Extricate or not extricate?

There are certianly some issues here! Just to throw my opinions in, here goes: To go along with somethings that have already been said, it's true there are a lot of people who need to wake up and realize that getting a paycheck for providing ems doesn't make you a better provider. 1. I've seen both paid and volunteers that i would crawl into to woods and hide to to die in peace if they were coming to treat me! (OK so that's a little excessive, but you get the point) 2.Attitudes on scene never accomplish anything. Pt care and scene safety are paramount, worry about other stuff later. 3. In my experience there are a great many ALS providers who may be the best at IV's, Intubation, Monitoring, etc. but have forgotten (or never learned) basic EMT skills. Fortuately for me, I don't have to deal with this problem on an MVA scene anymore. My department handles all aspects on a scene. We're an all volunteer Fire & Rescue dept. We bring the firetruck, the ambulance and the rescue truck. There are no quarrels between agencies on one of our MVA's, we're all on the same team. And if possible we have an EMT or ALS provider(what ever is available) in turnout gear in the vehicle with the patient if at all possible. The Paramedic in this situation should be investiaged by the OMD or a peer review committe because this type of attitude and patient care,(or lack there of) can be very detrimental to the potential patients. As far as i'm concerned if they patients have crawled out on there own by the time i get there, we're going to get them out, if it involves extrication or not. If they want to sign a refusal after that, so be it. OK, now I too am off my soap box! and hope these incidents can be a learning experience for all of us. Good luck to all in the paid-volunteer and Fire-EMS problems. I guess until we're all paid or all volunteer problems will always exist!

Here's a question related to the call itself - the rear seat passengers were alert and oriented, per the posting. Did they tell the medic that they were uninjured (other than the glass lac's) and refusing treatment? Possibly that factored into the decision to let the patients climb out of the car. A couple years ago I had a go-round with a fire co who thought that an alert, oriented, uninjured patient should be forced to go to the ER just because she rolled her car over.

I am amazed that in the land of lawyers any EMT would be prepared to take the chance of having the patients climb out! I have often seen confusion about whether a person who wasn't pinned in a wreck was really trapped. If you can't maintain the patient's in a safe body position based on the probable mechanism of injury then they are trapped whether pinned or not. Getting away with a bad decision doesn't make it a good decision and anyone who has been around trauma care for a while knows of cases where someone with unstable spinal fractures was walking round saying they were fine and others who looked and sounded like basket cases really had only minor injuries. We have an expression "be the first to believe there is a fire, and the last to believe it is out" Injury works the same way. Arguing at the scene is seldom productive, but it doesn't hurt to discretely but firmly let people know they will be held accountable if they act in a way that won't stand review. As a 28 year professional who often worked with volunteers, there is no place for petty jealousy in an extrication. Period. The "play with your toys" comment was unprofessional and wrong.
Jim Maclean, New Zealand

We have had several incidents with our medics over the years. Only one incident was similar to his one, pt. with little usage of lower extremities after being t-boned twice she showed no other symptoms. Daytime call so we were short personal, we called for mutual aid due to dual extrications. Just prior to arrival of the aid company the medics showed up and after we strongly voiced our concern(my partner & I were both emts trained to a basic level)the medic pulled the pt. out of the vehicle as she regained use of her legs. We didn't protest enough! In hindsight I will never allow this to happen again. I DO NOT WANT TO PUT A PERSON IN A WHEELCHAIR OR WORSE! Maybe some medics see it all or are not trained to the standards of extrication personal or is it they are not aware of how quickly most victims can be removed? It is to bad this happens. Perhaps a check of the training they are getting is needed or a combined drill that help them understand our view.

John DuCharme
Vadnais Heights Fire, MN

[This message has been edited by jducharme (edited 01-16-2001).]

I am a capt of my vollie dept and have done many extrications and we have many emts and paramedics in my department and they will never tell me or my chiefs that extrication is going to be stopped and have the pt's climb over the seat to get out, if an emt/medic tells me how to do my extrication and tells me how to run my scene they will be moved out of the way.. qwe have our emts get in and size up pt's cuz our amb service shows up in tshirts and jeans and they are NOT allowed next to the vehicle until pt's are removed but we give them details on injuries and info for them to keep them informed and they know not to tell us what to do,, so there is my reply and good luck

I guess we are lucky. Most of our firefighters are FR level 3's and EHS (either BLS or ALS) is never closer then 15 minutes. This means that we normally do not have EHS parmedics to bother us during extrication until we are done.
However, there has been more then account that EHS has pulled people out of a vehicle via a open window......
Our chief has instructed any IC that they have total control of the scene.
Any MVA, regarless of size or impact, is instent spinal managment by our FR's. As part of our SOP's, our guys are in charge until the PT is on the ambulance stretcher.
I have been to many minor MVA's where we have started spinal and EHS shows up and doesn't take over. Once we turn over the PT, we are longer accountable for any injuries afterwords.

If the patients are not severely injured (nothing life threating is presenting itself) why not take the extra 3- 5 minutes to remove the doors and roof. Rapid extrication is just that RAPID and should only be done when needed. Think of patient safety. if roof removal was done patients could be immobilized wuth a KED and long boarded in the car. Also look at your vehicle. It does not take much dammage these days to "total out" a vehicle. If it is severly dammaged cut it. dont take a chance of a patient or rescue member getting hurt by crawling around in a vehicle. Make it safe for everone.

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Barry Butrymowicz FF/EMT
The views expressed above in no way represent the views of Mountain Ambulance Service or Riverview Fire Department.

Remember if it is bleeding-bandage it, if it is on fire-put it out.
and extricate when you have to.

I wonder if the "Medic" in charge would go see those patients once they become paraplegic's?? I work in the Spinal Cord field and have seen quite a few "walking victims" come in days after an accident and have a partially severed spinal cord. We recently had a rescue where we are the rescue service for a neighboring company. We were asked to remove the roof and pull two doors. There was a medic on scene, as well as an EMS Chief and Deputy. They started to pull this victim out before he was collared and boarded. Needless to say, he now is a C-4 C-5 incomplete quad! I was disgusted at the scene and voiced my opinion to my Chief. We all were upset. The patient was breathing, but unconscious. There was not an EMS person in the car to evaluate him. They did it from the outside. I hope this will shed some light on how we extricate our victims. They may seem fine. Always be cautious. Have a safe holiday to all.

Joe
Rescue 86

I'll second Lewiston2Captains sentiment. To me, the opposite of "professional" is "unprofessional", not "unpaid". It is possible to have both paid professionals and paid morons. Most lay people consider MD's as "medical professionals", but most medics know of more than a few doc's who are far from it. Professsional should describe your performance, attitude, and skills - not how you make a living. Enough said!

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R.A. Ricciuti, Firefighter
Mt. Lebanon Fire Department
www.mtlfd.org

I think we should straighten out some language here. I personally feel that we are all professionals, or at least, we should be. Now having said that there are two classes of professional paid professionals and volunteer professionals. It has long been a pet peeve of mine that when someone asks what type of fire protection or EMS is available in a particular area and the response is volunteer the reply I hear most is "Oh, so your not professionals?" I think that this is partly the fault of the Volunteer companies. (Before I get my head put on the chopping block I am one of the same.) In general, as volunteers we don't see ourselves as professionals because we don't get a paycheck.
Perhaps if we change our attitude we will be able to change peoples perception of us.

Just my two cents on the issue. Let me know what you all think.

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Shawn M. Cecula
Captain
Lewiston Fire Co. No. 2

I just can't belive what I just read. I'm a EMT instructor with vehicle rescue training and can't believe what this medic did. My first thought was, "let's wash our hands of this and let the medic take full responsibility." But that won't solve the problem. First, she needs to reaquaint herself to what she learned in medic school. And second, the rescue crew needs to step in where patient safety is jeopardized. The crew should have continued the extrication of the patients, and then the medic could use her "best judgement" to deem the patients health and let them sign off against medical advice. It at least transfers the patient responsibility from your team to your colleagues on the QRS(medics).

As far as the "us professionals" vs. "you vollies" attitude that this medic portrays. The only, and I mean only, difference is the paycheck. The hours of training, the material taught, and students in the classroom are the same. I have the luxury of been from the vollie ranks before my professional job. I deal with the same problem with my coworkers, and I have told them the same thing. And my response to them is, if vollies don't give their time in financially small communities, then who will? Vollies work just as hard and sometimes don't get the respect they deserve.

Please try to talk to these "professionals" and let them know the only people they will hurt are the patients they will help. Good luck.

In my town, EMS are full timers and usually arrive on scene before us. Typically if the patient is still inside the vehicle when we arrive, we will be packaging them up. In my experience almost everyone says they are alright, even if they obviously aren't. Luckily we have a pretty good relationship with EMS and they treat us vollies with respect and value the help we can provide them.

It is always interesting to hear the different perspectives on an MVA. As an EMT and dealing with a trauma situation, top of the list is ALWAYS, MOI Mechanism of Injury, ALWAYS.

For bias, personal grugdes, professional grudges & dislikes and anything else I can think of if I had time to come before Patient Care is, is, the worst crime any EMT could ever commit. The ([email protected]#$%^&) EMT that forgets about patient care should be hauled out back and well...

How many times have we seen patients who have had serious spinal injury and claim no tenderness or soreness? When we have patients who do not have any known immediate life threatening injuries, what does it hurt to take the time, cut them out and package them carefully? It doesn't hurt anything... The time requirement is ussually measured in munutes, not hours. But again, my disagreement is with the EMT or any EMT who failed to account for the MOI.

Our Specialized Rescue Team completes our own "Run Sheet" for each call we go on. We document everything and this is a classic example of why. This does require a follow up.

Does you EMS Director do "Case Reviews"? This would be an excellent case to throw out before a cross-section of EMT's in your area and get some differing opions. Maybe some "Basic Skill Refreshers" are in order.

Elmer Anderson, NREMT
Mountain Ambulance Service http://www.rescue70.org

just to put a different spin on things; for every one of the above stories about the wrecks where you think you should have cut,I can give a situation where a cut wasn't required. I've seen the folks who get ****y when they can't use the tools. it seems they have to play no matter what the situation is. Egos are a dangerous thing no matter what service you are in. Take a look at the big picture.
Those of us who use the terms "always" and "never" will get burned because when we think in a straight and narrow manner, we loose our ability to think and adapt to the situations presented to us. Flexibility is important folks.

To extricate or not to extricate, now that is the question. My answer....read the wreck. If the wreck shows the possiblity of mech's of injury, cut them out for all the reasons listed above. In my neck of the woods, the medics allow the rescuers to do their thing and then, and only when the IC says it is ok, do the medics get involved. I know that isnt the case everywhere. Guess we are just lucky. Read the wreck, and teach the medics to do the same.