Spinal stability

[fern]

Could anybody please comment on the following technique of extricating a casualty out of the rear seat of a vehicle with suspected spinal injuries:-

The casualty is seated in the rear seat of a vehicle in the neutral position, the roof has been removed and obviously the vehicle fully stabilised. The Casualty is fitted with a cervical collar and manual stabilisation is applied constantly. all commands come from the “headman” he always checks that everybody is ready before any movement takes place and nobody moves the casualty, or the longboard, without his express orders to do so.( pretty standard procedure so far)
The casualty is moved forward slightly to allow the longbboard stretcher to be slid between him and the rear seat.
The casualty is then held under the knees, buttocks & armpits by four persons a fifth person as previously mentioned applying manual c-spine stabilisation and controlling every movement during the entire operation. The casualty is then slowly slid up the spinal board until his hips are in line with the top of the back seat.(the head man is obviously applying no traction only stabilising the head)
Then the board is slowly pivoted into the horizontal position by a further two persons one at the foot of the board and the other at the head. At no stage is the back seat relied on to take the full weight of the board (Before you ask)
Finally with board now in a horizontal position the casualty is slowly slid up the longboard to the headbead and fully strapped to the board and the head secured to the headbead.

I have carried this technique very effectively in training with very favourable comments from both rescuers and simulated casualties alike.

So the technique works very well itself but does the initial controlled lift of approximately 30 inches up the board, even though the casualty is slid up the board slowly, and in a controlled manner, not actually free lifted, put the spine under excess compression or stress ?

I am open to any comments whatsoever thanks for your time.

Steve maddison

nb

[Halligan84]

I've tried that technique too and it works pretty well. I think the first time I saw something similar was in the Carbusters series. One thing that could cause some problems are exceptionally tall or heavy patients. The third door technique helps here and allows us to bring them out the side.

[billy]

I've taught this technique for some time. It seems to work very well while providing movement along the long axis of the body. The twisting movement usually associated with movement after LSP Halfback placement is eliminated, plus eliminating some time in it's application to the pt. I support the use of this technique.

An option while moving the pt. is the use of a rope sling. This device is described in the first edition of Vehicle Rescue (Grant/Gargan). I've used this tool with some success too.

An alternative to conventional management is the introduction of the RED. This is a vest-type device applied to a sitting pt. Subsequently it is molded around the person and the air is vacuumed out. Then it becomes a rigid splint. I've used the device in training and it seems to work well.

[kbud]

Billy, what's the full name for this 'RED' vest and who makes it?
Also, I seem to remember you mentioning a 'REEL' splint (may be mispelled) for splinting femur fractures in confined spaces (in your heavy truck class at the First Due conference). Do you have any product information on that as well?

As for the above technique, we used it to remove a child from a vehicle this winter and it worked great...

[billy]

The RED is the Renberg Extrication Device. You may email for more info. at: [email protected] The REEL splint is available from a supplier in CA. You may search for info. on the 'net. Simply type in REEL Splint.

[sullivan3]

Hey,
I have not been doing this long, and I by fare don't know it all. Be scared of anyone who says they do.

First, the guy in the back seat is a victim, not a casualty. Unless he/she is dead, in which case don't worry about spinal. As soon as you begin care, he is a patient.

Second, you must have a big fire department. If I count correctly this takes approx. 7 persons to pull off this move. In my department (volunteer), unfortunity that is everybody on the scene. If you are blessed with this many people, packing them in around the PT (patient) is dangerous, if someone slips it may create another PT, or give the first one further injurys. In a training situation, were conditions are perfect, ok, but if you already removed the roof, there must be further damage to the car. Lets says conditions are good, you have to fit two people in the back seat. If there is a second PT in the back, can't do it. Lets say there is only one. You took the roof off, so you're exposed to weather. Well if its 3AM and there's an ICE STORM (I live in New York's Adirondack Mts), your guys are tired and car seats are not very stable. Either way, too many people, too many things could go wrong.

Removal of a PT is very simple to me, get the person out as fast as you can, as carefully as possible, without making injuries worse. One of the best stabilizing devices in my opinion, is three simple letters "KED". Hey, everyone who replied, if you don't know what I'm talking about I will send you a picture.

I know what you are thinking, too many straps, too many steps, takes too long. Here is a couple of facts. One, I have seen a video in which a rescue crew at a race track was on a wreck. The time between putting the KED in the window, to the time in which the driver came out that window fully strapped down, was about a minute. I understand they do it everyday, but the point is, you can do it. And if anyone has this video, I need it. Two, simply placing it on the PT's back and tighting up one stomack strap, nothing else, increases the chance of stabilizing a spinal injury by 90%. Think about that, 30 more seconds of work means a better chance the person will WALK out of the Hospital.

Another thing, any shortboard device will do, it gives you a place to hold on. Making moving the PT much safer. With the PT immobilized properly, you can lift the device while keeping the PT in the same sitting position. No pulling on knees or arm pitts. Hips, back, neck, and head do not move. With the head stabilized to the device, you no longer need manual traction. This cuts down the number of personel needed to extricate.

As fare as "vacum splints", haven't used them, so don't have an opinion.

The thing I love about MVA's is there all different, never will you see the samething twice. So you can't always follow the exact thing you do in training. Take a second, size-up, and do what is best for the patient.

[fern]

sullivan

Firstly thanks very much for responding, and secondly, Just to set the scene the reason I am asking in regards to Spinal compression is as you know in the majority of cases removing the metal structure around the parcel shelf and then the rear seat itself is not only very time consuming but necessitates a great deal of noise at patient head level, and in the case of rear seat removal. The amount of seat back movement whilst cutting with tools is excessive no matter how much care is taken. So I have just about ruled that method out unless the car structure itself leans towards that technique. I.e. Hatchback with fold down seats and no parcel shelf.
Moving back to the controlled rotation of the casualty after third door creation or “B” post rip, Side removal, etc. I am in discussion at present with a spinal Specialist at Stoke Mandeville Hospital (National centre for spinal injuries) and a B.A.S.I.C.S Doctor from our region. And although controlled rotation is at present the preferred method for Rapid extrication from the front seat, (Within the U.K) I am still not convinced as are many medical personnel that actual rotation of a spinal injured casualty whether controlled or not is a safe and efficient procedure to be carried out from the rear seat of a vehicle? Whether some sort of side removal technique has been performed or not. This is even with a KED fitted. This is now even more difficult due to anti submarine seats i.e raised at the front edge and contoured around the sides. The position of the “C” post so that the longboard has to come in from the “3” o clock position necessitating full raise of the casualties legs above the raised seat edge. This is before I even start on rear seat side deployed air bags more prevalent now in a great deal of vehicles. (As Ron Moore could confirm)
To answer your second point fortunately we are blessed with a large Fire Dept a Pre determined attendance at a light one vehicle RTA is Two appliances (9 Personnel) and the incident commander can order on many more appliances as he requires currently about 35 front line fire appliances. To a confirmed multiple RTA or heavy Goods vehicle incident the pre determined attendance is Three front line fire appliances and a heavy rescue Emergency tender (minimum 15 personnel in total) All appliances carry a large section of Holmatro extrication tools and the heavy emergency tender, a great deal more specialised rescue and extrication equipment.
So thankfully we do not have the problem you mentioned as regards resources in attendance and a great deal of respect goes to you for managing a rescue with that level.
As regards calling a person in a car a casualty it is just a different Way of referring to an entrapped person in the U.K. Our emergency rooms (I think that’s what you call them) are called Casualty departments I am sorry you find that wrong but I can assure whether we call them casualties or patients they still receive the highest level of care we can possibility provide.
Yes I do take on Board what you said about KED stretchers and do agree with you if time is not of the essence fit a KED but as you know in some extreme cases this is not always possible and this technique is designed for that occasion, I am sorry I should of made that clear in my initial post.
But anyway both methods are being carried out at our Training centre with the B.A.S.I.C.S Doctor in attendance to give his view, and our Media Resource unit will video the extrication. The video is being sent off to stoke mandeville to be assessed by the Specialist there.
This is all taking place on the 4th of May if anybody want the results I will email them no probs.
Well sorry for taking up your time with such a long post and once again thanks to everybody for replying it is great to have such an informed and experienced personnel to bounce ideas or problems off.

Take care

Steve maddison

[fireemt03]

Just a thought we have also used this technique. if possible we try to use the KED as much as possible. one thing that we have also done is put the long back board in between the patient and the back seat ( or front seat) and slide the patient straight up the board. then pivoting the board on to the car. this works especially well if you can cut the seat supports to further lay the seat back (front seat mostly). I have done this AND seen it on a video (that is where I "stole" it from) works really well.
Good Luck.


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Corey J. Molinelli NREMT
Asst. Fire Chief

[firemedic1979]

To answer the compression question. If the patient/casualty is moved in a constant equal manner, there should be minimal compression of the spinal cord. If the upper and lower sections are moved together then the cord should be remain in line and with equal pressure. Stretching out the spine can be as devistating as compression.

Remember the most important part of the spine we are protecting is the cervical spine. I am not saying the the throacic, lumbar and sacral sections are expendable because they are not. KED/RED/XP-1 are all good devices to use but do not get hung up in them if there are other potentially critical injuries. The patient with resp. problems, cardiac problems, abdominal problems etc., is needing rapid safe controlled extrication/removal. Collar, rapid takedown to LSB, secure and CID.

Every time we extricate a person from a vehicle, we should be preserving the spine.

Last comment. There is no set method of removing our patients. Each accident is different and presents different obstructions to us. Use your head, accept suggestions from others and give your patient the best care possible.

I recently had a patient with chest injuries at a mvc. 78years old, full restraint, no airbag, head on. She was rapid takedown due to chest injuries, c-coller and stablilzation was maintained throughout. Pt was diagnosed with cardiac contusion, fx rib and sternum and C-6 fracture with compression of the cord. Supprised?? We were, no cervical tenderness and no neuro deficate. Mechansim said coller and c-spine. Patient presentation said OK. We are glad we "played the book". PS - she did fine.

[Sparkill Fire dept]

And after all this is done the patient gets to the ER. The doc asks "does your neck or back hurt? The patient says no!
And the doc says
"you can take all that stuff off"

Seriously - It's nice to see the continuation of professional and technically oriented posts in these forums. Keep it up.



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Sparkill FD - [email protected]