By Charlie Kemp
When we read an article on extrication, we are usually looking for the latest and greatest techniques in the art of cutting vehicles apart. Sometimes, we forget the main objective of extrication: our patients. Without good patient care from the beginning to the end of the extrication, even the best firefighters and extrication techniques will not have good patient outcomes.
Like most things in the fire service, we must have a solid foundation from which to build when it comes to patient care, starting with our initial patient contact. This contact is made during our inner circle, remembering that completion of the inner circle must be done before touching the vehicle. Once the vehicle has been cleared, we can start our interior stabilization, patient assessment, and care. A new term in the extrication world is interior stabilization. Although the term is new, the concept is not. Stabilizing the patient compartment helps identify patient condition, creates space for patient removal, helps secure the vehicle, and identifies any entrapment problems. All of these can slow the removal of the patient. By addressing issues early, we improve patient care and decrease extrication time.
There is a systematic approach that I have been using in the field and teaching to the students I have the pleasure to instruct. As I approach the vehicle from the front and off to the side, I’ll make contact with my patient. Approaching from the front side allows you to keep eye contact with the patient, but also keeps you in a safe area in case the vehicle moves.
A firefighter approaches and asks the patient to follow some simple commands at an extrication scene.
I then identify myself and ask the patient to follow a simple command, like grabbing the steering wheel with both hands. This simple task request does two things. First, if they are able to follow this command, their ABC’s are intact. Second, it shows me they have no upper extremity entrapment.
If they are not able to follow my simple command, I need to find out why. If the patient is unresponsive, our course of action changes. We must identify and address the issue causing our patient to be unresponsive, and the interior stabilization now must be assumed by another rescuer. If we determine that our patient is a rapid–meaning they are either dead or dying without immediate intervention–they need to be removed through an opening that the vehicle affords you. This means a window, a door that opens, rear window slide, or the quickest opening you can create through mechanical extrication. Once we determine our patient is a rapid, we must communicate this to our extrication leader. We try to do our best with C-spine precautions on the patient removal, but remember, with a true rapid patient, if we don’t get them out immediately, they may die in the vehicle.
If the patient is able to follow the simple command, I continue with my process, remembering to execute a rapid plan in case the patient takes a turn for the worse. If I’m not able to make access into the car, I may ask the patient to perform a few tasks to help stabilize the vehicle. If they are unable to assist with these tasks, I will do them as soon as I can gain access to the interior of the vehicle. The tasks to stabilize the interior consist of making sure the vehicle is in park, engine off, parking brake set, hood release pulled, and hazard lights activated.
The rescuer puts the vehicle’s parking brake on and activates the hazard lights.
I also use all the electronics to my advantage to create space for the patient. This includes rolling down windows for better communications to the exterior, sliding seats back, moving steering columns and pedals, as needed. By activating the hazard lights, everyone knows that the 12-volt system is still operational. Once the interior of the vehicle is stabilized, I start with my primary patient assessment at the patient’s feet and ask if they can move them. If they can’t, I try to identify why.
From the feet, I start my upward physical exam by doing a physical assessment and blood sweep. I proceed with the exam up from the feet, lower extremities, pelvis, hips, abdomen, chest, upper extremities, and to the C-spine. When I have C-spine stabilization, I can finish my exam on the head by checking ears, nose, and mouth. At this point, I have stabilized the interior of the vehicle, identified any entrapments, and done a primary assessment on the patient. This whole process should take under a minute to accomplish. Next, you can pass all that information onto command and let them work on a safe and efficient plan to extricate the patient from the vehicle.
As with all patients, constant monitoring during extrication assures their condition has not changed. This information must be relayed to command so they are aware of any changes as they happen.
When it comes to developing extrication plans, think about patient position in the vehicle to maintain a nose, belly button, toes orientation for patient removal (keep the patient as straight as possible on removal). We learn all these great techniques to create large openings in vehicles to bring our patients out and then slide a backboard under their buttocks to twist and torque them out. The reason for big openings is to avoid undue twisting and torqueing of our patients. The less stress on the patient, the better the outcome.
A training tip is to practice these techniques with any vehicle you have around the station. Take your crew out and run them through a scene size-up, outer and inner circle, patient contact, accessing the vehicle, and interior stabilization. Practice makes perfect, and perfect patient care is what we strive for.
Charlie Kemp is a lieutenant and pramedic with Central Pierce (WA) Fire & Rescue. He began his career in the fire service in 1992 as a volunteer with KCFD#46 and Enumclaw Fire Department, and later became a firefighter/paramedic for the Puyallup Fire Department. has been a member of the Pierce County Special Operations Team since 2000 and is currently a Rescue Specialist with WA-TF1. Charlie is one of the original members and a lead instructor for the Puyallup Extrication Team and has competed with the team at a regional, national, and international level. He enjoys passing on the training and techniques he learns at these events, to other firefighters, through classes taught throughout North and Central America.