’s blood or other body fluids  2. Why would you wear a face protection or gown? –Chance of blood or body fluids splashing into face, eyes, nose, or mouth; gown when there is a chance of clothing becoming soiled with body fluids or blood  3. What three words sum up the actions required to respond to danger appropriately? –Plan, observe, & react 11

12. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 1. Scene Safety Dispatcher Information 1. Nature of Emergency– medical vs. trauma 2. Patient’s level of consciousness 3. Patient’s breathing 4. Presence of life threatening physical conditions– loss of consciousness, chest pain, shortness of breath (SOB), abdominal pain 5. Violence on scene– police en route or on scene 6. Fire or smoke condition reported 7. Special equipment needed—heavy rescue extrication 8. Special rescue– confined spaces, hazardous material 9. Traffic conditions– fastest route and traffic delays 10. Other responding emergency vehicles 12

13. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 13 1. Scene Safety  When approaching a scene, first ask, “Is the scene safe?” –Assess the scene for hazards –Control those hazards before making a patient care decision  Eventually, EMT will automatically integrate the process of approach, assessment, and control into practice  takes experience

14. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 14 1. Scene Safety  Staging –Avoid entering scene hastily Better to make assessments for hazards than be pulled into a dangerous situation –Staging: places an emergency vehicle a safe distance from the scene  2 reasons 1. Keep EMT out of harms way (explosions, gunfire, hazardous materials) 2. Give EMT time to assess the scene from safety of the vehicle

15. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 15 1. Scene Safety  Staging –Ensures the EMT identifies the danger present before rendering care STOP, LOOK & LISTEN! –Stop the ambulance several hundred feet from scene –Look and scan the scene with binoculars –Listen with window down for signs of danger ahead

16. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 16 1. Scene Safety  Scene size-up –Note a dark house or quiet scene: 2 possibilities 1. EMT responded to wrong address 2. EMT could be walking into an ambush –What do they do?  CONFIRM the location & consider requesting law enforcement to the scene

17. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 17 1. Hazard Identification  Risk factors –Risk: exposure to a hazard that could lead to injury –Many hazards are predictable  preventable Ex: broken glass = wear heavy-duty gloves –Predictable risks are grouped together and called risk factors (Table 12-3).

18. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 18 1. Hazard Identification  Risk factors –MVC Oncoming/passing traffic Spilled fuels-rear Spilled antifreeze-front Wires down Utility pole suspended Smoke from vehicle Visible fire Unstable surfaces Broken glass  Risk factors –House calls Animals Damaged stairs Loose rugs Poor lighting

19. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 19 1. Hazard Identification  High index of suspicion: –A way of “thinking”  EMT should always take this viewpoint when approaching a scene Ex: patient with chest pain may also have SOB Ex: if MVA = broken glass, spilled fuel, traffic jam –Consider what hazards could be present, look and listen, and decide whether hazards are present

20. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 20 1. Hazard Identification  Hazards at a House Call –Most common type of call Pets Poor lighting Physical hazards Keep pathway to the nearest door clear Deadly weapons or potentially dangerous instruments –Device intended to produce death Stairs

21. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 21 1. Hazard Identification  Hazards at a MVC –Flammable liquids, slippery antifreeze, sharp glass, and jagged metal edges –Trucks Visible fumes Any diamond-shaped hazardous material placards Name of the carrier

22. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 22 1. Hazard Identification  Hazards at a MVC –Downed power lines All downed lines should be treated as potentially dangerous A downed power line is not safe until the power company physically removes or isolates it

23. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved Stop & Review 1. What is the purpose of staging? Allows for an EMT to observe the scene and determine safety prior to entering the scene 2. What is a risk factor? Provide examples of risk factors for a house call & MVC call. A potential hazard that could lead to injury (grouped together) when they are predictable in a certain situation 3. What information can be obtained from the dispatcher regarding an emergency scene? Number of patients, nature of emergency, violence/danger, special equipment needed, level of consciousness, etc. 23

24. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 24 2. Identifying the MOI or NOI  Need to determine the nature of the patient’s problem –Dispatch already provides insight into whether patient is medical patient (ill) or trauma patient (injured). Nature of illness: patient’s medical condition is caused by internal factor (NOI) Mechanism of Injury: external force caused the injury/injuries (MOI) –Occasionally, may be combined**

25. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 25 2. Identifying the MOI or NOI  Kinematics of Trauma –Trauma = leading cause of death for people between 14 and 40! ; 3 rd leading cause of death overall—behind heart disease & cancer –Care depends on extent of injuries Not always simple  hidden injuries can be fatal Need to determine MOI to understand seriousness of injuries –Tells likely injuries or patterns of injury

26. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 26 2. Identifying the MOI or NOI  Kinematics of Trauma (MOI) –Velocity is speed at which an object moves Velocity is more important than weight in producing kinetic energy –↑ Speed = ↑ energy –Rate of speed change is significant Series of impacts ** each impact has potential of causing harm –Car impacts object –Occupant impacts car interior –Occupants organs impact inside body surface –Commonly falls, MVC, fire, explosion, penetrating objects

27. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 27 2. Identifying the MOI or NOI  Car Crashes  5 basic types –Head-on impact –Rear impact –Side impact –Rotational impact –Rollover EACH HAS PREDICTABLE PATTERN OF INJURY AFFECTED BY TYPE OF RESTRAINT (SEATBELT, AIRBAGS, CARSEAT)

28. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 28 2. Identifying the MOI or NOI  Motor Cycle Crashes –Injuries greatly reduces when rider wears helmet No helmet = 340% chance of severe injury or death –3 types Head on Angular Ejection

29. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 29 2. Identifying the MOI or NOI  Recreational Vehicle Crashes –ATV Expect head, neck, and extremity injuries Difficult to get to scene due to environment

30. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 30 2. Identifying the MOI or NOI  Falls –Most common MOI –Depends on: Distance of fall Anything interrupting fall Body part that impacts first Landing surface –Feet first = fractures of spine, hip, femur, heel and ankle > 15 ft will damage internal organs –Head first = injury to neck & chest –Sever fall = 2x pt’s height or > 15 ft onto unyielding surface

31. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 31 2. Identifying the MOI or NOI  Penetrating Trauma –Object is pushed through the surface & into soft tissues of body Knives, guns, arrows, projectiles, etc. –Surface injury may be misleading  internal damage typically dangerous Look for entrance & exit wounds

32. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved Stop & Review  1. What are the five basic types of car crashes? Explain why it is important to recognize each one. –Head-on, rear, side, rotational, and rollover. It is important to recognize each one, because each is associated with a distinct pattern of injury  2. What is the most common mechanism of injury? When is it considered severe? –The most common MOI is a fall. A fall is considered severe when it is two times the patient’s height or > 15 ft onto any unyielding surface 32

33. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 33 3. NECESSARY RESOURCES NUMBER OF PATIENTS FOR HAZARDOUS MATERIAL SPECIAL RESCUE

34. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 34 3. Determining Necessary Resources  Once personal safety is ensured & I.D. MOI/NOI, then need to decide what additional resources are needed –HAZMAT –Extra EMS personnel –Electric or gas company –Heavy rescue  REQUEST ADDT’L HELP ASAP

35. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 35 3. Determining Necessary Resources  Situations which may require additional help: –Number of patients Too many patients = call for additional personnel/ambulances TRIAGE  determine who needs treated first –Based on injury severity S.T.A.R. TRIAGE MODEL

36. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 36 Determining Necessary Resources  START Triage

37. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 37

38. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 38 3. Determining Necessary Resources  Situations which may require additional help: –HAZMAT Very common  stored in homes & businesses Transported by ground, sea, air Require specialized training to manage & decontaminate Be alert and call ASAP –Special Rescue Law enforcement  violence, traffic, bystanders, crowds Fire Power/gas company Special rescue

39. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 39 Stop & Review  1. When is the best time to call dispatch to request extra assistance you need on scene? –Before beginning patient care. It is too easy to get caught up in patient care and forget to call  2. Why should the number of patients be determined during the scene size-up? –To make sure you have all necessary resources to provide emergency care to patients. Requesting early will help them get to patients quickly.  3. In what situation will you need to call for law enforcement? –Violence or potential for it, traffic, bystanders, crowds, law-violations

40. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 40 Risk Management  Motor vehicle collision: Traffic –Traffic = single largest danger to the EMT at the scene of a MVC** Careless drivers focus on the wreck and fail to notice the rescuers working around the scene –Effective warning devices & proper vehicle placement reduces the chance of an EMT being struck by passing motorists

41. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 41 Risk Management  MVA –Vehicle placement –Warning Lights –Road flares/alternative warning devices –Public safety –Damage Survey –Number of Patients –First contact –Vehicle Stabilization

42. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 42 Risk Management  EMT’s first duty is to himself –Refuse to enter an inherently dangerous situation –Cannot simply refuse to act Reduce danger & make it safe to provide care –Do NOT enter scene until danger is reduced to an acceptable risk

43. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 43 Risk Management  Motor vehicle collision: Vehicle placement –If the EMT arrives first, he is responsible to protect himself, the crew, and the patients –Position the emergency vehicle at the roadside of a scene to create a safety corridor Safe zone where EMT can work more safely

44. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 44 Risk Management  Motor vehicle collision: Vehicle placement –The distance between the emergency vehicle and the scene depends on Types of vehicles on the road Average speed of the traffic on the road Type and weight of the emergency vehicle –In all cases, the minimum safe distance to position an emergency response vehicle is about 50 feet

45. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 45 Risk Management The EMS vehicle should be at least three roadside markers away from the scene on a controlled- access highway.

46. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 46 Risk Management  Motor vehicle collision: Warning lights –Color is important  red, blue, yellow most common Some states have adopted red lights while others have adopted blue light for all emergency vehicles The most visible color at night, however, is yellow light –Turn lights on & leave on whenever emergency vehicle is on scene –Safest place for an ambulance is ahead of the collision site Face direction of travel to the appropriate hospital if possible

47. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 47 Risk Management  Motor vehicle collision: Warning Devices –Enhance scene visibility with flares or cones –Flares Portable and highly visible both day and night Very dangerous –Don PPE before lighting a flare

48. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 48 Risk Management  Motor vehicle collision: Road flares –Position and pattern of flare distribution determine effectiveness as a warning device –Order of flare placement is important to ensure safety DISTANCE OF FIRST FLARE FROM ACCIDENT = Speed limit  feet X 4 Ex: 30 mph  30 ft X 4 = 120

49. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved Risk Management 49 Flares Distances: Table 12-4 Speed Limit (MPH)Conversion to FeetDistance to First Flare (Ft) 30 120 40 160 45 180 50 200 5555 (+100)320 6060 (+100)340 6560 (+100)360

50. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 50

51. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 51 Risk Management  Motor vehicle collision: Alternatives –Despite proper use of flares, danger of fire and explosion still exists Electric or battery- operated hazard lights are an alternative

52. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 52 Risk Management  Motor vehicle collision: Alternatives –During daylight hours, traffic cones provide an excellent alternative –Further benefits of traffic cones Make a loud noise when struck, alerting the driver to the hazard ahead Are reusable and cost-effective

53. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 53 Risk Management  Motor vehicle collision: Public safety –Make a perimeter for motor vehicle traffic –Make effort to protect pedestrian traffic –Enlist the aid of law enforcement officers or fire police

54. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 54 The Last Word  Scene size-up is an important part of any call  Begins as EMT approaches the scene, even before they see the patient  DO NOT RUSH IN  Determine right away whether or not help is needed  Request additional help ASAP