By KAREN OWENS
Scenario: You and your partner are just starting a 24-hour shift on Medic 2. While you are checking out the truck, the tones sound and the dispatcher’s voice comes over the loudspeaker: “Engine 2, Medic 2, Medic 3, respond for a motor vehicle accident (MVA) at 4th and Main.” The caller states that a truck is T-boned. You realize that this call may involve extrication. Extrication is defined as “the act of moving a person from one location to another” and is the term most often used to describe the process of prying and tearing apart a car to access a patient.1
New vehicle technology has changed the way that first responders react and function at MVAs. New plastics, new methods of vehicle construction, and safer vehicles have increased the number of victims who are able to “walk away” from MVAs. However, there are still responses where first responders arrive on-scene and find that they must cut the car to access and extricate the patient.
Many providers focus on the extrication process itself, basing their decisions more on the vehicle’s construction, damage, and safety concerns. Often, they overlook the most important factor: the patient. Extrication is a patient-driven issue, and its decisions must take the patient’s condition heavily into consideration.
As you approach the intersection of 4th and Main, you and your partner notice that a two-door, medium-size truck has T-boned a four-door, medium-size sedan on its driver-side door. The driver of the truck is out of the vehicle. You assign the Medic 3 crew to check him out as you prepare to approach the sedan.
SCENE SIZE-UP
Scene size-up is the first step in any MVA response. Regardless of operational assignment (extrication team, command, and patient care) every provider should maintain a strict vigilance for safety while operating on-scene. Ensure provider safety when approaching the vehicle to initiate patient contact while simultaneously considering patient safety.
In this scenario, limit the movement of the patient’s spine by approaching from the front of the vehicle (at an angle to the fender) while verbally directing the patient to look forward. The second provider should approach from the rear of the vehicle to access the vehicle for the patient’s C-spine immobilization. However, no providers should enter until an extrication team has stabilized the vehicle (cribbing, struts, etc.) and guaranteed provider safety.
Scene size-up should also include determining vehicle damage for mechanism of injury and preparing for potential injuries. This also includes looking for air bag deployment and using the “lift and look” approach to determine if vehicle damage was caused by patient impact or by air bag deployment.
After the extrication team confirms the vehicle’s stability, you approach the vehicle and speak with the patient. The driver, an approximately 32-year-old male, responds to your questions. He advises you that he is having slight difficulty breathing and that he has pain on his left side, both chest and legs. He is also bleeding on the left side of his head. Your partner accesses the vehicle’s back seat and begins C-spine immobilization.
ASSESSING THE PATIENT
Conducting a by-the-book assessment of a patient still trapped in a motor vehicle may not be possible because of the limited patient access. You can complete initial assessment of the ABCs of scene size-up (Anticipate victim injuries, Breathing, Cars/Crowds) from a distance. If the patient verbally responds, the emergency medical services (EMS) provider knows that the patient has an airway, is breathing (though quality is still unknown), and has a pulse. EMS personnel can also attempt to visually assess the patient for additional injuries (obvious deformity, bleeding, swelling, etc.), which will give them an initial understanding of the patient’s injuries and treatment needs.
Now, initiate C-spine control. If patient access is possible, you may complete a rapid assessment of DCAP-BTLS (Figure 1) to provide a basic understanding of the patient’s injuries and the interventions that you must complete. Obtain vital signs and administer oxygen at this point. If there is a delay in removing the patient because of extrication requirements, EMS providers may also complete the head-to-toe detailed assessment prior to placing the patient on the backboard.
Because of secondary damage to the front passenger side door, you are unable to access the front seat and must conduct your initial assessment from the driver-side window. Your initial patient assessment finds him alert and oriented with a patent airway, good respirations, and a strong radial pulse. He complains of pain in his left side; on palpation of his ribs, you feel some swelling. Because of your position, you cannot access his legs but can establish that the patient can move his feet even though he is experiencing pain in his lower left leg. He also has a laceration on his left temple with moderate bleeding that is easily controlled. With this information, you determine that your patient is stable and can communicate with the extrication team leader.
COMMUNICATION IMPORTANT
Effective and open communication between command and operations staff is one of the most important steps in maintaining safe and controlled operations on-scene. Coordinate any activities involving approaching the vehicle, entering the vehicle, or moving the patient with all responders, especially incident command, the extrication team, and the EMS providers; EMS providers must establish scene safety prior to approaching the vehicle.
You must also effectively communicate with the extrication team to provide its members with information on your patient’s condition, which should dictate the methods the extrication team uses to access your patient and remove him from the vehicle. A stable patient means the extrication team can use a more methodical and potentially time-consuming process, whereas an unstable patient may dictate the need to complete quicker and simpler moves for patient access. If the patient’s condition deteriorates during the extrication process, methods may have to change to allow for quicker access. All of these decisions depend on good communication between the EMS providers and the extrication team.
Constant communication is also necessary between the EMS provider and the patient. An ongoing review of the patient’s condition makes the EMS provider aware of any changes. The EMS provider should also advise the patient of the tasks that the extrication team is completing. This may calm the patient and give him a better understanding of what is happening and why.
CARE DURING EXTRICATION
Since the patient is stable, the extrication team decides to access the patient from the passenger side and begins to remove the door. During this procedure, you communicate with the patient regarding the extrication team’s actions. You also place a tarp over the patient and provide him with safety glasses to protect him from airborne debris. Because the patient is experiencing some labored breathing, you place him on oxygen. You put a bandage over the laceration on his temple to control bleeding.
The treatments provided during a “normal” call may not be appropriate or doable during extrication. However, regardless of the problems you may encounter, you must complete appropriate patient care, such as securing the patient’s airway. For unconscious patients still trapped in a vehicle, airway control methods include manual stabilization (jaw thrust) and digital and nasal intubation. For longer extrication times with a more difficult to secure airway, rapid sequence intubation may be appropriate. You will need to complete these tasks prior to removing the patient from the vehicle and have the EMS providers working with the extrication team ensure that they have a stable environment within which to conduct the treatment.
You may also need to bypass the standard practice of starting an IV in the hand or AC vein if these areas are not immediately accessible. If necessary, you may need to look at securing access for fluids through an input/output or even for a jugular IV. These methods may not be appropriate for stable patients with a short extrication time but may become necessary in a long-term extrication.
After removing the tarp from the patient and the provider, you notice that his breathing appears more labored and shallow. You begin reassessing him and note that he has decreased breath sounds on his left side and is now complaining of significant left-side abdominal pain. His respirations are 24 and labored. You realize that your patient’s condition is quickly deteriorating; communicate with the extrication team as you begin securing a more stable airway and starting IVs.
While waiting for the extrication team to complete the process, continue to monitor and reassess the patient. Because the extrication may take an extended period of time, patient reassessment is critical in maintaining his condition and should continue throughout extrication and transport; additional interventions or treatments are not necessary. Because of the mechanism of injury, reassessment should occur every five minutes to ensure that the patient’s condition does not quickly deteriorate.
Treatment should also include protecting the patient from scene dangers. During extrication, glass is being broken and metal is being pried and cut. It is the EMS provider’s responsibility to ensure that the patient is protected by safety glasses or a blanket from flying glass and debris. If possible, consider using hearing and head protection. If the emergency workers are protected, the patient should be protected.
PACKAGING AND REMOVAL
The extrication team has removed the roof of the vehicle, and you now have full access to the patient. You realize that his level of consciousness is deteriorating and that he is responsive only to verbal stimuli. You and your partner determine that a rapid extrication is necessary. After securing a C-collar, you work with the firefighters on-scene to remove the patient from the vehicle and onto a backboard.
Once you establish full patient access, the next goal is to appropriately package and remove him for transport. With full access, quickly reassess the ABCs and conduct a detailed assessment from head to toe. Move the patient in the direction of the long axis of the body when possible2 (photo 1). This ensures minimal aggravation of spinal injuries. If the vehicle’s roof is removed, then movement should be up and out. If a door or side is removed, the rotation should occur prior to removal from the vehicle.
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| Photo by Matt Daly. |
ADDITIONAL CONSIDERATIONS
Death of a passenger in a vehicle changes the dynamic of extrication in many ways. First, if the deceased passenger is the only individual involved, the extrication procedures will depend on the medical examiner and police investigation into the cause of the crash. Extrication in this case is obviously not patient driven.
However, if there are multiple patients in the vehicle, dealing with both living and nonliving patients may become more complicated. A dead body becomes “evidence” during the investigation into the cause of the crash. It also becomes property of the medical examiner and, as such, cannot be moved without his approval. However, that changes if the deceased patient must be moved to gain access to a living patient. If a deceased patient is preventing access to a living one, you must move the deceased quickly while maintaining as much detail of the scene as possible. If this must be done, you must document the original location and condition of the body prior to movement.
During extended extrications, consider using a helicopter to transport the patient from the scene to the hospital. Because patient access is not normally delayed, use of helicopters is not standard practice for MVAs, since the ambulance can begin transport almost immediately. However, a delayed transport time because of an extended extrication creates an opportunity to use medical helicopters for transport. It is another measure to ensure that the patient is delivered expeditiously to definitive care.
After packaging your patient, you transport him to the nearest trauma center, where you transfer care to the doctors. After cleaning up and restocking, you return to your station and run a critique of the call to ensure that everyone is prepared for the next one.
MVAs may provide an opportunity to use skills in nonconventional manners. Extricating a patient changes the assessment and treatment methods that most providers are accustomed to using. However, regardless of the severity, remember that the patient’s needs dictate the providers’ actions, whether initiating patient care or patient access.
Endnotes
1. Moore, R.E.. Vehicle Rescue and Extrication, 2nd edition. (St Louis, Missouri: MosbyJems, 2003.)
2. D. Limmer, et al. Emergency Care: 10th Edition. (New Jersey: Brady/Prentice Hall, 2007.)
KAREN OWENS is the emergency operations assistant manager for the Virginia Office of EMS, where she has been employed since 2001. She oversees the emergency operations training programs including multiple casualty incident management, terrorism awareness, and vehicle rescue. Karen has a B.A. in psychology and a M.A. in public safety leadership. She is a Virginia-certified firefighter and has been a Virginia EMT-B instructor since 2002.
