By Rommie L. Duckworth
Great vehicle extrication involves a collaboration between rescue and emergency medical personnel for the purpose of delivering effective trauma care, not simply opening up a vehicle as fast as possible. For the best extrication teams, this collaboration extends to everyone from incident commander (IC), rescue boss, and extrication technician to primary care provider and support personnel.1, 2
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Even experienced rescuers can become overly focused on “tools and tasks,” a form of tunnel vision that may result in perfectly executed cuts, pushes, spreads, and rolls while leaving patient care to whatever way EMS personnel can work around the rescue team. A coordinated approach to extrication leaves the “tools and tasks” decisions to the expert rescue technicians, but ensures that these technicians get the information they need from the experts in patient care. In other words, the WHEN (choice of rapid / careful), HOW (choice of tools / techniques) and WHY (strategic goals / objectives) on the RESCUE side are informed by the WHO (what patient), WHAT (is wrong with them) and WHERE (are they injured) from the EMS side.
A Four-Step Approach
Coordinated extrication consists of a four-step approach.
• Arrival–Approaching the scene. As you approach and arrive on scene, you know that a good size-up can determine how well the rest of the call goes.3 Although they may not relay it over the radio, every responder should perform a personal size-up to identify dangers on scene as well as the best way to integrate their roles in the extrication operation.4 This is the very essence of the concepts of Situational Awareness and Crew Resource Management.5
There are many mnemonics for extrication size-up. One that is easy to use on virtually any scene is “U-CAN”:
√ Unit: Who are you (what is your role)?
√ Conditions: What are the first things you see?
√ Actions: What is the next thing you are going to do?
√ Needs: What do you need to do it?
√ Dangers: What hazards might stop you from doing it?
This simple mnemonic can aid responders in identifying what is going on on scene and what they are going to do about it.
The next step is to establish or integrate with command-and-control on scene.6 They may not always be visually defined by cones, flares, or scene tape, but even basic extrications will have Hot, Warm, and Cold zones. Just as with hazardous materials incidents, extrication Hot, Warm, and Cold zones define the level of hazards in an area as well as the training and protective equipment responders will need to operate there.
• Access–Putting EMS personnel in contact with the patient. It can be tempting to “jump in” right away, but the responder gaining access should accomplish or verify the following general tasks:
√ Check 720+ around the vehicle (360 outer circle survey, 360 inner circle survey, plus above and below the vehicles) and mitigate immediate hazards.
√ Stabilize the suspension, and chock/set the brake.
√ Put power doors, seats, windows, steering wheels, and so on in the optimal position.
√ Kill the vehicle ignition and remove the key.
√ Turn the headlights off and the hazards on.
√ Disconnect the battery and, in the cases of EV or hybrid vehicles, shut off the HV disconnect or pull the fuse as appropriate.
Once these initial actions have been completed, the Inside EMS provider(s) will make initial contact with the patient or patients inside the vehicle, communicates with him; protects him from further injury; assesses the injuries; provides immediate life-saving treatment; and, if possible, stays with the patient throughout transport.4
Immediate life threats such as Massive hemorrhage, Airway difficulties, Respiratory emergencies, Circulation problems, and Head Injury (MARCH) will necessitate immediate patient removal; assessment findings such as patient paralysis, significant neck or back pain, severe angulation of an extremity, impalement, significant crush injury, or the need for pain management or other medication administration will require a slow and careful removal.7
As with every other aspect of fireground operations, clear and concise communications are the key to effective action. One way the Inside EMS provider can quickly relay key information on the patient is with CAN reports —Condition, the Actions the Inside EMS provider is attempting, and what the Inside EMS provider will Need to accomplish these actions.8
Action: Initial Emergency Care
The rescue boss’s extrication plan (insert your local designation for the person assigning extrication strategy/tactics here) must include immediate medical priorities. The immediate medical priorities can be summarized by the phrase “MARCH Forward to the Emergency Department!” This plan often can be rapidly implemented by responders with EMS training, regardless of agency or advanced life support (ALS) responder status as long as they are trained and equipped to operate in the Hot Zone.
March
A responder’s first priority must be to deal with the problems that are most threatening to a patient’s life. These conditions can kill a patient quickly, but first responders can deal with virtually all of them in the first few moments of patient contact.9
Massive Hemorrhage
To control excessive bleeding, responders must follow the “5 Ds”: Detect (find the source); Direct pressure (compress the bleeding site); Devices (use equipment such as tourniquets, clotting gauze, pressure bandages, and clamps to free responders’ hands); and Don’t Dilute (if you can obtain an IV, don’t water down the patient’s blood).
Airway Difficulties
Management of airway emergencies during extrication should begin with basic life support (BLS) oral or nasal airways and suction and proceed to devices such as supraglottic airways, endotracheal intubation, and cricothyrotomy, as needed and as a provider’s certification / licensure allows.10
Respiratory Emergencies
Management of immediately life-threatening respiratory emergencies may include assisting a patient’s breathing with bag-valve mask (BVM) ventilation; dealing with a flail chest; sealing a sucking chest wound; and, for ALS providers, decompressing a tension pneumothorax.10
Circulation Problems
Whereas management of massive hemorrhage focuses on first stopping bleeding, circulation focuses on keeping the blood perfusing the body. Considerations include obtaining IV or IO vascular access, administering only enough fluid to maintain a minimum blood pressure without diluting the blood, coordinating careful movement of the patient so as not to dislodge any internal blood clots that have formed, and possible pain management or patient sedation to help rescuers remove the victim more quickly. In some advanced systems, this may also include administration of blood products or medications such as tranexamic acid to minimize internal bleeding. 9, 11-13
Head Injury
Management of life-threatening head injuries require a provider to avoid the four “H-Bombs” that kill brain: hypoxia (keep the patient’s oxygen saturation above 90%), hyperventilation (don’t ventilate faster than 10/min), hypotension (keep BP >90 mm/Hg systolic), and hypoglycemia (keep blood sugar above 70 mg/dl).
Forward
While immediate patient care and extrication efforts continue, Outside EMS providers and support personnel can begin to prepare to move the patient out of the vehicle and into the ambulance. Using a concept from rapid intervention teams, providers should “harden the egress” by ensuring that belts are cut, glass is fully removed, sharp edges are covered, and hoses and equipment are cleared along the path of the patient’s exit path.14
To Trauma Care
The idea here is not simply to transport the patient to an emergency department, but rather to get him to the appropriate level of trauma care and to ensure that the trauma team is ready for the patient’s arrival. For patients with severe injuries, this will mean coordination with and transport to a designated trauma facility.15 For the trauma team to be prepared, it must typically receive prenotification of the victim as early as possible.
After: Follow-Up and Preparation for the Next Call
After the last patient has been removed from the vehicle and is on the way to definitive care, a number of EMS aspects of extrication remain to be dealt with.
Pictures
Although there is no doubt that video and photographs of real extrication incidents can contribute to responders’ training and education, the guidelines for who should take them (and who should not) as well as how they are handled and who owns and has the right to distribute them (and who does not) should be well defined and clear to every responder. Most often, the best policy is one that makes it clear to responders what rights the public has and what ethical, if not legal, obligations responders have to sometimes obstruct public views of incidents to protect the privacy and dignity of the patients involved without coming in direct conflict with the photographer.
Pain/Pathogens
Responder safety from physical and pathogen hazards should be evaluated after each incident: Are all of the responders safe? Were there any near misses? What could we have done to improve safety? These questions should be asked after each call.4
Post-Traumatic Stress Disorder
Some incidents, especially those involving large numbers of victims, young children, or fellow emergency responders can have a significant psychological and emotional impact on those who respond. Just as we evaluate the potential for physical injury for our responders, we have to keep in mind their psychological well-being as well.
Preview/Review
Departments should learn from every incident. Formal or informal after-action reviews are the times to evaluate not only what occurred but also how the response team(s) can improve each aspect of their response to better prepare for the next call.
Practice
Review and self-reflection are the beginning, but great extrication teams put words into action by practicing and performing hands-on skills they have identified as those that will get them from good to great.
***
In the end, all fires eventually go out, all bleeding eventually stops, and all patients eventually get freed from their vehicles. Yet, with consideration of and coordination with the EMS aspects of extrication, rescuers each arrive to do their own size-up and know their own roles and zones. They know that the vehicle is safe so that they can access the patient rapidly to assess what the patient needs from the extrication team. They don’t wait for ALS providers to perform life-saving BLS actions, but when ALS skills are needed, paramedics are ready with the tools and training to do the job. The best rescue teams take a look back after each call and ask What can we improve? This is how integrating EMS aspects into the heart of your training and operations makes a good crew into a truly great extrication team.
BIO
ROMMIE L. DUCKWORTH is a career captain/paramedic EMS coordinator and past volunteer chief officer. He is the co-founder and director of The New England Center for Rescue and Emergency Medicine, the editorial director for RescueDigest.com, and executive director of the First Few Moments nonprofit emergency services education corporation. As a dedicated emergency responder and an award-winning educator with more than 25 years of experience working in career and volunteer fire departments, public and private emergency services, and hospital healthcare systems, he is a frequent speaker at national conferences and a contributor to research, magazines, and textbooks on operations, leadership, and emergency services education.
References
1. IFSTA. Principles of Vehicle Extrication. (Pearson Education, Limited, 2010).
2. IAFC & Sweet, D. Vehicle Extrication. (Jones & Bartlett Publishers, 2011).
3. IFSTA. Essentials of Firefighting. (Pearson Education, Limited, 2013).
4. Limmer, DJ et al. Emergency Care (11th Edition). (Prentice Hall, 2011).
5. LeSage, P, Dyar, J & Evans, B. Crew Resource Management. (Jones & Bartlett Learning, 2010).
6. FEMA. National Incident Management System. (FEMA, 2008).
7. ACS. ATLS Advanced Trauma Life Support for Doctors – Student Course Manual. (2012).
8. Kastros, A, “Mastering Fireground Command,”fireengineering.com, 2011.
9. Tourtier, JP, et al, “The concept of damage control: Extending the paradigm in the prehospital setting,” Ann Fr Anesth Reanim, 2013; 32:520–526.
10. NAEMT. PHTLS. (Jones & Bartlett Publishers, 2010).
11. Roberts, I, et al, “The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial,” Lancet, 2011; 377: 1096–1092.
12. Raedler, C, et al, “Treatment of uncontrolled hemorrhagic shock after liver trauma: fatal effects of fluid resuscitation versus improved outcome after vasopressin,” Anesth. Analg..2004; 98:1759–66– table of contents.
13. Krismer, AC, et al. “Employing vasopressin as an adjunct vasopressor in uncontrolled traumatic hemorrhagic shock. Three cases and a brief analysis of the literature.” Anaesthesist, 2005′ 54: 220–224.
14. Baker, L. “Harden the Egress,” FireRescue, February 2011.
