Managing Your Scene

Attack One responds to a report of a motor vehicle crash. Arriving at the freeway scene, the crew finds one automobile with extensive damage in the middle of the road, its engine compartment on fire. However, bystanders aren't looking at the damaged vehicle. Instead, they're standing on the right shoulder, looking and pointing down a roadside embankment. Traffic is moving slowly on the left side of the freeway. It is a freezing cold day, and the crew is already in its bunker gear.

Attack One is on the scene. One vehicle with severe damage in the road, with engine compartment fire, and appears to have a victim trapped!"

The driver parks beyond the wreck and grabs an extinguisher. A woman is trapped in the vehicle, and she appears to be unconscious. After quickly extinguishing the fire, he can access the victim through the window. She is breathing, with a rapid, thready pulse, and unresponsive. The driver looks for his partner, who has astutely followed the bystanders and is waving from the top of the embankment.

Tractor trailer down over the embankment, unsure of cargo. Driver not responding to me. He is at least 70 feet down, and the cab is badly damaged!"

Attack One to Dispatch. Will be Interstate Command. Now have two vehicles. Fire extinguished, but two fuel spills, and unknown cargo on a tractor trailer over the embankment. Stand by until we complete our size-up!"

Organization of the Incident
Command is established and size-up performed using the ABCDEF approach described in the January issue of EMS (Table 1):

1. -Anticipate victims and injuries
2. -Breathing: Is this possibly a toxic environment?
3. -Cars/crowds
4. -Disability: What are further threats to victims and rescuers?
5. -Electricity
6. -Fuel/fire

Organizing scene size-up this way allows fast initial recognition of safety and management priorities. Organizing Incident Command also requires the skillful management of first-arriving resources and the communication of incident priorities to all incoming crews. Once again, this can be accomplished with an ABCDEF approach (Table 2):

1. -Apparatus: What resources are responding, and what further resources are needed to manage the incident?
2. -Building or emergency ground sketch for scene logistics
3. -Climate and its effects on operations
4. -Deployment of initial and incoming resources
5. -Exposures
6. -Fire or hazard containment

Establishing Command requires proper communications, logistics and utilization of emergency resources. As the incident commander sets up the system, he evaluates what resources are necessary to manage the particular incident and calls for those resources as quickly as possible. These resources arrive on vehicles, so the A stands for apparatus. Resources should be identified in a preplan so that dispatching time is not wasted searching for phone numbers and access points.

As those resources approach the scene, they must be deployed to achieve maximal efficiency. Command must create an emergency ground sketch-paint a picture of the scene, so to speak-to allow equipment and people appropriate access. It is critical to address logistics early, with the communication system another integral component. Sizing up any buildings involved also allows rescuers to understand possible entrance and egress routes (a safety issue). So preparing a virtual map of the structure or area, noting entrance and exit possibilities, produces the B for building/emergency ground sketch.

Climate, particularly inclement weather, may have a major effect on operations. Inclement weather often results in needs for additional personnel and appropriate equipment to handle conditions (e.g., extreme heat, extreme cold or snow, freezing rain, or loss of utilities in events like tornadoes and hurricanes). It may also dramatically affect how patients are managed. Thus C stands for climate. Once vehicles and personnel arrive near the scene, they must be placed into service, so D stands for deployment of existing and incoming resources. The incident commander will give a high priority to scene-safety factors identified in the initial size-up, such as a hostile crowd, oncoming traffic, dangling electrical lines, spilled fuel and fire hazards. Early control of these hazards will improve operating conditions for both rescuers and victims. Consequently, E stands for exposures, whatever they may be. And for certain incidents, the threat comes from fire or contamination "hazards, so F represents fire or other hazard conditions that must be addressed rapidly. Together, these constitute the ABCs of initial Incident Command.

Once these important priorities for scene management have been addressed, victim care can begin. The medical priorities for a major incident are established during triage, with overall management of victims taking priority over any individual victim's care. Triage will evaluate the number and type of victims and allow the most appropriate application of medical resources.

Incident Command and Scene Management
"This incident was organized effectively by the Attack One crew. The ABCs of scene size-up are summarized in Table 1.

Additional evaluation is necessary for complete size-up. The second Attack One crew member starts down the embankment. The smell of diesel fuel fills the air, and a bystander (with torn and dirty pants) at the bottom of the embankment yells up that the slope is too slippery to negotiate. The saddle fuel tanks ruptured when the tractor trailer left the highway, spraying the hill with a slippery coating. Since the bystander is already down the hill with the driver, he is asked if the driver can tell him what was in the trailer. "A big load of chemicals" is all he can report.

There is nothing visibly leaking or emanating from the trailer, and the only smell is diesel fuel. The trailer is marked with the name of a company that transports routine cargo. There are no placards indicating a hazard. The crew member takes a wide path around the spilled fuel, upwind of the trailer, as he navigates down the slope. He notes that a few small trees and an area of brush will need to be trimmed to make extrication of the driver more efficient.

On arrival at the bottom, he finds the truck driver trapped, awake and complaining of chest pain and shortness of breath. It will be a moderately complex extrication. When pressed for details, the driver reveals the cargo is household chemicals, cleaners and aerosol cans. The bill of lading lists no hazardous substances. The tractor and trailer are in a stable position down the slippery hill, but it will take short ladders to access and extricate the driver.

Command, now established on the freeway, designates Downhill, Uphill and Hazmat sectors. The Downhill Sector can now give a complete size-up to Command, covering victim, fuel, cargo, necessary pathway clearance and tools needed for extrication. The Uphill Sector reports a grave situation for the auto driver, who is unconscious and in shock. The care of both victims must include considerations for the very cold temperatures, and rescuers will need to stay warm as well. A helicopter is requested for the automobile driver, meaning a Landing Zone Sector will be needed. Command designates this.

Victims are extricated as rapidly as possible. The truck driver remains conscious and continues to complain of chest pain. The cargo is stabilized and a path cut through the brush and trees to carry the victim. He is removed in a Stokes basket to the top of the hill, and then to the hospital.

Organizing Triage
Many fire and EMS organizations use triage systems that result in patients being numbered in sequential fashion. The Emergency Assessment box represents the results of that triage process here. The crews triaged two patients, categorizing them by compromise of ABCDE body systems.

Victim Outcome
Both victims were red-triaged. The automobile driver had a moderate head injury, contused lungs, multiple intra-abdominal injuries that required emergency surgery, and bilateral leg fractures. She had a long hospital recovery but an excellent outcome. The truck driver had an acute myocardial infarction. It was due to severe coronary disease, which was acutely aggravated by the trauma, cold exposure and extrication. He underwent coronary artery bypass grafts and had a fair outcome.

The triage system effectively classified patients by their needs for care and allowed timely transportation.

Case Discussion
Essentially all EMS and fire agencies have embraced the Incident Command System. Using this system on a daily basis familiarizes personnel with it and makes scaling up for large incidents a familiar routine. An incident that is an actual or potential major medical emergency will require an approach using Incident Command. The ABC approach can be easily recalled for caring for victims. ABC approaches have also been developed for scene size-up and initial scene management. This allows first-arriving responders to organize the initial approach and identification of hazards, and communicate them efficiently. This system can be applied in all types of emergencies.