There are plans to overhaul the way people are rescued from car crashes amid growing evidence that current methods of waiting for people to be freed may be harmful.
Last year in England there were 127,967 casualties and 1,560 deaths caused by motor vehicle collisions. During the same period, more than 7,000 patients needed help getting out of the vehicle through a process known as extrication, in which rescue teams use the “Jaws of Life” and other tools to separate the remains and then carefully extricate the people.
Although in some cases patients’ limbs are immobilized or they are unable to move because their injuries are so severe, in most cases they would be able to climb freely with minimal assistance, e.g. after removing a stuck door, but remain in their vehicles due to pain and/or concern that moving them could worsen their injuries – especially spinal injuries.
“Since at least the 1980s, firefighters have been trained with movement minimization as the absolute paradigm,” said Dr Tim Nutbeam, consultant in NHS emergency medicine and medical director of the Devon Air Ambulance. “They’re told that one millimeter of movement can turn someone into a wheelchair user, so they’ll often dismantle the car around the patient to avoid neck movement.”
Still, it takes time – 30 minutes on average – and if that person has another serious injury, such as a head, chest or abdominal injury, every minute counts.
Nutbeam began researching the issue after noticing a disconnect between concerns about spinal motion and the injuries she was seeing in her patients—including the experience of people dying in their vehicles or shortly after being removed.
He found that trapped patients were almost twice as likely to die as those who were quickly freed from the wreckage. Furthermore, the prevalence of spinal injuries among such patients is actually extremely low – only 0.7% – and in about half of these cases they had other serious injuries requiring emergency medical attention.
“Our absolute focus on minimizing movement works for maybe 0.3% of patients, but prolongs the time to capture for 99.7% of them,” Nutbeam said. “Potentially hundreds of people in this country have died as a result of prolonged detention, and if you multiply that around the world, that’s many, many people.”
Nutbeam and colleagues attached motion sensors to healthy volunteers and measured their neck and spine movements as they were extricated from various vehicle crash scenarios using a variety of techniques.
Although these experiments are ongoing, early results suggest that spinal motions associated with assisted extrication are much greater than when volunteers are allowed to climb out of the wreckage on their own, and that rapid assisted extrication techniques produce movements, similar to the slower ones aimed at minimizing movement.
In other words, the more movement a patient can do on their own, the less spinal movement is likely to be associated with it. Although patients with true spinal injuries will still need a gentle approach, “probably self-removal where possible will be better regardless of the type of injury,” Nutbeam said.
Currently, only around 3% of fire and rescue services in the UK use self-extrication on a regular basis, but this is likely to change as a result of these studies.
In a consensus paper, UK stakeholders, including the National Fire Chiefs’ Council (NFCC) and the College of Paramedics, reviewed the existing evidence and agreed a set of principles for future guidance.
These include the recommendation that independent or minimally assisted extrication should be the standard “first line” for entrapped patients who are conscious and likely to be able to stand with assistance, and that minimizing entrapment time should be the goal for all patients.
“This research will reduce both deaths and injuries and help us achieve our vision of zero deaths and serious injuries on UK roads,” said Sally Lines, chief executive of Trust Road Safety, which funded the research. “We look forward to the practical application of this research used by emergency services.”
Already, the UK Rescue Organization (UKRO) has adopted the new principles for its September 2022 Extrication Challenge, in which UK fire and rescue teams compete to extricate people from a variety of challenging scenarios.
They should also enable fire crews to develop new extrication techniques, such as pulling vehicles out of obstacles with victims still inside, said James Coomber, road collision instructor for UKRO. “Without 360-degree access, ambulance staff often struggle to fully expose and assess patients, resulting in missed injuries or significant delays in treatment. By adopting these new principles and revising techniques such as moving the vehicle, we can [potentially] reduce release time, increasing their chances of survival.
The NFCC is also planning additional testing in light of Nutbeam’s research. “The UK Fire and Rescue Service’s primary aim is to save lives and prevent injury, so we will always be looking to update and change guidance,” said Chris Lowther, chairman of the NFCC’s operational committee. “As a result of this research, further work will be undertaken on what the extraction might be.” [performed]. Once we receive this we will look at how changes can be introduced to our national operational guidelines.
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