Next Victim!

     Attack One responds to a report of a child struck by a car. It's late afternoon in a residential area. The crew quietly hopes for the best. Today Attack One is staffed by a senior paramedic and two relatively new EMTs. Approaching the scene, they notice a frantic nature to the crowd. A child on a bicycle is trapped under the front end of a vehicle. The child is unresponsive, and no helmet is visible.

     The young girl has been struck and knocked to the ground on her left side. She has an obvious head injury and responds by posturing when touched. She has a contusion to the left chest and a pulseless lower left arm. Her legs cannot yet be assessed. It will require at least three rescuers to pull her from under the vehicle and immobilize her-if it can even be done without lifting the vehicle. The responding fire engine is still several minutes away, and law enforcement is not yet on scene.

     As the paramedic weighs her options, there is a scream in the crowd. Bystanders start calling for help, and one comes and grabs the medic. "This guy is down and bleeding!" the bystander yells.

     The EMTs are left holding the young child under the vehicle while the paramedic is dragged into the crowd to assess the new victim. The victim is the young male driver of the car, who'd been standing apart for a few minutes to try to stay calm. He has abruptly collapsed on the sidewalk and cracked his head. Bystanders say they can't feel a pulse, and his forehead is spurting blood. Prying the bystander's hands off her shoulder, the paramedic kneels to quickly assess the young man. He is diaphoretic and has a slow, regular pulse; his bleeding stops with direct pressure. There appears to be no other trauma, but he's struck his head hard enough to need immobilization and removal.

     The paramedic has to return to the young girl, so she finds a bystander who can assist in immobilizing the driver's neck and applying pressure to his laceration. She hands her gloves to that man, explaining to the bystanders that she must return to care for the traumatized child. (Good Samaritan laws protect emergency bystanders who offer such care in this state; be sure to know your state's laws.) The EMTs have immobilized the child's neck and surveyed the car; they believe the child can be safely pulled out without lifting the car.

     The fire equipment has now arrived, as has law enforcement. Fire personnel can assist with the extrication of the young girl, and two are asked to immobilize the young male driver. A medic unit is requested for him; the young girl needs rapid removal to the pediatric trauma center.

     As the process of pulling her from under the car is initiated, there is another scream from the crowd, on the opposite side of the car. "Help! There's someone collapsed!" Another set of hands pulls the medic to the other side of the scene. She finds a young lady, down and hyperventilating. Once again prying herself free of the bystanders, the medic asks the young lady to slow her breathing and open her eyes. She has a regular pulse and no signs of trauma, but continues to breathe rapidly. The bystander closest to her reports that the young lady came running up to the scene, saw the child, said she was her babysitter and began breathing rapidly. She then collapsed without saying anything else. The paramedic beckons another member of the engine crew to care for the babysitter, and again returns to the critical child. She asks the engine crew officer to determine whether another medic unit will be needed to remove the sitter, and to please care for any further urgencies at the scene.

     The Attack One crew is able to gently roll the child from under the front suspension and, using the small tarp off the engine, slide her out without further injury or spine movement. The paramedic does a rapid trauma assessment, leads the placement of the child on the backboard and directs the crew to quickly package and place her in the medic. The child is breathing erratically, so she is assisted with a bag-valve mask. Her left arm is straightened, and a pulse returns to the lower arm. She is placed in the ambulance, and the cabin is warmed for her transport. The paramedic checks with the engine officer to make sure no more equipment is needed for the other two victims, and that the fire officer is prepared to manage their transportation.

     Rapid transportation ensues to the pediatric trauma center, with a trauma alert. The Attack One crew conducts secondary assessment during transport. They place a pulse oximeter on the fingers of the child's obviously fractured left arm and find a good pulse signal. The child is bagged with 100% oxygen, and the crew keeps suction available, staying ready to roll the child if she vomits. The lower extremities are fractured on the child's left side. She continues to posture in response to painful stimuli.

Hospital Course
     The ED is prepared on arrival, and the patient is assessed by the emergency physician and trauma team. The major life threat is severe head injury. Multiple orthopedic injuries will also require extensive repairs. The child has a left-side pneumothorax, which is relieved by a chest tube. A long hospital course and rehabilitation period are ultimately successful in returning the child to school.

     Both the older victims are removed to the hospital; neither is found to have serious medical problems. Both have significant mental stress, but are gratified by the child's survival and potential for long-term recovery. It appears the child darted in front of the car, and the driver was unable to avoid the collision. In a story that is all too familiar, the child was not supposed to be riding the bike while in the care of the sitter. She'd left her bicycle helmet in the garage.

Case Discussion
     Serious incidents involving children can evoke strong emotions in bystanders, relatives and even rescue personnel. It is almost predictable that someone will be "going to ground" when a child is severely traumatized, bleeding or in arrest. The experienced emergency provider is always prepared for that second victim (and any subsequent ones). This incident demonstrates how rapidly a situation can deteriorate, and how care of the critical victim can be disrupted.

     A management plan should be in place at every scene for managing "the next victim." Support can be provided by EMS, fire or police personnel until more resources can be mobilized. Very early in the response, bystanders may be the only assistance available. Bystanders can be quickly instructed to observe, monitor breathing, stop bleeding (with a pair of your gloves), immobilize a head and neck, calm the patient and yell for you if the victim's condition changes (be clear on your state's laws in this area). That role may be invaluable in the early minutes, as essential EMS personnel perform triage and lifesaving care for the victim with more severe problems.

     Being prepared to pull the trigger on getting more assistance is a key step in managing unexpected events, more victims or a deteriorating scene. It allows the initial rescue team to focus on triage and treatment of the highest-priority victim(s). Incident Command is the system for managing personnel involved in care and rescue, especially as an incident escalates. A key management principle: Don't let care of the critical victim be compromised!

     In this case, the paramedic was physically pulled away from victim care by well-meaning bystanders. The scene cannot be allowed to fall apart with the loss of a single individual, so the EMTs were prepared to continue the work plan until the paramedic could extricate herself and return. Verbal disagreements with bystanders (especially early in the scene, and before adequate resources arrive) are best avoided, and in this case the quickest way to manage the bystander issues was to perform a very rapid assessment, assign resources to deal with the additional patients and make it back to the original, critically injured patient. Additional fire department resources were mobilized to complete victim mangement.