The Team Approach - Immobilisation & Extrication
Once your extrication plan has been implemented and you have created enough space, your casualty can now be removed from the vehicle and transported on to definitive medical care.
It is important to emphasize that the method you adopt here must conform to your local procedures and reflect the training you have received and the equipment you have available. There are several well practiced methods for the immobilisation and exctrication of your patient and the one you choose depends on several factors, namely:
- Patient condition
- Patient location and orientation
- Available resources, equipment and personnel on scene
- Training
Around the world extrication is viewed as 2 distinct disciplines, namely technical and medical. So for many rescuers it will be this point where they look at the medical team to step in and complete the job. However in some other countries the technical and medical aspects are not as separate with rescuers and fire fighters well trained in trauma care and having a good understanding of mechanism of injury and kinematics (see my previous blogs). The removal of your patient is a technically and physically challenging task that must be completed safely and rapidly, ensuring gentle handling of the casualty at all times. It is a skill that should be practiced as much as any technical cut or spread.
Critically though, it must be medically led. That is to say the person who is in charge of this phase must have the knowledge of the patients condition, and MUST always guide any movement.
We have already described the Team Approach that the officer in charge (OIC) is the decision maker, using the information they have gathered in order to formulate a plan. However this critical phase of the rescue requires a shift of control. The medic in the vehicle must be in control, and more specifically, the person who is performing manual stabilisation of the cervical spine.
Whichever way you practice immobilisation and extrication there are some general principles you should consider.
Safety
Remember that your space creation process will have created many sharp edges on the vehicle. These must be covered so the area is safe. Lifting a casualty, no matter their size, provides the potential for rescuer injury. It is important that good manual handling procedures are adopted to protect the rescuer, and also the patient being lifted.
Gentle Handling
Due to their injuries, patients require swift, yet gentle handling. Rough treatment can exacerbate injuries and worsen the patients medical condition rapidly. Remember it is not just spinal injuries we have to immobilize and protect, but also internal injuries, pelvic and long bone injuries, all of which can result in major blood loss and lead to hypovolemic shock.
Teamwork
The movement of your patient will take more than one person, therefore teamwork is vital. Clear communication from the lead medic prior to any movement is crucial.
Minimum Rotation
Keeping your patient in line as much as possible is crucial. That's why our 'gold standard' extrication route involves taking the roof off and removing the patient in line. Of course this is not always possible due to their location within the vehicle, but every effort should be made to create maximum space to prevent rotation where possible.
Finally, we must remember that the immobilisation and extrication phase can come much earlier in the rescue due to the rapid worsening of your patient's medical condition. In such cases we must still attempt to provide a level of immobilisation and still try to prevent rotation. Of course this will be much harder to achieve and the amount of effort you make to ensure this must be balanced with the immediate needs of your critically ill patient.
As ever, I welcome your thoughts.
Ian