EMS Firefighter Tools in Car Crashes: The Key to Coordinated Rescue

For professionals in vehicle extrication, the array of tools and sophisticated techniques designed to manipulate mangled metal are undeniably captivating. However, it’s crucial to remember that the ultimate objective of any vehicle extrication scenario is to deliver optimal care to individuals trapped within. This begs the question: why does a perceived conflict often arise between the fire-rescue operations and EMS protocols at the scene of extrication incidents? While personality dynamics and differences in organizational cultures can contribute, the core issue frequently boils down to conflicting priorities between fire-rescue and EMS teams.

Ask any firefighter about vehicle extrication, and they’re likely to launch into a discussion about advanced high-strength steel, the complexities of modern vehicle construction, and sophisticated supplemental restraint systems. They might detail the specialized tools and innovative techniques required to effectively “create space” within contemporary vehicles, emphasizing how these differ vastly from the simpler methods of “popping a door” on older car models.[1] This perspective is understandable; modern vehicle extrication demands highly specialized skills and focused execution from trained technicians.

Conversely, EMS providers will often highlight the demanding circumstances of delivering critical trauma care within confined, chaotic environments, all while being acutely aware of the precious time elapsing before the patient reaches definitive hospital care.

Both fire-rescue and EMS teams operate with a high degree of task-orientation, sometimes leading to limited patience or appreciation for the objectives and challenges faced by the other. This can unfortunately result in outcomes ranging from uncoordinated efforts to, in more severe cases, interpersonal conflict among responders. Despite the diverse range of fire, rescue, and EMS systems prevalent across North America, there is a universal need and opportunity to enhance inter-team coordination during extrication scenarios.

Effective synergy between EMS and fire-rescue personnel is paramount for the swift and safe removal of casualties, directly enhancing the quality of trauma care delivered.[2, 3] To achieve this level of cooperation, leadership from chiefs and officers down to individual firefighters, EMTs, and paramedics must foster a coordinated approach that spans horizontally across fire-rescue and EMS disciplines, and vertically through the incident command structure.[4, 5]

In a truly coordinated extrication effort, the expertise of fire-rescue teams in “tools and tasks” remains central, but is informed and guided by the patient care insights of EMS professionals. Essentially, the decisions of why, when, and how to extricate are made by rescuers, but these decisions are fundamentally grounded in the EMS assessment of who, what, and where concerning the patient’s condition.

The Four Critical Stages of EMS-Fire Rescue Extrication Coordination

Successful extrication hinges on seamless coordination between EMS and fire-rescue teams, particularly across four pivotal stages.

Stage 1: Initial Arrival and Scene Size-Up

A comprehensive scene size-up is the bedrock for effective incident management,[6] and this principle extends beyond the initial responding unit. Every responder, regardless of their role, should conduct a personal size-up to effectively integrate into the ongoing extrication operation and identify any immediate hazards.[7] This embodies the core principles of situational awareness and crew resource management.[8, 9]

Various size-up techniques exist, but a particularly versatile and straightforward approach applicable to almost any incident is the “U-CAN” method.[10] This mnemonic helps responders focus on essential elements and their role within the operation:

• Unit: What is my specific role at this incident (beyond just the apparatus I arrived on)?
• Conditions: What hazards are present at the scene?
• Actions: What is the immediate next step I need to take?
• Needs: What resources or equipment do I require to perform my next action effectively?

Stage 2: Gaining Access and Initial Patient Assessment

While the impulse to immediately engage in rescue actions can be strong, the initial responder tasked with gaining access, whether primarily fire or EMS, must first accomplish or verify several critical tasks: a comprehensive 720+ check of the vehicle. This involves a 360-degree survey of the outer perimeter, followed by a 360-degree survey of the vehicle’s interior, plus assessments above and below the vehicle. This thorough check enhances situational awareness, identifies potential hazards requiring attention (even if addressed by others), and provides vital information for prioritizing subsequent actions.

Once vehicle stabilization is confirmed and the power is secured if necessary, the EMS provider who gains interior access should immediately establish contact with the patient(s). Their priorities are to protect patients from further injury, conduct an initial injury assessment, initiate immediate life-saving interventions, and ideally, remain with the patient throughout the extrication process and during transport to definitive care.[4] This in-vehicle care provider could be from fire or EMS, ALS or BLS certified – the designation is less important than ensuring they are equipped, protected, and prepared to deliver effective care and communication.

Immediate life threats, encapsulated by the MARCH protocol (Massive hemorrhage, Airway obstruction, Respiratory distress, Circulatory compromise, and Head injury), necessitate rapid patient extrication.[11] Conversely, specific findings such as patient paralysis, significant neck or back pain, severe extremity angulation, impalement injuries, significant crush injuries, or the need for pain management or medication administration may dictate a more deliberate and careful extrication process.[7]

The in-vehicle EMS provider should deliver a concise patient status report utilizing the CAN format:

• Conditions observed inside the vehicle.
• Actions being taken by the in-vehicle EMS provider.
• Needs of the in-vehicle EMS provider to effectively carry out these actions.[12]

Stage 3: Coordinated Action and Intervention

The extrication plan must effectively integrate immediate medical priorities with the necessary rescue strategies and tactics for patient removal. The EMS component of this plan can often be rapidly initiated by any responder with basic EMS training, regardless of their primary agency or ALS certification, provided they are trained and equipped to operate safely within the extrication zone.

The paramount concern must be addressing MARCH problems that pose the most immediate threat to the patient’s life. These conditions are potentially fatal, but responders can effectively manage almost all of them within the initial moments of patient contact.[11]

Massive Hemorrhage Control: Employing the 3 Ds

• Detect: Rapidly identify the source of significant bleeding.
• Direct Pressure: Apply continuous pressure to the bleeding site to promote clotting.
• Devices: Utilize specialized equipment such as tourniquets, hemostatic gauze, pressure dressings, and clamps to effectively control bleeding and free up responders’ hands for other critical tasks.[13]

Airway Management: Ensuring a Patent Airway

Airway emergencies during extrication should initially be managed using Basic Life Support (BLS) techniques, such as oropharyngeal or nasopharyngeal airways and suctioning. Progress to advanced interventions like supraglottic airways, endotracheal intubation, and cricothyrotomy as dictated by the patient’s condition and the provider’s training and scope of practice.[14]

Respiratory Support: Addressing Breathing Emergencies

Managing immediate respiratory threats may involve assisting patient ventilation with a bag-valve-mask (BVM), stabilizing flail chest segments, sealing open pneumothoraces (sucking chest wounds), and, for ALS providers, performing needle decompression for tension pneumothorax.[14]

Circulation Management: Optimizing Blood Flow

Circulatory support considerations include establishing intravenous (IV) access and administering intravenous fluids judiciously – enough to maintain a minimum blood pressure without causing hemodilution. Careful patient movement is crucial to avoid dislodging any formed internal blood clots. Pain management and patient sedation might be necessary to facilitate quicker and safer patient removal. In some EMS systems, pre-hospital blood product administration or medications like tranexamic acid (TXA) to minimize internal bleeding may be indicated.[15–19]

Head Injury Management: Protecting the Brain

Compromised brain tissue is highly vulnerable to fluctuations in blood flow and oxygenation. Managing life-threatening head injuries requires diligent avoidance of the “H-Bombs” that exacerbate brain injury:

• Hypoxia: Maintain patient oxygen saturation above 90%.
• Hyperventilation: Avoid excessive ventilation rates; target no more than 10 breaths per minute.
• Hypotension: Maintain systolic blood pressure above 90 mm/Hg.

Even brief episodes of desaturation or hypotension can dramatically increase mortality risk in head-injured patients. The combination of hypotension and hypoxia multiplies the risk of death by more than sixfold.[20, 21]

Preparing for Patient Movement and Transfer

While extrication efforts are ongoing, firefighters can concurrently prepare for patient removal from the vehicle and transfer to the awaiting ambulance. This includes ensuring seatbelts are completely cut, all glass is removed from the patient’s path, sharp edges are covered or shielded, and hoses and equipment are cleared from the intended patient egress route.[22]

Expedient transport to definitive trauma care, ideally at a designated trauma center for severely injured patients, is critical.[23] To optimize trauma team readiness, early notification of the incoming patient is essential, followed by a streamlined and effective patient care handover upon arrival at the hospital.[24–26]

Stage 4: Post-Incident Procedures and Review

The EMS aspects of extrication extend beyond patient removal from the vehicle.

Incident Documentation: Capturing video and photographic records of extrication incidents can be invaluable for training and educational purposes. However, clear guidelines must be in place regarding who is authorized to take such recordings, how they are managed, and who has ownership and distribution rights. Policies should balance the public’s right to observe with ethical and legal obligations to protect patient privacy and dignity, potentially requiring responders to obstruct public views in certain situations without directly confronting photographers.[27]

Post-Run Analysis: Pain Points and Pathogens

Essential questions to address at the conclusion of every incident include:

• Are all responders accounted for and safe?
• Were there any near-miss incidents during the operation?
• What aspects of the response went well?
• What specific actions could be implemented to enhance safety and efficiency in future incidents?[7]

Addressing Post-Traumatic Stress Disorder (PTSD)

Incidents involving mass casualties, pediatric patients, or fellow emergency responders can have profound psychological and emotional repercussions on those involved. Just as we prioritize physical safety, proactive consideration of responders’ psychological well-being is crucial.[28]

The Well-Oiled Rescue Machine

During vehicle extrication incidents, rescue and EMS personnel are inherently on the same team, regardless of uniform distinctions. Everyone strives to be part of a successful team, and this is only achievable through genuine coordination and collaborative effort. When rescue and EMS teams function as a cohesive, well-oiled machine, tasks are completed more efficiently, obstacles are overcome with greater ease, and both patients and the public gain confidence in the responders’ capabilities.

In coordinated EMS and extrication operations, rescuers arrive prepared to conduct a U-CAN size-up, understanding their role, identifying hazards, prioritizing actions, and anticipating resource needs. They efficiently access the patient to promptly assess their needs from the extrication team. They do not delay initiating life-saving BLS actions awaiting ALS personnel, but ensure paramedics are readily available when advanced skills are required. The most effective rescue teams consistently review each incident, proactively seeking opportunities for improvement.

References

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