Head, Belly, Toes-In Line: A Case Study of a MVC Gone Awry

Article and photos by Dave Dalrymple

Vehicle rescue is a patient-driven practice. We all know this to be true, be it whatever job you are doing at the time, whether it’s staffing a charged line to provide fire suppression protection, operating a power hydraulic rescue tool to create space to disentangle a patient, providing hands-on patient management (photo 1), or facilitating the mitigation of the incident as the incident commander (IC). All parts of the response package are equally important in achieving a better patient outcome. If you have read any of my articles or attended any of my presentations or training classes, you know I firmly believe that you need to believe this and know it to be true if you are to be a good rescue technician. The bottom line is, Do no further harm.

(1)

Sometimes, things do not quite happen this way. Many times, these things are minor and are of little consequence, but sometimes they can have far-reaching impact. I am presenting the following case study for you to ponder as a rescue technician.

The Scenario

An engine company arrived on scene, isolated power to the vehicle keys were removed to apparatus, and battery cables were cut), noted no supplemental restraint system (SRS) deployment, chocked and stabilized the vehicle, and pulled and charged a line for fire suppression protection.

A rescue company arrived and began to prepare for a complete side removal, based on the initial assessments. Other than for the neurological deficits, the driver had no other complaints, so BLS placed the patient on high-flow O₂, administered a C-Collar, and prepared to package the patient in a Kendrick Extrication Device (KED), and then transfer him to a long spine board (LSB).

Unified command on scene decided to change the extrication plan to simultaneous side removal of the driver side and roof removal, since the patient was hemodynamically stable with no respiratory issues, but had neuro deficits and was medically entrapped because of his position in the vehicle. It was felt that since both rescue apparatus were on scene, this could be accomplished (photo 3) in 10 to 15 minutes while BLS packaged the patient for disentanglement. The driver of vehicle 2 signed a refused medical attention (RMA) waiver on scene and thus refused treatment.

(3)

At this point, the advanced-life support (ALS) unit arrived. In New Jersey, all ALS is hospital based and, with few exceptions, is non-transport based, and is provided out of a “chase” or “fly” vehicle. An ALS in usually comprised of a two-person crew, both of whom are mobile intensive-care paramedics. As one of the crew began to unload equipment from the vehicle, the other crew member walked over to the incident. Neither was wearing any personal protective equipment (PPE) other than for a basic uniform, not even high-visibility vests, a Department of Transportation (DOT) requirement. The ALS provider who had walked over to the scene looked at the vehicle and said to the rescue crew, “You don’t need to cut this car.” At that point, he stepped into the open driver’s opening to prevent the rescue crew from beginning to work. The BLS crew then attempted to explain its actions to the ALS provider and give a brief patient history, which was ignored.

The ALS provider then began a heated discussion with the chiefs from the fire department and EMS/rescue and the operations officer. He basically berated them for unnecessarily cutting apart a vehicle that is repairable and said that they were just a “bunch of whackers who want to play.” He said that since the driver’s front door was open, the patient could just be pulled out through that opening.

The chiefs and operations officer explained to the ALS provider that the patient was stable, had neuro-deficits in all four extremities (photo 4), and that the vehicle had sustained more than two feet of rear-end crush and was struck hard enough to break the driver’s seatback.

(4)

The ALS provider put his hand up in their collective faces and told them that “he has the highest medical authority on scene and they will do as he tells them”; they do not need to and will not cut the vehicle since the patient is under his direct care.

The EMS/rescue chief told the ALS provider to get into the vehicle and put his hands on the patient and assess the patient himself to get a better grip on the situation. To this, the ALS provider retorted, “I’ll assess the patient in the ambulance once he is removed.”

The patient was loaded into the ambulance. Then, the ALS providers performed a patient assessment. As their assessment progressed, the patient said he could no longer feel or move his legs, which the ALS providers found to be correct. While in the vehicle, he had told the crew that although he had tingling and numbness he could feel and move all his extremities. At this point, the second ALS provider conferred with command and requested aeromedical evacuation to a trauma center since the patient had lost sensation below the waist. The engine company set up a landing zone, the aeromedical helicopter landed, and the patient was transferred to their care and flown to a level 2 trauma center, the closest trauma center to the area. The second ALS provider thanked the officers for their assistance.

When the chiefs approached the first ALS provider to speak with him, he told them he had nothing to say to them and that if they had a complaint to take it up with his director.

What Would You Do?

Reread the story up to this part again. Think about it for a minute. Jot your thoughts down. What would YOU have done if you were faced with this same scenario? You may even have faced similar situations. Let’s review a few things in a nonjudgmental way.

What pathway would YOU have created when faced with a patient with the injuries presented above? You note that the vehicle (photo 5) had at least 24 inches or more of rear-end crush and that the driver’s seat back broke up in the collision. You note no obvious vehicle hazards, no fuel leakage, or SRS deployment, but frontal systems are present. You also note that the vehicle is a late-model Mercedes Benz E class–in its day, a high-end vehicle. The damage to the front end of the newer Malibu is moderate, with frontal SRS deployment. BLS assessment finds the patient to be stable without respiratory concerns but, noting the above neuro deficits in all extremities, the patient is still capable of moving all of them. The patient is supine in the driver seat against the rear seat back, so the patient is medically entrapped because of his body positioning and the fact that, even with the driver’s front door open, the vehicle side and roof are in the pathway you would traverse to disentangle the patient. Remember, we always strive to move patient “head, belly, toes in-line” as much as we possibly can.

(5)

But that’s not what happened. Who is right, and who is wrong here? Again, we are NOT supposed to do further harm, right? Yes, the ALS provider did indeed have the highest medical authority on scene and had authority on patient management, thus placing him technically in charge of patient care. But now the question arises: What happens when you have an ALS provider who is out of his depth with the technical aspects of the incident at hand? Is this an incorrect statement?  How many EMS providers have worked on and performed patient care in a technical rescue environment (photo 6)? Although a MVC is not as critical as a trench or a structural collapse, technically speaking, today’s MVC presents myriad hazards and concerns for patient and rescuer alike.

(6)

First, let’s look at the technical no-no’s here: (1) No PPE was worn, not even the required DOT high-visibility vest; (2) The ALS provider inserted himself into an ongoing tool evolution; (3) He made a patient evaluation by looking at the vehicle from one direction; and (4) He proceeded to engage in a heated discussion with the unified command structure within earshot of the patient, the other EMS providers, and the engine and rescue crews. 

The unified command structure of the responding agencies have the proper scope, jurisdiction, training, and authority to mitigate the incident and the proper staffing, equipment, and apparatus to provide for a pertinent rescue effort to ensure a potential better patient outcome. The ALS provider basically was freelancing and acting outside the accepted scope of practice by not performing a proper patient assessment (his primary mission), disregarding the technical issues outlined above, and beginning patient movement on his own accord.

The patient did not meet the current Prehospital Trauma Life Support guidelines for a rapid extrication. A “patch of power” on one’s arm does not give one all-knowing powers in every incident. The actions of this provider showed he had neither proper nor formal rescue services training or he had completely forgotten all of it. Once again, rescuers are NOT supposed to do any further harm to the patient.

ALS providers might indeed have the legal basis and skills and abilities to treat a patient on a certain level, but when the technical skills of the incident are presented and their training and abilities are not up to what is required to function on scene and manage the patient appropriately, they need to take advice from individuals whose knowledge base and skills are able to mitigate the incident, at least to the point where it is safe to conduct an appropriate level of patient management.

The bottom line: The ALS provider should have gotten into the vehicle and performed a hands-on assessment himself to make an informed judgment on what was indeed best for the patient (photo 7). Many times we go through the motions of C-spine management on scene because we are taught to do so, only to have everything ripped off the patient in moments after they pass through the emergency room doors and are unloaded. Statistics say that we might indeed go overboard with C-spine management and spinal management, but at the very least it is in the patient’s best interest, prehospital-wise.

(7)

Although I have left out many technical details because of HIPPA, it is important to point out that common, everyday emergencies like MVCs can have far-reaching consequences. Many times we do things because there in greater chance for potential injuries than the presented ones. This is one of those times when the potential was real and, unfortunately, ignored, not by the initial responders but by the higher-level patient-care provider.