AT EVERY EXTRICATION CLASS. We hear or should hear that the patient is the reason we are there. Yet, how many times do you see a manikin or (gasp!) a live patient as a patient representation in the vehicle or scenario? How often do you train in a real-world, scenario-based exercise? Although instructors always say they do, how many do not do it well or at all? Is the focus on the patient in vehicle rescue today?
Vehicle extrication is the mechanics or the methodology of vehicle rescue. Vehicle rescue is our global mindset; our methodology encompasses the whole package to mitigate operations on scene at the motor vehicle accident (MVA).
Much of today’s vehicle rescue education has been interwoven with the basis of modern emergency medical services (EMS) education. The original orange emergency medical technician (EMT) textbook had a sizable chapter on vehicle rescue; the U.S. Department of Transportation curriculum had complete slide trays on vehicle rescue. What has happened since then?
Technology Advances
Technology concerns arose—first, supplemental restraint systems (SRS); motive power changes; and, more importantly, vehicle materials and construction advances. The last item has become the largest overall concern with vehicles today:, it has changed injury patterns and the way we do business. EMS broadens its scope of care and its ability to deliver it, so medical advances take priority over trauma care in the long run. Extrication training 1s dropped first as a practical, then classroom hours are cut. Training materials are not up-to-date with what 1s on the street Extrication today must be strategic, focusing on weakening the vehicle structure and releasing the crash energy the vehicle structure has absorbed. Creating a large space Is your priority; think about maximizing your space-making efforts (photo 1).
Patient-centered care must return to its position of importance. Hands On care from the EMS providers in the environment should be the norm, not the exception. New devices to assist in disentanglement must be used.
Coordinated Vehicle Rescue
Coordinated vehicle rescue should be a best practice across the country and the globe. Intertwined EMS and rescue functions that occur simultaneously are best practice. We should all strive for that and work that way from now on.
Even EMS trauma prehospital educational programs such as Prehospital Trauma Life Support, International Trauma Life Support, and others are slow to realize the impact of vehicle technology changes. Only the Anaesthesia Trauma and Critical Care Group educational programs are current with vehicle technology, but what do these EMS trauma prehospital educational programs have to do with extrication? Since EMS providers will be caring for the injured in the MVAs, they need to understand the environment they are working in. It’s no different than responding to a medical emergency at a residence.
Trauma Is a Disease of Time
We know the “Golden Hour.” Or do we? We now know that Dr. R. Adams Cowley never really invented the term “Golden Hour,” but he believed that a trauma patient needs to be at a trauma center as rapidly as possible for surgical intervention, trauma is the disease of time. Now go back to the late 1980s, when J. Steven Kidd and John D. Czajkowski developed the first video instructional series on vehicle rescue, Catbusters! In their patient management video in the series, they speak of an even more limited time, “The Platinum 10.” This referred to our on-scene time of 10 to 16 minutes, from when our wheels stop to transporting the patient to definitive care. That’s a lot of work to do in a short space of time. Can we do it today? Absolutely yes, but probably not every time. However, we can employ measures and methodologies to cut down our scene times. Finally, on vehicle rescue education, in the past 15 years, every progressive vehicle rescue educational program—whether it’s a book, a video series, or a practical delivery—makes patient management an integral part of the program
The Newest Blue Widget
When did you try out the latest movement device? With the widespread adoption of the NEXUS study protocols, we no longer have spinal immobilization devices; we have movement devices, including the long spine board. [The National Emergency X-Radiography Utilization Study (NEXUS) 1s a set of validated criteria used to decide which trauma patients do not require cervical spine imaging Trauma patients who do not require cervical spine imaging require all of the following: They are alert and stable, have no focal neurologic deficit, have no altered level of consciousness, are not intoxicated, have no midline spinal tenderness, and have no distracting injury.]
The Kendrick Extrication Device (KED) comes to mind, but it’s not new or the correct device for today. It was developed in the early 1970s for the vehicles of the day. The automotive interior primarily had bench seats and large door openings, whether it was a two-door coupe or a four-door sedan. Vehicles today have bucket seats with a center console for interiors and four doors, but they are much smaller—small enough that the driver and front seat passenger sit actually behind the vehicle’s B post. That alone means if you need to move these people through the door opening, they need to go forward before they can go out the opening. KEDs only work well today if the vehicle roof is removed completely.
So, if the green KED is problematic, what do we do? Long spine boards still work as a movement device; just stay within the protocols when transporting (photo 2). A vacuum mattress is a much better device to use for a trauma patient for transportation and immobilization (photo 3). North America has to catch up with the rest of the world on that aspect. When using a vacuum mattress, we usually need to employ a scoop stretcher to get the patient onto the device or a long spine board
There are a few types of movement devices, including board devices, a vest device, and a long webbing/padding device called a rescue boa (photo 4). The rescue boa wraps around the patient’s shoulders and clavicle; built-in handles allow you to move your patient. Since the rescue boa is completely padded, there are no stress points on the patient’s body as you are moving the patient onto a litter or other movement device. It’s a very simple and straightforward device; use it and see for yourself.
The vest device is an interesting tool for patient management (photo 5). Designed by a firefighter in the Netherlands, it uses the methodology of controlled patient movement inside the vehicle, so it is much akin to the board devices. However, the device attaches to the steering wheel and column to hold onto the patient while a long spine board can be slid in place or the seat back can be removed. Once the movement device is ready, the vest is released from the steering wheel and the patient is moved normally.
Extrication boards vary in price, construction, and design; they may be made of plastic or carbon fiber (which is more durable) and originated in motorsports rescue. It is difficult to remove drivers from a motorsports seat without their assistance, so theses devices are made for ease of use and minimal access and include straps to allow for better packaging and to facilitate movement out of the vehicle
Although the inflatable C-Collar is not a collar to use every day, in tight spaces, you can easily slide it in place and inflate it with its attached inflation bulb. Give one a try!
Injury Patterns Today
Look at the last half-dozen MVAs you have responded to. Recall when you first started on the job and the first MVAs you responded to. Do patients get hurt the same way they do today vs. five years ago? Or 10, 20, or 30 years ago? Nol! Thirty years ago, we just started with frontal driver SRS. People didn’t wear seat belts. They would hit steering wheels and windshields while bouncing around inside the vehicle’s front interior, suffering mostly upper body trauma. Twenty years ago, vehicles had frontal driver and passenger SRS, but also side impact and curtain SRS are here. They were more likely to wear seat belts but still not like today. Ten years ago, we had SRS basically in the same place as 20 years ago, but now all vehicles have them.
The big change is how and from what material vehicles are constructed, which changes the way vehicles absorb crash energy; likewise, changes in injury patterns and the vehicle’s ability to crush hide this fact. Lower extremity injuries are the worst. Textbooks take a long time to catch up to these changes and keep current with vehicle technology-related concerns (photo 6)
In the past five years and in the next five years, we will witness another challenge and change with our patients. In the future, all glazing in passenger vehicles will be laminated, which will affect the injuries we see regardless of what type of MVA it is. The primary importance of the glazing change is that it adds 30% more structural integrity to the vehicle’s structure. Composite materials have become mainstream, so carbon fiber, carbon fiber-reinforced plastic, and plant-based composites are all in normal production vehicles, which adds complexity both as respiratory hazards and as materials with different properties.
We need to get a higher level of education with the power of unbiased research to help in the field of vehicle rescue. We need to know why something works or if we can do something faster that is just as safe and works on today’s vehicles, not just on Mr Cotter’s orange Yugo wagon or Wayne’s AMC Pacet.
We have so much fine science for structure fire and hazmat, shouldn’t we have the same for technical rescue too? Vehicle rescue is an art, but it is definitely also a science, especially concerning vehicle occupant injuries. It’s time for serious academic research into the basis of technical rescue and vehicle rescue.
Authored by David Dalrymple
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