By Jeff Pugh
Nearly everyone reading this article has found themselves in the following situation: You respond to a motor vehicle accident (MVA) with possible entrapment. On arrival, you make the scene as safe as possible through defensive parking, emergency scene indicators such as lighting, cones, flares, and so on, and you find the vehicle (or vehicles) involved with minor to moderate damage.
Someone in your company or at the scene must make contact with the victim(s) to see if they are injured, entrapped, or both; this responsibility is that of the firefighter or the fire/medic performing the “inner circle,” which is a rapid 360° size-up of the vehicle by the assigned rescuer, who approaches the victim(s) from the correct angle (so as not to have the patient turn his head), communicating to the victim(s) inside the vehicle. The inner circle rescuer does not touch the vehicle nor does he approach it from the front because of the unknown hazards associated vehicles involved in MVAs. The questions that the inner circle or first person who makes contact with the victim(s) should assist in determining what form of extrication will be required: “self” or “mechanical.” As the inner circle, ask the victim the following questions:
- Please turn the car off, place it in park, and turn your hazard lights on. What is your name?
- Are you injured?
- Are you the only one that was in the vehicle?
- Have you been out of the vehicle?
- Can you get out of the vehicle under your own power?
If the victim is not able to self-extricate, explain your “mechanical” extrication to help remove him from the vehicle with the following points (see point #5 below):
#1) If your patient can or cannot perform the functions or answer the questions, you have just determined his level of consciousness. If he is able to perform the functions, this will aid in resolving some safety issues with MVAs.
#2) What are your patient’s injuries? If the injuries are critical, consider the patient “rapid.” A rapid patient will more than likely expire in the next few minutes. So, rapid extrication is deemed appropriate.
#3) This question is especially important in a rollover situation or an MVA with obvious signs of potential ejections. This also aids in whether additional assistance is needed at the scene.
#4) If the victim(s) has been ambulatory and has been out of the vehicle, he is able to self- extricate again, which aids in de-escalating the incident and additional resources.
#5) If your victim(s) cannot self-extricate, explain the procedures you will use to remove him from the vehicle such as: Mechanical extrication from the vehicle as well as securing him onto a backboard with c-collar attached (or whatever your policies are for MVAs). Once you explain this to your victim(s), you may reevaluate whether he is injured and can self-extricate.
This line of questioning happens quickly and should be used when there is a question as to a patient’s injuries or entrapment. In our line of work, this gray area happens frequently, yet these questions can help determine if mechanical extrication is needed. Obviously, these questions would not be asked if there is a confirmed entrapment or injuries. Remember, you are there to treat the patient with due care and caution. I will always err on the side of caution and remove patients the way they should be removed—in line/long access.
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The next time you are at an MVA and there are spectators on the scene, note how many of those people are videotaping you, your efforts, the extrication, and communications. In this litigious society, we live and work in ways where we can easily find ourselves up against an insurance company, an attorney, or a family member wanting to know why we further injured the patient(s) with our poor extrication techniques or lack thereof.
These questions help eliminate some of the guesswork as to whether the victims/patients need to be mechanically extricated. Educating the patient on mechanical extrication as well as his removal from the vehicle puts the responsibility back onto the patient.
Once you determine that mechanical extrication will be the method to free the victim, the next question you must ask is: Who becomes the extrication leader (or, in some departments, the rescue group supervisor)? This is an open-ended question considering that operations differ in departments regarding standard operating guidelines or procedures and extrication policies.
I am sure you have seen this go either way; i.e., a fire officer with a strong command presence is on scene who feels he should be the person in charge of the actual extrication. Or perhaps it’s a medic—fire-based or private—who feels he needs to take the positon if he is the highest medical authority on scene. I have asked this question for years while teaching and lecturing on extrication and the command and coontrol of an MVA, and it has prompted great debates.
We are there to do what is best for the patient, not just cut the roof off of a Mercedes. Here is a system that my own department has adopted for auto extrication, and it is one that has been working well. As fire officers, we place the individual with the most “extrication experience” in the role of extrication leader. Just because you wear a different color fire helmet or have the “collar brass” does not necessarily mean you should be the extrication leader.
Conversely, the extrication leader does not need to be the person with the highest medical education. Yes, it can very well be the officer of the first, second, or subsequent arriving companies, but it can also be the firefighter sitting in the third seat. The officer core in my department has learned to put his pride aside and use the most experienced firefighters for these rolls if they possess more experience in this discipline. Don’t get me wrong, the company officer is still in charge of the apparatus, the firefighters’ safety, and accountability, and he is expected to take the roll of incident commander (IC) until a higher ranking officer arrives.
The IC and the extrication leader are two separate rolls with different objectives, priorities, and responsibilities. Can the first on-scene company officer be the extrication leader as well as the IC? If he is the most experienced in extrication or by virtue of being first on with a higher ranking officer minutes behind, then the answer is yes.
Understand that your goal, as it pertains to extrication, is “saving time.” The World Rescue Organization (WRO) feels that we should set our time line (goals) at 10 minutes for a rapid patient (advanced life support) who, if he is not extricated within these 10 minutes will most likely expire. In addition,you’re your time line to 20 minutes for an individual that is not rapid but is injured or who needs to be mechanically extricated. You can reduce extrication time through the items discussed in this article; command and control at MVA scenes; training; and, of course, teamwork. This article’s information will assist all of us in meeting the goal of reducing extrication times across the board.
Jeff Pugh is a firefighter/officer with Central Pierce Fire & Rescue in Puyallup, Washington. He is the president of and a lead instructor for the Puyallup Extrication Team (PXT) (www.ThePXTeam.org), which offers hands-on extrication classes and is a mobile, DPSST certified, nonprofit company. Pugh is a 23-year professional firefighter who also has four years as a volunteer. He has been part of PXT since its inception in 1999. Pugh is also an FDIC Instructor with a background in technical rescue covering 17 years on his department’s special operations team. He also serves as a rescue manager for FEMA WA-TF-1.