Vehicle extrication is an extremely complex discipline which requires a high level of skill, knowledge and understanding in order to ensure a safe and successful outcome. Whilst it is heavily reliant on teamwork and multi-agency working, its ultimate success requires a robust extrication plan which must be conceived and communicated by the incident commander. This plan can only be formulated by rapidly identifying and acting upon key information in the initial stages of the rescue. The ability to do this is no mean feat, but what training have you had in order to do this successfully?
When I look back at my career, I was trained well in technical tool application and quickly learned the best methods of stabilising a vehicle, managing glass, gaining access and creating space for the patient. I was also well disciplined in incident command and successfully managed many types of incident without any of my crew members getting hurt. That said, I was never trained in how to formulate an extrication plan; I learned this organically through my own experience and self-study. I was never aware (and I am still not) of any formal training in the art of forming an extrication plan.
Of course, I was made aware of A plans and B plans, A being my preferred extrication plan and B being an emergency route, but I was never actually taught how to contrive and implement these. This planning methodology is widely used and, sadly, often misunderstood. Which plan do you come up with first, A or B? Even after 25 years there is scope for confusion, not only within fire and rescue services but also across the multiple agencies on scene.
Even today, the internet (most people’s favoured source of information) is awash with ‘how to’ videos, all of which relate to technical aspects of the rescue operation; there is very little (if any) instruction on how to make the best use of our skills, knowledge and understanding by developing incident commanders in the art of planning. This astonishes me and where possible I have always tried to relate everything I teach, not only to the patient, but to the plan.
Over the next two articles I will outline the main considerations for extrication planning, offer an alternative to A and B plans and also focus on the importance of on scene communication.
Contriving the plan
The incident commander, in conjunction with the rest of the team and on-scene medics, is responsible for formulating the extrication plan. The plan must be contrived as a result of key information gathered during the early phases of the rescue process.
We should remember that an effective extrication plan is a fine balance between:
- Available time based on medical information regarding the patient and technical information regarding the vehicle
- The patient’s location, orientation and dynamic medical condition
- The patient’s level of entrapment (how they are trapped)
It therefore follows that the information MUST come from two areas (in addition to always considering safety):
The on-scene medical team must feed information to the incident commander, to allow the formation of the plan. Critically the patient’s condition, level of entrapment and orientation are all major factors in decision making. It is imperative that medics on scene understand the need to identify and feedback this information and this highlights the need for multi-agency training, something sadly lacking in many areas of the world.
The team members responsible for the technical extrication and space creation will inform the incident commander of issues which may affect the creation of extrication space, and also offer best options based on experience.
The extrication plan should consider patient information that will be obtained once initial access has been gained or following a brief from a medic who is already on scene (see table).
We should take these factors into account when formulating our extrication plan and preparing to execute the immobilization and extrication phase of the rescue.
Once the plan has been formulated it must be communicated to all rescue personnel (and relevant personnel from other agencies). The best and most efficient way to do this is for the incident commander to call the team together and fully brief them. This should take no more than 20–30 seconds; however, they must ensure:
- The plan is fully understood by everyone
- Team members are given the opportunity to give input
- Medical personnel on scene confirm that the plan is consistent with the patient’s condition
Where possible, the final extrication path should allow for the patient to exit the vehicle HEAD FIRST. This makes the management of the cervical spine easier. It is important to remember, however, that this is not always possible, and the incident commander should (with information from the medic) decide on the extrication path that is most sympathetic to the needs of the patient.
Three fundamental principles should be considered when formulating the extrication plan:
Patient is physically trapped
The patient cannot be physically removed due to the structure of the vehicle preventing extrication, e.g. high-speed frontal impact resulting in the driver trapped by the dashboard and steering wheel. They are in the danger zone.
Once safety is established and the vehicle has been stabilized and glass has been managed, the priority must be to remove the physical entrapment, e.g. by performing a door removal and a dashboard roll, enabling rescuers to remove the patient from the danger zone. Failure to do this will mean they cannot be removed immediately. Once the initial physical entrapment has been removed, enough space must be created to allow a rapid extrication before going on to create full access for the urgent plan.
Patient is medically trapped
The patient, although not physically trapped by the structure of the vehicle, cannot extricate themselves due to their medical condition, e.g. relatively low-speed frontal impact with the driver complaining of severe pain in the neck/back.
If the patient is only medically trapped then the initial priority, once safety is established and the vehicle has been stabilized and glass has been managed, is to create enough space to allow a rapid extrication before going on to create full access for the urgent plan.
Occupant is neither physically nor medically trapped
There are occasions where there is a vehicle occupant who is neither physically nor (following a medical examination) medically trapped, e.g. a low-speed side impact with multiple airbag deployment.
Once safety is established and the vehicle has been stabilized and access gained, a full medical examination can be completed. If there are no medical conditions detected and there is no physical entrapment, a ‘walk out’ can be considered. This must be done only with medical supervision.
Changing the plan
An incident commander must be prepared to change their extrication plan if necessary. This can be as a result of:
- A change in the patient’s medical condition (on information received by on-scene medic)
- A change of medical priority where multiple casualties are trapped
- Challenges faced by the vehicle structure
If it is necessary to change a plan, communication is vital. The incident commander must communicate the change of plan, ensuring full understanding by all technical and medical rescuers on scene.
In the next article we will focus on the critical need to establish and maintain open lines of communication on scene. This will ensure that the plan is carried out safely, efficiently and in a timely manner. More critically, however, it allows all rescue personnel on scene to dynamically adapt to changing circumstances.
We will also look at our current approach of A and B plans and why I feel we should move on from this concept. I will offer alternatives that provide more flexibility and will facilitate a more patient-centred rescue. Until then, please make extrication planning the subject of your next training session and promote discussion of the topic with your team.
For more information, go to www.iandunbartrainingandconsultancy.com