PATIENT CARE AT MOTOR VEHICLE ACCIDENTS

Vehicle Rescue is a patient care-driven skill. The focus here is on patient care in such an environment. Ultimately, we always strive to provide our patients with the best outcome possible, in both our tool operations and medical care. That is a given. However, are we doing enough for our patients in light of the current developments in vehicle rescue? Much of the focus of our efforts, education, and training revolves around tool operations, but when have you practiced packaging and disentanglement of a patient or reviewed caring for an injured person in the crashed vehicle?

PATIENT CARE

We strive to perform proper pertinent patient care when we respond. We also focus on providing appropriate metal/material movement evolutions. Yet, how often do we combine these tasks in training and operations? We need to practice these skills together, making the “tempo” of tasks at the motor vehicle accident (MVA) flow smoothly. In “Patient and Rescue Considerations” (Extrication Tactics, May 2005), I had mentioned the concept of “rescue real estate.” One of my fellow instructors, Steve Pawlak, had coined this concept based around the need for simultaneous operations on-scene and to apply the concept logically. The idea behind “rescue real estate” is that EMS needs to be providing patient care in the environment-i.e., inside the vehicle-and the rescue team “owns” the vehicle’s exterior, especially the vehicle sides between the wheels. This concept allows EMS and the rescue team to operate together and enhance the speed of the rescue.


Photos 1, 5-8, and 13 by author. All others by Denyel Cusimano.

On arrival at the scene, we should start our patient-care process with a visual survey, even before we make “contact.” Reading the wreck, so to speak, will give us information related to potential injuries, vehicle damage, and “crush.” Look at the windshield: Is it damaged or intact? But remember that frontal airbags damage the windshield as part of their normal operating parameters. Regarding interior damage, are the steering wheel and column intact? Are airbags deployed or not? Remember side impact-side curtain and knee bag systems. Always try to approach the patient from the front of the vehicle. This is important for making visual contact first, keeping the patient’s focus on us, and minimizing movement prior to hands-on contact and C-spine management. Attempt to establish verbal contact also. Maintain visual and verbal contact throughout the rescue, ensuring communication to and from the patient as well as reassuring the patient.


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Never leave the patient unless it is absolutely necessary. It is a good practice to have a rescuer maintain visual/verbal contact with the patient while another rescuer accesses the vehicle to begin hands-on patient care.

PATIENT EVALUATION

Once you have begun the primary survey, evaluate the ABCs. The airway evaluation is straightforward: breathing, remember quality as well as rate; circulation, remember to look for and manage gross hemorrhage as needed.


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C-spine management is next. It includes manual management and application of a C-collar.


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Oxygenation comes after that: the proper fit and application of a nonrebreather O2 mask as warranted. Note: The use of a nonrebreather O2 mask also helps protect the patient from glass dust and other airborne particulates. As the rescue effort progresses, constantly reevaluate the patient for status changes, good and bad. Communicate this information to the rescue team and the incident commander (IC); this facilitates appropriate decision making and operational planning. Communication is a key element, regardless of the part you play on-scene-EMS provider, tool operator, or IC.


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This is just an overview of what basic care should be going on in the vehicle. However, the care would be appropriately adjusted according to the patient’s needs, depending on the skill level/ability of the care givers on-scene.

SPACE MAKING/VEHICLE ISSUES

Now, let’s take a look at the “wreck,” so to speak. Even though most times we put tools to the vehicle to create a pathway for patient disentanglement, part of the concept of “space making” is to create space as required. That includes making space for us inside to work properly and safely. It includes reproportioning the inside of the vehicle as needed.

Strategic cutting operations. As vehicles become smaller, strategic cutting operations will become the norm, not the exception. Think of these considerations: displace a roof off or away from a patient’s head and face, better airway control, and C-spine management, as well as the psychological impact and effect. How about cross-ramming the interior to improve access to work or to gain access to the patient’s lower extremities or the patient himself? The vehicles we dealt with in the past had plenty of space, plenty of room for access, so we really didn’t have the need to consider such tool operations that often.


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How about “popping” doors? Is there enough room for such an operation in today’s vehicles? Is a side removal warranted today? A side removal evolution is also many times easier than a door pop because in a door pop you are operating tools to force hardened components on both sides of the door. With a side removal, you still need to force a latch; however, the balance of materials usually are of lesser strength. Remember that ultra-strength material reinforcements can now be found in the B-post areas as well.


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Also consider strategic cutting. Many times, you are faced with dash areas that have dropped onto the patient’s lower extremities or footwell areas that have folded up around the extremities. Performing a fender evolution that severs the crumple or energy absorption area greatly assists in displacing the dash and footwell. This same evolution also provides access to the door hinges and the dash relief cut “cheat” hole. Therefore, by moving the fender as part of that evolution, you have “helped” with two other tool evolutions, saving time. And remember that time saved helps produce better patient outcomes, especially if you can do these things consistently.


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If you need to perform these operations frequently, you should aggressively and proactively evaluate the wreck and set up for such evolutions before you arrive on-scene, as part of your operational guidelines.


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Remember that since we are cutting more often today and encountering harder materials, it is increasingly important to provide a rigid barrier between our tool operations and the patient and interior rescuer. Remember, too, that the roof post closest to the patient’s head should be cut last. Moreover, don’t forget issues surrounding safety systems such as airbags, seat-belt pretentioners, and rollover protection systems. Observe and evaluate the space between these systems and you and your patient. That also includes where you place your equipment.

Packaging/disentanglement. Once you have created your patient-removal pathway, cover up the sharp edges resulting from tool operations and the crash itself. Do this as tool work progresses if possible.


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Let’s take a look at what the patient is sitting in. How much space is found in today’s vehicle interiors? Recall that many patient-packaging techniques evolved from vehicles built in the ’60s, ’70s, and even ’80s. Take a good hard look at the configuration of these vehicles’ interiors compared with today’s vehicles. Although bucket seats were available then, think about how such seats have evolved and are the prevalent seat style today.


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Additionally, much of the equipment used to package patients today was also developed in the same time frame. Vehicle seats now are more like motorsport styled racing seats, designed to hold the body firmly into the seat as the operator drives, regardless (relatively) of the situation at hand. How difficult is it to package a patient in a KED or similar device in these seats today? How much space is needed just to apply these devices, let alone disentangle the patient once they have been applied? Look long and hard at these devices-what else is out there on the market, and how well would they work? More reason to make “space” and consider this idea proactively.


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From casual observation, it appears that many patients are removed directly from the vehicle onto a long spineboard, also known as a rapid takedown or extrication, derived from prehospital trauma life support (PHTLS). Consider the criteria for such a maneuver-rapid takedown/extrication focuses on an unstable trauma patient, which involves a very small percentage of MVA patients. Otherwise, the KED type device is warranted. Are these all unstable patients, or are we “cutting” corners because of space issues? You need to revisit the concept of space making, considering the possibility of being “medically entrapped” and preparing the appropriate amount of space to disentangle the patient properly.

Training. How are you preparing for an MVA today? Many of us are practicing tool evolutions out in the salvage yards, at training centers, and other sites. We are reading trade publications, attending programs/presentations, and surfing the Internet to keep pace with current vehicle technology trends, issues, and concerns. But how many of you are out setting up scenarios and “solving” the problem? Think about such training situations.


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Besides the obvious tool operations, consider practice involving other related issues such as command/control and power management. Have you practiced looking for batteries in alternate locations or dealt with multiple batteries? Practice finding potential supplemental restraint system (SRS) locations using adhesive “marking” simulations-i.e., decals, and hazard control by looking for and managing possible scene and vehicle hazards.


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How are you practicing patient care and patient protection? Many times, we use training manikins to substitute for patients or use our fellow rescuers as patients. Are these substitutes suitable for “simulating” patients? Sometimes, the scenarios set up are too hazardous for a live person and warrant using a training manikin; also, depending on your jurisdiction, regulatory constraints do not allow you to use a “live” person. It is important to know and understand the various facets of interaction with that patient. How else are you going to become comfortable and functional working in that vehicle unless you have trained and practiced in such scenarios?


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One way to resolve the patient-care skills issue is to use a medically trained and oriented “patient” or “casualty.” This concept is a crossover from the extrication challenges held here in North America and around the world and from the International Centre for Emergency Techniques (ICET) in The Netherlands. These training events regularly use such “simulators” to interact with the rescue teams and EMS providers. These simulators provide reality to the scenario in a controlled environment. I have used them in training programs and in assessing various extrication challenges and have found they add a realistic, professional tone and focus to the training. Student and team feedback has been positive and has reinforced the concept of providing for a better patient outcome.

EMS PROVIDER

The EMS provider himself, though not operating tools, is a critical component at the MVA. That professional is there to provide for a better patient outcome! However, training, education, and personal protective equipment (PPE) related to the MVA are neglected areas. Although many of the facets and skills of patient management are practiced, the training often is not in a wrecked vehicle. As mentioned already, although these patient management skills are practiced in the wrecked vehicle, how often do we train in them? How about vehicle technology concerns? Since the EMS provider is in the vehicle working, safety system concerns are just as important to this person as to the patient. Often, EMS providers work even more closely with these systems than the tool operators.

Some EMS providers often access the vehicle with minimal PPE. Are a helmet and maybe eye protection sufficient today? Even if the provider has a bunker coat, does it fit? Has it been taken off the ambulance in weeks or months? Think of all the dynamic vehicle hazards of today and the fact that the environment doesn’t always allow for a quick exit. We should provide flash protection, proper head protection (helmet) that actually stays on in the vehicle, proper gloves for the environment, and respiratory protection from glass dust and other airborne particles. Take a good look at some the latest PPE on the market for the EMS and technical rescue environments to address these concerns.

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We all know and understand the need for proper, pertinent patient care. We need to practice such skills and abilities in the environment in which they will occur. We need to understand how vehicles have changed over the years and how those changes impact our patients. We should apply these patient-care skills during the rescue effort and protect ourselves and our patients in a wrecked vehicle. By training on and practicing for all the challenges found at an MVA, we can consistently help ensure better patient outcomes.

DAVE DALRYMPLE is a career EMS provider for Robert Wood Johnson University Hospital/St. Peter’s University Hospital Emergency Services in New Brunswick, New Jersey. He is also a firefighter/EMT/rescue technician and former rescue services captain of the Clinton (NJ) Rescue Squad. Dalrymple is the education chair of the Transportation Emergency Rescue Committee-US and serves on the Expert Technical Advisory Board of the International Emergency Technical Rescue Institute as the road traffic accident advisor.

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