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Think patient stabilisation rather than our historic ‘immobilisation’ approach.

The team approach to vehicle extrication: time for change

The team approach to vehicle extrication is nearly as old as I am, which begs the question: why has it never been revised? No one can doubt that it is a checklist that has served us well for nearly three decades and has been a valuable aide-memoire for incident commanders, but with so much changing in the world of vehicle extrication, it is my considered view that it is simply no longer fit for purpose in 2018.

So, I am proposing some minor changes with the aim of:

  • Enhancing scene safety
  • Reducing extrication times (therefore scene times)
  • Improving patient outcomes
  • Considering the next generation of rescuers and incident commanders

I am amazed that no one has reviewed our approach before, especially when you look at the sheer number of websites dedicated to the subject and the many self-declared experts around the world. Although individual elements are discussed at length across many platforms (e.g. social media) there has never been (to my knowledge) a proposal to update our standard approach in a way that reflects modern vehicles, equipment, techniques and our own skills and understanding.

The team approach as we know it currently reads as follows:

  • Safety and Scene Assessment
  • Stability and Initial Access
  • Glass Management
  • Space Creation
  •  Full Access
  • Immobilisation and Extrication
  • Evaluation

We know that the phases of the team approach can be carried out in any order, with the exception of Phase 1. Safety and Scene Assessment must always be carried out before work commences; this is a fundamental understanding upon which the team approach has proved so valuable and must be maintained.

So what am I proposing?

Well, quite simply I am suggesting two additional phases, some rephrasing and some additional wording as follows:

  • Safety, Scene Assessment and Additional Resources Request
  • Consider Vehicle Relocation
  • Formulate Initial Extrication Plans
  • Stability and Initial Access
  • Glass Management
  • Space Creation (Internal & External) and Vehicle Shutdown Protocol
  • Full Access
  • Patient Stabilisation, Extrication and Patient Handover
  • Performance Evaluation

Why these changes?

After many years of training and assessing rescue teams from all over the world, there are common themes and issues that present themselves time and time again. These issues do potentially compromise safety, add to scene time and have some negative effects on patient outcomes. So these proposals are based on operational experience and from the witnessed performance of operational crews, not simply on a whim or change for change’s sake.

The changes do not reflect simple additional tasks but rather suggest fundamental principles that may greatly affect outcomes.

In addition, I am considering the new generation of rescuers who are in danger of thinking the way I did 25 years ago. I do not find this acceptable or conducive with the very best outcomes – something we all aspire to. Let me explain my proposed changes:

Additional resources request

In many countries in 2018, budgets in all services are stretched, so resources are very often delayed. A prompt to order additional requirements at the earliest possible juncture will inevitably lead to reduced extrication and therefore on-scene times. Once an incident commander becomes focused on the extrication, this can at best get delayed and at worst missed altogether. Resources can be anything from additional medical help, heavy-lifting equipment or additional rescue equipment. Of course, there is a fine balance between immediately ‘ordering the cavalry’ and making necessary and timely requests for assistance.

Consider vehicle relocation

Relocating a vehicle is now a genuine option for all extrication crews and can massively reduce extrication times by providing better and more effective patient access. Historically we have (up until very recently) always been very proud of our ability to stop a vehicle moving due to the long-held belief that we would make injuries worse. While I cannot advocate any uncontrolled relocation or vehicle movement without medical supervision, I also cannot advocate not considering moving a vehicle to make the job safer, easier and more patient centred. I have previously blogged about vehicle relocation and very (very) rarely see crews considering it as an option. In most extrications it will be either unnecessary or not an option for many reasons, however we MUST condition crews to immediately consider it on the understanding that the relocation time is NOT in addition to their perceived extrication time!

Formulate initial extrication plan

I do not imagine for a minute that incident commanders do not start to formulate their extrication plans as soon as they arrive (or even before arrival based on information received), but I very often see even very experienced crews struggle with extrication planning in terms of sequence and timing. This then has an impact on other aspects of the process and leads to delays. There is very little guidance or structured training when it comes to extrication planning and we must formalise this in our approach from this point forward. I would also like to add that although during my career I was provided with fantastic incident command training, I was never instructed in the real art of planning an extrication. Very little, if any, guidance on critical extrication planning exists although in my book ‘Vehicle Extrication Techniques’ I do devote quite a sizeable number of words to the subject.

Space creation (internal & external) and vehicle shutdown protocol

Space creation as detailed in the existing team approach immediately lends itself to using hydraulics to move metal. A gloved hand and some understanding of vehicle anatomy can achieve huge internal space (move seats/steering wheels/open windows) before a tool is even taken from the truck to perform, for example, cross ramming. It is important (in my view) to distinguish between this and external space creation.

We have become much smarter at shutting vehicles down, principally due to the perceived risks from hybrid/electric vehicles and SRS/Airbag systems, but this is not considered anywhere in the current team approach. The shutdown of a vehicle’s power systems must be in line with the extrication plan and any internal space creation MUST be performed before shutdown begins, simply due to the increased number of electrical systems on modern vehicles.

Patient stabilisation, extrication and patient handover

We have always referred to this phase as immobilisation & extrication, but we know very well that not all patients require immobilisation and many (actually most) just require some form of stabilisation. This can be provided by the patient themselves in some instances by simply adopting a more comfortable position or posture. We should be moving away from the instant application of a collar and KED (of course on clinical advice) and approach the medical aspects of extrication with a more open mind. Legally too, if we (fire and rescue) have treated the patient, we MUST handover in a predetermined fashion and provide documented evidence of our care using a patient report form.

Conclusion

The team approach was conceived a long time ago and has, until now, served us well. Things have changed and although its strength was in its simplicity, the team approach now has glaring holes in its contents, which could leave operational rescuers wanting at a crucial time. For the experienced and proficient technical rescuer, the above additions/changes will likely be just something you already do. However, my experience leads me to believe that in the vast majority of cases, a revised team approach will make you safer, ensure you are on scene for less time and your patient is given the very best possible chance.

From this point forward, this will be the team approach that I teach to all technical rescuers as it is my belief that we must move on.

For more information, go to www.ataccgroup.com

Top image: Think patient stabilisation rather than our historic ‘immobilisation’ approach.

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Ian Dunbar spent nearly 20 years in the UK Fire and Rescue Service before becoming a specialist technical and medical rescue consultant. He has worked in over 100 countries worldwide training operational rescuers and consulting on all issues regarding vehicle extrication. He was an assessor for both UK and World Rescue Organisations and author of ‘Vehicle Extrication Techniques. Ian is now a business development manager/rescue consultant for The ATACC Group.