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As you stop at a road traffic accident (RTA) you should develop a clear and logical plan of what to do. When you pull over, start to read the scene:
- What is the likely scale of injury in terms of numbers and severity?
- Is the road safe or is oncoming traffic a further threat?
- Is there fire, chemical spillage or risk from ruptured fuel tanks?
- Is there chaos or order?
- Are the emergency services already in attendance?
- Have an aura of calm, competence and authority. Do not be afraid to organise people.
Accident scenes are dangerous places and the dangers come in several ways.
Protect the scene:
- One risk is that oncoming traffic may plough into those there. It may be best to park obliquely behind the incident to fend off oncoming traffic.
- Leave on hazard lights and, if you have one, a green beacon.
- If you have access to a high visibility jacket, wear it (carrying a high visibility jacket is compulsory in some European countries). They are available with Velcro® DOCTOR signs. You do not want to become a casualty too.
- Protect yourself: cover exposed skin, wear gloves and a hard hat if available.
- Unless people are trapped or unable to move, get them off the road and out of the way of further harm. Get them to place warning triangles in both directions.
- Has anyone called the emergency services? If not, make a very brief survey of the scene to be able to give them more information but do not delay getting help. If the emergency services have been called, who has been called? The ambulance service is obvious. However, the police may be required to make the area safe and the fire service may be required if there is a need to extract victims from vehicles, tackle fires or deal with other hazards like chemical spillage.
- For more details on chemical and other hazards, see separate record Pre-hospital Care at Road Accidents.
- Most RTAs do not result in fire but a "no-smoking rule" should still be enforced. Unleaded petrol is far more inflammable than 4-star. Diesel is difficult to burn without a wick. Liquid petroleum gas (LPG) is potentially explosive. If an engine is still running, switch off the ignition.
- Immediate - e.g aortic deceleration injury, severe head injury
- Early - eg hypoxia and hypovolaemia
- Delayed - eg sepsis, multiple organ failure
Triage is used to divide the injured into 4 colour-coded groups:
- Immediate - colour code RED: will die in a few minutes without treatment, eg obstructed airway, tension pneumothorax
- Urgent - colour code YELLOW: may die in an hour or two without treatment, eg hypovolaemia
- Delayed - colour code GREEN: can wait, eg minor fractures
- Dead - colour code WHITE
One study found that the risk of serious injury increases in a non-linear manner according to the age of the patient.
Triage is a dynamic process. If someone deteriorates suddenly this will change the assessment. If you are present, not as a fully equipped expert in trauma and emergency but as a passing GP, remember your limitations. Your assessment may still be very helpful in terms of helping the ambulance crews decide who needs urgent removal to hospital, who can wait and who does not need the services of an emergency department.
Remember: English law does not currently require a doctor to confirm death has occurred or that "life is extinct" . Apply your skills to the living.
- Talk to the patient or patients if conscious. Come over as competent and reassuring as they will be very anxious.
- Ask where it hurts to get an idea of injuries.
- Read the wreckage - relate the damage of the vehicle to potential injuries:
- Steering wheel deformed = chest injury
- Dashboard intrusion = patella/femur fracture ± posterior dislocation of the hip
- Bodies are softer than metal: major bodywork distortion = major injury
- Assess the degree of pain.
- Fractures and abdominal trauma may produce considerable concealed haemorrhage. Check for signs of hypovolaemic shock.
- Identify the time-critical patient - some will die unless rapidly removed from the vehicle, at whatever cost. Entrapped patients should be removed in under half an hour.
- When the patient is unconscious remember the ABC of airways, breathing, circulation. If there is sudden deterioration, check ABC again for a possible cause.
- Whether the person is conscious or not beware of neck injuries and spinal cord compression. Many head restraints are unsatisfactory.
- Is everyone accounted for? Sometimes people can be thrown well clear of an accident and may be lying dead or severely injured a little way away and, especially at night, they may have been missed.
- What you can do will depend not just on personal skills but on what is available to you. You may have just your doctor's bag or not even that. You may have the equipment of a car from an emergency doctor service. A well-equipped ambulance may be on the scene.
- Paramedics have been well trained and, if it is many years since you last set up an intravenous infusion, then they will probably do it rather better than you. Let them do what they do well.
- Be careful about extracting those trapped in vehicles before the fire service arrives. They are the experts with the equipment and injudicious extraction can cause further injury. There are times when urgency has to take precedence over caution.
- The patient may well be in severe pain. Parenteral opiates are often appropriate. Give IV if possible, as peripheral circulation is probably shut down.
- If you can stabilise a patient's condition before transfer to hospital this is usually beneficial but there is a balance to be made between achieving what you can at the site and delay in reaching greater expertise and resources. Unless injuries are minor get venous access sooner rather than later, before peripheral circulation collapses. The issue of whether intravenous fluids should be given prior to hospital admission continues to be a matter of debate ('stay-and-play' vs 'scoop-and-run') and the conveyance of the patient to hospital should certainly not be delayed if there are difficulties in inserting an intravenous cannula. One study of patients treated on-site by helicopter emergency medical personnel, however, showed that the involvement of doctors rather than paramedics did not unduly delay care and may well have provided additional medical benefit.
- If there is any doubt at all about cervical spine fracture, apply a collar if you have one; however, there is still a need to support the neck, as even a well-fitted and well-applied collar allows some movement.
- There is currently no national standard protocol for early acute wound management in the prehospital care setting. Consensus guidelines on cleansing and dressings are needed.
In the United Kingdom there is no legal obligation for anyone to stop and help at a road accident. However, ethical guidance is provided in the GMC's Handbook 'Good Medical Practice' which states: 'In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence and the availability of other options for care'. 
If you stop, you are legally responsible for your actions and omissions. The "Good Samaritan" is not covered by NHS Trust indemnity but the main defence unions include in their basic policies medico-legal cover for accidents. It is recognised by most authorities that a doctor willing to stop is acting out of beneficence for the casualties and, in this country, legal repercussions are fortunately rare.
Further reading and references
Dries D, Hays W; Initial Evaluation of the Trauma Patient eMedicine.com 2008.
Triage; surgical-tutor.org.uk last updated July 2009.
Newgard CD; Defining the "older" crash victim: the relationship between age and serious injury in motor vehicle crashes. Accid Anal Prev. 2008 Jul40(4):1498-505. Epub 2008 Apr 21.
Dischinger PC, Siegel JH, Ho SM, et al; Effect of change in velocity on the development of medical complications in patients with multisystem trauma sustained in vehicular crashes. Accid Anal Prev. 1998 Nov30(6):831-7.
Wilmink AB, Samra GS, Watson LM, et al; Vehicle entrapment rescue and pre-hospital trauma care. Injury. 1996 Jan27(1):21-5.
Cotton BA, Jerome R, Collier BR, et al; Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma. 2009 Aug67(2):389-402.
Dissmann PD, Le Clerc S; The experience of Teesside helicopter emergency services: doctors do not prolong prehospital on-scene times. Emerg Med J. 2007 Jan24(1):59-62.
Jones AP, Allison K, Wright H, et al; Use of prehospital dressings in soft tissue trauma: is there any conformity or plan? Emerg Med J. 2009 Jul26(7):532-4.
Medical Protection Society; Benefits of Membership.
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