NYC (and beyond) paramedics/EMTs - you've just been called out to a serious vehicle collision!

1) EMT, EMS or Paramedic are basically interchangeable. NYC uses EMS and the individuals are EMTs or paramedics.

2) Cover the trapped person with a coat, take what vitals they could, get an intravenous in him if needed, direct traffic, shield the scene from onlookers and talk to the guy if he's conscious.

3) Take vitals, start IV's, prep for transport. Potentially deal with the punctured lung, but in Manhattan you're minutes from an ER.

4) Ask him about pain, where it hurts, is he having trouble breathing, getting vitals. Might ask for details of the crash, name of next of kin or someone to notify. Normally would not ask who was president or those types of questions unless there's an indication of concussion. EMS doesn't diagnose, they prep for travel and get them to the ER.

5) Pain induces a lot of feelings, from physical to mental. The range is so wild it really depends on what you need for your story as to how to make it believable.

FWIW, rescue tools such as the Jaws of Life are never 15-20 minutes away in Manhattan. A rescue truck is standard dispatch to auto accidents with injuries and often arrives before EMS transport. The rescue trucks in NY have paramedics on them.

Jeff

Can't speak as to the paramedics, but I can relate when I was in a car accident. An SUV ran a red light and hit me in my driver's side. I spun and ended up against a lamppost against my driver's side. I was told that the side of my head slammed against the side window, but I can't remember it.

4) The paramedics asked me who the president was, how old I was, where I was going. Reading my accident report is hilarious now, as apparently I could only recall that I needed lightbulbs.

5) I recall waking up in my truck with it looking really smokey from airbags going off. There was a pole on my driver's side door and people on my passenger side knocking on the window trying to get me to open the door. I was thinking to myself that I was dreaming and started to reach over to the door handle to open the passenger door. I don't remember opening the door but next thing I knew I was sitting on the grass with a cop. I don't recall his questions. Then I was on a stretcher. I was in and out a lot, but don't remember any pain. The pain came later at the hospital. I had a concussion and contusions all down the left side of my body and some spinal injuries.

Los Pollos Hermanos said:

1). In the UK we just say paramedics, but I've seen the term Emergency Medical Technican also used in the US. What's the difference between a paramedic and an EMT, and who would attend? If both attend, who does what?

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The term "EMT" can be used to refer to all EMS providers since it's technically part of everyone's full title. But in this contexts it's used to differentiate between EMTs and paramedics, "EMT" being used as shorthand for an EMT-Basic and "paramedic" for EMT-Paramedic. Those are not interchangeable and denote different skill levels.

As a very basic rule of thumb an EMT-Basic cannot administer medications or break the skin. No IVs, no intubation, no manual defibrillation, no EKG and so forth. All of those are reserved for the paramedic. (There may be slight variations depending on which state you are in and some states also have provider levels in between. New York has intermediate and critical care levels of EMT, but I've only ever known FDNY EMT-Bs and EMT-Ps.)

The FDNY has both ALS and BLS ambulances. Who gets dispatched depends on what 911 knows about the incident; they make the decision, but they can dispatch more people if necessary. Many cases of physical trauma can be handled by EMT-Bs, but your scenario calls for paramedics. (Although you might not get any. There are fewer of us because we're expensive, so we're busy.)

Los Pollos Hermanos said:

2). What would they do whilst the Jaws of Life were doing their thing?

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Fifteen to twenty minutes is an unacceptably long time for those tools to arrive. This isn't specialized equipment, it's basic stuff. If a firefighter is on scene, so are the rescue tools. So while our hose dragger friends are going to town we'll typically try to establish what happened and try to access the patient to the best of our abilities (being pretty small I've spent lots of quality time half buried in car wrecks assessing patients and stabilizing spines.) Directing traffic is for cops. And we use blankets to cover patients, not coats. Our coats are a couple hundred dollars, you get space blankets for a few dollars a pop.

Los Pollos Hermanos said:

3). When they gain full access how would they assess/treat the patient?

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Airway, breathing, circulation. Stabilize the spine. Assess vitals. Assess neurological status. Carefully extricate and immobilize the patient. IVs are standard. Supplemental oxygen, rapid trauma assessment, particularly lung injury and neurological symptoms, keep suction and laryngoscope ready due to patient's altered level of consciousness. Load and go, keep monitoring EKG, blood pressure, O2 on the way. Be ready for rapid needle decompression in case of tension pneumothorax. EMS absolutely diagnoses. (Just because a hospital is physically close doesn't mean you'll get there quickly. Traffic's a bitch in the city.)

Los Pollos Hermanos said:

4). What would they ask him? I know there's the "Who's the president?" kind of thing, but what else might they ask?

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What we want to find out is if the patient is alert and oriented (A&O) x4. Person ("What's your name?"), place ("Where are you right now?"), time ("What time is it?"), situation ("What happened?") Some places only do A&O x3 and omit situation. It's supposed to assess the patient's mental status, i.e. is there an indication for a brain injury? Those can be tricky to find and can become very dangerous without much warning, so those kinds of questions are pretty standard for just about every trauma patient. You can ask who the president is, too. It's pretty common for a patient with a head injury to have no memory of the accident or the time immediately before and/or after it, but anything beyond that is a cause for concern.

Other popular questions: medical history, do you take any medications, are you on any drugs, when was the last time you ate and drank and what, are you allergic to anything? And of course: Are you in pain? What does it feel like? Where is the pain? Does it spread? On a scale from 1 to 10, how bad is it? Can you feel me touching you? Where am I touching you right now?

This question takes me back...

I started a reply, but it's taking longer than I thought and I really have to run. So if you could hang tight until tomorrow that'd be great.

A few things on your second round (note, not a NYC EMS/Paramedic so some things may be different):

1) Traffic can add whatever you need for your scenario to work. Try getting an accident while the UN and the Pope are in town.

3 a/b) You can do a lot from wherever you can reach the patient. From your description of the crash, just sealed doors, no rollover, etc. the paramedic should be able to get everything. It's rtare there is nobody on site small enough to get into tight spaces.

4) My reference to a coat was due to using a saw to protect from metal shards flying around. But yes, swampy and hot doesn't mean a patient can't go into shock.

5) Paramedics don't give painkillers (normally) and the truth is that the patient feels very little in the way of pain in the immediate aftermath. Body's normal reaction cuts out the pain impulse because it's no needed. They can, and likely will, hurt, just not to the point of pain killers. You also do not want a patient with depressed responses headed to an ER.

6) The basics reveal a lot. Blood pressure changes, heart rate or pulse rate changes, breathing difficulties.

7) Varies a lot, by individual and specific injuries. Again, write what you need to have for your story, rapid breathing or shallow, high or low blood pressure, etc. Pulse rate tends to skyrocket unless there are issues that affect it, but there really isn't a standard reaction to most things. The punctured lung and skull fracture will dictate some reactions, such as labored breathing, coughing or spitting blood, blood frothing or bubbling and the semi-conscious state. Which, while the head trauma is a good reason, could also be caused by low blood pressure.

8) If the patient can't give info, they can't give info. It may make the decisions tougher and some determinations difficult, but it happens regularly. Repeating questions often will piece together enough, or sometimes witness comments (paramedics usually don't question witnesses, they're always wrong...). ID from documents, wallet, cell phone, etc.

9) Here in Florida, it usually goes to the ER, it's always delivered when they arrive in person, whether or not it was transmitted in any other way. Vitals, drugs administered, procedures performed and basic information is delivered quickly. Things changed based on the hospital, trauma centers are better prepared to accept these patient types for example.

ASROC is in a better position to fill specific details for you, especially in a major metro environment.

One suggestion: Readers assume a lot due to all the medical and police/fire TV shows, much of which may or may not be realistic. The reader tends to judge your description better if you make a mention of something like "It's not like on TV, in real life everything is messy and confusing." or, "Heck, in the movies we would just stab him with a needle and he would get up and walk away." Or so I had an editor tell me...

Hope it helps.

Jeff

Okay, here I am. Let's see if I can get this to work right on the first go.

Los Pollos Hermanos said:

Jaws of Life can take a while to arrive here (so I'm told), even in cities - hence my wrong assumption.

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Well, I'm not going to claim it can't ever happen, but I don't think it ever did in my career. It's kind of like the firefighters showing up without a hose.

Los Pollos Hermanos said:

1). If the Manhattan crash occurs at 3.55pm, for example, approximately how long *might* it take for the JoL and an ambulance or two to arrive? Five minutes? Ten?

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We'd try to gun for 6--7 minutes for priority 1 patients and usually this worked out pretty well. If FDNY is anything like my service Fire is both better funded and better staffed than EMS, so they tend to beat us to the scene *grumblegrumble* 15:55 is early rush hour, but if this isn't happening on a major artery five to ten minutes should be fine.

Los Pollos Hermanos said:

2). How long *might* it take to cut into the car? Would the JoL just remove the side, or would it also cut away the roof?

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The Jaws of Life is actually a set of hydraulic tools, not just one thing; spreader, cutter, ram. Well-trained firefighters can cut the door posts, pop open the door and roll the roof back within just a few minutes, but it depends on things like the nature of the accident (car sitting the right way up will be easier than car hanging off a bridge), the type of car (some are sturdier and more difficult to cut) or how hazardous the scene is.

Los Pollos Hermanos said:

3a). How much would Paramedic A be able to do in way of assessment/treatment from the back seat?

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Quite a bit. Again, it's a bit dependent on the circumstances, but you can take vitals, do much of the physical assessment, especially around the head, start IVs and provide oxygen. Intubation is a lot more difficult in this position. It's not impossible, but requires a very experienced medic. A note though, if the scene is not safe until the firefighters are done, e.g. a high risk of explosion or fire due to leaking gas or something, the medics might stay out for the time being. The EMTs' safety trumps the patient's and we're not supposed to enter an unsafe scene. In practice, well...

Los Pollos Hermanos said:

3b). What else would they do once given direct access? I suppose the remaining stuff already mentioned?

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Yup, pretty much. They might also splint the injured extremities which I forgot to mention before.

Los Pollos Hermanos said:

4). Would Mr Fed be covered with a space blanket? I've been to NYC in August and it was swampy hot!

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Keeping the patient warm is important, especially if he might be in shock, like Mr. Fed with his internal injuries. With a trauma patient you need to check under, and often remove, the clothes to make sure you're not missing anything. After that you keep the patient nice and toasty.

Los Pollos Hermanos said:

5). Would they give him painkillers? If so, which one(s)?

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Not automatically, but if indicated, it's certainly an option. In some scenarios certain painkillers are contraindicated, such as head injuries. It's possible that they need an order to administer some of those meds, meaning they have to get permission from their medical control, a physician who supervises EMS operations. EMS painkillers are usually opioids. Morphine is very common and many services also carry stronger narcotics (we have Fentanyl, for example.) If it's a big hassle and their ETA is short they'll try to avoid it and let the hospital handle it. With this patient, especially his head and lung injury, they'd have to be very careful and if they do administer a painkiller they have to monitor very closely.

Los Pollos Hermanos said:

6). Not quite sure how to word this, but how would the less obvious of these injuries present themselves to a paramedic? What would s/he "find" to make them think some of these injuries could be present? I know the patient's condition can fluctuate from minute to minute - what deterioration might be seen over the course of 5-10 minutes? Every case is different, I appreciate that, but a realistic scenario to include would be great.

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Ok, let's see. Linear skull fractures often aren't really a big problem in an emergency setting, so chances are nothing's going to happen in that area until a doctor can take a look. A cerebral contusion can present with numerous signs and symptoms, many of them typical for neurological impairment, such as memory gaps, blurred vision, slurred speech, nausea and vomiting, seizures, confusion, pain, movement impairment and lapses in consciousness. Although sometimes it doesn't and that can end up being fatal. In the field without diagnostic imaging a medic can't really assess what exactly is wrong with the patient's brain, but she can usually tell that there is a problem, so she'll keep track of how the patient progresses and relay that information to the ER staff.

Broken ribs--pain and difficulty breathing, even more so if a lung is punctured. That doesn't automatically mean the lung has also collapsed, but it might. You'll listen for atypical breath sounds through the stethoscope, monitor the patient's blood oxygen level and watch for increasingly labored breathing.

The internal injuries are difficult to assess in the field. Pain is common, and if those injuries have caused significant internal bleeding there should be changes in the patient's blood pressure (drops), respiration (increases) and heart rate (also increases.) He'll also become pale, start to sweat and become increasingly confused and lethargic. Can't really be treated by EMS beyond fluid replacement, but it has to be monitored and documented.

Los Pollos Hermanos said:

7). Mr Fed is a healthy, active 32-year-old. If we assume he has average blood pressure and an average pulse rate, what sort of values *might* he be showing 10-15 minutes after the crash? What breathing rate *might* he have with this type of chest injury?

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A penetrating lung injury like that could cause BP and oxygen level to drop and pulse and breathing rate to increase. The BP drop especially if there is significant hemorrhage. The BP might drop below 100 systolic and the patient might become tachycardic (pulse rate of over 100) and tachypneic (more than 20 breaths per minute).

Los Pollos Hermanos said:

8). Mr Fed is making no sense, just the occasional garbled word or two. How else might the paramedics glean info from him? And, would you use the GCS?

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If there's no information to be gathered from the patient and there aren't any bystanders who know anything about him, then we just have to make do with what we can physically find.

Los Pollos Hermanos said:

9). When Paramedic A relays information - does it go to 911 dispatch or to the ER they'll be taking the patient to?

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The ER. During a typical call the only information you relay to Operations after you've been dispatched are status updates: we're on scene, we're en route to the hospital, we're clear and back in service, that kind of thing. (That's excluding things like more pertinent information coming in or the unit requesting backup and such.)

Los Pollos Hermanos said:

10). I've found information where they'd say things like "32-year-old potentially unstable male", and then give details of his injuries. I feel like I'm asking you good people to rewrite my chapter for me, and this part is especially aimed at asroc, but what would you say about Mr Fed when you radio through to whoever? I can tweak it, btw.

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Disclaimer: like many routine radio conversations there may be region-specific variations. It could be along the lines of "We're en route with a 32-year-old male patient, penetrating lung injury, suspected skull fracture and traumatic brain injury, multiple fractures [etc.]. Patient is in respiratory distress, disoriented with repeated loss of consciousness, GCS of [number, this is especially important if the GCS is bad, which it would be with this patient (9 or lower).] We started two IVs, he's on oxygen
[list major interventions you've done, such as meds, intubation, needle decompression and so on.] ETA is [time they think they need until they arrive at the hospital.]

You want to keep it short and only mention what the hospital really needs to know to prepare for the patient. You'll give a more detailed report when you transfer care.

Los Pollos Hermanos said:

If you ever need a kidney, just let me know...

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Well, mine still work pretty well but it never hurts to have a spare. *makes room in freezer*

I'm a firefighter...

Basically in terms of the extrication itself, the firefighters would first survey the scene for their safety (look for fuel leaks, power lines, etc). Normally the fire crew is in control of the scene and the paramedics/EMTs are responsible for the patient. Most firefighters these days have a great deal of medical training though and can assist the medics in their work. Usually it is EMS who assesses the patient and decides who's coming out first in the event of multiple patients. Fire tells EMS how they can cut into the car and between the two teams, they decide how best to get the person out. You're often looking at 20-30mins for an extrication if it's at all complicated.

Before doing any cutting, the vehicle has to be stabilized in some way. Usually this means putting 'cribbing' under the frame of the vehicle. The goal is not to actually lift the vehicle, but to keep it from rolling or rocking while it's being cut. Cribbing is usually wooden blocks of various sizes and lengths. 2'x4's, 4'x4's etc. During the cribbing process, a firefighter or medic will be standing in front of the patient, making eye contact and telling them what's going on if they're conscious. The goal is to keep the patient calm and keep them from moving. When the vehicle is cribbed, all the glass must be removed from the vehicle. In an ideal situation, the window furthest from the patient is broken, then a firefighter or medic enters the vehicle and begins patient care. NO ONE ENTERS the vehicle until it is stabilized. They are both usually covered by a tarp to protect from glass and debris, and some form of hard shield (either wood or plastic) is used as well. These are usually lightweight and will be held by the medic inside or someone outside depending on the situation. Every time glass is broken, the firefighter doing this must yell 'breaking glass!' or whatever is taught in their FD so the medic and patient inside will know what's going on. The medic will be explaining all this to the patient, again to keep them as calm as possible.

As mentioned above, the 'Jaws' are actually an assortment of tools. The tools will be laid out in easy reach, but not too close to the car when the Rescue truck arrives. A hydraulic pump runs all this equipment. The two most common extrication procedures are door removals, and roof removals. Considering the fact that a large vehicle has hit a small vehicle's door, it's hard to say what procedure would work best here. Depending on how/where the patient is tangled, it might make sense to make entry through the passenger door, if it is accessible around the light pole. If the driver's door isn't too smashed, then that would be the most likely option. They'll create a 'purchase point' with a hallogen bar or something similar, just above the bolt that holds the door latch. This creates a little hold for the 'Spreaders' to go in. The spreaders will pop the door latch open, and from there the door hinges can be cut with the cutters and removed entirely.

If the patient's legs are trapped under the dash, relief cuts will have to be made into the front of the vehicle, then either the 'Ram', or spreaders will be used to lift the dash and allow the patient to be removed.

This process is loud, intricate, and very organized. The goal is to get the patient out as quick as possible, while doing everything possible to not freak the patient out, or cause them more pain. The medic will do what they can to stabilize the patient while in the vehicle (stop bleeding, monitor vitals, often place the patient on oxygen, etc), then ultimately they'll be moved from the car onto a backboard. The goal of an extrication is to create the amount of space needed to neatly slide the patient out of the vehicle onto the backboard so they don't sustain further injury.

Typically the medic would be in the back seat behind the patient. The tarp is usually a literal blue tarp. The shields come in a variety of shapes, styles and materials. Some are plywood, some are clear plastic, some are other colors of plastic type material (they may be made of other materials other than plastic, but they feel plastic).

http://www.slideshare.net/whitmaha/vehicle-extrication Found this page with a lot of interesting stuff. Was trying to find pics of a shield, but I couldn't, sorry.

Well, shit, I write an answer and forget to post it. Sorry about that. Not sure I deserve the liver.

Los Pollos Hermanos said:

1). Would a Fedmobile SUV, assumedly built like a tank, take longer to cut into than a soccer mom version?

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Presumably? I'm not very well versed in non-SWAT fed vehicles. Is this guy a regular field agent?

Los Pollos Hermanos said:

2). Would it be possible for a small, wiry paramedic to somehow climb through from the back seat to the front passenger seat until the JoL give full driver's side access? The front passenger door is slammed up against a lamppost, but the back passenger door can be opened.

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We tend to work from the back seat in such situations, but in general, yes. *is 5'2" (that's 157 cm for the metric types)*

Los Pollos Hermanos said:

3). Checking Mr Fed for injuries. I assume they'd take off his seatbelt, loosen or remove (cut?) his tie and open his shirt to check his chest and abdomen? Then cover with the space blanket?

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They could just shred everything. A good pair of trauma shears can cut seatbelts, clothes and even pennies.

Los Pollos Hermanos said:

4). Mr Fed isn't really answering questions. Would the paramedic "gently prod" (bad words! haha!) his chest/abdomen to see if he responded to that? Would you see any marks to suggest there may be internal injuries?

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Shoulder shake is the typical approach. If the patient doesn't respond to that it's time to check a response to "painful stimuli." A very popular technique is the sternum rub where you rub your knuckles over the patient's sternum, as the name implies. Try it on somebody you don't like.

Due to its rather harsh nature the sternum rub has to be used with caution, though, especially if the patient has a chest injury. The best painful stimulus in such a situation is probably a squeeze of the trapezius muscle in the shoulder.

With blunt trauma you may not necessarily see anything suspicious at first, but you should always suspect internal injuries with this kind of mechanism of injury.

Los Pollos Hermanos said:

5). His left lung has definitely collapsed. How long does this take to happen and then for the effects to really show?

6). There's blood everywhere from the scalp laceration (I remember when a friend cracked her head open at primary school - an inch long gash turned the place into something you'd see in a horror film). Would you apply a dressing to stanch the flow?

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Eventually. Despite their dramatic appearance scalp lacerations are usually not life-threatening. You don't need a lot of blood to make a huge mess.

Los Pollos Hermanos said:

7). If I have his blood pressure as 83/51 (my most recent resting blood pressure - always been low - runs on Dad's side of the family - dread to think what the reading would be if this ever happened to me - not in a rush to find out), his pulse as 114 bpm and 27 breaths per minute, does that sound feasible for 10-15 minutes post-accident?

8). Would his breathing be very shallow so as to minimise pain from his broken ribs? Would the paramedics, if really concerned, insert a chest tube at the scene or inside the ambulance or see if he'll be okay until he reaches the ER? If pre-ER how long does it take for breathing to improve after tube insertion? Would he cough up any blood at any point?

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There isn't really anything that quite causes the same amount of panic as not being able to breathe. In that situation pain is secondary. He'll try to get as much air as possible.

Chest tubes are inserted in the hospital. In EMS we use needles. It's a somewhat risky procedure so you only want to do it if you're sure the patient needs it (reasonable suspicion of a tension pneumothorax, which is immediately life-threatening), not as a precautionary measure. A regular pneumothorax doesn't necessarily need immediate treatment.

Coughing up blood is possible.

Los Pollos Hermanos said:

9). Would you clip a pulse oximeter onto his (index?) finger to measure oxygen saturation? What sort of values might you expect to see ~10 minutes post-accident with these injuries?

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Is he already being treated at this point or is that when the medics first get access to the patient? If it's the latter you could easily see an SpO2 in the 80s (not cool.)

Los Pollos Hermanos said:

10). Neuro stuff. I have this idea that he's semi-conscious for ~30 seconds after it happens, unconscious for ~15 minutes, sort of comes round for ~5 minutes and then loses consciousness again. Is this feasible, or shall I knock him out cold from the moment of impact?

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Possible. Brain contusions can have very diffuse symptoms. An initial loss of consciousness is common. The repeated loss of consciousness is certainly worrisome.

Los Pollos Hermanos said:

11). GCS stuff.
Eye opening response: Only opens eyes to pain (e.g. when they put IVs in or splint his arm and leg), so assume that scores 2?
Verbal response: He's mumbling stuff at times, but not making sense. They can make out the odd word like when he mumbles his wife's name, but doesn't respond when they ask if she's his wife (or respond to any other questions) - would that score as 2 or 3?
Motor response: Would they do the press on the fingerbed thing rather than the eye notch pressure seeing as he's got a head injury? If so, he'd try to move his right hand away (other side has the compound fracture), but not do a very good job. Certainly not any strong purposeful movement. Would that score 4?

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E2 V2 M4 sounds about right. The problem with the finger squeezing is that it's a peripheral stimulus that might be misleading because it could a cause a spinal reflex without the signal ever being interpreted in the brain. So we've been moving away from that. Other central stimuli are mandibular pressure (not so good here) and the aforementioned trapezius squeeze.

Los Pollos Hermanos said:

12). Before he passes out for the second time he throws up. I've written it that he manages to drag the oxygen mask off his face, but in reality I reckon he's too out of it to even consider doing this. A bit grim, but what happens in such a situation? (I'm not good with puke!)

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Hopefully the medics are paying close enough attention to realize he's about to hurl. If not, well, time to swap masks. If he passes out right after they might use suction to get all the debris out of his airway. The noise is about as appetizing as the procedure sounds.

Edit: Bizarrely enough I actually had to think about this, but it's lamppost. I'm almost certain. (Wtf?)

"Mr Fed is a healthy, active 32-year-old. If we assume he has average blood pressure and an average pulse rate, what sort of values *might* he be showing 10-15 minutes after the crash? What breathing rate *might* he have with this type of chest injury?"

If he's going into shock (and I didn't read every word of the excellent replies above--got edits to do), his blood pressure would fall and his heart rate increase. So if he's pretty fit already, his normal heart rate would range in the 60-72 range while resting. His heart rate in shock might climb to 110, 120. He's lost a lot of blood, skull wounds bleed like crazy. The chances are that he may be bleeding also into his brain or lungs (I don't like the repeat loss of consciousness). Loss of awareness is abbreviated by US medical types as LOC (I read medical records and code them as my day job, and the Glasgow Coma Scale is definitely used, both by the first responders and by the docs in the ER). His normal blood pressure, let's say 120/70 since he's in good physical shape, will fall with shock. If he's getting critical, it might tank to the low 90s for the upper number and maybe 60 or under for the lower number. If they take his B/P repeatedly, as they would in a trauma situation, if they can no longer read out the lower (diastolic) number with their cuffs, it means he's getting very critical and they'd report the number as "60 systolic."

HTH -- you've got some most authoritative answers up above and I can do no more than add small detail.

Trauma patients do vomit without much warning, and don't necessarily "feel sick" or tell you about it if they do. They simply hurl. Then the paramedic's concern is aspiration, and she'll clear his airway without further fuss.

86% 02 sat if he's struggling to breathe seems pretty high/decent to me. I'd like his sats after oxygen is administered to come up to high 90s. I'd get really fussed if his sats didn't go back into the 90s once he's on a pretty high oxygen concentration (say, 4 liters? Correct me, pure medical types, if I'm wrong about the concentration). You might even show his ambient-air sats to be lower than 86%, just to dramatize how unstable they find him at first.

As far as the IV placement, I've seen them come in with the IV pretty much anywhere they can reach. If your small, skinny female EMS can reach his hand, yeah, definitely.

Take this with salt -- more experienced parties than I may correct the above, and rightly so.

IV would probably be normal saline. I'm not sure what beyond that is carried in the vans by paramedics. Ringers', maybe? I'm pretty certain they carry 5% dextrose in water. If they have even a suspicion of him being shocky, fluid resuscitation is an easy call and something all parameds are allowed to do and capable of doing. In some towns, an IV is mandatory in the field even if you're transporting a patient with a cut on his hand.

The more experienced will weigh in on the other factors you've mentioned. But I believe first, Small Skinny would call him (even if it's just "Sir! Sir!") to see if he hears and responds verbally, before doing the shoulder shake.

Let's see if I can get this to work again.

Los Pollos Hermanos said:

Trapezius squeeze: What sort of response would Mr Fed make to score him a 4? Would trying to move his hand when an IV is inserted also score a 4 for M?

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4 means there's a physical response to the stimulus but the patient doesn't really locate it. If you feel some pain somewhere and directly and purposefully move your hand there, that's a 5. If you try to move away from the pain, but don't seem to be able to find the source, that's a 4. What reaction corresponds to what number for the GCS can be pretty fluid of course, and it requires a bit of experience.

Los Pollos Hermanos said:

IVs: Would a second one be inserted? If so, where? I assume the first one would be inserted in the back of his hand? Would it be normal for him to try to pull his hand away?

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A second IV is very likely if there is suspicion of hemorrhage, especially internal (and with this patient's MOI there is.) In EMS we try to avoid starting IVs in the hand. The hand is a floppy place and with the patient moving around and the medics moving around the chance of accidentally tearing it back out is higher. Plus the veins have gotten pretty small in the hand and that's less than ideal if you quickly need to infuse a large amount of fluid, such as with a patient in shock.

Note though that protocols in EMS may vary depending on where you are and what the current standard accepted there is. Much of what works in EMS is only decided by doing something for a while and see if it works, and sometimes it turns out that well-established procedures don't really do much good. But it can take a very long time for any of that to actually make it into the protocols. So you have a situation where many agencies will backboard just about every trauma patient while other departments are using their boards a lot more sparingly and allow medics to clear spines in the field and where many agencies will aggressively treat shock by pumping as much fluid into the patient as possible while other agencies have adopted permissive hypotension, i.e. they will only increase the blood pressure to a comparatively low number (~ 80 systolic) and keep it there. Research has shown—this research is very new—that patients don't necessarily benefit from large amounts of fluid so my old service has started to be more restrained when starting IVs, meaning if the patient is not in serious shock he might end up with just one. (Considering our location my agency takes pride in being on the absolute cutting edge of medicine. This is new!? Awesome, let's do it!)

Los Pollos Hermanos said:

Throwing up: What clues that his late lunch is about to put in a guest appearance might Mr Fed give to the paramedics? Or, can it happen that they just throw up with no warning? *Big Cringe*

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Gagging, for example. Depending on the level of consciousness, moving their head to the side and trying to remove the oxygen mask. But, yeah, sometimes it's just "Hu-huuuuurgghhh..." "Aw, shit."

Los Pollos Hermanos said:

Cheers for the extras, which prompt a couple more questions:

1). How low could his O2 saturation have dropped if he's been struggling to breathe for the best part of 15 minutes (since the crash) until the paramedics are allowed into the stablised vehicle?

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Between low 80s down to 60% maybe; it's a little difficult to say and depends on the size of the pneumothorax and other factors. Below that and you have serious trouble. (I would also advise a number somewhere in the high 70s to low 80s simply because the effects can get pretty weird the more hypoxic you become and it'd just be difficult from a storytelling perspective.)

Los Pollos Hermanos said:

2). He's really struggling to breathe. Even with breathing in a high oxygen concentration would his sats go right back to normal levels?

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If he's really struggling to breathe he will be breathed for. With a so-called bag valve mask/BVM/ambu bag that forces air into the patient and, if he's losing consciousness, also with an endotracheal tube. Unfortunately collapsed lungs don't make this any easier, so you have to be careful.

Assuming he has a simple closed pneumothorax and no other airway compromise his SpO2 could go back to >90% fairly quickly.

Los Pollos Hermanos said:

I'm now re-writing the "in the car" scene. Small skinny female paramedic is now on the front passenger seat, one is behind holding the tarp and shield, another is next to her stablising Mr Fed's cervical spine and the fourth is passing equipment through to SSF paramedic in the front.

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That's a lot of bodies doing a lot of stuff below their qualification (I'd say pay grade but who am I kidding?) Holding c-spine, handing equipment, holding the tarp, that's all stuff firefighters can do. And barring extraordinary circumstances you're just not going to get four paramedics for one patient.

So, assuming the standard issue of two, one goes in. Checks, patient is breathing but in respiratory distress, only obvious source of hemorrhage is scalp wound. Patient doesn't respond coherently to verbal command or regular touch, but does respond—somewhat—to pain. Medic quickly examines head and neck of patient and applies c-collar = no more need to manually stabilize the spine. Medic administers oxygen and continues examination. (High flow oxygen in EMS is 10–15 liters/min via nonrebreather mask (the one with the green strap that goes over nose and mouth.) If the patient should have to be manually ventilated with the aforementioned BVM that gets turned up all the way to 15l.) How much clothes get cut off during this process depends a little the circumstances, how easy the patient is to reach, how soon they can expect to extricate him and so on. There aren't really any hard and fast rules on this beyond "Make sure you've checked everywhere."

The trauma assessment contains, among other things, the neurological assessment, both asking questions and checking whether or not the patient has sensation everywhere (obviously somewhat hindered by the patient not responding clearly), blood pressure (can initially be taken manually, with an arm cuff if patient has an usable arm, and a stethoscope, or by palpitation if it's too noisy), pulse and breathing rate. You count respiration just by looking and counting every time the patient takes a breath, also noting the quality of the breathing—irregular? shallow? labored? abnormal noises? Ideally you want to do this without the patient realizing that you're assessing his breathing, so a popular method is to do in conjunction with pulse: just continue holding the patient's wrist as if you're still taking the pulse while you count. Some people might move the patient's hand onto his chest so they can feel the respiration as well. With a bit of experience you may even be able to take pulse and respiration at the same time.

While IVs and intubation can both be done while in the car it is preferable to extricate the patient first. The more tubes are attached to the patient the more difficult it gets to get him out. So assuming Fire is finished they extricate the patient, secure him to backboard or whatever their immobilization technique du jour is (if patient is considered stable they might have immobilized him with a KED, which is a rigid wrap kind of thing that you can strap the patient's torso and head to while he's still sitting, but I don't know what FDNY's protocols are in that respect.) Move patient to ambulance, get rolling. Start IVs. The standard fluid is normal saline or lactated Ringer's. LR is somewhat better suited for a trauma patient, but in this case it shouldn't really make a difference. Any IV meds can go in through the IV port. The preferred site is the forearm, the elbow crease if that doesn't work, or, if necessary, the leg. Attach cardiac monitor, which conveniently also measures blood pressure and O2 saturation, and keeps track of them for the medics.

Los Pollos Hermanos said:

He then comes round and I'm okay with what happens next. Shoulder shake, trapezius squeeze, not much response, breathing getting worse, blood pressure dropping, etc, etc. The scene ends with them getting him out onto a backboard as another paramedic radios through to the ER that they'll be on the way in a minute. ?????

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We typically do not talk to the ER until we're already on our way and can estimate how long it'll take until we arrive at the hospital (usually a few minutes out.) The point is to give them enough time to prep for the patient, but if you're still on scene they don't care. You tell dispatch you're on your way, not the ER. (Or, if you have nifty technology that actually works, you can just press a button.)

Los Pollos Hermanos said:

I really appreciate all the time you've taken to explain things so clearly and in so much detail. Feel free to harvest any of my organs! Use them, sell them on eBay, whatever...

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Cool. Now how about you just lay down on that table over there; this won't hurt at all.

According to what I've seen reported in records, they'd intubate in the field if there's the slightest doubt he'd hold together till the ER.

As far as the lift, I've seen 3-4 people do it comfortably on a backboard. In the ER I worked in when I was young and strong and stupid, I often participated in three-person lifts on a blanket. I wouldn't try it now at my age.

Los Pollos Hermanos said:

1). Would Paramedic B be passing stuff through to Paramedic A (the small skinny female) from the back seat, or would Paramedic A have it all with her already?

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She should have most of her stuff with her, however it depends on how easily she can maneuver in there, i.e. it may be more convenient to get into place and then have someone hand her the bulkier stuff, like the c-collar or the oxygen tank (would probably be better if that were kept outside anyway.) (This is a lot more difficult without actually seeing the scene...)

Los Pollos Hermanos said:

2). Would Mr Fed look cyanosed-ish with oxygen sats of 79%?

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He could. The thing about numbers in medicine is that they're all approximations and ranges. Not every patient goes below 80% and boom, cyanosis. It is usually most prominent between 80 and 60%, though.

Los Pollos Hermanos said:

3). Mr Fed throws up and passes out seconds before the firefighters finish the cutting side of things. I assume the paramedics would "clean up" before moving him onto the spinal board and into the ambulance? Would they intubate him in the ambulance based on the fact that he's lost consciousness again and his breathing is really laboured, or hope he holds out until the ER?

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Intubate in the ambulance. A patent airway is the very first thing we're concerned about.

Los Pollos Hermanos said:

4). How many people would be needed to lift Mr Fed out of the SUV and onto the board? He's around 6'0" and medium build.

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You can do it with two if you don't like your spine, but three or four people would be better. (Fire will help, it makes them feel heroic and useful.) The books will always advise six, but dream on... (The patients in those pictures are always clean, too. Pfft.)

Los Pollos Hermanos said:

** Blue lights and two-tone siren - UK term - what's the US equivalent (if there is one) just out of interest?

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Isn't really. Lights and siren. We don't have two-tone sirens and light colors vary. Fire and EMS are generally red and white (sometimes with amber) while blue is mostly a police color (I believe NYPD is also red and white, though.)