Vehicle Extrication: Damage Control Extrication: An Approach to Critical Trauma Patients

By Bill Hallinan

The fire service is rapidly innovating and adjusting its fire attack methods to respond to 21st-century fires. Likewise, challenges in the field of vehicle rescue require firefighters to evolve their approach to provide critically injured patients the greatest chance for survival. Vehicle design changes such as high-strength super steels, impenetrable occupant compartments, complex restraint systems, and alternative fuels create survivable spaces for patients in collisions that would have otherwise been a recovery operation. The changing population of drivers leads to encounters with drivers that are older, obese, or living with complex medical conditions that impact chances for survival. Advances in the availability and types of rescue tools have also led to a reevaluation of our approach to vehicle extrication.

The concept of Damage Control Extrication (DCEx) was first described in 2009 by Dr. Mark Gestring, director of the Kessler Trauma Center at the University of Rochester. This method of rescue planning requires team members to assess the complexity of the rescue scenario and develop a plan that incorporates maneuvers to balance patient injuries and risk. The ultimate goal of DCEx is to provide the greatest chance of survival. Firefighters applying DCEx will perform larger displacing maneuvers that minimize time spent on scene while protecting the crew and patient operating in the hazardous hot zone.

The United States Navy describes damage control as “the capacity of a ship to absorb damage and maintain mission integrity.” This strategy and associated tactics imply that the members of a damaged ship will perform the needed actions to continue their mission and ensure the survival of the ship. They likely may not definitively or completely repair the damage sustained, but their maneuvers ensure the survival and integrity of the ship. Most citizen firefighters know about the heroics of the 1969 flight deck fire aboard the USS Enterprise, where 27 firefighting sailors were killed and 314 were injured as they relentlessly attacked a fire involving live ammunitions to save their ship. After the 2000 attack on the USS Cole, the actions of the crew similarly highlighted damage control tactics when, against intuition, they cut a hole in their ship’s hull while taking on water to overcome challenges in pumping out sea water.

Trauma surgeons have adopted the damage control concept as a means of increasing survival in multisystem trauma patients who require surgery. As the fire service adopted the Golden Hour, more trauma patients were delivered to waiting and ready trauma teams. Yet, despite rapid transport to trauma centers, patients continued to die from their injuries after undergoing surgery to repair the damage. Modern trauma teams employ damage control, performing only necessary maneuvers to stop bleeding and resuscitate the patient. The patient is then allowed to stabilize before undergoing additional surgery to completely repair his injuries.

DCEx is a similar four-phase process, intended to guide firefighters in their decision making. The four components of DCEx follow:

1. Pattern recognition.
2. Integrated rescue team operations.
3. Performing large displacement maneuvers.
4. Seamless transition to transport.

This process emphasizes a cohesive plan among the rescue group to integrate all the priorities of rescue and medical teams. DCEx strategies should allow for simultaneous tactics of patient access, disentanglement, and extrication techniques, where one process does not need to be completed before the other one starts. DCEx suggests that, before waiting for “Plan A” to fail, “Plan B” should already be ongoing, and “Plan C” should be ready to start, if needed. This also emphasizes that small displacement maneuvers, possibly resulting from our tunnel vision of the past, are often less effective because they lack the strong points to displace large amounts of material. DCEx promotes a large displacement of metal between known strong points to disentangle the patient. Last, this process formalizes the role of the “inside medic” and his role in the ongoing priority setting and eventual transition to transport and hand off to the receiving trauma team.

Components of DCEx

Pattern recognition. This first component is identical to the way firefighters profile behavior of fires inside a structure by assessing the quality of the smoke or fire. Every firefighter should be able to anticipate the challenges of balloon construction, lightweight construction, or ordinary construction in buildings. Likewise, the extrication of a patient who was unrestrained in a high-energy collision with failure of the patient compartment should be very different from the patient involved in a low-speed tipover while wearing a properly functioning restraint device.

In the current era of modern restraint systems and air bags, new patient injury profiles have emerged. The patient who previously would have died from injuries sustained in a less safe vehicle may now initially live and require a more complicated rescue. Air Bag Survivor Syndrome (ABSS) is an injury pattern seen in patients who survive a significant crash but are found trapped in their vehicle with severe long bone, pelvis, or lower extremity trauma. The National Highway Traffic Safety Administration’s Crash Injury Research Network provides the fire service with large amounts of data that can be used to help profile crash types; the injuries they produce; and those injuries that may be life threatening to patients, requiring DCEx. As valuable as knowing who requires expeditious rescue, it is equally useful to know which patients require a delicate and careful rescue. An unrestrained patient found in a car on its roof after multiple rollovers can be a tempting quick grab for the rescue team. However, crash data suggest that this patient profile has a high index of suspicion for spinal cord injury and he should be moved carefully. Proper extrication may require a full clamshell of the vehicle to gain necessary access.

Besides the collision and vehicle types, speed is a factor in pattern recognition. Speed kills; the chance of death or serious injury doubles for every 10 miles per hour (mph) over 50 mph. The Centers for Disease Control and Prevention updated 2011 guidelines for the field triage of injured patients to a trauma center may be used for applying DCEx. Changes in the guideline included modifications to definitions of “high-risk automobile crash,” the “older adult,” and persons on “anticoagulants or [with] bleeding disorders.”

Integrated rescue team. This second component of DCEx addresses the resources and personnel on the rescue team. It may come as a surprise that many fire departments operate in total isolation from their partners in emergency medical services (EMS). There are also many firefighters with conventional EMS training who have not received any additional education on their role as the medic integrated with a rescue team. In DCEx, the role of the inside and outside medic are declared, dedicated, and formalized in a rescue team structure. Firefighters who function as the inside medic on a rescue should be provided the proper equipment for vehicle entry and be educated on their role. The inside medic’s initial and ongoing assessment should provide the basis for the plan that the rescue group leader executes. Crucial information about vehicle restraint systems use or status, seat position, interior damage, patient entrapment, injuries, and preexisting medical history are important to patient outcome. The need for medical care during the rescue should never slow extrication efforts. Use an additional tool group to access the patient for care while disentanglement maneuvers continue. The inside medic must also be able to provide adequate patient protection including hard protection and the same eye and respiratory protection that firefighters use. Education about new vehicles and changing automotive technology has made some firefighters so timid that rescues can often slow to a crawl. Firefighters are experts at risk management and working safely in hazardous spaces. If the patient can be adequately protected from further harm and everyone in the hot zone is wearing proper protection, the rescue should proceed at a speed appropriate to the risks encountered. Personnel without proper protection must be excluded from the hot zone.

An integrated rescue team also refers to the resources needed or anticipated to complete the rescue. A mature culture of preplanning for high-risk structures and responding with reduced staffing levels has led to increased resources being sent on first alarms to fire incidents. This culture of preplanning has yet to transcend to rescue calls that would clearly benefit from additional on-scene resources and a preparedness to implement Plan B should Plan A not proceed as expected. Some firefighters consider calling additional rescues or tools to an incident a failure or an inadequacy of the first-due companies. Yet, the same culture that makes sure we have a backup line in place whenever a primary line is engaged in a fire attack should be applied to trapped patients. Extrications mandate readiness of adequate tools and resources to immediately get to work when needed.

Large displacement maneuvers (LDMs). This third component of DCEx is used as the primary method for disentanglement. LDMs maximize the value of time spent on scene. Some departments have settled into an “extrication rut” in training and on-scene management. They perform the same door removal, roof removal, and dash push every time, regardless of the situation. Although these are commonly needed skills that often work, everyone needs to know how to step up their game for challenging calls.

There are two main types of LDMs. The first involves sectional removal of the vehicle. The second is the displacement of large amounts of mass with a single maneuver. An example of LDM is removing the vehicle’s entire sidewall at one time (compared to the conventional removal of a forward door, then a back door, and working around or then removing the B post). A third LDM involves “cross ramming” or “inside-out ramming” to displace a vehicle’s sidewall from a side impact.

Challenges involved in LDMs include not having quick access to longer rams or larger spreaders. As vehicles have evolved to a more “roll cage” design, there are fewer strong points in the automobile, and they become more difficult to find. Performing LDMs requires greater knowledge of vehicles. A finer detail, but still important in performing LDMs, is the adequacy of relief cuts or gaps to displace the metal. Many tool teams abandon large maneuvers in favor of small ones when they do not achieve intended results. Often, this is the result of inadequate relief gapping that gives the material some place to go.

Cutting saws can also produce successful LDMs. The once popular metal cutting tools have fallen out of favor because of more powerful hydraulic tools, high-strength steel components, and concerns about sparks. Metal cutting tools should still be considered useful tools with which firefighters are proficient while still being aware of their limitations.

Another tactic that falls under this third component of DCEx is when to consider moving a vehicle with a patient still trapped inside. This has long been considered a prohibited maneuver, but well-trained teams can do it safely. The benefit can be a live rescue. One of the extreme risks of this maneuver is the possibility that the vehicle frame was fractured and, once the roof is removed, a resulting structural failure could cause the vehicle to collapse and further injure the patient when force is applied to the frame. Additionally, fuel systems that had been contained may fail, and resulting sparks may lead to a fire. Rescue teams need to discuss in advance under what conditions moving a vehicle with a patient inside is appropriate. With proper equipment like wheel dollys, long lumber, chains, and winches, this can be done. Discuss how the patient will be protected, if rescuers will stay with the patient, and how fire crews will work alongside wrecker services before any of those are attempted.

Timely and seamless transition to transport. This final component of DCEx can be very frustrating for companies that performed a quick, efficient, and safe rescue to return to service and see an ambulance sitting on scene with the patient. The rescue, treatment, and transport groups must all understand that they share the same precious field time allotted to the prehospital team. Opportunities to reduce on-scene time include the outside medic keeping transport teams updated on the progress of the rescue, transport teams being available and ready to transport the patient after extrication, and reducing repetition in patient assessments. An effective means of producing a seamless, accurate, and timely transition to transport is to keep the inside medic with the patient until handoff to the trauma team at the hospital. During handoff, accurate facts that would paint an important picture for the members of the trauma team are often lost. Transporting medical crews must be ready to receive the patient after he is extricated. Have ambulances well positioned, gurneys and immobilization devices ready, infusion lines primed, and adjuncts to keep the patient warm and secure.

Training to incorporate the concepts of DCEx requires an effort by all rescue group members. Provide operations officers, tool operators, and medics with the knowledge and opportunities to exercise the concepts to be successful. Pattern recognition can be taught through classroom instruction. Rescue team integration and decision making can be done on the extrication pad using scenarios or with tabletop exercises that review real-world cases. Fire departments that work separately from transport EMS need to discuss how working together can improve patient care in complex rescues.

The concepts of DCEx are familiar to firefighters who have been performing routine vehicle extrication. Bringing teams together to look at extrication as a complex process where the patient—not the vehicle—is the primary focus can be a new venture for some firefighters. As new members are trained to deal with the complexities of modern collisions, firefighters and officers must all understand how safe and timely disentanglement and extrication can improve chances for survival.

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References

1. Gestring, M. (2009, March). Damage Control Extrication. Studies of Trauma and Emergencies Project (STEP) Conference. Rochester, New York.
2. Burns, S. (2010). Cost of spinal cord injuries caused by rollover automobile crashes. Injury Prevention, 16, 74-78.
3. DeLesquen, H. (2014). Surgical management for the first 48 hours following blunt chest trauma. Interactive CardiVascular and Thoracic Surgery Advances, 1-10.
4. Kobbe, P. (2013). Increased morbidity and mortality after bilateral femoral shaft fractures; myth or reality in the era of damage control? Injury, Int. J. Care Injured, 44, 221-225.
5. Pape, H. (2009). Timing of Fracture Fixation in Mulitrauma Patients: The Role of Early Total Care and Damage Control Surgery. J Am Acad Orthop Surg. 17. 541-549.
6. Hussmann, B. (2014) Pre-hospital and early in hospital management of severe injuries: Changes and trends. Injury, Int. J. Care Injured. 45. 39-42.
7. Brown, J. (2012). The National Trauma Triage Protocol: Can this tool predict which patients with trauma benefit from helicopter transport? J. Trauma Acute Care Surg. 73. 319-325.
8. Jehle, D. (2007) . Risk of Injury and Fatality in Single Vehicle Rollover Crashes: Danger for the Front Seat Occupant in the “Outside Arc.” Academic Emergency Medicine. 14. 899-902.
9. Pintar, F. (2012). Thoracolumbar Spine Fractures in Frontal Impact Crashes. Annals of Advances in Automotive Medicine. 56. 277-282.

Bill Hallinan, RN, MS, EMT-P, is a 25-plus-year fire service veteran and a captain in the Spencerport (NY) Fire Department. Hallinan is also a member of the Monroe County (NY) Fire Bureau’s Special Operations Team and New York DMAT 6. He is the program officer at the University of Rochester’s Artificial Heart Program.