Rescue Real Estate: Simultaneous Operations at a MVC

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08/25/2010

Article and photos by Dave Dalrymple

From the 2010 vehicle extrication e-Newsletter, sponsored by

When was your last “pin job”? Did it flow well operationally? Does anything come to mind that could be enhanced or polished a bit? One of the concepts we learn on an operational level is that of simultaneous operations (photo 1), which entails using multiple tools at the same time and performing multiple tasks. But how often does this happen? Many of our training programs involve performing one task; completing it, and then moving on to the next one. That’s fine for learning tool skills; however, on an operational level, we need to hone our ability to multitask on a variety of levels. We need to focus on multitasking at a “task” or “job” level.

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One critical area we must focus on is integrating with the rescue team and EMS providers. We all realize that vehicle rescue is a patient care-driven skill, just as is any other rescue situation. However, many times our training revolves around tool skills. Although we give the patient “lip” service, how often do we use a patient during a drill, be it a manikin or a “live” person (photo 2)? Some may wonder what the big deal is, consider how we can make our personnel focus on patient-care issues if we never train with someone there?

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On-Scene Considerations

As an example, imagine an everyday motor vehicle collision (MVC) with extrication. An engine is on scene managing the hazards, EMS is beginning patient care, and the rescue company has arrived and goes to work. How many times does the rescue crew begin its evolutions only to find that it is working around EMS paraphernalia?

As the extrication progresses, one of the EMS providers continues patient management from outside the vehicle next to the side of the vehicle that is in the process of being removed. Sound familiar? Although this doesn’t always happen, many times it does.

I’m not picking on EMS providers, because I am one. So why does this happen? As I mentioned before, vehicle rescue is and will always be a patient care-driven skill. But ALL the components of the response package are important to provide a better patient outcome, whether you are on the hoseline providing hazard control, running a power hydraulic tool to remove the vehicle from the patient, providing patient management as the EMS provider, or wearing the white hat and OPS vest managing the incident. ALL are needed to effect a successful rescue.

Why do these EMS dilemmas occur? First, let’s examine equipment. Most of the responses EMS goes on are medical emergencies. What gear is employed on such calls? Usually, it will be a jump bag, O₂, an EKG/Defib, a clipboard or a laptop, and a carrying device. These tools become routine, a matter of habit.

What happens when we get a MVC? Well, our habits and training kick in, and all this stuff starts to make its way to the vehicle. Some of these items are indeed necessary, but what do we really need? A C-collar is important, and if trauma is involved, patient O₂ is a must, even without respiratory distress. Large dressings for controlling bleeding and a BP cuff are also important, but we can put those items in the cargo pockets of our personal protective equipment.

Can you think of anything else we really need until we are transporting? How effective is running a 12-lead EKG from inside a vehicle during the extrication process or even trying to take a blood pressure while the noise of the tool evolutions are progressing? How about writing information on the clipboard or typing information into the computer? Not too effective, probably.

Providing Patient Care

Let's consider where we are while providing patient care. Sometimes we have little choice but to provide care from the outside of the vehicle (photo 3). There may be a lack of space inside, or the patient may be accessed most easily from the vehicle’s exterior. But how often do EMS providers get the opportunity to train on providing patient care while working in the interior of a damaged vehicle? Many times, EMS providers are introduced to the interior of a damaged vehicle in a real-life incident--not in a training environment. If this were your first experience in providing such care, how confident would you feel working in such an environment? Over time, this presents less of a problem, depending on the number of MVCs to which you respond.

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Responders must disentangle the patient from the vehicle somehow. I doubt that the emergency room staff would be happy or prepared if you showed up with your patient still in his automobile on a rollback and you said, “Here you go.” Thus, we need to provide patient care properly while also providing an expedited extrication to enhance that patient’s outcome.

Rescue Real Estate

How do we coordinate our efforts on scene effectively, rapidly, and safely? Practice makes perfect, so train as you work. However, I would like to introduce a concept to you for consideration. A group of my fellow instructors were sitting around trying to come up with a way to simplify how rescuers could coordinate their efforts on scene. We were looking for a simple, straightforward, and flexible concept to manage change, so we broke down those tasks that usually occur at an MVC.

One of the instructors in our group, Steve Pawlak, came up with the idea of dividing the vehicle into areas where these tasks occur. The rescue team basically works from the vehicle sides, whether working on a roof displacement, a door pop, a side removal, or displacing a dash (photo 4) Remember: 99 percent of your tool work is done from the side of the vehicle; very little is done elsewhere.

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Regarding patient management, Steve came up with the idea that unless the patient is outside the occupant compartment, most, if not all, of your patient care is going to be rendered inside the occupant compartment--thus inside the vehicle (photo 5). Our group recalled the jobs we went on in the past, and these basic principles held true for the most part.

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Steve called his idea “rescue real estate.” In short, the rescue team “owns” the exterior of the vehicle, with the emphasis on the vehicle sides; EMS “owns” the vehicle interior. Both providers work in their “own” area simultaneously, yet in a coordinated fashion. Although this may be a little oversimplified, we have found that it really works well, and we have even added a new twist to the concept: The engine company “owns” the front and rear of the vehicle (photo 6). Why? Power isolation. We need to not only ensure that the vehicle is shut off and keys are secured, but also that the battery(s) is/are disconnected and isolated (photo 7).

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Finally, how many times do we have far too many people in the hot zone? The concept of rescue real estate keeps our personnel focused on the tasks at hand by using the right number of personnel for each task (photo 8).

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Although we all know the tasks I have described in this article and fully realize that they need to occur on scene, sometimes putting all this into motion can be difficult, especially if you are short-staffed (photo 95). Breaking down these on-scene tasks, simplifying them, and focusing on where and when they will more than likely occur help the process and make everything go smoothly. Additionally, it makes us look good out there on the street; most importantly, it improves patient outcomes. Remember: Making space is the name of game, and making that space count makes it all worthwhile!

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DAVID DALRYMPLE is a career EMS provider for the RWJUH Emergency Medical Services in New Brunswick, New Jersey. Previously, he was the rescue services captain for Clinton (NJ) EMS/Rescue. He has been actively involved with emergency services for 26 years. He is the education chair of the Transportation Emergency Rescue Committee-US (TERC); a certified international level extrication assessor; the executive educator for Roadway Rescue LLC; road traffic accident advisor to the Expert Technical Advisory Board of the IETRI; and a member of the IAFC Specialized Technical Rescue Committee. He received the 2007 Harvey Grant Award for Excellence in rescue. He is a NJ-certified fire service instructor and a certified ICET (Netherlands) registered International SAVER instructor. He is the author of the “Extrication Tactics” column for Fire Engineering.

2010 vehicle extrication e-Newsletter sponsored by Holmatro.