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July 16, 2008

Trauma and You: Final Exam Pt. Two
Posted by Jim Macdonald at 05:39 PM * 46 comments

Teresa, don’t look.

A more complex scene: Car crash. (Another copy here.)

What the video shows:

The scene is at the corner of West Third and Edwin C. Moses in Dayton, OH. 23 May 2004, 12:40 pm. A traffic camera looking at the intersection has the light red for the lanes entering from the bottom of the screen. One car is in the left-turn lane at a complete stop. Oncoming traffic, two lanes, is slowing to a stop. A pedestrian is in the intersection moving from bottom of screen toward the top, on the left side of the intersection, against a red Don’t Walk sign.

A PT Cruiser enters the intersection from the bottom of the screen against the light. The PT Cruiser strikes a Subaru SUV that has entered the intersection from the right, hitting it about level with the driver’s door. The PT Cruiser rotates around its vertical axis and comes to a stop. The Subaru rolls over twice, coming to rest on its roof. The Subaru rolls over the pedestrian.

You’re a witness to this collision. Okay, what do you do?

Discussion below the cut.

First, fast: Get help rolling. Instruct a bystander to call 9-1-1. If no bystander is handy, do it yourself.

Second: This scene is not safe. Make it safe. Most obvious hazard is other traffic. Grab a couple of bystanders and have them stop traffic. If you have flares (reflective triangles, traffic cones, flags…) available, hand them to a bystander and instruct him to flare out the intersection. If no bystanders are available, do it yourself.

Third: There are at least three patients: the two drivers and the pedestrian. You are in a multiple-casualty incident (MCI). Being mindful of hazards on scene (leaking fluids, broken glass, sharp metal, loaded bumpers, airbags) do a rapid triage.

Fourth: Assign bystanders to hold c-spine on all patients. Pick a red tag and start working on him/her following the ABCs. Airway, breathing, circulation, treat for shock. You know the drill. If no red tags, pick a yellow tag. If no yellow tags, pick a green tag.

Fifth: When professional help arrives, report what you have to the senior person and hand over your written notes. Request an assignment. Carry it out.

Sixth: Go somewhere and sit down until you stop shaking.

Followup: The pedestrian’s name is Scott Tegtmeyer, age 42 at the time of the incident. He was critically injured, but, thanks to fast and efficient Emergency Medical Services, survived. The two drivers had minor injuries thanks to seatbelts. There were no passengers.

Y’see? Trauma is easy!

Trauma and You: Final Exam Pt. One

Index to Medical Posts
Oh look! A hamster!


Comments on Trauma and You: Final Exam Pt. Two:
#1 ::: Jess A. ::: (view all by) ::: July 16, 2008, 07:51 PM:

Weird. I know just where that is. Less than 10 minutes from my house. (Though we weren't living in Dayton in 2004... but it's strange to see it pop up here.)

#2 ::: Laurie Mann ::: (view all by) ::: July 16, 2008, 08:02 PM:

I'm amazed the pedestrian lived. How the hell did that happen?

(Also, keywords near the video indicate there was a death as part of that accident, but I'm assuming that was wrong.)

I was a witness to a car accident in Worcester, MA when I was about 12. Two cars hit each other when one ran a stop sign. A cop happened by right after it happened. Luckily, people were just shaken up, and the cars didn't have major damage either.

(PS to Jim: Agree with you whole-heartedly on Chimay!)

#3 ::: Edward Oleander ::: (view all by) ::: July 16, 2008, 08:22 PM:

On the step 3 triage: Be prepared for weird shit from left field that will totally disrupt your train of thought...

Back in '89, I responded (for the very first time!) to an accident right outside the building where I was the in-house 1st Responder. Grabbed my jump kit and started jogging towards the scene. The scenario was just like the video above minus the pedestrian. I knew 911 had been called, so was going through my step-by-step plan, like yours above...

Went to the most heavily damaged car first, as other bystanders already had secured the intersection. Before I could begin speaking, the driver said: "Hi, Ed!"... It was an ex-coworker! Completely threw my concentration... Had to take a deep breath and remember my own instructor's lectures on re-focusing. That helped, and I was able to assist with the extraction without losing it... that came later!

Don't ANYONE underestimate the importance of step 6 above!

#4 ::: NelC ::: (view all by) ::: July 16, 2008, 08:24 PM:

I suspect Trauma is easier if you haven't seen it happening, even if only slightly. I thought the skateboarder video was shocking, but this... I'm still feeling shaky. I suck at Trauma.

#5 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 08:24 PM:

How the pedestrian lived: Do you see how the impact of the two cars bent in the side of the vehicle coming from the right? When that vehicle rolled, the pedestrian passed through that U-shaped void.

He was still critically injured, but thanks to fast and efficient EMS he survived.

#6 ::: Caroline ::: (view all by) ::: July 16, 2008, 08:27 PM:

Call 911 (or appropriate emergency number). Try to stop/warn traffic. I don't have flares or triangles in my car so I'm not sure how I'd do this; I'm not sure it would be a good idea to use my own car with hazards on as a barricade, although that's the only thing that occurs to me and is probably what I'd do (with, of course, regards to the safety of putting my car in that position -- if not safe I'd likely just pull off). If no other on-street bystanders I'd probably try to get someone else to get out of their car and help me.

Once 911 called and traffic dealt with, quickly assess the situation. Visually check the people in the cars and the pedestrian. If the car isn't on fire then leave people in place, more dangerous to move them. If it's just me and no one else is there to help, pick the person worst-injured and start there (my bet is this will be the pedestrian but I could be wrong). Ask him (or her) if I can help him. If he replies, he's breathing and I know I have A and B; hold his head in line with his neck and body until the paramedics get there. If not, check airway and clear if necessary, check if he can breathe. I don't know what to do if he can't; is it safe to try to breathe into his mouth/nose while I'm assuming spinal injuries and holding his head?

(I'm still assuming just myself. I live in a place where no one walks and I couldn't guarantee people in cars would stop, get out, and help. If I get someone else to help, have them hold his head and I do the rest of the ABCs.)

If he can then check his circulation. Is he bleeding? Apply pressure if he is to try and stop it. If his head is being held still and I don't see/feel any evidence of heartbeat, then chest compressions.

If ABCs are under control then start treating for shock. Again all of this is really hard if I'm the only one there and I'm holding his head.

Okay, so if I AM the only one there, should I prioritize holding his head (during which I can probably clear his airway and maybe deal with breathing) over ABCs?

Whenever the pros show up, tell them what I did so far and turn it over to them. I hope they turn up soon because I can't do much alone here.

#7 ::: Naomi Kritzer ::: (view all by) ::: July 16, 2008, 09:27 PM:

If it were me:

I would dial 911 on my cell while running towards the pedestrian. I would expect that other people would be getting out of their cars; if one of them had actual medical training, I would let them deal with the pedestrian and I would check on the people in the cars or, if there seemed to be multiple people with more first aid training than me, I would work on directing traffic, running to get things requested by the people who knew what they were doing, etc.

If I was the Most Qualified Person On Scene (is there a term for that?) I would instruct any other helpful bystanders to check on the people in the cars but NOT move them, to tell them to stay put and wait for the ambulance, and I would go to the pedestrian. I would check airway and breathing, apply direct pressure to any serious bleeding (and hold their hand if no direct pressure was needed), cover the person with my coat if I had one, reassure them that everything would be okay, and wait for the ambulance.

Alas, I would probably not remember that I have a first aid kit (complete with gloves) in the back of my car until I was trying to control the bleeding of a stranger with my ungloved hands.

I would not try to hold c-spine. I looked at the instructions and diagram Jim posted before and it's simply not clear to me what to do -- also, I have a hand tremor, and it gets worse under stress. I would fear that I would cause damage rather than preventing it.

When the ambulances showed up I would get the hell out of the way and let the professionals take over. I would answer questions if anyone had any for me, and then I would use my cell phone to call a friend or relative to pick me up, because there is no way in hell I would be in any shape to drive.

#8 ::: merryarwen ::: (view all by) ::: July 16, 2008, 10:30 PM:

Lurker coming out to see how much of my training I remember. I didn't watch the video because watching that stuff when I can't do anything just gives me bad adrenaline:

1. I call 911 assuming I have my cell-phone or I have a bystander to send. If I have neither, then I will move on to 2 first, acquire a bystander from stopping traffic, and then result in 911 call. On the streets near where I live, it's entirely possible that someone would drive right into the wreck and then I have more bodies.

2. Stop traffic. Do it myself if I have to, or direct other people to do it if I can. Use tools I have, if I have them, but I'm assuming I just happened to be by the side of the road (I don't have a car).

3. Reasses. I have three victims, so it's triage, but my first guess is that the poor pedestrian is going to be my problem - figure out how badly off the other drivers are by calling out to them. Also, if there's someone else already moving to do these things, either assist as they direct or, if it looks like I'm better at this than them (they're unsure) see if I can help.

4. Assuming I'm right about the pedestrian and I am the most qualified, get close enough to ask him if he's okay. If he can answer me, he has AB down and he can also tell me more about what else might be wrong (where the pain is, if he's got feeling in his limbs, etc). If not, make sure his spine isn't in danger of being screwed up, then start ABC. If he's breathing, start looking for bleeding and deal with that. Haul someone over with coats or a blanket or something for shock. Continue ABC-and-bleeding-check until someone with qualifications (hopefully the EMT) shows up.

5. Turn over to EMTs, with all the information I have.

6. Go throw up and cry, and find someone to come pick me up so I can finish crying at home.

#9 ::: Carol ::: (view all by) ::: July 16, 2008, 10:37 PM:

More of these tests at least periodically, please? Doesn't substitute for training, but reminds us that classes are out there, and it's amazing conditioning.

#10 ::: DavidS ::: (view all by) ::: July 16, 2008, 11:00 PM:

OK, trying without reading the other replies.

If I was driving, put my car into park and turn off the motor.

Recruit bystanders to (a) call 911 and (b) slow down traffic and direct it around the accident. If there are no bystanders, I do (a) and then (b) myself.

Regarding (b), if I have one person, she stands in the middle of the intersection. If I have a second, he stands off to the right 100 yards or so before the intersection, making sure that right to left traveling people slow down before entering the intersection.

Around this point, I start praying for a more experienced person to show up, because that pedestrian's injuries look way beyond what I can handle.

OK. Check that there isn't any gasoline leaking out or flames flickering from the hoods. Assuming the scene seems safe to approach, go over to the victims. Tell them I'm going to help. If any of them aren't breathing, see if I can spot something obstructing the airway. If there isn't an obvious cause of the non-breathing that I can remove, that probably means they're dead because I don't know CPR. Look for major bleeding, and try to tie it off. I know that whiplash and spinal chord injuries are a major risk, and that I should try to keep people's spines straight. People talk about doing this by holding the victim's heads straight. Try to do that and, again, try to recruit helpers.

Oh, I've been focusing on the worst case. Some of the victims might be conscious and appear okay. If they can, encourage them to walk out of the road way and then sit down on the grass. I often see people who are at risk for shock being wrapped in blankets, so that might be worth doing if I can find people and resources.

At this point, I am completely past my competence and I hope someone better shows up. The only useful thing I can think of doing is to gather names, medical data and emergency contacts from the victims.

#11 ::: Laertes ::: (view all by) ::: July 16, 2008, 11:16 PM:

Last time I was near an accident scene, it got much worse, fast.

It was a snowed-in highway. A minivan had struck a guardrail head-on. I don't know how he hit head-on the south end of a guardrail on the right-hand side of a southbound lane, but anything can happen on a snow-covered highway in Missouri.

Fortunately one of the first people to stop was some kind of EMT or paramedic--I don't know exactly what she was, all I remember was that she sent me to her truck to ask her friend for some piece of equipment that she needed. The driver of the minivan was unconscious, and lying on the shoulder next to the van. The woman with the first aid kit and one or two bystanders were tending to him somehow. I'd given the woman whatever it was she'd sent me to get, and was standing nearby, mostly just being useless.

I'm still fuzzy on the details of exactly what happened next.

There was another collision in the left lane. Way I remember it, it was someone rear-ending a car that had stopped to help, but why would a car be stopped to help in the left lane when all the action was on the right? It must've just hit someone who'd slowed down. All I remember for sure is one car hit another. And then within seconds another car hit them.

Very soon after that, another car managed to head-on the minivan that had been nose-in to the guardrail. That hit spun the minivan around about 180 degrees. I'm pretty sure it came to a stop right about where I'd last seen its' driver.

I was pretty close, I guess, because it hit the guy who was standing next to me and knocked him off the road and into the ditch. I didn't see the crash or anything. I was just there, probably talking and not saying anything very important, and then there's a noise, and there's a new wrecked car, and one of the old wrecked cars isn't where it used to be, and I can't see lying-on-the-shoulder guy anymore, and a guy is climbing out of the ditch and wondering where his glasses landed.

Ditch guy was shaken, but not badly hurt. I don't know what became of the minivan's driver. Official-looking people started showing up, and I drifted away along with the other amateurs.

I'll never forget that feeling as I watched the chaos spread. It felt fall, I guess. Helpless, small, vulnerable, and not even a tiny bit in control.

#12 ::: Anne KG Murphy ::: (view all by) ::: July 17, 2008, 12:48 AM:

One of my clearest memories from when I was a teen is of my father coming home and hitting the sixth step listed. He walked into the house looking fine, put his back to the kitchen counter, and leaned against it, and all the blood drained out of his face, leaving him pale and frail looking. My sister and I were immediately concerned, but he was all right, he'd just waited until he got home to let go and process the stress of being the first responder to an accident in which a kid on a bike crossing the street (with the light) hit a car coming in the opposite direction that turned left right in front of him (driver failed to see the bike).

Somehow the kid and the bike went over the car in such a way that both the kid's legs were broken - in my memory, this involved his legs getting wrapped around the handlebars of the bike, so when I crashed my own bike into a car years later I was so intent on getting away from the bike the bike went one way and I went another as I jumped off of it.

My body taught me to expect to need downtime after extended stress as well after an international move in 1998 that took four days - cleared and cleaned the apartment (day 1), hit another city to pick up some things, had trouble with regard to my visa at the border (Canada), though we eventually did clear it up (after I was sternly warned they didn't have to let me in),(day 2) cleared our stuff through customs into the new country, moved into the new apartment,(day 3) then came back to the States to my parents' house (day 4) and were about to leave the next day for a trip down Route 66 and my body had had it - I threw up and started hyperventilating that morning. A walk-in clinic doctor took one look at me and asked if I'd done anything stressful lately, and prescribed 3 days' bed rest... you really do have to let yourself recover.

#13 ::: Wirelizard ::: (view all by) ::: July 17, 2008, 12:54 AM:

"Fires, wires, gas, glass" - hey, nmemonics DO work, mostly.

I think there's a 2nd line I've forgotten, but that's the "is the scene secure" chant I got when I did Standard First Aid.

Rule Zero: Do Not Add To The Casualty Count. Especially, Do Not Add Yourself To That Count. Pretty sure Mr. Macdonald has mentioned this one several times!

So, phone 911 from cell, start flagging other cars down, then move to victims. You do no good to anyone if you get mowed down while kneeling in the road heroically holding c-spine on the pedestrian...

#14 ::: Cynthia Wood ::: (view all by) ::: July 17, 2008, 02:24 AM:

Definitely don't forget six. Particularly if you had any involvement, however peripheral, in the accident itself. Or you may find yourself being carted off by the EMT's after they get a good look at your shaking, gray-faced self.

#15 ::: ajay ::: (view all by) ::: July 17, 2008, 06:03 AM:

OK, without looking at the discussion:

1. Call for help. Location, time, multiple vehicles, multiple casualties.
2. Secure the area. Grab passersby and get them to start flagging down cars on the approach roads. Redirect traffic and set up emergency triangles (does everyone have to carry them in the US too)? Keep a lane clear from the next clear intersection to allow ambulance access, and look around for a suitable HLS. When there is no more traffic on any of the four approaches, grab a few capable-looking bystanders to help out with the casualties.
3. Triage the casualties, who will be: the bloke who was flattened by the Subaru; driver and pax in the Subaru; driver and pax in the PT; drivers and pax of other vehicles which may have made emergency stops, etc. If there's anyone in any of the vehicles with medical knowledge, grab them. While doing this,
4. Assess the vehicles too: are they about to catch fire or shift position, are they leaking POL, is there broken glass? Turn off engines if still running.
5. C-spine control on everyone in both vehicles and on Pancake Bloke, then Airway Breathing Circulation. Write down information on condition (apparent injuries, pulse and breathing, alertness, other) because this could change.

The rest would depend on the injuries...

#16 ::: Phil Armstrong ::: (view all by) ::: July 17, 2008, 06:18 AM:

I have a more general issue about incidents like this, if Jim doesn't mind me raising it here: How do you go about taking control in a situation like this as a first responder / first aider?

I was on the scene shortly after an incident involving a single vehicle on a major local road a year or two ago & one of the problems I had was stopping the rest of the people hanging around doing completely *stupid* things & endangering both the occupants of the vehicle and themselves in the process.

Afterwards, I realised that part of the problem was that I had failed to establish any kind of authority on arrival, but that's not easy when there's already a bunch of adults there "trying to help" and already arguing about what should be done: To a certain extent I was just 'another voice' in the ongoing argument & it was all a bit of a mess, although myself and another woman did manage to keep a lid on the situation in the end.

Some time afterwards I remember reading Jim's post here on ML on the importance of setting up a control hierarchy as part of incident response, which made me thing that a better approach would have been to ask "Who's in charge here?" when I arrived in the first place, the implicit message being that *somebody* needed to be in charge, and work in the hierarchy from there.

So I guess my question is: How do you go about taking the necessary control of the situation and getting people on your side? Any suggestions much appreciated: I'd like to do better next time, if there is a next time.

#17 ::: Phil Armstrong ::: (view all by) ::: July 17, 2008, 06:20 AM:

Is first responder the right term here by the way? Or is that what you call the first professionals who are sent to an incident? (Paramedics, etc)

#18 ::: Bill Blum ::: (view all by) ::: July 17, 2008, 06:48 AM:

Wow, I haven't seen footage of that crash in a while.

I was approaching the intersection from camera left, heading south on Edwin C Moses, trying to turn right and head to the gas station. Had both kids in the car, so I wasn't in a position to go out and physically help, but I did dial 911 on both my work and personal cellphones, after pulling into the gas station about 50 yards west of that intersection.

#19 ::: John L ::: (view all by) ::: July 17, 2008, 07:13 AM:

I had a real life situation like this several years ago.

Heading home one day from Asheville on I-40, there's a steep mountain grade going east. As we rounded one of the last sharp curves, we noticed smoke just ahead. Just ahead of us, a semi truck had taken the curve too sharp, his load of motor oil (in quart containers) had shifted, and he had flipped onto the driver's side and skidded into the center concrete median barrier. The tires were still spinning and we were one of the first ones there.

I stopped our vehicle downhill from the truck (so it didn't block anyone else), and my assistant and I ran up to help. People were already getting out and calling 911, so that was handled. When we got to the truck, the driver was conscious but immobilized by his position and the seat belt. He was covered in oil and diesel fuel, and fuel was leaking from the truck and quart oil containers were everywhere.

The only way into the truck was through the passenger door, 8' above everyone's heads. My assistant climbed up to open the door and I talked to the driver through the cracked windshield. He was complaining about leg pain and his left shoulder showed signs of abrasion.

VERY BAD abrasion. We didn't realize it until later, but his shoulder had been pressed against the pavement while the truck skidded on its side, and the arm was abraded down to the bone. His dark coloring and the oil helped conceal that.

Another trucker climbed into the cab to help get him free while my assistant helped pass things in and out until the EMS personnel arrived, probably less than 5 minutes although it felt a lot longer than that. Once they were there we cleared out of the way; about five minutes later we both got a severe case of the shakes as the adrenaline wore off and we realized what we'd seen of his shoulder injury was the arm bone shining in the center of the red injured flesh....

#20 ::: Cathy W ::: (view all by) ::: July 17, 2008, 08:18 AM:

I've been through ARC first aid training (and I agree with a comment on the other thread that it wasn't nearly comprehensive enough), but never had to respond to anything that needed more than a squirt of Neosporin and a band-aid. Pictures and videos of trauma make me woozy.

If I only get through steps 1 and 2 before needing to skip to 6, do I fail? Or is it likely that if I found myself in an actual emergency situation, training and adrenaline would kick in and I wouldn't notice that I needed to throw up until I sat down afterwards?

#21 ::: James D. Macdonald ::: (view all by) ::: July 17, 2008, 08:28 AM:

My trick for taking control when I'm first-on-scene to an event is to hang a stethoscope around my neck. It's the universal sign for "I'm a medical professional."

Generally, the way you take control is by taking control. Point to people and give them orders in a clear, calm voice. When they obey those orders you're in charge.

Remember that it's very hard to do patient care and run a scene at the same time. If your role is "caregiver" then hand off the scene to someone else who looks purposeful.

While it's better for patients to hold still than be moving around, holding their heads for them is better than just asking them to hold their heads. Reason being: To hold their heads in position they're using their muscles and tendons, and for leverage those muscles and tendons are pulling on ... the bones that may be broken.

Before going over to check on patients, stop traffic. The traffic is what's going to kill you.

#22 ::: James D. Macdonald ::: (view all by) ::: July 17, 2008, 08:30 AM:

Heck, if all you do is manage to avoid getting hurt yourself, you've done right.

#23 ::: Ginger ::: (view all by) ::: July 17, 2008, 09:56 AM:

Naomi@ 7: the important thing is to remember that you're preventing them from moving around more, not that you're putting the head and neck into anatomical opposition. Assume a comfortable position and hold the head where it is -- that's the critical part of holding the c-spine.

I have a picture somewhere of my father (a former EMT) in an exercise; he was lying on top of a car holding the "patient's" head that was sticking through the windshield. By lying down, he was able to properly hold on and keep the person from moving without shaking or moving himself. In this case, extrication did not require removing the top of the car, or else he would have been in the way. ;-)

#24 ::: Caroline ::: (view all by) ::: July 17, 2008, 12:21 PM:

So again real quick, just because I'm curious. If I am the only person there to help someone who probably has a neck injury, and also has other problems: should I just try to do ABCs and try not to move the head, rather than prioritizing holding c-spine?

I am thinking here of my friend who lost control of her car and drove off a mountain. She was found by another woman, also driving alone. She was still conscious but clearly badly hurt. She most assuredly did have spinal and neck injuries. I'm sure she was bleeding, although since she talked to the woman who found her, airway and breathing were okay (she then lost consciousness so they would have needed to be re-checked). It was 3 AM on a fairly remote piece of highway; no one else was likely to be there until the pros showed up. If I was the woman who found her, what should I do after calling 911?

#25 ::: Sarah ::: (view all by) ::: July 17, 2008, 12:52 PM:


Wow. The Buster Keaton escape.

#26 ::: Ginger ::: (view all by) ::: July 17, 2008, 01:05 PM:

Caroline @ 24: You have to prioritize in that kind of situation. Monitor the ABCs, because something wrong in one of those will result in fatality. When you have a stable patient, then you stabilize the c-spine. If you can, jury-rig something to stabilize the neck/head and stay on top of the ABCs.

By the way, keeping a patient cold by just a few degrees should help with reducing CNS damage. Mild hypothermia has been shown to prevent some of the damage secondary to head injuries. They're starting to use this for football players with neck injuries on the field. Cold mountain air is one way of keeping the head cold.

You just want to prevent severe hypothermia, as that causes metabolic disruption of all kinds -- although, given a choice between bad things, cold is the lesser of two evils.

In clinical (veterinary) medicine, I have certain "options" in some situations. When given a choice between hyperventilation and hypo, I'll hyperventilate a patient, because I can recover them from 0% carbon dioxide. I can't recover a patient with > 60% CO2 in their blood. When given a choice between a patient that's too warm or too cold, I'll take the "too cold" option -- I can more successfully recover a patient that's cold, but I can't recover a patient that's gone >106 degrees F. I've lost patients that went up to 108, and recovered the one who went down to about 87 degrees* F.

In an emergency, you prioritize which is the most important thing to keep up, and which leads to more likely survival -- and then you keep your patient pointed in that direction.

*It was such a cold night that I was using the hand warmers for me.

#27 ::: James D. Macdonald ::: (view all by) ::: July 17, 2008, 01:51 PM:

One rescuer, a critical multi-trauma patient, a remote location?

Oh, that sounds like a real challenge.

What you do: Take stock of the situation and do the best you can with what you've got. Start with the "If I don't fix this s/he will die" items, then (if you ever get that far down the list) work on the "If I don't fix this s/he may die" items.

Do what you can and hope it's good enough.

Drop back to basic principles (e.g.: Shock kills people) and make a plan. Modify the plan as events unfold.

A quick prayer to St. Michael the Archangel wouldn't go amiss.

#28 ::: Hank Roberts ::: (view all by) ::: July 17, 2008, 04:01 PM:

I'd only add:
-- Turn on my 4-way flashers.
-- Yell to the other drivers to please turn on theirs, move up the road a ways, stop, flash headlights, blow horns, anything to stop traffic.
-- Grab my huge cow-stunner LED flashlight both for looking into vehicles and getting attention.
-- Pull my fire extinguishers out of the car and set them by the car.
-- Grab my seatbelt-cutter

#29 ::: Matthew Brown ::: (view all by) ::: July 17, 2008, 04:53 PM:

All this reminds me of growing up in Scotland between the ages of 6 and 9, approximately; we lived in the gatehouse of a local Lord's estate (my dad was part-time head gardener for him while he went to college to get his horticulture diploma). The road in front (the A77) was a serious accident black-spot and we had at least one fatality a year there.

(Damn, Google Maps has satellite at high resolution; here. Our house was the one just above center.)

The bend just south of the house was also at a dip in the land and as well as being a deceptively sharp turn, the true radius hidden by trees, it also flooded regularly during heavy rains, which are a constant thing in western Scotland. It rains pretty much all Autumn.

I think they actually corrected the road alignment sometime during the late 1980s to help this, reducing the dip and making the curve smoother and shallower.

It got to the point that we knew exactly what a crash sounded like and called 999 (British emergency number) immediately, before we even left the house to go and see.

Obviously being young my parents didn't let us see the gory ones, though. Probably a good thing.

Crashes don't sound like they do on TV or in the movies. Partly because they always slow-mo them, I guess, and because they over-do the broken glass sounds which are much quieter than the dull metallic THUD of steel impacting steel.

#30 ::: Leigh Butler ::: (view all by) ::: July 17, 2008, 05:38 PM:

The most upsetting ones are where you can't do anything except steps 1, 2 and 6.

Some years back, a friend of mine was driving (in her tiny compact car) down a residential street and got T-boned by a pickup truck that ran the stop sign right as she was crossing the intersection.

Somehow the combination of momentums (the truck's and her car's) slewed them both past the intersection so that my friend's car ended up pinned between the truck and a telephone pole, with the truck on the driver's side. Or in the driver's side, rather.

A bystander called 911 and then (at my friend's request) called us. We were only a couple of blocks from the accident so we beat the emergency response folks there by a good five minutes.

Jesus, that was horrifying. The car looked like a giant had picked it up and squeezed real hard. And because of the way it was squashed between the truck and the pole, none of us could even get near my friend, much less administer first aid. Her chest, neck and head appeared okay (as far as we could see, which wasn't very far), but her left arm was trapped in the wreckage of the door, and her entire lower half was wedged underneath what was left of the dash and steering wheel.

The only thing that kept us from completely losing our minds was that she was conscious and talking, and (apparently) lucid enough to give out phone numbers. We did the only thing we could, which was to stand in her line of sight, keep her talking, and try to be comforting presences, until the firemen got there with the Jaws of Life.

All things considered, she was very lucky - her knees will never be quite the same, and she had to have surgery twice to remove embedded glass from her jaw, but she had no internal injuries, and her left arm, amazingly, was only cut and bruised, once they freed it from the door. Crazy.

Oh, and the idiot truck driver? Nary a scratch - on her or on her three year old daughter she had in the truck with her. Yes, this woman deliberately ran a stop sign with a toddler in the vehicle. (She said it was because she was "mad at her ex-husband". There are no words.)

#31 ::: Madeleine Robins ::: (view all by) ::: July 17, 2008, 08:50 PM:

The one time I was on scene at an accident the only things I was able to do were to get someone to call the EMTs, and to get a blanket to cover the victim. Mostly I got yelled at, which was neither helpful nor fun.

Step back: the victim was an elderly man who was crossing the street at 10pm (on the main drag through the town, on a block where both the streetlights had blown out). The victim and his son-in-law had been walking across the street into the lane whence the car was coming: the son-in-law stayed in the far lane, the victim kept walking into the path of the car. So the driver couldn't swerve left without hitting the guy who'd stopped walking, and swerved right, stomping on the brake. The victim kept walking into the path of the car until he was struck.

As it turned out, the victim's entire family lived in the house directly next to the accident site. I had to argue with them to get them to call the police and EMTs; they seemed to be more intent upon swarming all over the site yelling "YOU KILLED GRAMPS!" I had a blanket in my car and put that over the victim, then stood there trying to calm the driver (a friend from school). In the end, the victim had caught his fingers in the grille of the car and hit his head when he landed, but was otherwise okay. If he had been bleeding to death with compound fractures on three limbs, I'm not at all certain that the family would have behaved any differently; it sure made trying to be helpful an uphill slog.

Short of a stethyscope or yelling "Shut up, you moronic Kallikaks! Someone get a blanket!" what is the best way to take charge at the scene?

BTW: watching that clip is the best argument against jay-walking I've seen in a while.

#32 ::: Tom Whitmore ::: (view all by) ::: July 17, 2008, 09:04 PM:

It is surprising how often talking confidently (rather than asking others what we should do) makes a difference. I've only had to deal with lower-level problems, like a bigrig turning a corner and slowly pushing a car on the other side of the road off the road (splintering windshield and door as it did so) -- no serious damage to people involved, thank heavens. Managed to get traffic stopped, got 911 called, and spent time talking with the slightly injured people in the car (3 generations of Mexican-Americans).

#34 ::: Naomi Kritzer ::: (view all by) ::: July 17, 2008, 10:39 PM:

Leigh @30: We did the only thing we could, which was to stand in her line of sight, keep her talking, and try to be comforting presences, until the firemen got there with the Jaws of Life.

I've described this accident here before, but: my sister was in a terrible car accident in 2001. Afterwards, in her panicky, adrenaline-charged daze, she was convinced she needed to get out to seek out help. She did not know that her neck was broken in two places.

Someone stopped his car, came running, told her to stop trying to move, and then held her hand and kept her calm until 911 arrived.

Her neck was broken, but the nerves stayed intact, and after three months in a halo vest, she was back to normal rather than adjusting to life as a ventilated quadriplegic (one of the broken vertebrae was C2) or a paraplegic with partial hand functionality (the other one was C7).

Never underestimate the value of just being there to reassure someone.

#35 ::: Rachel Brown ::: (view all by) ::: July 18, 2008, 01:26 AM:

Taking charge: I have found, in many different types of situations including traffic accidents, that if you look a person in the eye, point to them, say, "YOU!" and then give them a simple order like, "Stop the traffic" or "Call 911," they will do exactly what you say without argument or question.

#36 ::: Lila ::: (view all by) ::: July 18, 2008, 01:03 PM:

Jim, I work in an outpatient physical therapy clinic, and several times a year we have to talk patients into going to the ER (with the advice of their primary care doctors over the phone). Sometimes they go, sometimes they don't. Reasons include suspected spinal injury (confirmed) and possible heart attack (sometimes confirmed, sometimes not).

An acquaintance of mine is still alive today because her ophthalmologist recognized during an eye exam that she was having a hemorrhagic stroke.

Please, folks, if a medical professional examines you and thinks you need to go to the ER, consider the possibility that either (a) they know something about vital signs or neurological symptoms that you don't, or (b) whatever condition they're worrying about (diabetic shock, heart attack, stroke) may be affecting your thinking.

#37 ::: Terry Karney ::: (view all by) ::: July 20, 2008, 08:26 PM:

No reading of anything but description/seeing the video.

call 911 (or local equivalent)

Approach; as safely as practicable.

Secure the Scene. Look for potential for fire. If fire is possible, evacuate anyone not directly helping. Alert Responders of fire danger (911, etc., by directing an onlooker to call)

If needed, evacuate the wounded, with as much care for possible spinal injury as can be done.

Query for anyone else with first aid knowledge. Take charge (barring someone whom you have reason to believe is more knowledgeable).

Triage the scene. (odds are really good you have multiple casualties)

Use the ability of any other person to treat people (stabilise c-spines, rescue breathing, hold bandages, reassure, etc.). Instruct as you go.

Check the injured for(ABC). Assign someone to intiate rescue breathing as needed.

Search for bleeding: Repeat on other victims.

Eyeball for evidence of TBI (leaking CSF, diliation, coherence). Stop bleeding, Splint breaks, Treat for Shock. Reassure the victims.

Report all treatments/observations to medical personell when they arrive.

Puke somewhere out of sight.

Talk to someone about it later... esp. if any of the people you treated dies.

#38 ::: Terry Karney ::: (view all by) ::: July 20, 2008, 08:45 PM:

Laertes: I think I can safely say you know what it's like to be in a firefight.

Phil Armstrong: You take control by looking as if you know what you're doing. A clear voice, loud; but not shouting, instructive directions, "You, talk to him, keep his head from moving (this last is tricky... if you are too rushed/panicked in delivering that instruction the patient might decide they are injured, and psychogenic shock might set in).

People in those sorts of scenarios are flailing. They want to help, they don't know what to do and are casting about. If you look as though you know more than they do... they will give you the authority, so they don't have to assume the responsibility.

#39 ::: James D. Macdonald ::: (view all by) ::: July 21, 2008, 07:29 AM:

Further for Laertes #11 (I'll never forget that feeling as I watched the chaos spread. It felt fall, I guess.)

Scenes can go straight to heck, fast. Faster if you don't aggressively take scene control.

Just for everyone's information, how to flare out a scene:

Put one flare one hundred feet from the scene, another two hundred feet from the scene. A third three hundred feet from the scene. Repeat in every direction that traffic can come from.

Be aware of flammables while you're doing this. Be aware of traffic. Know which way you're going to jump.

#40 ::: elise ::: (view all by) ::: July 22, 2008, 12:39 AM:

Before I read the rest:

Make sure somebody's calling 911. Do it myself if I don't get somebody doing it in the first minute.

Make sure somebody's flagging traffic. Preferably four somebodies, as no direction should be left unflagged in this situation.

Get a look at everybody and figure out who to work on first.

Um, shock. Deal with it. And the c-spine thing, which the skateboarder quiz reminded me of.

Gonna need more people to help with this one. Draft 'em as they come in.

...OK, gonna read responses in a minute. First, though, a reminiscence: I did have a real-life "make the scene safe" task once, and thank God I had the right reflexes to do it, though I lucked out that there was no first aid required, because I wasn't thinking that way at all in the crunch. Here's what happened: I was returning from a rehearsal with my singing partner Jane, on a snowy winter's night in Minneapolis. I lived on a busy main drag about midway up a steep hill (46th and Xerxes, for those of you who know the town), and the street was, as usual, full of parked cars on both sides, but it's a nice wide street. It was wide enough that when the newly-minted teenaged driver going up the hill started to swerve and then gunned it and corrected wrong, she did a solid 180, missing the parked cars on the uphill side (in her lane) and making solid full broadside impact on the parked car in the downhill lane, totalling it.

We pulled over and parked. This was before cellphones so I ran into the house, told someone there to call 911 and tell them there was a car accident out front, and ran up to the top of the hill to flag traffic, since it's steep enough it was almost blind. I yelled to Jane to get flares as I passed her. She brought me some, and I set up two at the top of the hill and kept flagging, while she set up one at the bottom. The driver of the car turned out to be OK, from what we could tell from the actions of the paramedics and police. She was last seen being reunited with a parent who, at the moment, seemed mostly in the "Oh thank God, you are alive!" phase, though with flickers of "O my God, the car!" starting to show.

No other cars got involved in the accident, and I know we helped make that so. It was good to be useful, because it sure could have been much worse.

#41 ::: debcha ::: (view all by) ::: August 01, 2008, 10:07 AM:

#31, Madeleine: ...watching that clip is the best argument against jay-walking I've seen in a while.

Really? Because even though I can't see all the lights, it seems pretty clear that one of the drivers erred, not the pedestrian - one of them should not have entered the intersection (hard to say which one with the given information). From Jim's info, it's not clear whether the pedestrian started crossing with a green (now red) or whether this is the kind of intersection where the pedestrians have separate walk signals, with all traffic stopped. But for me the clip highlights how, as a pedestrian, you are supremely vulnerable to drivers making bad decisions, no matter how careful you are.

#42 ::: Jim Macdonald ::: (view all by) ::: May 17, 2009, 08:25 PM:

A first-person account by an on-scene witness to a serious MVA. Think ahead: what would you do?

#43 ::: John Houghton ::: (view all by) ::: May 17, 2009, 10:36 PM:

I know what I would do based on my training (I had actually typed the details and discarded them), and I know what I would be in danger of screwing up, but does anybody offer training in managing a scene like this with willing but untrained bystanders as responders? How do you, without obvious authority (other than a trauma bag), keep well meaning people from doing the wrong things (like removing breathing victims from vehicles that aren't on fire)?

I wanted to post a comment on webranding's diary that he did a good job, but there is a 24 hour delay for comments from new members :(=

#44 ::: Niall McAuley sees a spam probe at #44 ::: (view all by) ::: April 15, 2011, 03:49 AM:

Incoming probe

#45 ::: fidelio sees spam ::: (view all by) ::: March 26, 2014, 08:25 AM:

spam, spam, spammity spam...

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