In the previous article we looked at the initial stages of extrication planning and focused on the gathering of information, establishing our priorities, contriving the plan based on the initial and ongoing needs of the patient and communicating our findings. We also looked at the process of having to change our plan based on our dynamic observations.
For the second part of this series we will focus on planning methodology and the need to maybe consider moving away from A and B plans. Additionally, we will also consider on-scene communication and the importance of maintaining dialogue to ensure the nominated plan is carried out in a safe, timely and casualty-centred way.
For many years fire and rescue services have used A and B plans as the basis of their methodology with the A plan being the preferred extrication route and the B plan being the emergency option in the event of a deterioration in the patient’s condition. My experience is that for some, this has proved confusing, especially when the expectation is for the B plan to be contrived prior to the A plan. Regular conversations I have surrounding this topic often leads to much discussion and some considerable misunderstanding.
I genuinely feel that having only two options which are (in most cases) perceived as ‘fast’ and ‘slow’ is not casualty centred and I feel we must make the process of extrication planning more reactive to the needs of the patient.
For that reason, I would urge incident commanders to consider the following approach of ensuring that they (as soon as practical) can react to the following eventualities.
WALK OUT (Self Extrication)
There is much debate at present around self-extrication, and it is not my intention to cover this subject in this article to any great depth. However, with our increase in understanding of mechanism of injury and evidence to suggest the possible (and likely) historic over use of hard collars (and immediate immobilisation), we must consider this as an option. We should, however, be guided clinically on scene and always work within the scope of our local/national guidance. This area will continue to be a hot topic for discussion in the coming years and organisations should endeavour to maintain their understanding.
In the event of the casualty suffering an immediate event, e.g. cardiac arrest/respiratory arrest, they can be immediately removed from the vehicle so medical intervention can continue. The priority here is the dire need for medical assistance that cannot be performed whilst they are inside the vehicle, e.g. chest compression/intubation. It therefore follows that to facilitate an immediate extrication, any physical entrapment which prevents removal of the patient from the vehicle, must be removed as a priority. Even though this is an immediate extrication, every care should be taken to keep the casualty inline as much as possible. However, the priority must be dealing with the issue that has led to this course of action.
If during medical assessment it is noticed that the casualty’s medical condition is worsening, there may be a need for a rapid extrication, e.g. within 5 minutes. This will allow medical intervention to continue and should be completed as soon as possible with minimal rotation of the casualty.
If the casualty remains relatively medically stable, we can extricate using our preferred method, creating the appropriate amount of space relative to the identified injuries. Where possible, the casualty should be kept inline (straight) therefore minimising rotation of the spine/pelvis. Ideally, the extrication should be completed in 20 minutes or less
Being able to work towards Rapid, Immediate and Urgent extrication plans removes any confusion that currently exists in relation to A and B plans and in what sequence they come. Understanding the fundamental concept of ensuring we can react to any of the above eventualities means we can be more logical and therefore casualty centred in our approach.
It is imperative that early lines of communications are established and that everyone on scene knows their responsibilities in terms of passing on relevant information in a timely and succinct way. Regular and effective updates allow the incident commander to respond to risk-critical issues and amend their plan as necessary. Once a safe system of work is established (and maintained), the following communication should be established and maintained throughout the rescue process:
Incident Commander – Technical Team
The incident commander must communicate effectively with the rest of the team, detailing potential hazards and advising as necessary. They must detail the desired extrication plan and check the team’s understanding by asking them to confirm (and give feedback). Throughout the rescue, the incident commander must constantly update, encourage, maintain momentum and, if required, cease all activity if safety is compromised.
The technical team must constantly update the incident commander with details of their progress and potential problems they may encounter. Based on this information the incident commander will be able to change and adapt the plan, if necessary.
On Scene Medic – Casualty
At the earliest opportunity (once safety and stability have been taken care of) the medic must establish communication with the casualty in the vehicle. Only by doing so can the assessment begin, and can the information be passed onto the incident commander.
Incident Commander – On Scene Medic
Once the extrication plan has been formulated, the incident commander should communicate this plan to the medic and receive confirmation of understanding. If the plan has to be adapted or changed for technical reasons, the incident commander must inform the medic to ensure this change is viable. The incident commander hands over control of the extrication to the on-scene medic (all casualty movements should be controlled by the person who is immobilising the cervical spine), when full access has been created and the extrication is about to begin
Once the initial brief has been given, the team medic must give regular updates to the incident commander so if in the event of a rapid change of medical state, the plan can be changed to allow immediate/rapid extrication.
On Scene Medic – Technical Team
During the extrication process, the medic will have close contact with the casualty. If the actions taken by the technical team during the rescue are having a detrimental effect on the casualty, the medic must have an open communication channel with the team so they can advise them, thus allowing them to adopt a different position or technique. Once full access has been created, the medic must deliver a casualty-focused brief to the technical team, before they assist with the extrication
Incident Commander – Other Agencies on Scene
It is imperative that the multiple agencies who attend the scene of road traffic collisions communicate effectively. Poor communication between fire, ambulance and police (the three major attending agencies) will not expedite the extrication process and may, in the worst cases, compromise safety.
In my experience, the key relationship is between the technical and medical rescue services (i.e. fire and ambulance) and this is dependent upon several key factors. Firstly, if the fire service is in attendance first and they have deployed their medic, then upon arrival of the ambulance crew, a clinical handover must be completed as it is (usually) custom and practice for the organisation with clinical primacy (i.e. the ambulance service) to take over the role of patient care. The attending paramedic must also be made aware of the nature and timeline of the nominated extrication plan as this allows them to make the most appropriate clinical decision. From this point forward, the incident commander and paramedic must maintain communication (as detailed above in the section incident commander – on scene medic). If the ambulance service is in attendance, then the medical condition of the patient must be conveyed to the incident commander at the earliest opportunity thus enabling the formulation of the extrication plan.
Although the on-scene communication between fire and ambulance is fundamental to a casualty-centred extrication, the importance of liaising and communicating with other agencies should not be forgotten.
The police have differing priorities and will usually appreciate expected timelines so decisions can be made in relation to (for example) road closures and diversions. In the event of more serious collisions, the police will require further information relating to injury severity and with all collisions, fire and rescue need to be mindful of their duty of care in respect of scene preservation and any likely accident investigation. For these reasons, effective communication with the police is vital.
Over the previous two articles, we have covered the main elements of extrication planning. We have covered the need for identifying key information, communicating our initial findings, establishing priorities and establishing and maintaining effective communication. We have also looked at an alternative to our long-standing approach of contriving A and B plans – the cause of some confusion in my experience.
With seemingly endless access to application videos and the latest rescue tools, we need more focus on the human factors that have such an impact on extrication as it is my belief that it is in this area where we can make the largest gains. A logical approach that is well communicated, regularly reviewed and updated will no doubt lead to better patient outcomes. I would urge all personnel and agencies involved in vehicle extrication to look critically at how they approach planning and communication. In my experience, whilst incident command is a well-practised skill in many countries around the world, the finer nuances of planning a technical extrication, whilst considering the medical needs of the patient has tended to be somewhat overlooked.
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