Introduction

Emergency medical services (EMS) have several responsibilities at the crash site, whether involving an automobile, aircraft, boat, or other types of vehicles. The key responsibilities of EMS covered in this resource include scene safety evaluation, triage coordination, prehospital medical treatment, and crash site investigation.

Issues of Concern

Scene Safety Evaluation

Scene safety evaluation should begin before EMS responders arrive at the incident site. Based on the available information, the review begins by determining whether it is safe for EMS responders to proceed to the scene and what safety equipment is required. Crash sites are highly dynamic environments that may change from safe to unsafe. Accordingly, the scene safety evaluation should be continuously addressed and monitored. If the situation becomes unsafe, personnel must be given as much warning as possible to withdraw.

Crash sites often contain a combination of hazards, including wreckage, hazardous material, fire, and noxious fumes. Depending on the location, season, and time of day, different environmental hazards may also be present, such as those found in urban, marine, mountain, desert, winter, or nighttime settings. Most modern EMS agencies have access to the equipment required to keep personnel safe in all but the most extreme environments. Understanding when to wear the appropriate protective gear minimizes risks to both rescuers and victims.

Personal protective equipment is the foundational safety gear commonly used in most EMS response scenarios. However, each crash site is different in scope and severity, affecting the decision of which gear to wear. For instance, if the crash site spans a large area, as is typical for an aircraft crash, EMS personnel may also require radio communication, fire suppression, construction machinery, and casualty collection transport to provide a safe and effective response.

EMS agencies play a crucial role in ensuring the safety and medical treatment of all personnel at a crash site, including firefighters, law enforcement officers, bystanders, and media personnel. Minimizing the risk of injuries to personnel and bystanders at a crash site prevents time and resources from being focused on the victims.[1]

Triage

Most crash sites are mass casualty incidents with injuries ranging from uninjured to deceased. EMS providers must triage patients quickly and efficiently to help prevent local resources from becoming overwhelmed. A common mistake observed in previous mass casualty incident responses is prioritizing uninjured patients for transport while leaving critically injured individuals untreated in the field.[2]

There is no universally accepted triage system, and triage procedures may vary from hospital to hospital within the same region.[3] Although no evidence indicates that one triage system is superior to another, using multiple triage systems during the same mass casualty incident leads to confusion and disorder, ultimately delaying patient care.[4][5] Each EMS agency must train its respective responders to understand the local triage system and provide a unified response to a mass casualty incident. Although each mass casualty incident differs in scope and available resources, as a general guideline, a triage system includes relevant triage categories and category collection points.

EMS personnel assign mass casualty incident victims to a triage category upon their initial presentation. Each triage protocol may vary in terms of the data used to categorize patients. Category metrics may include the Glasgow Coma Score, vital signs, and visible injuries. This initial assessment efficiently minimizes delay in patients receiving definitive treatment and allows EMS responders to move to the next victim. Triage categories are marked and highly visible for appropriate transportation and patient care. These category designations can be a system of color-coding, numbering, lettering, or transporting the patient to a designated category collection point. As part of their survey and planning, EMS leaders designate collection points accessible from the crash site and for transport to medical facilities. Compounding the challenge of mass casualty incident triage logistics is the potential for a patient's condition to deteriorate as time elapses. Therefore, EMS duties include continuously monitoring patients during triage and transport.

The study of real-world examples shows that without prior training or a unified triage protocol, responders transport patients on a first-come, first-served basis, and critical patients encounter treatment delays. On-scene emergency medical personnel are responsible for administering and maintaining a uniform triage plan for each mass casualty incident and managing the crash site to maximize the survivability of victims.[6]

Prehospital Medical Treatment

EMS personnel are responsible for providing pre-hospital medical care to all crash survivors. As with all other EMS scenarios, medical care begins at the initial encounter and continues throughout the patient's transport to the medical facility. According to the Advanced Trauma Life Support (ATLS) protocol, responders treat life-threatening injuries first before transporting the patient from the crash site to a collection point. Less severe injuries are treated at appropriate stages of patient evacuation according to the triage system in place.

Specific to aircraft crash victims, data from the post-crash analysis show that lower extremity fractures are the most common injury of hospitalized aircraft crash survivors. Other frequently reported injuries include head injuries, open wounds, upper extremity fractures, internal organ damage, and burns.[7] Rotary aircraft crash victims have a high potential for spinal column injuries, and it is important to consider c-spine immobilization for transport.[6][8]Trauma victims commonly have multiple distracting injuries. EMS providers are trained to conduct a thorough assessment, determine each patient's injury severity, identify immediate treatment needs, and stabilize patients for transport to definitive care facilities.

Crash Site Investigation

The investigation of a crash scene and the cause of the accident may vary based on the incident. In the case of an aircraft crash, investigators not only examine the events leading up to the crash, which can span several years, but they also examine the immediate aftermath, including eyewitness accounts from EMS first responders on the scene. During the triage process, the deceased are left in their original position, with only minimal movement to perform necessary evaluations. The investigation that follows evaluates the passengers' positions relative to the crash and extrapolates the cause of injury or death. By this same token, investigators may ask EMS responders to recall the location of debris moved or altered to reach potential survivors. The investigations of crash sites have led to improvements in processes, materials, and training, ultimately helping to prevent future loss of life.[9]

Clinical Significance

EMS has several responsibilities, including triage, patient care, and preparing victims for transport. EMS plays a crucial role at the crash site, and when executed properly, this response can maximize the number of lives saved and reduce morbidity.