BY STEVE PRZIBOROWSKI
When does scene size-up begin-when you arrive at the incident scene, when you get the call to respond to the incident, or when preplanning your response area? Regardless of when you think size-up begins, the reasons for sizing up follow: to ensure a safe scene for emergency responders, to determine the appropriate number of resources needed to mitigate the incident, to determine the severity of the incident, and to determine the strategy and tactics needed to mitigate the incident.
I first heard of “ENAMES” when I was attending the EMT program at Chabot College in Hayward, California, in the early 1990s. Our primary instructor, JoAnn Berven, introduced the acronym to us. Because it was so relevant and appropriate, I have used it religiously since I succeeded her as head of the EMT program.
ENAMES helps to ensure an adequate and appropriate size-up:
Environmental Dangers
What associated hazards might be present? They may include, but are not limited to, animals, exposed electrical equipment, fire, smoke, hazardous materials, traffic, hostile/emotional bystanders, patients, or family members, building collapse potential, cliffs or steep slopes, confined spaces, or unstable vehicles. Anything qualifying as an environmental danger must be addressed and mitigated as soon as possible to prevent injury to responders and bystanders.
If the scene is unsafe to enter, do not enter. To make the scene safe, call the appropriate resources, or, if you have the training and capabilities, take the appropriate actions. Entering an unsafe scene is unacceptable unless there is an immediate life-threatening issue you are sure you can mitigate or avert to save the patient’s life. If you are injured entering an unsecured scene, you add to the problem: More resources will be needed to assist you and take care of the original problem.
Number of Patients
Most EMS responses are dispatched to treat a single patient. Always look for additional patients, especially at motor vehicle accidents. When responding to vehicle incidents, I expect the firefighters I work with to tell me immediately how many patients there are and their condition. The number of patients present is the most important information I need because it determines if and how many additional resources are needed. The incident’s successful outcome depends on requesting additional resources early in the incident; ordering them later will delay patient care and transport.
Patient condition can be categorized using the Critical/Noncritical criteria or Immediate, Delayed, Minor, Deceased criteria.
I prefer the second option; the first is very subjective. What is the difference between critical and noncritical? It may not be obvious. Using standardized triage criteria-Immediate, Delayed, Minor, or Deceased-helps a company officer to determine more precisely the need for additional resources, specifically ambulances and fire crews to assist with packaging/preparing patients for transport.
Some basic rules I use when calling for additional ambulances or fire crews to assist with patient care follow.
• One ambulance can transport only one Immediate (or Critical) patient to the hospital at a time, because of the need for focused treatment and assessment.
• One ambulance can transport at least two Delayed or Minor (or Noncritical) patients to the hospital at a time. Two may be the maximum if both are set up with full spinal precautions, because they will both be secured on backboards. Most ambulances can accommodate only two patients on backboards safely secured to the benches. If the patients are ambulatory, the number of patients that can be transported in one ambulance would depend on the number of seat belts and securing devices in the vehicle and the capability of the personnel assigned to manage more than one patient.
Additional Resources
On an EMS call, the number of patients determines the need for additional resources. They may include additional fire apparatus to assist with multiple patients; truck or rescue companies to assist with extrication; hazardous materials teams to deal with chemical spills, leaks, or releases; supervisory personnel to assist with the incident command structure (e.g., safety and public information officers); law enforcement personnel/supervisors to assist with traffic control, combative patients, evacuation, or belligerent bystanders/family members; ambulances to assist with the transporting of multiple patients; utility companies to deal with downed power lines, energized electrical equipment, or open gas lines; public works to deal with spills or roadway cleanup; or technical specialists from local, state, or the federal government to assist with the situation or problem (most likely for hazardous materials incidents).
At a fire scene or other nonEMS call, you will also be evaluating the use of the above-mentioned equipment, as well as other specialized equipment, apparatus, and personnel that may be unique to your agency or surrounding area. Be creative, and remember that the goal is to mitigate the problem-or at least not exacerbate it.
Mechanism of Injury/Illness
An EMS response that involves trauma represents a Mechanism of Injury; a response that is medical in nature represents a Mechanism of Illness. What can you expect in injuries when evaluating trauma patients? The valuable information you may be able to piece together by finding out exactly what occurred will help to determine how the victims got to their final locations and the type of injuries that can be expected.
Extrication Required?
If extrication is needed, you will need additional resources. Hopefully, this was determined during your initial on-scene observations and report on conditions while you were determining the number of victims and estimating additional resources that might be needed. If extrication is necessary, you will need rescue capabilities most fire apparatus normally cannot provide. You will have to special request a rescue company or truck company with extrication equipment.
Spinal Precautions?
If there is any chance the victim has been involved in trauma affecting the head, neck, or back (or has pain in one of these body regions), you must consider the possibility of a spinal injury. Someone must be immediately assigned to manual spinal immobilization (not traction) and in-line stabilization, and the victim must be prevented from moving his head until a paramedic or an EMT has ruled out a spinal injury or the victim has been completely secured to a backboard or other full-body immobilization device. If the victim is unconscious, use the Jaw Thrust maneuver to open the airway.
Although ENAMES was created to handle EMS responses, it can be used for all types of responses. Any member of the emergency crew (e.g., chief officer, company officer, engineer, firefighter, police officer, EMT, paramedic) can use ENAMES to size up the scene and also to ensure that the scene is safe for personnel. Just as a scene size-up should be continuous and ongoing, so should the ENAMES evaluation.
No acronym can substitute for common sense and street smarts, but the more tools we use to ensure responder and public safety, the better the chance we will go home at the end of the shift.
STEVE PRZIBOROWSKI is a 14-year veteran of the fire service and an acting battalion chief for the Santa Clara County (CA) Fire Department. He is an adjunct faculty member in the Chabot College Fire Technology Program, where he has been teaching fire technology and EMS classes for 13 years and served as fire technology coordinator for almost five years. Prziborowski is president of the Northern California Training Officers Association executive board and a state-certified chief officer, fire officer, master instructor, hazardous materials technician, and a state-licensed paramedic. He has an associate’s degree in fire technology, a bachelor’s degree in criminal justice, and a master’s degree in emergency services administration and is participating in the Executive Fire Officer Program at the National Fire Academy.
