From Chaos to Control: Scene Safety and Assigned Roles for Effective Emergency Response
Paul F Beattie PhD, PT, FAPTA, OCS, WEMT
Imagine this situation: you and a fellow PT are carefully working your way down a steep, slippery trail with several other hikers whom you just met. Up ahead of you a woman suddenly slips and falls backward hitting her mid-back and head on a rock. She starts bleeding profusely from an obvious wound on the back of her skull. You yell to her, “are you ok?” She moans. You yell to her again, “stay where you are! We are coming to help you.”
Suddenly one of the other hikers starts running down the steep trail and shouts, “I am going for help!” He slips in the mud and lands hard on his knee, but continues down the trail limping. Another hiker begins running back up the trail to get help.
Two young men push past you and approach the patient, “let’s get her up and help her walk down the trail!” A young woman who was hiking with the injured person stands in the middle of the narrow trail shaking and screaming, “She looks awful! I think she is dead! Oh no, what are we going to do?”
Chaos, noise, blood, a dangerous portion of trail, and people who are panicking. What should you do?
This is time to fall back on your training. Your first concern in a wilderness medical emergency is always scene safety and this scene is not safe. There is an injured person, and onlookers are rattled leading to bad decision making. This situation is getting worse quickly. You need to decide to lead, follow, or get out of the way. The people on scene clearly need direction. Since you have experience in wilderness medicine, you establish yourself as scene leader. This can be challenging, especially with people that you don’t know well, but leadership isn’t easy.
Your first action is to calm everyone down. Let everyone know that you have a background and training in wilderness first aid and that everyone must work together. You have an emergency patient to care for but everyone else on scene is a potential patient too, so you have a lot to manage. An effective way to start is by assigning specific jobs to people. This gives everyone on scene something to focus on and, in turn, will calm the environment.
Consider what jobs need to be done— you need someone to be in charge, someone to care for the patient, and someone to write things down. You also need tasks to keep other people at the scene safe, busy, and productive. We at Wilderness Physical Therapy Educators (WPTE) recommend the following roles:
The scene leader is the overall manager whose main responsibility is the welfare and protection of everyone on scene. This person continually monitors the scene for safety concerns— in this case the main safety concern is untrained and emotionally distraught individuals on a dangerous trail. The scene leader also needs to be aware of available resources for patient treatment, survival, and communication. This person directs the sequence of patient evaluation and treatment procedures. The scene leader makes the decision to stay, go, or call for help and, if necessary, to brief individuals who are going for help.
The care provider is the most experienced medical person on scene and is the primary person interacting with the patient. The care provider's responsibilities include establishing the patient’s degree of responsiveness, obtaining permission to treat, performing the initial assessment (MARCH protocol), and providing immediate first aid for any life-threatening conditions. Following this, the care provider performs secondary examinations including the head-to-toe exam, SAMPLE history, and ongoing first aid treatment for any additional conditions.
The scribe documents all aspects of the patient encounter and measures vital signs at appropriate intervals (this includes during any evacuation). The scribe needs to alert the team leader and care provider of any change in the patient’s mental status or vital signs. Importantly, the scribe communicates the patient encounter to EMS personnel during transfer of care.
There are many important jobs for other people on scene. Their job is to inventory resources (gear, water, food, shelter) and to upgrade the scene. For example, they can construct shelters and get food and hydration for the rest of the crew. They also might need to construct a make-shift stretcher and participate in patient transport.
Let’s get back to our scenario. Immediately after you assume leadership you instruct your fellow PT to be the care provider. She approaches the patient and follows the protocol for scene size-up and primary examination while instructing another hiker to provide C-spine support. One of the other people on scene is a retired nurse and volunteers to help. You ask her to be the scribe, i.e. take vitals and write everything down. You give instructions for the rest of the people on scene to begin inventorying equipment. You ask someone to stay with the injured hiker’s friend to give her some support and help her calm down.
Things stabilize as everyone goes about their tasks. Your mind races as you consider the possibilities of calling for help and staying on scene versus trying to carry the injured person out. Your fellow PT (the care provider) reports that the patient is now alert and oriented X 4, has consented to care and the bleeding from her forehead has been controlled with a bulky dressing. The injured hiker has a low-grade headache but is mainly complaining of sharp pain in her upper back where she landed. This area, T6-7, is quite tender to palpation over the spinous processes. The cranial nerve and extremity examinations reveal normal findings. She has no medical problems and has not consumed any alcohol or drugs. The scribe indicates to you that the vital signs are normal and stable.
Considering the mechanism of injury and the presence of local tenderness over the spine, the patient should remain recumbent with C-spine precautions [1]. You will need to call for help. You take a breath as you call 911. The scribe provides an excellent report to the dispatcher. They tell you to stay put; help is on the way.
What should you do while you are waiting? Remind the care provider to carefully monitor the patient’s neurologic status, maintain spine support, and be prepared for the patient to vomit and/or have dramatic changes in mental status [2]. The patient and crew need to be kept warm and sheltered. Importantly, everyone needs to stay together and be prepared to help when the rescue crew arrives. Exhibit leadership by keeping everyone involved and calm.
After what seems like an eternity (but was actually 50 minutes) you see several young Rangers jogging up the trail. You introduce yourself, the scribe gives a report, and you transfer care. Suddenly you hear the reassuring whomp, whomp, whomp of a helicopter approaching with two rangers on a short haul. Things are going to be ok.
The patient was diagnosed with an unstable fracture through the body of T6. Fortunately, her spinal cord was not injured. Had she been moved improperly the fracture might have displaced causing serious neurologic damage. Imagine if the well-intended hikers had tried to have the patient stand-up. Imagine if more people had tried to run for help and became lost or injured. Imagine if no one had stopped to help. Your willingness to act and your effective scene leadership made a difference [3].
References
1. Quinn R.H., Williams J, Bennett B.L. Stiller, G. Islas, A.A., McCord S. (2014) Wilderness Medical Society practice guidelines for spine immobilization in the austere environment: 2014 Update. Wilderness Environ Med. 25: S105-S117
2. Auerbach PS, Constance BB, Freer L, et al. (2013) Field Guide to Wilderness Medicine 4th ed. Elsevier, Mosby, Philadelphia, Pa
3. Beattie P, Jernigan D, McDavitt S, Hearn D. (2022). Point of View: Physical Therapists Can Be Value-Added Providers in Wilderness Medicine. Physical Therapy and Rehabilitation Journal 102:1-4
