1. Remem­ber your own safety

“Some­times we get so over­whelmed with emo­tions, adren­a­line, excite­ment – we for­get our own safe­ty,” Casey says.

Arriv­ing on the scene to find an agi­tat­ed caller and a con­fronting scene, prac­ti­tion­ers can eas­i­ly over­look risks such as being near the road, fuel leaks, and shat­tered glass.

“How­ev­er, it’s often the nuanced risks such as airbags that may be missed,” Casey says. 

“If the airbags haven’t gone off, and the car is fit­ted with them, they can spon­ta­neous­ly go off – some­thing to be mind­ful of if you’re treat­ing a patient who is still in the car.”

“In an urban envi­ron­ment, the fire ser­vice would hope­ful­ly be respond­ing as well, and would poten­tial­ly arrive before the ambu­lance crew. Their respon­si­bil­i­ty would be to make things safe, dis­con­nect the bat­tery, sta­bilise the vehi­cle and deal with any fuel leaks, for exam­ple. In a remote envi­ron­ment, this isn’t often the case.

“Also con­sid­er vehi­cle sta­bil­i­ty. Often when we find vehi­cles, they don’t have all four wheels sit­ting on the ground. They’re on their side or their roof… It’s impor­tant not to rush into a scene.”

2. Allow suf­fi­cient time to prepare

“The moment peo­ple hear the word ​‘crash’, they pic­ture the worst,” Casey says.

“We’re deal­ing with high speeds, long dis­tances, big trucks on these rur­al roads. But it’s impor­tant to not let the emo­tion take over; to take your time and not rush.

“Before leav­ing, make sure you have the nec­es­sary equip­ment on hand. Some cen­tres have well-equipped vehi­cles, but in many places, there is a troop car­ri­er with an oxy­gen bot­tle and a stretch­er in the back. Equip­ment or bags may be grabbed from the shelf [on departure].”

The dis­tances, which are typ­i­cal­ly longer, may influ­ence what you need to bring.

“If you have trans­ferred your trau­ma bag to the troop car­ri­er, it is impor­tant to ask ques­tions such as: does it con­tain enough anal­ge­sia to pro­vide pain relief for that patient for poten­tial­ly two hours of dri­ving – spent not in a hos­pi­tal bed, but on a bumpy out­back road?

“[Also], if it takes you an hour and a half to arrive and that patient has been sit­ting in the sun, what start­ed out with just a bro­ken arm could now involve a patient that is poten­tial­ly dehy­drat­ed. Have you got enough fluid?”

Estab­lish­ing a detailed under­stand­ing of the sit­u­a­tion before depar­ture will help you to make informed deci­sions about what equip­ment to bring. This may be time-con­sum­ing, and although the speed of the response is impor­tant, it is nec­es­sary to bal­ance this against arriv­ing well-pre­pared, Casey says.

Be aware that loca­tions may be mis-com­mu­ni­cat­ed by callers who are unfa­mil­iar with the area. Com­mu­ni­ca­tion is at the crux of pre­pared­ness – both before you head out and while you’re on the road.

“Do you have satel­lite phones or radios?” Casey asks. ​“Do you know how to use them? Are they charged?”

3. Assess the most appro­pri­ate loca­tion to deliv­er treatment

“It’s impor­tant to under­stand when to be urgent and when not to,” Casey says.

He pos­es the exam­ple of a patient with major chest trau­ma, and poten­tial car­dio-vas­cu­lar and res­pi­ra­to­ry prob­lems. In such a set­ting, first respon­ders will right­ly con­sid­er C‑spine precautions.

“We also need to remem­ber, it can take an hour and a half to get a patient out of the vehi­cle and keep their spine per­fect­ly in align­ment,” Casey says.

“[The ques­tion then becomes] – if they have major chest trau­ma and are strug­gling to breathe, and we’re an hour and a half from the near­est clin­ic or airstrip… Is it bet­ter we get this patient out quick­er and trans­port them to a more appro­pri­ate setting? 

“You need to be assess­ing your patient – under­tak­ing a good qual­i­ty pri­ma­ry sur­vey – and mak­ing that clin­i­cal decision.”

Casey encour­ages prac­ti­tion­ers to ask them­selves: ​“What needs clin­i­cal inter­ven­tion now… and what’s bet­ter off being dealt with back in the clin­ic in a clean­er, ster­ile, calmer environment?”

4. Assess and com­mu­ni­cate the extent and nature of the trauma

Under­stand­ing the mech­a­nism of injury helps prac­ti­tion­ers to appre­ci­ate poten­tial injuries and antic­i­pate the poten­tial for deterioration.

“You may have a patient who is pre­sent­ing quite well,” Casey says.

“But, for exam­ple, if you know that it was a high-speed inci­dent and the vehi­cle has rolled, this tells you this body has bounced around and had major forces exert­ed on it.

“If there’s two peo­ple in a car and they hit a tree, it may hap­pen that one per­son has severe neck pain, a bro­ken leg, or mul­ti­ple frac­tures in dif­fer­ent spots, while the sec­ond per­son appears to have no injuries.

“Some­times that’s the case, but what we teach is that both of those peo­ple are in the same car, their bod­ies have been through the same trau­ma – as a gen­er­al rule.

“If one per­son in a car is very sick, assume every­one in the car at least has the poten­tial to become that sick. It’s always impor­tant to find a means of get­ting that patient back to the clin­ic, where you can con­tin­ue to mon­i­tor them.”

A practitioner’s atten­tion can also be mis­di­rect­ed by ​‘dis­tract­ing injuries’, a con­cept Casey often dis­cuss­es with new stu­dents and para­medics. Such injuries draw atten­tion away from more seri­ous risks to the same patient, or from a high­er-risk patient in a mul­ti­ple-patient scenario.

To this end, it’s vital to per­form effec­tive pri­ma­ry and sec­ondary sur­veys, and to con­tin­ue to reassess through­out the treat­ment period.

The mech­a­nism of injury and extent of trau­ma also need to be effec­tive­ly com­mu­ni­cat­ed dur­ing han­dover, while fol­low­ing the ISBAR process.

“If you say the words ​‘motor vehi­cle crash’ to 100 peo­ple, every­one will pic­ture 100 dif­fer­ent things,” Casey says.

“We want to clear­ly relay the mech­a­nism of injury and the extent of trau­ma, so the [amount of trau­ma isn’t under­es­ti­mat­ed] and the patient isn’t undertreated.

“Dur­ing han­dover, aim to com­mu­ni­cate a clear pic­ture of the scene – how dam­aged the car was, intru­sions, how many times it might have rolled, the esti­mat­ed speeds, how far debris was spread up the road.”

Lead with the most con­cern­ing details, rather than those of sec­ondary impor­tance, and if pos­si­ble, take pho­tos of the crash to show those you are hand­ing over to.

5. Know what resources are in your area

Resources are less like­ly to be avail­able in remote Aus­tralia. There­fore, rec­om­men­da­tions that are appro­pri­ate for well-equipped urban set­tings may not apply.

For exam­ple, jaws of life – and the­fire­fight­ers or emer­gency res­cue per­son­nel trained in their use – will not typ­i­cal­ly be avail­able to attend a crash and extract patients in remote Australia. 

“Every sit­u­a­tion is going to be dif­fer­ent, but the more peo­ple you’ve got there to help you, the bet­ter,” Casey says.

“If you’re lucky enough to have a vol­un­teer fire ser­vice, I’d encour­age you to go out and meet them, find out what they’re capa­ble of.”

“If not, ask your­self and those who have worked there before: what oth­er resources do we have avail­able local­ly? Farm­ers who can help, order­lies, dri­vers on call, police? Where’s the near­est clin­ic? Is there some­one in the com­mu­ni­ty – a vol­un­teer in the school for exam­ple – who can come out and pick RFDS up from the airstrip and dri­ve them out to the scene? Does the local school have a bus we can use to get [mul­ti­ple] patients to the clin­ic or airstrip?

“If you can answer as many of these ques­tions in a calm envi­ron­ment, and a day comes when there’s a crash, know­ing answers to these ques­tions will pre­pare you to respond.”