Guest Editorial: 10 Minutes of Kryptonite

In January, while transporting a patient to the hospital (without lights or sirens), one of the ambulances on my shift was involved in a fatal MVC. This was not the first ambulance accident I’ve responded to (or been in), nor even my first fatal ambulance accident. It was, however, the first time I responded in the capacity of an operational supervisor.

When the unit first called for help, the cavalry started toward them. I had just about 10 minutes before I’d arrive on scene. Ten minutes is plenty of time to preplan for an MVC with a known number of patients. From the preliminary reports I was already calculating how many units, who would have to change locations to provide area coverage, and what the best egress routes might be—that’s all second nature. Then one logistic issue after another came seeping into my racing thoughts: vehicles, personnel, staffing, reporting—one after another they tumbled into the spaces between my concern for my crew and focus on the reports coming in.

As I hit the third or fourth minute into my response, it occurred to me that 10 minutes is not enough time to preplan how you’re going to hold an entire agency together for the next 24 hours. As the next arriving paramedic on scene, I knew that once I got there I would be engaged in patient care—there was at least one critical being extricated. That meant I had only the balance of my response time to get some orders out to the rest of the crews. Where to start? 

My agency is young, evolving, finding its way toward its best staffing and response models. We have rough and refined SOPs for calamities from animal attacks to avalanches to volcanoes, but this was not out of the average playbook.

In this age when provider safety is paramount and just culture seeks a secure footing in our arena, the second most important part (after the response) of any incident is the after-action review. Let me share what happened in the minutes and hours after this accident and what we learned to improve—not as clinicians but as an organization.

Staffing—With this one accident I lost 25% of my staffing for the next 18 hours minimum. As a result of the response, I also lost coverage for two neighboring areas, with no available units to backfill. This left approximately 700 square miles without timely coverage for 1–2 hours. Fortunately, one of the other battalion chiefs called to ask what she could do to help. My one sentence was, “Get these shifts covered.” That was a godsend.

The takeaway is that if you do not have a formalized recall process, create one. Use a method of your choosing for mass contact and ensure your providers’ contact information is accurate and available. Delegate that task immediately. Even if you end up calling in more than you need at first, you may find your needs change in the hours after. Member-of-service (MOS) incidents have a heavy impact, and uninvolved staff may end up needing to be relieved as well.

Administrative needs—The chain of command needed to be alerted ASAP. The agency’s safety officer would have to be notified to respond. While nobody is thinking about paperwork during the incident, the procedure that gets followed afterward can impact everything from compensation claims to the content and focus of subsequent investigations. While I was able to come free from the scene after handing my patient off to the medevac, for the duration of the incident both I and the EMS chief were directly involved on scene, and we had no clearly identified third to pick up the reins.

Have someone to pass the operational baton to—someone tasked with managing day-to-day operations until you can extricate yourself from the incident. As we all know, 9-1-1 doesn’t care what else you have going on.

Communication—Hopefully that early notification to your chain of command will naturally put one of them in charge of handling public information. Much of this should be integrated in a process worked out with your dispatch center. Their job is communication; make sure they’re informed on expectations in advance of an MOS incident so they can assist you. 

Decide early as an agency how and what you’re going to share with your staff, because they will find out. Alaska is very social media-dependent for communication, and with our radio not being encrypted, there isn’t much that the local folks don’t hear about, usually within minutes. My phone blew up before I was halfway to the call, and by the time we transported the crew out, there were off-duty staff waiting at the emergency room. 

Another takeaway is your emergency contact list. We all fill them out for our jobs, but does your agency have a process that indicates who has access and how and when that information will get used? 

Resources—Food, rest, support services—do you have them in place? There are now extra personnel, a pieced-together roster, and logistical things to consider. Do crews have field relief if they need it? Are you watching them for stress? Do families of the injured crew need rides? Will the crew need transportation home or any additional assistance? 

You’ve lost a vehicle from your fleet, perhaps permanently. Is it impounded for investigation? Do you have a means to secure any recoverable equipment and personal items from it? Never forget the narcotics—do you need to secure them in another vehicle? 

Aftermath—Don’t wait for a crew member to ask: Anticipate the need for some version of debriefing. Give those involved an opportunity to offload. Within an hour of our accident, the chaplain from Anchorage was on the phone offering his services, and to be frank I was still too fresh from it to even realize that would be a need, but it was.

“I’d recommend all supervisors have a plan for managing the emotional aspect of the providers involved,” said Capt. Jess Young, who was riding (properly belted) in the back of the ambulance at the time of the collision.

Consider the logistics of triage when crew members are patients, and devise training sessions to prepare. “Scenarios where I was being yelled at or put in any kind of high, intense pressure and required to consider myself and my crew’s safety and make tough decisions would have prepared me better,” Young said.

There is a natural aversion to MOS incidents. We are the heroes, after all, invincible by design. The uniform makes us bulletproof, the back of the ambulance immune to the laws of physics. I believe we must retain a sliver of that belief; that shade of bravado is what lets us step into someone’s crisis and help. The downside is that it fosters a belief that the worst can’t happen to us. 

That belief is our kryptonite, and it can kill us. Planning for your superheroes to fall now will help you get them back on their feet later. 

Author’s note: For more details and insight into the accident, turn to this month’s Midlife Medic column. And for God’s sake, wear your seat belts.

Tracey Loscar, NRP, FP-C, is a battalion chief for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, Alaska. Her adventures started on the East Coast, where she spent the last 27 years serving as a paramedic, educator and supervisor in Newark, N.J.  She is also a member of the EMS World editorial advisory board. Contact her at taloscar@gmail.com or www.taloscar.com.