#1  
Old 03-04-2012, 05:13 PM
guitarmedic87 guitarmedic87 is offline
 
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Question MCI's

It seems everytime I turn on the news over the last few weeks there has been somekind of MCI in Canada. Buses, trains, vans, they all seem to be crashing.. Thankfully most of us will never have to experience one in our career, nevermind be the first arriving paramedics. That being said it is something that I don't think is practised enough. Heres my question, which I have my thoughts on, just looking to see what others think/would do... Do our current standing orders like a Trauma TOR apply during an MCI or do you feel once someone is Tagged Black, that is it..??

Heres where I see this scenario... You respond to MVC with 5 pts, you are the first arriving ambulance, 2nd is greater than 15mins away and third is 20mins out. Upon arrival you find one pt in the vehicle who is VSA with no obvious trauma, the second pt has been ejected is also VSA, Your third pt is a semi conscious Adult in rear passengers seat with abdominal injuries and pale in colour, your fourth Pt an adult is the driver, conscious but lethargic, obvious head and chest trauma, and your 5th pt is walking wounded, possible# arm..

So initially, two medics, five patients, Its an MCI and triage applies, the two VSA get Tagged black, the other two are serious and require one medic for each. The 5th is monitored from a distance. 17mins later both other vehicles arrive at the same time.. Is this still considered an MCI? We now have 6 medics and 5 patients? Does everyone agree that the two Tagged Black remain tagged black and nothing furthur is done, or would you attach your monitor and run your Blunt Trauma protocols which will likely lead you to a TOR.?

What happens if your second and third vehicles arrive 5 mins after you? Would you change your treatment or follow a different protocol?

There are all kinds of what ifs out there.. but as our infrastructures age and violence seems to be growing, MCI's may become something we will all have to deal with more than once and its something we should be talking about a little more often.. I think..
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Old 03-04-2012, 06:22 PM
cprted cprted is offline
 
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First off, you're kidding yourself if you think you will never be faced with an MCI. It doesn't need to be front page nationwide news like the Via Crash to be an MCI.The very scenario you've painted is a very real possibility no matter where you work.

But on to your scenario. Yes it is an MCI. We have more patients than resources=MCI. If it is just my partner and I, backup is a ways out, I have no first responders, no extrication required for anyone and I have 2 Black, 2 Red, and 1 Green. I would seriously consider loading the reds into the back (one on the cot, the other on the bench) and the Green in the cab. If practical, I might meet another car halfway and transfer one of the Reds to their unit.

If additional resources are available within 5 mins, my transport plan would change. As resources become available, blacks can be reassessed and reclassified.

I agree revisiting triage and MCIs is valuable. I just happened to do a triage/mci refresher course yesterday

PS-I'm unfamiliar with what a "TOR" is ...

Last edited by cprted : 03-04-2012 at 06:29 PM.
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  #3  
Old 03-04-2012, 07:16 PM
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dentedhead dentedhead is offline
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Originally Posted by cprted View Post
First off, you're kidding yourself if you think you will never be faced with an MCI. It doesn't need to be front page nationwide news like the Via Crash to be an MCI.The very scenario you've painted is a very real possibility no matter where you work.

But on to your scenario. Yes it is an MCI. We have more patients than resources=MCI. If it is just my partner and I, backup is a ways out, I have no first responders, no extrication required for anyone and I have 2 Black, 2 Red, and 1 Green. I would seriously consider loading the reds into the back (one on the cot, the other on the bench) and the Green in the cab. If practical, I might meet another car halfway and transfer one of the Reds to their unit.

If additional resources are available within 5 mins, my transport plan would change. As resources become available, blacks can be reassessed and reclassified.

I agree revisiting triage and MCIs is valuable. I just happened to do a triage/mci refresher course yesterday

PS-I'm unfamiliar with what a "TOR" is ...
Termination Of Resuscitation.

Dead is dead and they stay that way two Pts with injuries as described require on on one Tx the walking wounded I would initially have a FF or try emphasis on try to get a cop to stay with the Pt.I would still want the third car to Tx and transport the # arm largely because with an accident of that kind I would be very concerned about the possibility that person starting to circle the drain,walking or not he gets full BTLS packaging.

Regardless of first responders on scene or not or even if it is the 15ish minutes for the next cars, stay and work the injured if the weather is warm package them set a Tx area and then both you and you partner are in close proximity to each other if a pt starts going south. Winter time try to get both into the back of the ambulance,rescue or pump if available.

I was always taught and practiced under the simple rule of first car in last car out and as mentioned dead is dead and thats how they stay.Im surprised the VSA baby/toddler wasn't thrown in for fun!

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Last edited by dentedhead : 03-04-2012 at 07:26 PM.
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Old 03-05-2012, 06:27 AM
guitarmedic87 guitarmedic87 is offline
 
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Originally Posted by cprted View Post
First off, you're kidding yourself if you think you will never be faced with an MCI. It doesn't need to be front page nationwide news like the Via Crash to be an MCI.The very scenario you've painted is a very real possibility no matter where you work.

But on to your scenario. Yes it is an MCI. We have more patients than resources=MCI. If it is just my partner and I, backup is a ways out, I have no first responders, no extrication required for anyone and I have 2 Black, 2 Red, and 1 Green. I would seriously consider loading the reds into the back (one on the cot, the other on the bench) and the Green in the cab. If practical, I might meet another car halfway and transfer one of the Reds to their unit.

If additional resources are available within 5 mins, my transport plan would change. As resources become available, blacks can be reassessed and reclassified.

I agree revisiting triage and MCIs is valuable. I just happened to do a triage/mci reer course yesterday

PS-I'm unfamiliar with what a "TOR" is ...
DH is right, Termination Of Resuscitation, in parts of Ontario we now have Medical and Traumatic TOR protocols, doesnt matter if you are an ACP or PCP. Basically, if the pt is greater than 16yrs of age, and VSA with no Shocks delievered we have to patch to the BH to get a cease.. MCI's dont seem to be talked about in these protocols and its never really been clarified which protocol supersedes the other. Initially, MCI and Triage I think, but at what time can we forget about hooking up the monitor and doing the whole TOR scenario.? On scene with 3 patients, I have one, my partner has one, and I've already "tagged" one as Black, does the second crew just ignore that VSA pt and relieve me or my partner from our patient or should they run their Traumatic VSA protocol?

I've often thought about that whole transporting issue too, we only have single stretcher rigs here, and its considered a big no no to transport two code 4 patients at the same time.. That being said, I have carried two pts fully immobilized and one in the captains seat in a single stretcher rig, none however were serious and our third vehicle was 50mins away, 2 crews took 3 pts each...


I'm more curious about the TOR's, "back in the day" dead was dead and that was good enough. (You don't need to be a doc to know when someone is dead). Now it seems we need a BH Doc to tell us dead is dead, it seems like a waste of time and resources but it all comes down to CYA
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Old 03-05-2012, 05:14 PM
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dentedhead dentedhead is offline
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Originally Posted by guitarmedic87 View Post
DH is right, Termination Of Resuscitation, in parts of Ontario we now have Medical and Traumatic TOR protocols, doesnt matter if you are an ACP or PCP. Basically, if the pt is greater than 16yrs of age, and VSA with no Shocks delievered we have to patch to the BH to get a cease.. MCI's dont seem to be talked about in these protocols and its never really been clarified which protocol supersedes the other. Initially, MCI and Triage I think, but at what time can we forget about hooking up the monitor and doing the whole TOR scenario.? On scene with 3 patients, I have one, my partner has one, and I've already "tagged" one as Black, does the second crew just ignore that VSA pt and relieve me or my partner from our patient or should they run their Traumatic VSA protocol?

I've often thought about that whole transporting issue too, we only have single stretcher rigs here, and its considered a big no no to transport two code 4 patients at the same time.. That being said, I have carried two pts fully immobilized and one in the captains seat in a single stretcher rig, none however were serious and our third vehicle was 50mins away, 2 crews took 3 pts each...


I'm more curious about the TOR's, "back in the day" dead was dead and that was good enough. (You don't need to be a doc to know when someone is dead). Now it seems we need a BH Doc to tell us dead is dead, it seems like a waste of time and resources but it all comes down to CYA
Back in the day as the kids like to put it.Pre TOR all we had was the Decapitation,Transection or advanced signs of death, rigor and or lividity,in TO we had greater autonomy to go ahead an call the coroner if we were certain someone was dead.Then with ALS field pronouncements were all the rage.Initially a patch was required then eventually a standing order was made for the circumstance,if it was traumatic most guys would patch for direction met times a pronouncement was made.

Triage the rules kinda go out the window.If someone is VSA and there are other viable pts that person stays vsa a viable pt is anyone who is not VSA and Tx is done accordingly and they are tagged accordingly.If you are triaging you are not supposed to be treating once you commit yourself to the reps depressed pt you cant leave them Im sure every service has its protocols so there really is no concrete answer!

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  #6  
Old 04-01-2012, 11:00 PM
Onpcp Onpcp is offline
 
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cprted has it right, more pts than medics=MCI, once youve determined number of pts and that youll be running the call as an MCI, you start running the scene in a triage setting. Dont even think about taking out the defib pads. As for the TOR's dont confuse this with the 'obviously dead' (code 5) protocol. TOR isnt for obviously dead pts and is a very welcome addition to our protocols as before TOR we had to transport everything that didnt fit the 'obviously dead' criteria. Now a trapped MVC pt whos not 'obviously dead', and not in PEA rhythm with less than 30 minutes to the nearest hospital, can be prounounced via BHP, instead of waiting 30+ minutes for Fire to extricate while doing upside down CPR. (But even before the Trauma TOR, some medics had no problem calling it in to the BHP for a situation like this and having the BHP call it.)
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Old 04-02-2012, 04:56 PM
guitarmedic87 guitarmedic87 is offline
 
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Originally Posted by Onpcp View Post
cprted has it right, more pts than medics=MCI, once youve determined number of pts and that youll be running the call as an MCI, you start running the scene in a triage setting. Dont even think about taking out the defib pads. As for the TOR's dont confuse this with the 'obviously dead' (code 5) protocol. TOR isnt for obviously dead pts and is a very welcome addition to our protocols as before TOR we had to transport everything that didnt fit the 'obviously dead' criteria. Now a trapped MVC pt whos not 'obviously dead', and not in PEA rhythm with less than 30 minutes to the nearest hospital, can be prounounced via BHP, instead of waiting 30+ minutes for Fire to extricate while doing upside down CPR. (But even before the Trauma TOR, some medics had no problem calling it in to the BHP for a situation like this and having the BHP call it.)
The true defination of an MCI as per training package in 2000 after the Windsor incident states that an MCI is an event where ambulance resources are overwhelmed for 15mins.. So, if my partner and I show up onscene of a two vehicle MVC with 4 pts.. But I have three other crews within 15 mins, im not sure this would be classified as an "MCI"... I have to triage.. Yes, but from what I understand CPR must be initiated on that VSA pt, while your partner continues triaging, or working on the next most critical pt. If the pt is not code 5 then TOR protocols need to be followed.. So there could be two critical and two vsa. Those vsa from what I understand need to be worked on first.....I'm not saying I agree with it.

NOW if my third vehicle is greater than 15mins out... I am now faced with an MCI, dead is dead, tag, move on.......

Do you think Im wrong with this? I agree it goes against everything I have ever been taught and done and prior to two days ago would never consider working that VSA when I had potentially viable pts. There just seems to be such a grey area here where no one in the position of authority seems to want to commit to an answer.. I've heard the line use your best judgement.. Well guess what.. My best judgement is only good if everything works out and nothing is done wrong.. If something goes down the BH, MOH, and Lawyers etc are going to ask what does it say on paper and at that point if you didnt work that VSA and you were not in a true MCI you might be PWF?

Thoughts?
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Old 04-04-2012, 04:44 PM
Onpcp Onpcp is offline
 
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good post. Your right it is scary how much accountability there is when situations like the one above occurs yet most of the answers you recieve from those who will be questioning you during the subsequent inquest or MOH investigation will be 'use your best judgement'. Im sorry but 'best judgement' is really subjective from one person to the next. When my ass is on the line it would be reassuring to know that there are clear cut guidelines to base my defense on, I did this as per policy x, etc.etc. As im sure your aware, with the release of the new provincial protocols, theres more of an emphasis on us to be 'free thinkers', thats why youll notice the language is more vague, no more bullet points, more open to interpretation. While some may see this as a good thing, less restrictive, others may see this as very scary, for the reasons above. As for the 15 min window, that is something ive never heard of. Its strange why 15 mins would be chosen, a lot can happen in 15 mins. I dont see the efficacy of stopping to do cpr on someone dead when there are 20 more pts, possibly viable, whether or not the next truck is 5 mins away or 50 mins away, a lot of those red tags could die in that first 15 min. I think youd more likely be sued by the relatives of the red tags that died while you were waiting for a miracle working on the black ones.
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Old 04-05-2012, 06:03 AM
guitarmedic87 guitarmedic87 is offline
 
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Originally Posted by Onpcp View Post
good post. Your right it is scary how much accountability there is when situations like the one above occurs yet most of the answers you recieve from those who will be questioning you during the subsequent inquest or MOH investigation will be 'use your best judgement'. Im sorry but 'best judgement' is really subjective from one person to the next. When my ass is on the line it would be reassuring to know that there are clear cut guidelines to base my defense on, I did this as per policy x, etc.etc. As im sure your aware, with the release of the new provincial protocols, theres more of an emphasis on us to be 'free thinkers', thats why youll notice the language is more vague, no more bullet points, more open to interpretation. While some may see this as a good thing, less restrictive, others may see this as very scary, for the reasons above. As for the 15 min window, that is something ive never heard of. Its strange why 15 mins would be chosen, a lot can happen in 15 mins. I dont see the efficacy of stopping to do cpr on someone dead when there are 20 more pts, possibly viable, whether or not the next truck is 5 mins away or 50 mins away, a lot of those red tags could die in that first 15 min. I think youd more likely be sued by the relatives of the red tags that died while you were waiting for a miracle working on the black ones.

Damned if you do, damned if you dont. Just had a huge discussion last night at work about this.. Of the 8 medics standing around only one had heard of the 15 minute thing before, but once I showed the documentation to everyone, none of us are really certain as to what to do. And no one wants to commit to answer. In fact I just got my hands slapped for not Calling the BH on an MCI where I had three DOA, and and two critica. Apparently I was suppose to patch for a cease...... Like you said, Best judgement isnt the same for everyone and it their oppinions against ours and it seems people forgot just how difficult some of these decisions are once they get sitting in an office somewhere.

Last edited by guitarmedic87 : 04-05-2012 at 06:35 AM.
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Old 04-07-2012, 02:25 AM
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Buckster Buckster is offline
 
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Small rural NB community here, thinking oh nothing like a MCI will ever happen here......April 2001 bus accident with 35+ patients, 4 black tags......can happen anywhere for sure
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