5 scene size-up tips for EMS providers
You are the first arriving unit to a potentially chaotic scene; does your scene size-up for other units measure up?
The scene size-up is performed as units first approach their call. While the activity is part of most EMS training programs, it is often limited to the student asking: "I perform my scene size-up, what do I see?" and then being given answers by a well-meaning instructor looking to move the scenario along to the "important clinical part."
On the job, very few calls present consequences for the responder if a thorough scene size-up is not performed; as a result, providers become complacent and out of practice. All skills in medicine fade with disuse and many providers weren’t proficient at a scene size-up to begin with. More often than not, a cursory size-up is performed and rarely is it communicated to other responding units.
Here are five tips for a more effective scene size-up to inform other EMS providers and initiate effective incident management.
1. Practice makes perfect
Standardization is one of the common ways to increase safety and reduce the chance of an error. Many new EMS providers are advised to perform their history and physical exam the same way every time to reduce the chance of missing a portion of the assessment.
If you’re sitting at post or clearing a call, listen in to your fire department colleagues on their radio frequency. Whether for a structure fire or a motor vehicle collision, chances are the company officer will provide the same type of information in the same order every time. Often these assessments are standardized throughout the department. As a result, the next-arriving apparatus has a good idea of what to expect and what tasks to accomplish when pulling up to the scene of a fire or other significant incident.
While you certainly don’t need to provide a scene size-up over the radio for every medical call, practice surveying the scene for hazards, a general impression and ingress and egress routes on every call. If you find something, make a note of it. On incidents where you suspect you may need additional resources, provide the size-up over the radio so your next EMS units know what to expect. Practicing a scene size-up on every call and broadcasting it when necessary helps to standardize your size-up and keep you sharp for an incident when that information is important.
2. Communicate early, communicate often
As a general rule, EMS providers entered the industry to care for the sick and injured. As a result, on scenes where a size-up is most important, there are likely one or more patients who could really use your help. There is a drive among EMS providers to render aid as quickly as possible and while that goal is admirable it can get you into trouble.
On most medical calls, you can practice your scene size-up when approaching, parking, getting your first-in equipment and walking to the front door. On larger incidents, however, particularly those when a size-up should be relayed over the radio, you need to fight the urge to rush to the aid of the first injured or sick person you see and take a moment to collect your thoughts. Your initial report of general impression, mechanism of illness or injury, hazards, ingress and egress routes and staging locations sets the stage for a successful incident. Your first communication after arriving on scene is extremely valuable.
Once you have provided an initial size-up, be diligent about updating dispatch and other arriving units as information becomes available. In the early stages of an incident, it is good to get in the habit of communicating back to dispatch every five minutes or so even if there isn’t an update. This practice will keep you aware of the need to communicate and can help you stay on track.
3. Safety first
Among the other often-recited phrases in EMS education is "scene safety, BSI." Think about all of the nearly automatic ways EMS providers protect themselves on a daily basis. Crews generally park at an accident scene so that a wayward driver would strike a heavy and unoccupied fire engine before the crews or the ambulance. In the winter, you may back up a patient’s driveway so that you don’t have to navigate a loaded gurney down a sheet of ice to the ambulance.
While you probably navigate these risks without giving them a second thought, consider communicating what you see to your partner, other crews and, if appropriate, to dispatch. This will help everyone stay in the habit of maintaining situational awareness and may point out areas of risk no one but you was aware of. Additionally, establishing a regular practice of identifying potential safety concerns on every scene will make you more likely to identify those concerns on a call where substantial risk exists.
4. A way in and a way out
Identifying ingress and egress route serves both as a convenience and as a means to ensure provider safety. On a standard call, your ingress route is generally whatever street you happened to be driving down to get to the address and your egress route is simply continuing down that street but with a patient on board. In some cases, however, establishing ingress and egress routes may occur in conjunction with fire and law enforcement colleagues and communicating that to other units could be the difference between a successful or unsuccessful incident.
Think of a motor vehicle collision southbound on the freeway north of your regular service area. If all the other units driving north take the freeway, they will be caught in heavy traffic behind motorists slowing to watch you work while waiting for additional resources. If, however, you are able to convince law enforcement to shut down southbound traffic, your additional units may be able to arrive more quickly and assist you more readily. If this routing is not specifically communicated to ongoing units, they won’t know how best to arrive at your scene. It takes a provider practiced in identifying the aspects of a given scene — and skilled at speaking with law enforcement — to develop and implement a plan like this.
Identifying and establishing an egress route is a means to keep patients flowing in one direction during an incident but also provides EMS crews with one or more ways to depart quickly if a scene becomes unsafe. Consider when approaching a scene how best to get back to your ambulance if you need to evacuate and how best to get your ambulance a safe distance away from the scene. Consider the width of streets, choosing well-lit routes and how to find your way back to major, familiar roads most quickly.
5. Ask for help
This tip actually serves two purposes. On scene when performing the size-up, close your initial communication to dispatch with a request for resources based on the estimated number and severity of patients. This means that you may cancel or downgrade responding units later as triage continues. Nothing confuses a request for resources more quickly than asking for "one more ambulance" several times in quick succession. You will lose track of what you’ve asked for and what is on the way and so will dispatch.
The other interpretation of this tip is to find someone within your agency or a partner agency who provides these types of size-ups regularly over the radio and ask them to mentor you. A company officer from a local fire department may be a good resource to get you in the mindset of practicing an effective and consistent size-up. Remember that standardization is an excellent risk mitigation strategy.
You arrive on scene and survey the incident. The police department appears to have the altercation under control and has established a line protecting the injured patients. The aisles in the parking lot are narrow and the lot has only one way in and one way out which requires driving around hundreds of parked cars. You elect to park just outside the lot and have the fire department extricate patients from an informal casualty collection point to your location. As your partner exits the ambulance with a stack of triage tags, you begin your size-up report for dispatch:
"Medic 4 on scene of the University Incident, Engine 7 will be establishing University Command. We have approximately 12 patients injured in a fight involving about 20 people. Law enforcement is on scene. Please start four additional ambulances and a supervisor to this location. Advise incoming units to approach westbound on University Avenue and to line up alongside Medic 4. The egress route will be to proceed on University to Maple. Triage is ongoing and I’ll advise in five minutes with an updated patient count, do you have any questions?"
What are your scene size-up tips?
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