Extrication (Bigger the hole the better)

[todd nelson]

Extrication Techniques: We are in the process of gathering important information from the Trauma Centers receiving the patients that were involved in a confirmed extrication. Are the techniques we are using helping or hindering the patient. They say the bigger the hole the better for patient care. Sometimes when the patient is going down the tubes in a hurry and you have to perform a dirty rescue (grab and go) and have to manipalate the patient, that is understood. But what if we have time to do some work, do we make the hole as big as possible so to assit Rescue in good patient removal or should we treat all patients the same and take the patients out by manipalting them through small openings which may cause the injury to become worse. We have just started this study and I will let you know what comes out of it. Are we doing to much at extrication scenes by removing roofs and blowing out doors. Please let me know and I will add it to my study.

[ALSfirefighter]

Todd,<br />I applaud you and your group for the study you are attempting to perform. However, I think that you will have too many variables to get a definitive answer. Basically it comes down to 2 decisions. Patient status and the object you are extricating from. The size of the "hole" wil always vary on patient condition. If you have a patient with an arterial bleed, or any decompensated shock, you want to get them out fast. If the patient has more stable injuries, meaning not immediately life threatening (uncomplicated fractures, etc.) then I would say big hole. Basically, we use the presumption that if your ABC's are in jeopardy, rapid extrication. Included in those are head trauma, respiratory arrest etc. <br />This is the time where good lines of communications between the Paramedic (or other care provider) is absolutely imperative. The FD is basically there to assist ems, and remove hazards and the patient.

-----------------------------------------------<br />The above is my opinion only and doesn't reflect that of any dept/agency I work for, deal with, or am a member of. <img src="biggrin.gif" border="0">

[LYFDChief]

I agree with the above. Unless the vehicle is literally on fire when we arrive, my department relies heavily on the involved EMS personnel to make decisions involving extrications. While we set-up our rescue equipment, the senior fire officer typically consults with EMS to decide the best course of action. Over the past year, we have blown-out doors more often than we have cut roofs, but as was mentioned in the response above...that may simply be a result of the type of accidents we've experienced lately. Good luck with the study.

[MetalMedic]

Interesting topic. When I took my first BTLS class, they advocated roof removals and verticle movement for any suspected spinal injuries. The reasoning being that there is no way to maintain the long axis movement when you need to turn a patient onto a backboard in order to remove them from a vehicle. While I agree with that theory, I certainly got my wings clipped the first time I had a victim in the back seat of a Bronco II, that had rear ended another vehicle, who was complaining of lower back pain. My training had told me that the proper course of treatment was to take the roof, especially considering that there was no easy way to get someone out of a back seat in a 2 door SUV. However, the officer in charge about flipped because he did not want us to "total" the vehicle in the interest of patient care because the Bronco II was not hurt too bad. Not having any bugles on my helmet, I was overruled and the victim came out the back hatch door, by going up and over the back seat. Not my choice, and I doubt that the vehicle was ever put back on the road. So, roof removal is not a very common practice around here.

[ 12-03-2001: Message edited by: MetalMedic ]</p>

[PAVolunteer]

When we get on scene, 9 times out of 10, EMS is already there and in the vehicle. They tell us which passengers need to be extricated and whether or not they're stable. We then go to work and we don't stop until the patient is out. We take the doors, start taking the roof, set up front-end displacement, and we just keep going until EMS has them out of the car. There have been times when we've taken the roof when it was unnecessary, but we'd rather do too much than not enough.

Stay Safe

[rmoore]

How do you tell whether the patient's condition when presented at ER is crash-generated or extrication generated?

If you're trying to evaluate large hole vs. small hole, how do you measure the "size" of the patient?

How do you measure the opening the patient came out of? How big is an opening when you perform total roof removal? How big is a door opening if that is how you brought the patient out?

I'll tell you right now that an extremely small portion of the movement we do to a patient makes their condition any worse. Nobody's spine inside a crashed car is in the same position as they are when packaged on a longboard.

Excessive and unnecessary on-scene time does make things worse. If your Priority One patients are on scene more than 10 minutes, you are making their situation worse. A more interesting survey would be an up-to-date comparison of on-scene time to patient outcome at crashes.

Ron Moore

[tmeyer]

Up here in the Northwest it is slowly becoming practice to make big holes and to take roofs. It seems that the people who have the least amount of training are the hardest to convince to take the roof. And everyone still wants to flap roofs. My peference is to take it all the way off. Pull trim and recip saw. <br />Vehicles these days are disposable. A car 5 years old with mild- moderate damage with airbags deployed will be a total.

[Rescue101]

Upgrade:A brand new car with "moderate"damage and airbags deployed will in better than 85% be "totaled".T.C.

[lutan1]

Hey Ron, I'm concerned by your statement "that an extremely small portion of the movement we do to a patient makes their condition any worse."

If that's the case, why do we stabilise a car? Why should we always be aiming to remove a casualty in the same direction as the torso is positioned?

The answer to that is easy- everything we do as rescuers has an impact on the outcome of the casualty. If thats not the case, we wouldn't immobilize, we wouldn't use KED's or boards, etc.

Rescuers need to make "smarter" cuts to cars. Why remove a roof for access, then remove the casualty from the side door openings?

We should aim to remove all casualties in line to where they are facing when we arrive- ie: in front/rear seat positioned normally, then remove them via the back window or similar. If they're positioned side ways in vehicle, then remove them in that direction via doors, etc.

Quite often there is a lack of communication on scene- Ambo's don't understand what rescuers can do for them, and rescuers don't understand what ambo's want done and why. (We had an ambo lecturer over here in Oz, Rick Kehoe, and he said one day in a rescue symposium that "Generally, Ambo's are rescue dumb, and rescuers are medical dumb.") Beleive me, of all the people who fired questions to him afterwards in an open forum, it was the ambo's that took the most offense and took him to task over it!

If rescuers started to train by using the simple rule I mentioned above, they will find that on scene times are reduced, they're making smarter cuts to cars, they're assisting ambo's with patient care....

[todd nelson]

I somewhat have to agree with Lutan, why do we pakage patients the way we do (KED's longboard complete imobilization). I have 21 years of experience in the Fire Service and have been to many Extrication Seminars and they spend alot of time on if you have the time make the hole as big as possible so to keep your patient inline as best as possible. With new car technolgy (air bags, safety glass windows and others)we may have to devert to old ways by taking patients through car doors due to being unable to make a big hole due to air bag not being deployed and its in your way. I hope in the near future we the Fire Rescue Service and the Car Dealers get togther and come up with an atomatic kill swith for all air bags. Even now with side air bags and curtain air bags not deployed we can still make a big hole by removing the roof (Along roof rails not interfering with the curtain air bag). So keep up the training and stay involved. Be safe and hope every body had a great and safe New Year.

[todd nelson]

I somewhat have to agree with Lutan, why do we pakage patients the way we do (KED's longboard complete imobilization). I have 21 years of experience in the Fire Service and have been to many Extrication Seminars and they spend alot of time on if you have the time make the hole as big as possible so to keep your patient inline as best as possible. With new car technolgy (air bags, safety glass windows and others)we may have to devert to old ways by taking patients through car doors due to being unable to make a big hole due to air bag not being deployed. I hope in the near future we the Fire Rescue Service and the Car Dealers get togther and come up with an atomatic kill swith for all air bags. Even now with side air bags and curtain air bags not deployed we can still make a big hole by removing the roof (Along roof rails not interfering with the curtain air bag). So keep up the training and stay involved. Be safe and hope every body had a great and safe New Year.

[MikeF25]

I stand by the bigger hole the better. If you are cutting the car is totaled. A trauma nurse or doc will never fully understand what you are doing before the pt. arrives at the hospital unless they experience it for themselves.<br />We did a training with some E.R. nurses who now have a better understanding and respect for what we have to do.

[ALSfirefighter]

I have to side with Ron on this one. I basically posted the same thing he said in the tire deflation board. The fact is yes we stablize with cribbing, and use long-boards (which is a completely different argument about how we use those now also), etc. The point I want to make on top of Ron's, is that you do all of the skills we were trained with, to minimalize the amount the patient moves. The fact is the amount a patient moves during an extrication, is no more, and I'm willing to bet, less then what we have to move them to get out of the car. The fact also still remains that spinal injuries account for a very low percentage of injuries from motor vehicle accidents. The majority of trauma's today involve chest trauma, extremity trauma, and internal organ/vessel shearing. (The aorta severing in two pieces from deacceleration.) It likes I posted in my first post on this board, it depends on PATIENT STATUS, and the object you are extricating from. Making a big hole to keep your patient "inline" is great, unless the patient has an open chest wound or has an arterial bleed. You can keep him in-line all you want, that's not his problem. I think that if you go back are re-read Ron's post you will notice he never opted for small hole vs. big hole or vice versa. He just stated a fact. That minimal movement will not effect the patient's overall outcome. Not when gross movements will be performed to get the patient out whether its through a door or where the roof once was.

-------------------------------------------------<br />The above is my opinion only and doesn't reflect that of any dept/agency I work for, deal with or am a member of. <img src="biggrin.gif" border="0">

[Tower310]

Lookin for some help. I am looking for pictures of<br />a extrication scene using the "side fold forward technique" If anyone can help me it would be greatly appreciated. OR if anyone knows a web site that would have these pictures. It is for a Powerpoint presentation for a volunteer department on techniques and updates in Extrication.

Thanks in advance<br />[email protected]