Crash Course

The crew members in Attack One’s passenger compartment have just started to care for their patient en route to the hospital.

The 78-year-old gentleman’s chest pain had begun about an hour before his 9-1-1 call, and when the crew arrived they evaluated him quickly in his home before placing him on the cot and heading to the hospital. The paramedic was concerned that the patient was very pale in appearance, had a history of heart disease, and had a number of prior heart procedures done at the region’s heart hospital. Those included receiving two coronary artery stents, which according to the patient had averted a major heart attack. His symptoms at that time were exactly the ones he is having now.

The heart hospital is about an 18-minute transport in the midafternoon hour, and the crew moved quickly to take the patient there, because a 12-lead EKG done in the house showed no acute myocardial infarction, and the paramedic felt she could do the rest of the treatment en route. The patient is feeling more comfortable after a nitroglycerin spray, and the paramedic is opening the narcotic box when…crash! A violent impact on the ambulance’s passenger side lifts its wheels off the ground and sends people and objects flying. The rig spins about 90 degrees to a screeching stop.

The first voice is actually that of the patient, still secure on the stretcher: “Are you guys OK? Are you guys OK?”

The paramedic is on the floor. The EMT is still belted in his seat, battered by a number of objects dislodged in the collision.

The driver of the ambulance is next to pose the question: “Is everyone OK? I don’t know what hit us!”

He reports the accident to the dispatcher, leaps out his door and crawls into the rear compartment through the back doors. The patient is still safely restrained on the stretcher, but the paramedic is down, blood coming from her head. On the bench, the EMT is bleeding from his right arm and looking at a left that is obviously fractured. The paramedic finally lifts her head and asks the patient if he is all right.

The driver uses his radio to report details to dispatch: that the unit was involved in an accident, two crew members and the driver of the car that hit them are injured, and they will need an extrication response to free the occupant of that car.

Moments later the EMS supervisor is on her radio, specifying that five ambulances should be dispatched, as well as an extrication assignment and the on-duty chief. She arrives on the scene minutes later to find the ambulance driver caring for the automobile driver, who is injured and unable to get out of her vehicle. The original cardiac patient is strapped on the stretcher in the ambulance, with the paramedic and EMT sitting together on the bench. Both are injured but want the supervisor to care for the original patient first.

“Please, connect him to a monitor and remove him from the vehicle,” the paramedic requests. “He is still having pain, and I haven’t been able to give him anything yet but some nitroglycerin spray. He needs to go to the heart hospital.” This direction comes despite a large bleeding gash in the paramedic’s forehead and a right arm and left lower leg that are obviously fractured.

The EMT is also in a great deal of pain, with a fractured left arm and other lacerations.

“We’ll get your patient cared for, and you also,” the supervisor says. “You lie down, stay quiet and let me get some equipment to immobilize your injuries.”

Additional crews arrive quickly. Responders stabilize both vehicles, shut down the ambulance’s oxygen tank and batteries, and remove the original patient to the first-arriving ambulance. The arriving fire equipment and personnel stabilize the small car that struck the ambulance and quickly remove the driver’s door to extricate its single occupant, the young woman who was driving. They assess her injuries and find them not immediately life-threatening.

The paramedic and EMT are packaged and immobilized, then removed from the back of the ambulance. Though in pain, the injured paramedic keeps working throughout the process to direct care of her original patient. Finally the EMS supervisor tells her, “You have been relieved of your duty to this patient by my order, and with the presence of two other paramedics who have assumed care. The patient is on his way to the hospital. We did not find any crash-related injuries, and his condition, 12-lead EKG and ongoing monitor are stable. You are now my patient, and I instruct you to tell me only about your injuries and what we can do to make you more comfortable as we prepare you for transport to the trauma center.” Similar instructions have to be given to the EMT.

The ambulance driver, who had rushed to help his colleagues and the other driver, is also injured, although he refuses any care or assessment until everyone else is stabilized. Then he asks to speak with the EMS supervisor.

“I don’t know what happened,” he says. “We were about a minute into the transport and were proceeding without lights and siren. We were going through the green light in an intersection, and I never saw what hit us. The only thing I saw on the right side of the intersection was a large box truck in the left turn lane, and then we were hit. Would you please ask the police officers what others are saying?”

“I’ve already been briefed by the police,” the supervisor responds. “The witnesses, including that truck driver, all give very clear and consistent stories that the car went through a red light while the driver was looking down at something. The truck driver said his truck would have blocked you from seeing her coming. She never hit the brakes. I can tell you that her injuries do not appear serious.”

The supervisor has noticed the driver has been limping around on the scene and also has an injury to his right lower arm. She tells him, “Now, at this point you are also to stop being a provider and are now a patient. We will take care of your obvious injuries, and you can complete a statement with the police at the hospital.” She places him in the fifth ambulance and notifies the police supervisor that he will provide his accident statement at the ED.

The department chief arrives on the scene and is briefed. All victims are now removed, and the vehicles stabilized. He calls the department’s public information officer (PIO) to the scene, then meets with the senior law enforcement officer. They agree the state highway patrol will be in charge of the accident investigation and report, since the crash occurred on a state road and local law enforcement requested the patrol oversee the incident. The law enforcement PIO will be the lead information officer, and the EMS PIO will assist and help facilitate a joint information center for the media. The state highway patrol PIO will also assist.

The chief personally notifies the family members of all three injured personnel, and offers to send crews to pick them up and take them to the hospital. A conference room near the emergency department is established as a meeting site for families and other department members.

Hospital Course

On arrival at the trauma center, staff assesses the injured. The original patient with chest pain is in stable condition and receives a timely workup for an acute coronary syndrome. He is found to be having unstable angina, and shows no injuries related to the crash. He undergoes cardiac catheterization, and surgeons place another stent in two of his coronary arteries. He recovers and ultimately returns home.

The injured paramedic is awake on arrival in the ED, and an initial assessment finds no further injuries. Her scalp injury has an underlying skull fracture, but a head scan reveals no brain injury. She also has fractures of the right arm and left lower leg. These are casted, and she begins a slow recovery. She’s in the hospital for a week. Investigation of the ambulance’s passenger compartment finds she was struck in the head by a corner of the portable computer used to document patient care. That corner had blood and strands of her hair on it. The computer had been placed on one of the counters as the paramedic completed her report, and it became airborne in the collision.

The injured EMT is awake on arrival, and his initial assessment finds an unstable but closed fracture of the left arm. Then he becomes nauseated and develops pain in his left abdomen. His abdomen becomes more tender, and the trauma surgeon ultimately orders a CT scan. This detects a ruptured spleen, which is removed to control bleeding. The EMT recovers in time from that surgery and his broken arm. Investigation finds he was struck by the oxygen cylinder that had been used to treat the original patient in his home and then in the ambulance. The patient’s oxygen cannula had been connected to the vehicle’s oxygen system, but the portable bottle remained on the cot and became airborne in the collision.

ED staff also treats injuries to the driver of the striking car; they suture her forehead laceration, clean and dress some forearm wounds and then release her. She was found to be using a portable computer at the time of the accident, apparently composing a message when she entered the intersection against the red light. Her forehead laceration occurred when she was struck by a GPS device that was lying on the dashboard and became airborne in the collision.

The injured EMT who was driving the ambulance was found to have a fractured right forearm and a contusion to his right hip. He is treated in the ED and released. Investigators conclude he struck his arm on the computer bracket mounted between the seats.

Case Discussion

The everyday events of EMS delivery can be interrupted at any time. EMS vehicles’ presence on the roadways makes them constantly susceptible to crashes, even with the safest driving practices. Injured EMS personnel need the same level of care delivered to civilian patients.

Ambulance’s patient care compartments are not configured for crashworthiness. In addition, there are numerous pieces of equipment and patient care items that dislodge in a crash and injure occupants. It is ideal to have EMS providers restrained at all times when the ambulance is in motion.

The electronic devices that have become so useful in our lives can be associated with some dangers. In moving motor vehicles, they can distract drivers and occupants and cause physical harm if dislodged in a collision. Even their fixed brackets can be struck by occupants. Emergency providers have been injured by computers and brackets affixed to vehicles after production; these brackets are often constructed of reinforced materials and located close to the driver and front-seat passengers.

When a crash occurs, the law enforcement agency in the jurisdiction where it happened (unless the state highway patrol is involved) has responsibility for investigation and information release. The EMS chief officer(s) and public information officer will need to coordinate information release with the responsible law enforcement PIO.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.