CEU Review Form Scene Size-Up (PDF)Valid until February 1, 2008

Scene size-up is a vital part of any call, yet one that often doesn't get the attention it
deserves. In classroom simulations, students traditionally wave their gloved (or simulated
gloved) hands and magnanimously proclaim "Scene safety and BSI!" as if a magic wand could
be waved over the scene to make it free of everything from violence to microbes. If only this
were possible, or the scene size-up that simple.
The 1994 DOT EMT-Basic National Standard Curriculum lists five key components of the
scene size-up process:

Number of patients

Mechanism of injury/nature of illness

Resource determination (heavy rescue, hazmat, etc.)

Standard-precautions (BSI) determination

Scene safety.

The article will break down each part of the process with a focus on how it affects both our
safety and the smooth flow and disposition of the incident.
CASE SCENARIO
Your ambulance is dispatched mutual-aid for a motor vehicle collision in an adjoining fire
district. You arrive to find a small pickup truck has collided with a large dump truck loaded with
gravel. Four people are out of the pickup and ambulatory.
As you approach the patients, you walk by their vehicle. There is considerable intrusion into
the front end of the pickup. You notice the rear of the passenger compartment has only sidefacing jump seats, and you see the patients are two men and two boys. The local engine
company is holding stabilization on one of the men.
You get an initial report from the firefighters: five people involved. They don't believe the
dump truck driver is injured.
In this real-life scenario, a combination of crossed signals and crossed jurisdictional
boundaries caused considerable disorganization--and delay in patient care. The incident

commander thought the ambulance crew would handle the request for other ambulances. The
ambulance personnel felt they shouldn't call because they were in another district.
The initial triage really wasn't: The one patient who complained of pain distracted EMTs
from the other who was truly injured. The man with internal injuries denied complaints so EMTs
would take care of his son.
After a delay, fortunately brief, priorities were determined and additional ambulances were
called to the scene. Four patients were transported to hospitals; one refused. All survived the
crash--and the lack of triage.
The five steps of scene size-up, if followed here, could have prevented the delays and
disorganization. To properly size up this scene:

The first-arriving unit would have assumed command and provided a report on the
scene and potential numbers of patients.

Any hazards with the large truck would have been dealt with by the fire department.

Arriving EMTs would have more thoroughly considered the mechanism of injury. In this
case, the patients' vehicle was an older pickup truck without airbags. The front-seat
victims, given the significant mechanism of injury, would have received a higher initial
priority until injuries were ruled out.

EMTs and fire personnel would have worked together to call for enough rigs to handle
the number of patients on scene.

The dump truck driver would have been considered a patient, even if he were a signoff. Even the sign-off requires an assessment and paperwork.

A modified triage system would have been utilized to screen all patients for hidden
injury.

To ensure success on your next call, conduct a thoughtful and detailed size-up that includes
each of the following five components.
Number of Patients
We know that multiple-casualty incidents can range from two to hundreds of patients. In
fact, the term multiple-casualty incident evolved from mass-casualty incident because the
latter seemed to imply a need for numerous patients before invoking incident management
principles.

A motor vehicle collision with three or four patients can stress a small or rural EMS system-or even a large municipal system already operating at capacity. Furthermore, failing to identify
the number of patients and other challenges in the scene size-up makes it less likely you'll take
the necessary and appropriate actions once you begin patient care. Once that slippery slope
begins, time wasted calling for additional resources becomes painfully obvious.
It also pays to implement the Incident Command System. Simply designating an incident
commander and triage officer at smaller scenes is a worthy investment in time and resources.
Incidents are usually handled based on their numbers of patients. Multiple-casualty
incidents are often classified as follows:
Level 1: 2-10 patients
Level 2: 11-25 patients
Level 3: 26 patients or more.
Are you prepared to handle the small to medium-size incident? Is there an EMS Command
vest in the cab of the ambulance? Do you know where your MCI kit is and what's in it? A major
incident is not the time to become familiar with its contents.
Mechanism of Injury/Nature of Illness
Mechanism of injury has sent us a mixed message over the years. While the MOI in a
trauma patient helps us decide whether he receives a rapid exam and prompt transport or a
slower and more focused exam, experiences over the years can leave us skeptical about the
value of such determinations. Many of us have arrived at vehicle rollovers to find occupants
who have crawled out of the wreckage and are leaning against it and saying they feel fine.
Two concepts in mechanism of injury are worth noting. First, it's only one piece in a puzzle.
Matching the MOI with trends in vital signs and the patient's apparent injury is necessary.
Second, mechanism of injury is a one-way street. Patients with surprisingly unimpressive
mechanisms can still be seriously injured. Lack of significant mechanism can't be used to rule
out injury.
Airbags have changed the way we look at mechanism of injury. They reduce serious injury
in certain crashes, but can cause trauma themselves. Trauma from the steering wheel and

dashboard is still possible from secondary impacts. A thorough MOI determination involves
lifting and looking under the airbags for steering wheel or dash damage that indicates trauma.
The EMT curriculum mentions reconsidering the mechanism of injury during your focused
trauma examination. Rechecking the mechanism on the way back to the ambulance with the
patient will allow you to match injuries you've found with mechanisms that didn't make sense
or were initially missed.
Nature of illness (NOI) is the red-headed stepchild of mechanism of injury. We don't think
about this much, but remember, medical and trauma assessments are different. Medical
assessments are largely history-based, while trauma exams are predominantly hands-on. This
is how we get the best information for both types of patients. Plus, our first views in the scene
size-up give us an indication of how critical the patient is--or may be. This information is
filtered directly into the general impression. Patients with obvious chest discomfort, respiratory
distress or altered levels of responsiveness become higher priorities for care and
transportation.
Resource Determination
It is best to call for any additional resources as soon as possible--hazmat, extrication, utility
companies, wreckers or anything else you need to handle the scene effectively. In order to
make these determinations, the scene must be carefully evaluated before patient care begins.
Threats such as hazmat and downed wires should be recognized before you set foot outside
the ambulance. One clue to downed wires is an asymmetry of telephone poles as you approach
the scene.
Standard Precautions (formerly BSI)
Today decisions about standard precautions are commonly made before any observation of
the patient. Precautions are taken in the ambulance or engine and never thought of again.
The concept of the standard-precautions decision is based on seeing the patient and
determining what is necessary. Failing to do this frequently means taking too many precautions
(which is acceptable to some) but can sometimes mean not taking enough--and that's
dangerous.
Gloves and eyewear can be kept on a provider's person or immediately accessible in kits, so
they can be donned at the patient's side after evaluation of what's needed. Donning gloves

before reaching the patient may cause tears and loss of integrity resulting in subsequent
exposure to blood or other potentially infectious materials.
Should a patient suddenly deteriorate and require ventilation and suction, additional
precautions will be necessary. Unless providers realize that decisions regarding standard
precautions are dynamic and can change throughout the call, protection will not be adequate.
Finally, although it's heresy to many, precautions aren't necessary on every call. It is
conceivable that some calls may not require any protection--even gloves. Break the "Scene
safety and BSI!" routine and make your personal protection a thinking process, not a rote one.
Scene Safety
Before a discussion of traditional scene safety principles--principles which primarily involve
protection from violence--a look at how EMS providers die is in order (see Table 1). Over the
past three years, per the National EMS Memorial Service, 59 EMS providers have died in the
line of duty. Of these, three (5%) were killed by acts of violence.
Even a small number of deaths from violence is too many. But the point is that, whether by
collision or from events set into motion long before the call (such as heart attack), most
providers who die on duty don't die on scene. And remember, the Memorial Service only tracks
deaths. Each year many more are injured, some seriously, from the causes listed in Table 1.
While the following material on scene safety is pertinent and important, staying alive in
EMS is more than a tactical consideration. Care when responding to calls, in traffic and in
choosing a healthy lifestyle is equally important for survival.
OBSERVATION OF SPECIFIC DANGERS
Much of the scene-safety training EMS providers receive is focused on how to respond to
danger. Additional attention must be paid to prevention of danger through observation. Most
calls give clues, some subtle, that danger is likely. Observing these and preventing danger is
preferable to dealing directly with it.
The potentials for danger are endless, and observing for anything out of the ordinary at an
emergency scene, including unusual silence, is vital. Some providers talk of a "sixth sense" or
gut feeling that indicates danger. Experienced providers use these feelings in clinical

situations. There is a place for them in safety and survival. Many crime victims report feeling
something bad would happen before it did.
If you get this feeling, listen to it. Depending on your location, the nature of the call and the
help available at the scene, your actions may include anything from stopping to investigate to
calling for backup to retreating.
It goes without saying that drugs and alcohol are frequently involved when people do dumb
things--including assaulting cops and EMS providers. Remember that intravenous drug users
often carry their "works" (needle, tourniquet, etc.) with them. Assess these patients carefully to
avoid accidental needlesticks. Many addicts will tell you if they have needles. Ask before you
assess.
Hidden dangers of the drug trade include weapons and money. The money itself isn't
dangerous, but the lengths to which people will go to protect it are. It isn't unusual for people
to use booby traps to protect their stashes and cash, even in outdoor locations like marijuana
fields.
Drug labs pose another significant hazard. They may be operational, inoperative or
dismantled/discarded. Regardless of its condition, each lab is a hazard that should be mitigated
by hazmat and law enforcement personnel. Identify labs by chemical odors and trash
indicating the presence of chemicals. Inside you may find ventilation devices, heating mantles
and burners, and glassware.
Labs may be anywhere. They require utilities for light, heat and ventilation, and a location
that allows trash disposal and ventilation of chemical odors without causing attention.
Disassembled labs have been found in abandoned cars, trucks, trailers and storage units.
WHEN FACED WITH DANGER
Safety is best assured by preventing and avoiding danger, but there are times when this
just doesn't happen. In this event, immediate and decisive action will be required to assure
your safety.

Take a position of cover or concealment. Cover protects your body from bullets, while
concealment hides it without offering protection.

Retreating from danger is almost always part of a successful survival strategy. Get
distance, plus as many items of cover as possible, between you and danger.

Distraction will assist with retreat. Throw your first-in bag at an aggressor. Wedge your
stretcher in a doorway between you. Close doors behind you as you retreat.

As soon as it is safe to do so, radio for help. This will ensure you get the assistance you
need and prevent others from ending up in the same situation you did.

It is important to remember that what constitutes danger at a given scene may vary. We
talk a lot about knives and guns, but everyday items--and fists--are also weapons capable of
causing significant damage. Dangers are evaluated not just by weapons, but by the patient or
family's affect (e.g., hostility, aggression), the crowd and external factors such as previous
events at the location.
You will be choosing and executing these tactics and strategies under perhaps the most
stress you will ever face--a fight for your life. As important as the tactics you choose is your
desire and drive to survive.
CONCLUSION
The scene size-up usually takes less time than any other part of the assessment process,
yet the results have a profound effect on every portion of the call that follows. The five
components of the size-up--number of patients, mechanism of injury/nature of illness, resource
determination, standard-precautions determination and scene safety--are the steps to a
successful run.
CEU Review Form Scene Size-Up (PDF)Valid until February 1, 2008
Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. He
is the author of several EMS textbooks and a nationally recognized lecturer.
Joseph J. Mistovich, Med, NREMT-P, is a professor and chair of the Department of Health
Professions at Youngstown (OH) State University, author of several EMS textbooks and a
nationally recognized lecturer.
William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St.
Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in
Toledo, OH, and a nationally recognized lecturer.