By Anthony Correia
People are screaming, and twisted metal and steam have created a greenish haze. You pull up to the scene as the officer for this rescue. You encounter a mess of bodies tangled in metal on the highway. You are in charge! What do you do? If this were a video game, you would get to do it over again and again you mess it up. But, this is real life, and two cars are twisted into one. Blood is flowing, and people are screaming for help.
While this may sound a little extreme, it does happen. It’s happened thousands of times, and how you manage these incidents from the time of dispatch to the transport of the last patient to the trauma center will make all the difference in the outcome. You can be the most proficient rescuer in operating tools in extrication or the most adept paramedic at doing a needle decompression, but if you don’t manage the whole incident and scene properly, those skills won’t make much of difference. What will make all the difference is how well all the services rendered on scene were meshed into the performance of one cohesive team performing a common mission.
Managing extrications and complex highway incidents is not a simple one-size-fits-all process. Many functions are performed at an extrication. To be effective requires an orderly and a manageable process. Many extrications involve patients suffering from dire consequences of the crash. Many times, they have life-threatening injuries that need to be identified and treated rapidly. Oh, and you have to do this while cutting the patients out of a tangled mess of metal and glass. In addition, you are fighting the clock: Most extrications should optimally be performed in 15 minutes or less for the best patient outcome.
It’s about the Patient!
I’ve been involved in hundreds of extrications in various roles–as tool operator, emergency medical services (EMS) provider, and incident commander. I have had my fair share of incidents go bad. Over time, my frustration with individuals and departments turned to reflecting on the whole incident and identifying the contributing factors. As I looked back, I realized it wasn’t a person or an organization; it was the process as a whole. The father of Total Quality Management (TQM), Dr. W. Edwards Deming, noted: “A bad system will beat a good person every time.” No matter how good one person is at the tasks on the extrication scene, if the whole team isn’t operating as one synergistic, systematic team, patients are going to suffer.
Successful management of extrications must have as their priority that the overarching priority of the mission is, “It’s about the patient(s).” This must be understood by all. It is not about how crafty you are at cutting up the vehicle. It not about how awesome you feel when doing a needle decompression. Extrication is a team sport. It doesn’t matter who the most valuable player is. The patient must be the winner. The patient wins through a cohesive performance of the whole extrication team–a comprehensive approach in which all disciplines integrate into one disciplined team to rescue the patient.
Achieving optimal performance necessitates taking action before an incident. It takes getting the people involved in these rescues together to develop relationships before the extrication. Building relationships is one the keys to developing a team approach. Knowing and understanding what others bring to the effective mitigation of an incident makes it easier to use their resources. Many issues can arise when determining who will be in charge and how this will be decided. It’s no secret that egos and strong personalities surface at the scene of an incident if preplanning has not been done. Creating Traffic Incident Management Teams is one way to address leadership and personality issues before you’re dispatched to a scene. Team members meet regularly to plan and train together on roadway incidents. The team should include representatives from fire, EMS, police, communications, tow truck services, and the departments of transportation and public works, to name just a few. The team’s makeup will be determined by the agencies that respond to extrications and roadway incidents in your jurisdiction.
Planning, preparation, and training must be done on an ongoing basis. Managing and performing extrications is a dynamic process; you can’t set the ship in one direction and let go of the wheel. You must maintain situational awareness and plan for the future (this includes having a Plan B and Plan C if Plan A fails).
When there is a real emergency, successful management of an extrication begins at the time of dispatch. Make an initial assessment of what you will need based on the report of the number of patients involved, the direction of travel based on traffic, the weather, and roadway conditions. Determine what hazards may possibly be encountered–down wires, leaking fluids, and traffic, to name a few. Also consider the resources that are responding vs. the resources you need.
Before you get in the truck, make sure that you are physically and mentally ready to do the job. As you enter your vehicle, make sure your team members are wearing this personal protective equipment and are wearing their seat belts. If you don’t arrive alive, you can’t help others to survive. Check your directions quickly with whatever you may use: map book, GPS, phone, computer, or other navigation tool. Be aware of alternate routes if needed. Consider from where other apparatus will be responding. A checklist of tasks (a piece of paper or computer app) would be helpful to make sure all assessment points and tasks are covered. None of us is perfect all the time. Use applications like “Extricate,” which helps you to review vehicle composition and hazards. If available, live pictures or video from the scene will help you get a head start with scene size-up. With today’s technology capabilities, applications like Facetime, Skype, Ustream, and Periscope are all free and allow for instant video from almost any phone or tablet. If you are the apparatus operator, your job is to get everyone there alive. Don’t cause another emergency. Speed and sirens don’t get you there faster. An experienced operator knows how to handle the vehicles and knows his way to the scene.
Hopefully, your apparatus has headsets for all occupants or is a wide, open cab so you all can be communicating with the crew on the way to the scene. Everyone should be on the same page and clearly know what to expect from each other. There is no better way to start an avalanche of missteps than not doing what you are expected to do. Verbal and visual communication is key from this point until incident demobilization has been completed. Using Crew Resource Management (CRM), a system that makes optimum use of all available human factor and other resources to improve effectiveness and efficiency and promote safety during incident operations will improve your team’s overall performance.
As you get close to the scene (half mile, quarter mile, or 500 feet out), everyone should be scanning the scene for hazards, scene size-up, and positioning of the apparatus so it protects those operating on the scene and offers an effective operation position. Putting resources too close will compress and cramp the work area. As a rule of thumb, no vehicle should be closer than 100 feet to the vehicle on which you are working. A transporting ambulance should be positioned for easy egress from the scene to the hospital or helipad. This might mean it may have to be 200 to 300 feet away. Rescue vehicles and ambulances have portable equipment so that vehicles not needed can be staged out of the way and personnel can walk up to a personnel collection area for further assignment.
On disembarking from your vehicles, you should be clear on your assignment. Have on your vest, and be aware of traffic before exiting the vehicle. If someone is on scene already, report to the incident commander (IC) face to face for assignment and a situation status report. Do not freelance. If you are the first unit on scene, it’s your responsibility to establish command and do a scene size-up. Establish command on radio, and provide your initial windshield assessment and location of the command post. If you are not going to be the senior commander, provide a face-to-face report on what you found so far to the officer who will be the IC. Also include a situation status of what you have and haven’t completed to this point; then wait for the new IC to acknowledge your report and give you an assignment.
The IC position is responsible for overall scene coordination and is not generally a hands-on position. The IC’s job is to coordinate, oversee, and manage the incident action plan (IAP). As discussed earlier, extrications are a dynamic process. The IC needs to have a continual situational awareness that includes unexpected changes or obstacles, which will necessitate a revision of the IAP. All changes and updates need to be clearly communicated to all those involved in the extrication. A situation in which the patient’s blood pressure is dropping is important for all to know. It may change tactics and treatment.
Some of the other responsibilities of the IC are accountability, safety, staging of personnel and equipment, and ordering resources as needed. To be effective, the IC’s responsibilities must be delegated as the incident grows. Use a checklist to keep abreast of the situation and to determine what tasks still need to be accomplished. Additionally, if you transfer command, this checklist will provide more detail on the status of the incident.
There is only one incident commander. The large majority of extrications do not require a unified command. There is no Fire Command, Rescue Command, or EMS Command. Depending on the size of the incident, there are EMS, rescue, and police group supervisors or branch directors. With that said, the IC should not micromanage each of the disciplines working the extrication. The IC should let them oversee and supervise their respective disciplines. Rescue and EMS supervisors should have input into the overall IAP as well as of strategy and tactics their personnel will be carrying out. Implement the incident command system the way it was designed. Don’t create a local version to satisfy egos. Determine the IC is and how that position is chosen in the planning sessions.
Scene size-up, as discussed, should start with initial dispatch and be ongoing throughout the incident. When initiating an on-scene size up, quickly, but cautiously, assess the scene for any hazards between you and the vehicle(s) involved. Then make a quick assessment of the patient(s) for life threats that can quickly be resolved such as opening an airway or applying a tourniquet to a severely bleeding extremity. If there are more patients than you can manage, triage. All the while, be alert for other hazards you may encounter. As soon as possible, the IC should perform a 360˚ walk-around of the whole scene. Then, preferably someone who will be working in and about the vehicle(s) should conduct an inner, outer, under, and over survey. This survey should include an outer circle survey initiated 10 to 15 feet out from the car and an inner circle survey in close proximity of the vehicle(s) involved, including looking under the car and in the car. These surveys help you to identify hazards, the extent of damage to the vehicle (s) and the patient(s’) level of entrapment and severity of injuries. These combined surveys should take approximately 10 to 30 seconds in most cases. Surveys for larger and more complex incidents, such as a multivehicle crash, obviously will take longer.
Gaining access, patient care, disentanglement, and patient removal are phases of an extrication that are integrated into a continuous process. Although extrication and EMS personnel have tasks specific to their disciplines, it is imperative that they work as one team for one mission–the patient. As far as I am concerned, extrication is part of patient car. It’s not a separate entity. While each discipline is doing its “own thing,” they all must understand what the others are doing. EMS needs to know what a dash roll is, and rescue needs to understand why a tourniquet is being applied, for example. EMS providers should have a basic understanding of the tools and their operation; and they should operate them under close supervision in training so they can feel the energy when you pop a door or cut a steering wheel. Conversely, Rescue should be able to assess a patient for critical life threats, use a bag valve mask, and apply a tourniquet. The best scenario would be to have fully crossed-trained personnel who are equally comfortable with nasal airway and a hydraulic cutter.
Communication between Rescue and EMS working in and around the patient is critical. Communications is a key area on an extrication scene that is prone to break down. Those working on the incident must keep each other and their supervisors updated on the progress of the operations and the patient’s condition. The supervisors need to funnel information out to the IC to help the IC’s overall incident situational awareness. Communication is not simple when working at an incident with loud noises and multiple emergency personnel on scene who are talking simultaneously. Additionally, if you do not establish in the planning stage with whom personnel should be communicating on scene and when, the results will be confusion and failure of important messages reaching the proper parties involved in making critical decisions. Using the CRM process will promote effective and efficient information exchange.
While operating in and around the vehicle(s), all parties must pay attention to the smells, sounds, sights, and surroundings at all times. Although focused on their task(s), they must not get tunnel vision. They should be aware of things such as the car’s shifting with every cut, the strong smell of fuel from a leaking hose, or the sound of glass shattering—in other words, all the potential hazards to you, those working in the vehicle and the patient. Additionally it’s important that extrication personnel know the patient’s status and the type of care being given. EMS needs to know what extrication procedures are being performed and how they may impact the patient. It’s important for all to understand the impact of lifting a dashboard off an abdomen where the aorta may be compromised or cutting a steering wheel pressed up against a flail chest.
Just as a single extrication event is fluid and dynamic, so is the evolution of extrication. Cars are changing daily in construction materials and designs and more technology, newer safety devices such as spring-loaded, pop-up roll-over protection systems (ROPS) and detonator-activated air bags. There are hybrid and other alternative powered vehicles. These are just a few of the ever-changing components of newer vehicles. For this reason, it is imperative that you continually increase your knowledge on new vehicles and revised extrication practices. Additionally, changes in EMS treatment and tools, such reduced use of spinal immobilization practices and use of newer blood-clotting agents like tranexamic acid, change our approach to extricating patients. Additionally, the players change because of change in position and retirement. This all translates into the need to continually update your relationships and revise your practices and protocols while continually training.
Anthony Correia has been active in the emergency services for 38 years and an educator/instructor in the emergency service disciplines for more than 35 years. He has presented nationally and internationally, and has been in career and volunteer executive leadership positions in fire and EMS services for more than 25 years. He is a graduate of the National Fire Academy Executive Fire Officer program