EMS and extrication: Coordinating clinical care during vehicle rescue
Follow these steps to define roles, identify and mitigate hazards, and work toward the best possible patient outcome
Rom Duckworth presents “Extrication and EMS: Coordinating Delivery of Critical Care” at FDIC 2022 on April 28 at 3:30 p.m. Learn more and register here.
Despite the focus on tools and techniques to bend metal, the goal of any vehicle extrication is to provide the best possible care to the entrapped patients. So why is it that so often, the fire-rescue element of extrication incidents seems to conflict with the EMS element? Personalities and organizational culture are certainly a part of the issue. But competing priorities between fire-rescue and EMS are usually the core of the conflict.
If you ask the average firefighter to tell you about extrication, they will likely mention ultra-high-strength steel, modern automotive construction and supplemental restraint systems. They’re liable to tell you about the tools and techniques needed to “make space” in late-model vehicles and how different they are from “popping a door” on cars of the past.1 This makes sense, as modern vehicle extrication requires highly skilled technicians focused on their job.
Similarly, EMS providers will describe the challenges of providing trauma care in a cramped, noisy space while critical time ticks away for the patient to get going to the hospital.
Both teams, fire-rescue and EMS, are highly task-focused, often with little patience or understanding of what the other team is trying to accomplish. This leads to everything from an uncoordinated effort at best to conflict among personnel at worst. While there are many different types of fire, rescue and EMS response systems in North America, virtually every one of us has room to improve our coordination when it comes to extrication.
Effective coordination of EMS and fire-rescue personnel leads to efficient removal of victims and improved trauma care.2,3 For this to happen, chiefs, officers and firefighters should coordinate the extrication effort horizontally across fire-rescue and EMS, as well as vertically from the incident commander to individual firefighters, EMTs and paramedics.4,5
When rescuers use a coordinated approach to extrication, they leave the "tools and tasks" decisions to the fire-rescue experts but make sure the fire-rescue team gets the information they need from the experts in patient care. In short, rescuers need to decide the why, when and how of extrication, but they base this on the EMS assessment of who, what and where.
The four stages of coordinating extrication and EMS
There are four key stages of an extrication where coordination among groups is vital to a successful outcome.
Stage 1: Arrival
A good scene size-up determines how the rest of the call goes6 – and this applies beyond just the first-arriving apparatus. Every responder should perform a personal size-up to best integrate their roles in the extrication operation and identify critical hazards.7 This is the very essence of the concepts of situational awareness and crew resource management.8,9
There are many different types of size-up. A simple one that is easy to use on virtually any scene is "U-CAN.” This technique can help focus on the key elements on scene and how you fit in with the operation.10
- Unit: What is my role here (not just what vehicle you arrived on)?
- Conditions: What hazards are we facing?
- Actions: What is the next thing I need to do?
- Needs: What do I need to do it?
Stage 2: Access
It can be tempting to jump in right away, but whether they are primarily fire or EMS, the responder gaining access should accomplish or verify the following general tasks: completion of a 720+ check around the vehicle (360-degree outer circle survey, 360-degree inner circle survey, plus above and below the vehicles). This check improves your situational awareness, helps identify hazards that have to be dealt with, even if you aren’t the one who will deal with them directly, and gives you information to help you prioritize your next steps.
Once the vehicle has been stabilized and powered down, if necessary, the inside or in-the-vehicle EMS provider should make initial contact with the patient or patients inside the vehicle, protect them from further injury, assesses their injuries, provide immediate lifesaving treatment, and, if possible, stay with the patient throughout extrication and transport.4 This care provider can be primarily fire or primarily EMS, ALS or BLS, or whatever works best for the resources available. Regardless of their patch or uniform, they need to be equipped, protected, and ready to provide effective care and communication.
Immediate life threats such as Massive hemorrhage, Airway difficulties, Respiratory emergencies, Circulation problems and Head Injury (MARCH) necessitate rapid patient removal.11 Findings such as patient paralysis, significant neck or back pain, severe angulation of an extremity, impalement, significant crush injury, or the need for pain management or other medication administration may require a slow and careful removal.7
The in-the-vehicle EMS provider can give a quick report using the CAN format:
- Conditions inside the vehicle;
- Actions the Inside EMS provider is attempting; and
- Needs of the in-the-vehicle EMS provider to accomplish these actions.12
Stage 3: Action
The extrication plan should coordinate the immediate medical priorities with the strategy and tactics necessary for patient removal. The EMS side of the plan often can be rapidly implemented by responders with any EMS training, regardless of agency or ALS responder status, as long as they are trained and equipped to operate in the extrication area.
The priority must be to deal with the MARCH problems most threatening to a patient's life. These conditions can be fatal, but responders can deal with virtually all of them in the first few moments of patient contact.11
Massive hemorrhage: Control excessive bleeding by following the 3 Ds:
- Detect (find the source);
- Direct pressure (compress the bleeding site); and
- Devices (use equipment such as tourniquets, clotting gauze, pressure bandages, and clamps to free responders' hands).13
Airway problems: Airway emergencies that occur during extrication should generally be approached with BLS techniques first, such as oral or nasal airways and suction, and proceed to devices such as supraglottic airways, endotracheal intubation and cricothyrotomy, as needed and as a provider's training and scope allows.14
Respiratory threats: Stopping immediately life-threatening respiratory emergencies may include assisting a patient's breathing with bag-valve-mask (BVM) ventilation; dealing with a flail chest; sealing a sucking chest wound; and, for ALS providers, decompressing a tension pneumothorax.14
Circulation problems: Considerations include obtaining vascular access, administering only enough fluid to maintain minimum blood pressure without diluting the blood, coordinating the careful movement of the patient so as not to dislodge any internal blood clots that have formed, and possible pain management or patient sedation to help rescuers remove the victim more quickly. In some systems, this may also include administration of blood products or medications, such as tranexamic acid to minimize internal bleeding.15–19
Head injury: Injured brain tissue is susceptible to any changes in circulation. Management of life-threatening head injuries requires a provider to avoid the three "H-Bombs" that kill brain tissue:
- Hypoxia – keep the patient's oxygen saturation above 90%;
- Hyperventilation – don't ventilate faster than 10/min; and
- Hypotension – keep BP >90 mm/Hg systolic.
Even a momentary drop in oxygen saturation or blood pressure can double a victim's chance of dying, and a decrease in blood pressure and oxygen at the same time increases the patient's chance of dying by more than 600%.20,21
Prepare for patient movement
While extrication efforts continue, firefighters can prepare to move the patient out of the vehicle and into the ambulance. They should ensure that belts are cut, glass is entirely removed, sharp edges are covered, and hoses and equipment are cleared along the path of the patient's exit path.22
Getting a patient to trauma care means coordination with and transport to a designated trauma facility for patients with severe injuries.23 For the trauma team to be prepared, it should receive notification of the incoming victim as early as possible. Then there should be an efficient patient care hand-over.24–26
Stage 4: After the incident
After the patient(s) are removed from the vehicle(s), EMS aspects of extrication remain.
Pictures: Video and photographs of extrication incidents can contribute to responders' training and education. However, guidelines on who should take them, how they are handled, and who owns and has the right to distribute them should be clear to every responder. The best policy is one that makes it clear to responders what rights the public has and what ethical, if not legal, obligations responders have to sometimes obstruct public views of incidents to protect the privacy and dignity of the patients involved without coming in direct conflict with the photographer.27
Pain/pathogens: Questions to ask at the end of the incident include:
- Are all the responders safe?
- Were there any near misses?
- What did we do well?
- What could we have done to improve safety?7
Post-traumatic stress disorder (PTSD)
Incidents involving a large number of victims, young children or fellow emergency responders can have a significant psychological and emotional impact on those who respond. Just as we evaluate the potential for physical injury for our responders, we have to keep in mind their psychological well-being as well.28
When an extrication incident occurs, rescuers and EMS personnel are on the same team, even if they are wearing different uniforms. Everyone wants to be on a winning team. The only way that happens is when everyone is truly coordinated and working together. When rescuers and EMS work together as a well-oiled machine, tasks get completed more quickly, obstacles are overcome more easily, and patients and the public know they are in good hands.
When EMS and extrication operations are coordinated, rescuers arrive doing their U-CAN size-up to know their role, hazardous conditions to watch for, their next priority, and what they need to make it happen. They access the patient rapidly to assess what the patient needs from the extrication team. They don't wait for ALS providers to perform lifesaving BLS actions, but when ALS skills are required, paramedics should be ready. The best rescue teams look after each call and ask, "What can we improve?"
- The 2020 Extrication Supplement. Fire Engineering (2020).
- Ginglen, J. G. & Tong, H. EMS Gaining Access and Extrication in StatPearls (StatPearls Publishing, 2021).
- Dami, F. et al. Coordination of Emergency Medical Services for a Major Road Traffic Accident on a Swiss Suburban Highway. European Journal of Trauma and Emergency Surgery 35, 265–270 (2009).
- International Fire Service Training Association. Principles of Vehicle Extrication, 4th Edition Manual | IFSTA (Fire Protection Publications, 2017).
- Sweet, D. Vehicle Extrication Principles & Practices. (Jones & Bartlett Publishers, 2011).
- IFSTA. Essentials of Firefighting. (Pearson Education, Limited, 2020).
- American Academy of Orthopaedic Surgeons. Emergency Care and Transportation of the Sick and Injured (Jones & Bartlett Publishers, 2017).
- Nini, M. Situational awareness: What it is and why it matters as a management tool. CQ Net - Management skills for everyone! (2020).
- Okray, R. & Lubnau, T. Crew Resource Management for the Fire Service. Fire Engineering Books.
- FEMA. National Incident Management System | FEMA.gov. fema.gov (2021).
- Duckworth, R. Combating the Trauma Triad of Death. Fire Engineering (2019).
- Kastros, A. Mastering Fireground Command. fireengineering.com (2011).
- Haukoos, J. & Sasson, C. Prehospital Hemorrhage Control-Leveraging Successes From Cardiac Arrest to Optimize Population-Level Effectiveness. JAMA Surg 154, 930–931 (2019).
- NAEMT. PHTLS Prehospital Trauma Life Support (Jones & Bartlett Publishers, 2020).
- El-Menyar, A. et al. Prehospital administration of tranexamic acid in trauma patients: A 1:1 matched comparative study from a level 1 trauma center. The American Journal of Emergency Medicine 38, 266–271 (2020).
- El-Menyar, A., Sathian, B., Asim, M., Latifi, R. & Al-Thani, H. Efficacy of prehospital administration of tranexamic acid in trauma patients: A meta-analysis of the randomized controlled trials. The American Journal of Emergency Medicine 36, 1079–1087 (2018).
- Shiraishi, A. et al. Effectiveness of early administration of tranexamic acid in patients with severe trauma. Br J Surg 104, 710–717 (2017).
- Shand, S., Curtis, K., Dinh, M. & Burns, B. What is the impact of prehospital blood product administration for patients with catastrophic hemorrhage: an integrative review. Injury 50, 226–234 (2019).
- Guyette, F. X. et al. Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial. Ann. Surg. (2019) doi:10/gf873n.
- Spaite, D. W. et al. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surgery 154, e191152 (2019).
- Spaite, D. W. et al. Evaluation of the Impact of Implementing the Emergency Medical Services Traumatic Brain Injury Guidelines in Arizona: The Excellence in Prehospital Injury Care (EPIC) Study Methodology. Academic Emergency Medicine 21, 818–830 (2014).
- Baker, L. Harden the Egress: FireRescue (2011).
- Hashmi, Z. G. et al. Access Delayed Is Access Denied: Relationship Between Access to Trauma Center Care and Pre-Hospital Death. Journal of the American College of Surgeons 228, 9–20 (2019).
- Simon Lang. EMS Handover; make a difference to all alerted patients | HoEFT NHS Emergency Medicine Podcasts. HEFT EMCAST (2015).
- Craig Wylie. The art of the EMS Handover. #badEM (2015).
- Wood, K., Crouch, R., Rowland, E. & Pope, C. Clinical hand-overs between prehospital and hospital staff: Literature review. Emergency medicine journal: EMJ 32, (2014).
- Hurst, E. Social Media: The Offensive Strategy. Fire Engineering (2019).
- Setera Hopkins, J. PTSD 360: Size-up and Tactical Considerations. Fire Engineering (2019).