Vehicle rescue is a patient-care driven skill. A given, you say? Although the focus of most of our education and training for mitigating issues at motor vehicle accidents (MVAs) revolves around tool evolutions and vehicle concerns, let’s consider patient care and considerations in the rescue environment and our ability to provide a better patient outcome. After all, the patient is the overall reason rescue services are performed.
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Good trauma care starts with good basic life support (BLS) care. Airway management, manual C-spine stabilization, application of C-collar, and oxygenation are basic BLS skills used in the initial care of a patient in an MVA (photos 1, 2). Mass hemorrhage control comes next. It sounds simple and straightforward, but let’s think about the many issues that affect our ability to provide the necessary prehospital care.
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Think about how vehicles are configured today. Do you have enough room in the vehicle to perform basic patient care skills? Take a good look at the way the dash and controls “wrap” around the driver and front passenger, forming a “cockpit”-like configuration. How about seating? How many vehicles have bench seats, bucket seats, or racing-style seats? These make for tighter spaces, leaving less room and less space for our equipment and ourselves (photo 3).
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Let’s not forget about those supplemental restraint systems (SRS). We should be attempting to observe “space” between those devices and ourselves, and our equipment as well. Visualize for a moment those “spaces,” the frontal airbags, side impact airbags, and side curtain airbags. We even need to be aware of devices such as seatbelt pretensioners and rollover protection. Many times, providing the appropriate amount of space means displacing vehicle components (see “The Art of Space Making,” Extrication Tactics, Fire Engineering, March 2005).
Consider packaging a patient in a KED or similar device in today’s cars, SUVs, and pickups. Will you have the right amount of space to remove the patient with door access alone? Many of the mechanics of patient care and packaging being taught today were built around vehicles of the ’60s, ’70s, and even ’80s. Do they still apply in today’s MVA environment? Recall that most of our education on patient access and removal revolves around either “opening” a door or displacing a roof. Although both techniques are indeed viable, think of the additional variables that exist today. It is not as straightforward as it used to be.
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Take a good look at patients’ injuries, and focus on where they occur. Do you see the same head and chest trauma that you used to see decades ago? How about injuries to the lower extremities and the pelvis? Ever think why? There are a few reasons here. Frontal SRS, driver and passenger side front airbags and knee airbag systems, although sometimes causing injury, can and do protect occupants from injury sustained from the crash, even when seat belts are not used. But when seat belts are not used, these frontal airbags have a tendency to “push” the occupant down and under the dash. Now connect this with the way vehicles are constructed and configured today. Vehicles are designed to absorb energy from the crash and crumple inward. If the vehicle structure is crushing in and, say, the frontal airbags push the unrestrained occupants down, is it any wonder we see what we see today in terms of injuries? Even when the front occupants are restrained, the vehicle’s structure can become crushed so badly in a high-energy crash that responders may see some of the same injury patterns as above.
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With side impact crashes, the same principle with energy absorption still applies, but now the vehicle’s structure is much stronger and more resistant to lateral forces than before. Add to this side impact and side curtain airbags designed to protect vehicle occupants. However, now there is less space than in the past between the occupants and the impact. Although the various safety systems and the vehicle’s construction and configuration do indeed protect occupants effectively from side impacts, think of how they hinder our work to provide care in the environment and package and extricate the patient from the wreck. We need to strip interior trim prior to any sort of roof evolution today to avoid cutting the gas generator for the side curtain airbags (photo 4). We need to watch for side impact airbag systems when we force doors or perform side removal evolutions. Consider also vehicle construction material in these evolutions. We now end up pushing and prying against hardened materials used for reinforcement and lightweight “soft” materials, such as enhanced plate glass and lightweight body “skin” alloys. Think of the interactions we need to have to successfully mitigate the issues of both ends of the material spectrum (photo 5).
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We need to be aggressive when assessing MVAs and to take a proactive approach in disentangling a patient from the wreck as well as providing prehospital care to enable us to provide a better patient outcome. This requires that we perform simultaneous operations, caring for the patient and creating a pathway to remove that patient (space making). EMS responders provide patient care in the same “rescue real estate” as the rescue team, which needs to have access to the exterior of the vehicle, especially the side between the wheels (photo 6). EMS needs to be with the patient and be comfortable working there and should be keenly aware of the potential vehicle hazards as well. EMS personnel must allow the rescue team to perform necessary tool evolutions to displace vehicle components to make appropriate space to remove the patient expediently.
The rescue team needs to be sharp and to understand the issues/hazards involving the vehicle, their tools/evolutions, and how they will interact with the vehicle materials. Rescue personnel must also be aware of patient care considerations to make the best, safest, and most efficient pathway for that patient.
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We need to provide prompt patient care simultaneously with our space-making efforts. Part of that requires us to get into the “environment” not only to enhance patient care but also to create a rapid pathway for removal. A better patient outcome can result when these operations are combined. Personnel operating tools and performing space-making evolutions need to understand the vehicle technology concerns of today, but so do EMS providers. As part of providing care, EMS providers operating in the environment interact with many of today’s vehicle hazards. They need to have proper background knowledge of these concerns and use proper PPE for the environment in which they are working. ■
■ DAVE DALRYMPLE is a career EMS provider for Robert Wood Johnson University Hospital/St. Peter’s University Hospital Emergency Services in New Brunswick, New Jersey. He is also a firefighter/EMT/rescue technician and former rescue services captain of the Clinton (NJ) Rescue Squad. Dalrymple is the education chair of the Transportation Emergency Rescue Committee-US and serves on the Expert Technical Advisory Board of the International Emergency Technical Rescue Institute as the road traffic accident advisor
Photo by Denyal Cusimano.
