FIRST RESPONSE TO MEDICAL EVENTS
BY RICHARD T. HAASE
One of the fastest growing aspects of fire department operations is primary response to emergency medical care requests. Fire service organizations across the country are implementing first-responder emergency medical programs that supplement private or third-party ambulance transport services. The main reason these services are being rendered is to provide the public with prompt medical care in times of emergency. These services also provide the community with more value for the tax dollars expended on their local fire service agencies.
Medical first-responder programs have developed from simple programs that included personnel with basic first-aid training staffing rescue squads to elaborate programs that have paramedics staffing advanced life support squads or engines. Metal first-aid boxes have been replaced with high-tech trauma bags equipped with drugs and defibrillators. Large areas that once were covered by overworked ambulance services with long response times now are being supported by citywide fire service first-response units that can triage patients and coordinate appropriate levels of transport.
Once the decision to implement a first-responder program has been made, it is time to step forward and produce a working plan. Operating a first-responder program can be as simple or as complex as a fire department wants to make it. Many issues must be worked out before taking a medical first-response program to the street (see sidebar on page 76). The bottom line, however, is that the system must be effective and be able to work on a consistent basis.
A first-responder plan that will work for any type of department is a plan that makes SPECTACLES of each and every response. You may raise your eyebrows and shake your head, but don`t stop reading yet. The word SPECTACLES is a simple acronym that can provide the basis for any level of first-responder medical program. The acronym stands for the following:
S — Safety of the rescuers/scene
P — Primary access/Protection from exposure
E — Exam/Evaluate the patient
C — Control life-threatening injuries
T — Treat secondary injuries
A — Assist transport/rescue needs
C — Communicate with transport
services
L — Log pertinent data
E — Evaluate care provided
S — Service equipment
Let`s look at each of these components.
SAFETY OF THE RESCUERS/SCENE
Safety of the rescuers begins with the receipt of the alarm until the time the incident is terminated. The need for rescuers at the scene of all incidents cannot be overemphasized. We tend to become somewhat lulled to sleep during the “routine” medical response calls.
Traveling safely to the scene and being aware of potential hostile situations and possible exposure to chemicals must become part of our everyday safety routine. The list of safety requirements for even the simplest medical first response includes such procedures as wearing the appropriate personal protective equipment (PPE), thoroughly assessing the scene for hazards, instituting an incident command system, and using proper lifting techniques. The bottom line is, Do not underestimate the routine medical first-response run. Most fire service and police agencies typically view these types of incidents as run of the mill. If you take them too lightly, the mill may run over you.
PRIMARY ACCESS/PROTECTION FROM
EXPOSURE
The two “Ps” of a SPECTACLE response include gaining primary access to the patient and providing proper protection from exposure. Gaining primary access may be as simple as walking into a house or as difficult as climbing through the wreckage of a collapsed building. Whatever the incident may be, the same basic principles must be employed when gaining access. The basic principles include the following:
Gain access to the patient as soon as possible without endangering the rescuer or patient.
Simplify access evolutions (i.e., try before you pry, use the stairs instead of the ladder) as much as possible.
Ensure you have an exit path from your access location.
Providing protection from exposure should be a routine procedure, but sometimes we tend to let our guard down. To prevent this, provide adequate protective equipment and constantly remind response personnel of the need for protection. Place gloves and other appropriate protective equipment in high-visibility areas. Have all personnel carry extra gloves and CPR masks with them at all times when on duty. Attach small signs to the vehicle`s dash to remind personnel of the need to wear the appropriate PPE. The bottom line: Remind the personnel and then remind them again.
EXAM/EVALUATE THE PATIENT
This phase of the first-responder care cycle is centered around the primary and secondary surveys of the patient. Many times, responders rush through this phase of their response and miss items that ultimately could affect the patient`s long-term care.
Numerous formats for primary and secondary surveys are available. First responders must pick a format that meets their needs and follows their level of medical training. For the most part, the primary survey follows a relatively universal format. The “ABCs” of the primary survey include Airway, Breathing, and Circulation. The secondary survey should immediately follow the primary survey. It includes a complete head-to-toe survey, a history of the present illness or injury (including allergies, medications, and past medical history), a complete set of vital signs (pulse, respiration, blood pressure, pupils, and level of consciousness), and a chief complaint. Some medical systems also require that trauma scoring be part of the survey process.
First responders must do the following during the patient exam phase:
Survey the scene for possible mechanisms of injury or illness. The mechanism may be a spidered windshield, a broken ladder, or an empty bottle of medication and can provide a key piece of the injury/illness puzzle.
Determine an initial set of vitals. The importance of the initial set of vitals cannot be overemphasized; it is used as a base of comparison for all future vitals.
Establish an initial communication with the responding transport unit. A short patient report will help the responding transport unit prepare for the transport and to understand what equipment and medications may be needed, what procedures may be required, and to what facility the patient may need to be transported.
Adequately document the findings of the patient assessment to ensure they are available for the transport services. Several methods can be used; one of the best methods is a small, three-part carbonless form. First responders can retain the first part for their records. The second and third copies can be given to the transport services. The transport service keeps the second copy, and the third copy is relayed to the receiving facility.
CONTROL LIFE-THREATENING INJURIES
Many first-responder agencies are so focused on this phase (controlling life-threatening injuries) of the overall incident that they forget other key elements. Of course, treating life-threatening injuries in a quick and effective manner is the major purpose of a medical first-responder program.
Life-threatening injuries typically are defined as those that will cause irreversible damage to the patient if gone untreated for a very short period of time. Typically, these are viewed as cardiac arrest, respiratory arrest, and a major bleed. All responders, no matter how basic their training, need to understand the basic care for these injuries.
However, other injuries should also be considered life-threatening, and personnel should be prepared to take rapid intervention to deal with them. They include head injuries, anaphylatic shock from bee or other stings, poisoning, hazardous materials exposures, burns, and diabetic reactions. Although these injuries/illnesses are not always considered life-threatening problems, the body`s reaction to them many times will lead to cardiac or respiratory distress. First responders must be aware of this potential and be prepared to treat the patient for life-threatening injuries.
To deal with such injuries, first responders should be trained and equipped to perform basic airway maintenance, perform CPR, administer oxygen, and control major bleeds. For basic services, this may mean oral airways, CPR masks, oxygen systems, and basic dressings. For advanced services, this may include intubation equipment, cardiac drugs, and defibrillators.
TREAT SECONDARY INJURIES
Although many response agencies don`t believe it, first responders` treating of secondary injuries can be the key to lowering the delivery time to an advanced medical care facility. Many first-responder agencies treat life-threatening injuries and then await for the transport services to perform routine “patient-packaging” activities. This waiting game allows precious time to tick off the “golden hour” of patient care.
Treating secondary injuries includes splinting suspected fractures, dressing wounds, and immobilizing suspected cervical spine injuries. A well-equipped trauma kit is essential for providing this care. Adequate supplies of backboards, cervical collars, head blocks, and splints are also required. Additional advanced life support equipment is needed if personnel have been so trained.
With the proper equipment readily available and a well-tuned team of first responders, patients sometimes can be completely packaged by the time the transport service arrives. Of course, the time available to package the patient will weigh heavily on the response time of the transport service; but even if packaging is underway when the transport service arrives, it will save time. Of course, a real key to the secondary treatment process is joint training between first responder and transport services. If like treatment protocols are not developed, secondary care may have to be redone by the transport service if its personnel do not agree with the treatment initially provided.
ASSIST TRANSPORT/RESCUE NEEDS
Assisting transport and rescue needs usually means doing little tasks that shave more time off the “golden hour.” Such assistance includes clearing a path for the patient`s removal, clearing initial response vehicles so the transport service can access the area, ensuring proper manpower resources are available to help move the patient, and readying pertinent patient-related details. Patient-related details include tasks such as acquiring information relative to the patient`s medications, establishing the patient`s choice of medical-care facility, acquiring the name of the patient`s doctor, and establishing which family member or representative will accompany the patient to the care facility.
Again, doing any of these seemingly minor tasks prior to the arrival of the transport service will save time. In a typical three- or four-person engine company, usually two persons initiate patient-care procedures, leaving one or two others to continue other tasks such as clearing furniture, turning on lights, and interviewing family members or bystanders.
Believe it or not, this phase of the incident response, if conducted correctly, will save a lot of embarrassment. This portion of the response is a catch-all period that can be used to check and double-check details. It is embarrassing to do an excellent assessment and provide outstanding patient care and then realize you cannot move the patient out of the area because the hallways are too narrow or there are not enough personnel to lift the patient.
COMMUNICATE WITH TRANSPORT SERVICES
Communicating with the transport services usually is a quick task, but it should not be overlooked. This task is especially important if first responders have begun patient packaging. Transport personnel need to know what is underneath those bandages and splints. If first responders don`t relay appropriate information, transport services have no recourse but to remove bandages or splints to perform assessments that already had been completed.
Information that must be communicated includes findings of the primary and secondary surveys, a list of the patient`s chief complaints, a list of patient medications, the mechanism for injury, and basic patient information (name, age, doctor`s name, hospital of choice, next of kin, etc.). Finally, the care given to the patient should be discussed, including the type of patient care tasks performed and any changes in the patient`s status that occurred as a result of the patient care.
As outlined earlier, a standard report form outlining the above information is very advantageous. It enables transport service personnel to refer to the written document as necessary. A good written document will cut down the time needed to explain the many details of the overall patient-care cycle.
LOG PERTINENT DATA
Logging pertinent data is a standard procedure included in all types of emergency responses. This task includes completing all standard report forms mandated by the local agencies. This task may seem boring, but it is essential. You will be glad you completed the paperwork if the incident ends up in court at a later date.
EVALUATE CARE PROVIDED
At the conclusion of each incident, conduct a short postincident analysis to review the care provided. If possible, the transport services should be involved in the process; however, that is not always possible. If the transport services cannot attend, they at least should attempt to provide some type of feedback to the first responders on a routine basis.
The postincident analysis should include a review of what went right and what went wrong. Some departments have even initiated a run review process, which helps other units learn from the incidents encountered by other units. If this process is used, documentation will play an important role in recreating the specifics of the incident.
SERVICE EQUIPMENT
All the equipment must be serviced. This includes replacing disposable items, retrieving equipment from the transport services or medical facility, disinfecting all nondisposable articles, and recharging battery-operated equipment.
A well-documented list of first-responder equipment will greatly speed this process. Use the inventory list to check the on-board inventory of equipment.
Developing a standard response procedure as outlined above will make your medical first-response program thrive. Making SPECTACLES of future medical response incidents may not be as complicated as you think and will make your program more effective and consistent. n
COMMON CONCERNS/QUESTIONS
RELATED TO MEDICAL
FIRST-RESPONDER PROGRAMS
What level of care will response personnel (i.e., first responder, EMT-Basic, EMT-Intermediate, paramedic) provide?
Will all medical personnel be trained to the same level, or will there be multiple levels of training among response personnel?
What will be the staffing of medical first-response units?
Will the medical first responders be associated with a local emergency medical system?
Will responders work completely off standing orders, or will they interface with the local hospitals via radio?
Will only certain designated vehicles respond, or will all departmental vehicles be equipped to respond to medical incidents?
What type of equipment will be carried on medical first-response vehicles?
Will the same type of equipment be carried on medical transport vehicles?
How will disposable equipment be replenished after an incident?
How will costs for disposable equipment be recouped?
Will first responders be dispatched to all medically related calls or only to certain predetermined calls?
What type of rescue services will medical response units be able to provide?
How will the success of the first responder program be measured?
Who will provide transport services?
What level of care will transport services provide?
If transport services provide a lower level of care than first-response units, how will the appropriate level of care be maintained throughout the incident? n
–RICHARD T. HAASE
RICHARD T. HAASE is emergency response coordinator at the Shell Wood River Manufacturing Complex in Roxana, Illinois, and assistant chief for the Stauton (IL) Volunteer Fire Department. He is a national- and state-registered EMT/instructor and a state-registered emergency rescue technician and a certified firefighter II, fire instructor I, fire apparatus engineer, hazardous-materials incident commander, and rescue specialist-roadway extrication. He is a member of the Illinois Firefighters Association, the 3M Firefighters Association, the Illinois Fire Chiefs Association, and the IAFC. He has associate?s degrees in fire science and industrial electronics and is completing requirements for a bachelor?s degree in advanced fire administration. He lectures extensively and is a contributor to various fire service publications.
