The first few minutes of any complex scene, especially a car accident, are critical. Emotions are high and the environment is extremely unforgiving. The priorities we address or fail to address in those first few moments guide the direction of the scene for the duration of the call.

Some priorities can dramatically impact our safety and the wellbeing of our patients. But what should you do first? It can be tempting to rush to the first injured person and begin patient care. Instead of getting lost in the confusion, take a deep breath and remember to ask and answer these six questions.

1. Does everyone know the safe operating area?

Some EMS actions can dramatically impact provide and patient safety. (Photo Greg Friese)

As a firefighter, operating on an accident scene in a roadway is one of the most dangerous things I do. I’m far more likely to be struck by an inattentive motorist than to be injured on a ladder or inside of a burning building.

Use emergency vehicles to create a safer working area on your scene and make sure everyone is aware of the designated working area. Often, just saying it out loud is a good reminder to everyone to stay inside the designated protected area. Walk facing traffic whenever possible and watch out for your crew and civilians.

If you don’t have an assignment, step back and watch the scene. If traffic is erratic or the scene protection is less than ideal, consider posting a lookout to watch for oncoming traffic and yell a warning if a car fails to yield for your warning lights.

2. Can I account for every occupant from every vehicle?

Knowing exactly how many people were involved in the accident should be one of your first priorities. It’s also a task that can easily get lost in the initial chaos. In many cases, individuals who may have been occupants are mistaken for bystanders and witnesses. Worse yet, occupants thrown from the vehicle may not be seen at all. Check out this state trooper's dashcam video of a semi colliding with a stopped vehicle.

A great initial question is, "How many people were in this vehicle with you at the time of the crash?"

If the answer is anything other than, "Just me," ask the patient to identify who else was with them and where they were in the vehicle.

Unoccupied infant and child car seats are a huge red flag. Even if a patient states that they were alone in the car, I’ll point to the empty car seat and ask, "Where is the child who normally rides in that seat? Where are they right now?"

When presented in that way, we force the patient to ponder the actual whereabouts of their child instead of offering a simple yes or no. While it may seem overly cautious, I find most parents welcome my concern over the safety of their child.

3. Are the vehicles secure and stable?

It’s easy to get pulled into patient care without examining the vehicle first. Adopt the habit of looking at the vehicle before you get drawn into an interaction with the patient. By now, you’ve likely heard plenty about mechanism of injury, compartment intrusion, skid marks and other potential injury indicators.

But one thing you might not be checking for consistently is the stability of the vehicle. Sure, a vehicle teetering in a precarious spot will catch our attention, but how about the cars sitting on relatively level ground?

Regardless of the apparent potential for movement, it’s a good habit to confirm that every vehicle is in park, the keys are removed from the ignition and the emergency brake is activated. In the rush and stress immediately following an auto accident, these details are frequently missed by the driver before exiting the vehicle. Before you begin patient care, make sure you have a secure platform to work.

4. Am I between the airbag and the patient?

Deployed airbags are often noted early in our scene size-up, but the airbags that do not deploy remain a hazard. Airbags can retain a charge long after the crash has occurred and still have the potential to deploy while you are involved in patient care.

Airbags can be located in the steering column, the door panel, the ceiling and the B pillar. It’s nearly impossible to perform a complete patient assessment without placing yourself in the potential path of an un-deployed airbag, but you should still make it your habit to avoid putting your body in these potential deployment zones for any longer than is necessary. Ask the firefighters stabilizing the vehicle and extricating patients if the risk of airbag deployment has been mitigated.

5. Are there flammable liquids present?

Many potential hazards are readily apparent when we approach an accident scene, however, flammable liquids are not always so obvious. Avoid standing or walking in gasoline and other petroleum products. Not only do they have ignition potential, they will off gas in the back of the ambulance. A medic unit that reeks of gasoline is uncomfortable and a possible respiratory irritant to the patient.

Mitigation of fuel spills on scene is typically the job of fire department personnel. If there is a large volume of fuel on the ground, consider waiting for them to mitigate or having the firefighters bring the patient to you.

6. Do any quiet patients need attention?

We typically don’t miss the noisy patients. They cry and scream; begging for our attention. When critical treatment priorities get missed in initial scene size-up and patient triage it is almost always the quiet (or unresponsive) patient that gets missed. Especially if there is another noisy patient.

Countless times, I’ve watched care providers fail to recognize critically injured patients because they were too focused on a noisy patient. Noisy patients typically (always?) have patent airways and adequate breathing. While a noisy patient may have critical injuries, never assume that the quiet occupants are quiet simply because they are uninjured. Often, the patients who require immediate intervention are as quiet as a church mouse. Make it your rule to figure out why the quiet patients are quiet before you explore why the noisy patients are noisy.

The first few minutes of a car accident scene can be chaotic and confusing. Our calming presence as we step out of the ambulance can often be the moment when the scene begins to shift from chaos to order. To begin with confidence, address these priorities. Create a safe working area, check for fluids and un-deployed airbags, account for all the patients on scene and check on the quiet ones first.

I think that you’ll find that a few minutes spent on these priorities will get the scene moving in the right direction. Leave a comment and let me know how it works for you.