1. #1
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    Thumbs down You Make The Call #16- Spinal & Casualty Handling?

    A bit concerned by the "You Make The Call #16" and the way in which the casualty was extricated...

    Plano Fire Rescue members arrived at this incident to find the driver trapped and seriously injured. As the door was being forced open, the lightweight Nissan Sentra's door panel tore. The rescue crew used their recip saw to cut the remaining metal. The door was widened manually. The patient was extricated feet first out the door opening onto a longboard.
    Looking at the picture below of the incident, the casualty appears to be quite a tall person. The impact is obviously quite significant looking at the way in which the roof has buckled down onto the casualty and the side of the car has been forced in.

    Surely with an impact like this, spinal injuries must be a priority concern. It is stated that the casualty was seriously injured...

    Removing a casualty (In this case a tall casualty, inside a car with a partially crushed roof) feet first, out the side of a car, onto a spine board would be a questionable technique???

    Stabilize the vehicle, shutdown the electrical system, force open the driver’s front door, remove a section of the front A-pillar or the entire roof, ‘jack or ‘roll’ the dash, remove patient
    45.2% of 341 votes suggests that possibly removing the roof may have been a better option. Surely after flapping the roof to the front of the car or removing it totally, a better technique would have been to do an "in-line" removal of the casualty over the rear parcel shelf in a KED and on a spine board...?

    I firmly beleive that removing a suspected spinal injured casualty out the side of a vehicle and onto a board (Obviously twisting the spinal cord) is a thing of the past- what's your thoughts?
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    Lutan,
    Spinal injury is only a priority if there are no other significant injuries present. The problem I had was the one question in which they asked you what would you do to remove the patient....to me the question that I wanted to ask was: What was the patient's condition?

    Looking at the impact, you are obviously right to be concerned about the mechanism of injury. However, it did say the patient was seriously injured. Looking at the pics, the patient obviously struck the windshield, and concaved it a significant distance. If the patient had any of the following: moderate to severe head trauma, altered mental status, a glasgow coma scale of less then 8, and/or unstable vital signs. You go to the point that you can get the patient out and stop there. Rapid extrication is acceptable based on patient condition. I can tell you that the KED would be the last thing I would grab for a patient with serious injuries.

    As far as twisting the patient on the seat, as long as you maintain cervical spine stabilization, manually along with a collar, you should be able to spin a patient as a unit. Additionally it has been my experience that your biggest concern and chance of injury is with the cervical spine in MVA's, where patients stay in there seats. The Thoracic vertabrae are your strongest, and generally the lumbar stays supported by the seat, and is isolated when the head hits the windshield. The exception to this is generally when a patient shows signs of a pelvic fracture, you may also want to suspect lumbar and lower vertabral injury. Also with this patient you would also be suspect of injuries to either ends of the c-spine...C-1/C-2 and the C-5 to C-7 areas, with the higher percentage to the C-1/C-2 area due to the impact forces and the angle of the windshield. I have never treated a person with a fractured vertabrae on any section of spine that wasn't in severe pain.
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    Agree with you ALS, but remember the KED doesn't have to be used to as immobilization device.

    It can be fitted in about 2 minutes and be used as lifting aid (ie: not using all the straps and immbilization components). Steve Kidd wrote an excellent article in FireRescue last year about using the KED in this fashion- well worth the read. We've been using it with great success for many years.

    Another option would still be to do an inline lift over the rear using a strap or rope under the arms and across the chest. Still achieves an in line move for the spine.

    As far as twisting the patient on the seat, as long as you maintain cervical spine stabilization, manually along with a collar, you should be able to spin a patient as a unit.
    I really can't beleive it's possible to NOT twist the spine in a seat when removing from the side- dependant obviously on how it is done.

    It's a huge debate amongst everyone....

    What does everyone else think?
    Luke

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    I had a similar discussion with an EMT instructor about the option of going in-line out the back as opposed to out the door. He thought I was crazy. Wondered where on Earth I would ever get such a crazy idea. His claim, find one EMT class that teaches removal out the back. We are just finishing up our EMT core recert class, and when doing the KED sessions, all were done in cars that were in perfect shape, with victims that had no real injuries. When you train/educate that way, you never see a different method. I'm with Lutan on this, no matter how good you put the KED on, there is some twisting going on while removing out the door. Is the twisting going to compromise anything? Hopefully not. We've done the in-line, out the back at a drill, everyone liked it and thought it made sense, but on actual calls, we still go out the doors. It seems like the in-line method will be an uphill battle for acceptance, at least in my area.

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    Lutan,

    I have been at conferences where lawyers have lectured about being extremely cautious and weary of using equipment in a way that it wasn't designed for and/or not using it in a manner in which you were trained. If I was gonna use the KED, I would take the time to do all the straps. But again, if I'm gonna take a roof, its gotta be for a reason.

    As far as this incident at hand, I'm still sticking to my size-up that the patient had a serious head injury. I'm still not gonna wait for that roof to come off.

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    After reading Steve Kidd's article, I actually wrote a letter (email) to Steve and in turn he passed it onto Rick Kendrick, the inventor of the KED. He fully endorses the use of the KED as a lifting device. It is actually what it is designed for along with being an immobilization device.

    Try fitting it and using it that way- it works well.

    As for waiting for the roof to come off- if a crew works well together and understand each other, it should only take upto 2 minutes provided there is no problems encountered....

    Anyone else using the KED this way, and any other thoughts on this incident?
    Luke

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    we used an KED once on an mvc. it was the accident that i posted awhile back where the car plowed under the drainage ditch under a road. the car was up to it's dashboard under the road. we had about 1-2 feet on both sides to work with. the concrete ditch went up at about a 45 degree angle. we placed the pt in a KED and removed the roof. from there with someone holding the patient, the upper portion of the seat was laid back and the backboard placed on the trunk of the car. the patient was lifted up and onto the backboard, then the leg straps released. this patient was combative the entire time leading us to belief he had a head injury. in my opinion the KED made the job alot easier.
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    This vehicle has what I call a "zipper roof"All the posts are small.I have no qualms whatsoever about reducing any vehicle to whatever level is necessary to do a proper rescue.ANY insurance company would rather buy a car than a human being.I'll go along with Lutan,if this were my job I'd snip the roof,the seat back and do a vertical/horizontal extract.Of course I wasn't there and don't know all the little factors that can influence these decisions.T.C.

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    In reference to using the KED as a lifting device - I recently read all of the product literature that came with a new KED, and no reference was made to utilizing the KED as a lifting device. If it is designed to be used to lift, why does the manufacturer not mention this in their literature? What is the load rating of the plastic buckles and the sewn handles?

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    Both sides of this issue have valid points.

    I'm going to lean towards ALS on this one though, because I'm assuming that the patient condition called for rapid extrication. There are numerous conditions the patient could be presenting that would preclude waiting on roof removal--even if that only took a couple of minutes. In particular, if the patient's airway was compromised and he needed intubation, getting him out of the car fast takes precedence over complete spinal immobilization.

    Just my opinion.
    Bryan Beall
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    Bryan,just got to play Devil's advocate here.Do you really think it would take that more time to remove the roof than it would to mess with that mangled door.Severely bent doors aren't where I would start my rescue ops if given a choice.If not given a choice I'd probably opt for a third door conversion.T.C/
    Last edited by Rescue101; 08-02-2002 at 09:15 PM.

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    Not having been on the scene and seeing the photos. I would hope that the option was at least discussed to "take the roof". I think our crew might have snipped that baby right off. But! I have done it the other way too. A good crew with a lot of hands-on can remove a "SICK" patient pretty smoothly. I just think that it might have a little safer (spine safe) for the patient to take the roof. If the patient was dying in your hands. Then the decision to take the quicker route (leave the roof in place, laterally lower to a board and the do a long axis slide on to the board while doing an oblique rotation to a supine position)might have been preferred.

    Regarding the KED. I read an article that Mark Somers wrote (he is Ambulance Paramedic Clinical Instructor with the Metropolitan Ambulance Service in Melbourne, Australia) regarding this issue. He teaches that a KED could used as a lifting or hauling device and of course he teaches that it is used for the typical uses we see and use it for. I know others teach similar stuff out there. I have used it for exactly what Lutan is referring to as well. Although most of the rescue companies in our department have the KED's collecting dust in their compartments. It still is an underused device. It is nice to see that others are using it more in different scenarios.

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    Default Another point of view

    also i don't know if this would be accurate but consider that there are other companies that make devices that look like KEDs. I believe the KED is a patented product and therefore the other companies can not make the device exactly the same as the original KED. now i have not seen any of the other companies' KEDs but maybe they don't put the handles on or attach them to handle lifting patients with.
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    Ryan,

    No, I probably wouldn't start with the mangled door either, but that seems to be what Plano did is this case.

    Maybe the progress they had made on the door allowed them to finish the door removal faster than if they stopped and did a roof removal.

    It's hard to say. I have chosen to extract victims from automobiles without complete spinal immobilization when situations warrant. Without knowing what the patient was presenting with, it's hard to make that call.
    Bryan Beall
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    Silver, I have also had to take patients out of a car with only manual stablization also, it does happen.

    Just to clarify, I never said not to use the KED as a device to assist with lifting. That is actually what it is called a "Kendricks Extrication Device" not spinal immobilization device, although it also does that. What I referred to was if you are going to use it, use it as it was intended to be used, with all the straps.

    I also have to say that in this case if the patient presented as I implied, if the door was gone the patient would be out. I wouldn't wait 30 seconds with a patient with severe head trauma or any other significant traumatic injury. Either way you still have to remove that door at some point if you have to lift the dash and apply the KED easier and to get your hands in there to lift the patient by the handles. I would cut the posts and have them ready to go that far, but once that door was off, and I had to, that patient is out and beign transported.

    I honestly have to say that I think that the potential of a spinal injury is being focused on a little to much here. That is my point. If I pull up in my engine/flycar or whatever and he is CAOx3, with minimal injuries, yes take the roof. But any other injuries like I stated in my first post, he goes. The spine is not that high on the list when compared to head trauma, unconciousness, a GCS less then 8, arterial bleeding, and/or unstable vital signs. Which we all know that patients experiencing any of those and a few more I don't have time to mention should be off scene within 10 minutes.
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    Good points made by all, I tend to agree with Lutan and others that removing a single door and manipulating a large patient out a small opening may not have been the best course of action, regardless of the patient's condition.
    The picture Lutan posted of the Plano wreck shows a relatively undamaged driver's side rear door, looks like you can open it by hand or relative ease with a spreader. My plan A may have been to perform a Maxidoor( b post rip) on that side. With the rear door open already, tool time would have been pretty short to remove the B post and swing the entire side out on the front hinges. So for a time critical patient, the maxidoor gives you a large opening in a very short time with unobstructed patient removal and very little manipulation of the patient's spine - probably a quicker end result than the removing the single mangled door and now having to work the patient's headand torso around the B post,etc.
    Removing the entire roof would be another good option, 2-3 minutes as other's have said. Another technique we've been practicing the last few months has been sliding the patient out the rear window opening, distorting the roof opening with a spreader if necessary. This is very fast, and only requires you being able to operate the front seats reclining lever( assuming the patients is not pinned by the dash). Attached is a photo of the rear window slide( my thanks to our Aussie brothers for sharing this technique).
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    There are three issues that have been raised, with each needing to be addressessed individually:

    1. Rear Window Vs Side Door
    2 Rapid Extrication Techniques
    3. KED Uses

    1. Rear Window Vs Side Door

    The aim of patient care is to do no further harm. To do no further harm in removing a patient, two basic rules need to be followed in extricating a patient - Manitain Spine Alignment & Minimal Body Twisting. Both will help prevent further injury.

    If the patient is sitting in the front seat as in this case, a rear window extrication is indicated. For what reason would you want to twist the patient inside the vehicle. The suggestion that you can twist the patient inside the vehicle when a centre consule is in the way and space is limited is invalid. I would suggest that at your next training day, undertake a rear window extrication with KED and without, then undertake side door extrication with KED and without, with each person having a go at being the patient. I would be interested to here from anyone who found the side door to be the prefered method. In Victoria Australia, we have been teaching the rear window extrication for 9 years with excellent results. If you jump onto http://www.neann.com/verwf.htm you will see how simple and quick it is as compared to side door removal. Further, video both techniques, go inside and watch it as a group to further compare. It will be the last time you go out the side.


    2. Rapid Extrication Techniques

    For rapid extrication, we again teach rear window extrication. It is faster than side door removal as it often only requires the window to be broken, seat rolled back, board inserted, patient laid on the board and out. This is much faster and easier to co-ordinate than going out the side door and requires less rescuers. If door is jammed why wait for rescue to open it when you only have to break a window. Again give it a go to see for yourself.


    3. KED Uses

    For the last 9 years, we have been teaching the KED as a lifting device and this has been well supported by FERNO. Simply insert, apply three chest straps and 2 pelvic straps and extricate. Leave the head section alone. This in combination with a cervical collar will give you 50% spinal immobilisation overall and as you will no longer be twisting the patient around, it will be adequate immobilisation to slide the patient onto the Long Spine Board. Application time is as low as 90 seconds for a well trained crew. Considering the advantages the KED will give you for patient removal ie handles, the 90 seconds is saved over co-ordinating manually pulling.

    Finally the suggestion you only use a device for what it is designed for is to limit your ability in the field. Do you only use a long spine board for spinal care??


    Emtec
    Last edited by neann1; 08-02-2002 at 09:51 PM.

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    Further information for the "You Make the Call #16" discussion;

    This image shows the vehicle after patient removal and during some of the "shutdown & pickup" action. The rapid extrication of the patient became the primary tactic once the driver's LOC, respirations, and BP deteriorated not long after patient contact.

    Opening this jammed door is a good call, even if you are going to remove the roof partially or totally. You can't remove a patient out any opening unless the feet and lower legs are free. Opening the door provides this vital information.

    The roof removal assignment was underway. In this case, the 24-v DeWalt can still be seen on the roof. The pillars were actually being stripped and ready for cutting when the patient went 'south'.
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    Rapid extrication is 'rapid' and aggressive action taken to save the life of a critically injured patient. It cannot be done for the convenience of the rescuers. Rapid extrication must be justifiable based on the patient's deteriorating medical condition.

    Rapid extrication is not always possible out the back of a vehicle or through the former roof opening area. In this crash, a "horizontal rapid extrication" was accomplished by having EMS providers inside the car in the rear seat area, on the passenger's front seat area, and along the opened driver's door area. With a cervical collar in place and manual stabilization of the spine maintained, the patient's feet and legs were moved towards the opening by the door hinges. A longboard was placed in-line under the front edge of the driver's seat and the patient extricated feet first out onto the board.

    Several clues to patient's mechanism of injury include;
    crushed A-pillar both at the feet area
    crushed A-pillar along the upper areas where there was head contact, crushed driver's seat,
    buckled floorboards,
    blood inside the vehicle, and
    (in my opinion the most important clue)the deformed steering wheel and hub assembly
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    In the "You Make the Call #16" decision process, when told that YOU are in charge and given the first image, about 84% continued with the full 360 walk-around. This is good and this is the correct choice.

    Yes, 14% said they would stabilize and that is important but YOU are in charge and YOU have to see the entire challenge first. Order stabilization but DO NOT get distracted by a tactic. Stick with YOUR priorities and check out the whole scene first.
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    I am surprised that the majority of "Officers-In-Charge" of You Make the Call #16 ordered full deployment of a handline before ordering stabilization. The second image provides evidence of a huge oil, antifreeze and transmission fluid spill so that was the distractor. The decision that had to be made by YOU, the OIC of this incident, is how to best deploy your personnel. You are one member of your crew and you see your paramedic getting ready to climb inside the opened passenger rear door. That accounts for two of your crew. If you have a four-person crew, then there's only two more people available. At this time, other responders are still enroute.

    It is good that you realize that a handline should be deployed but the question is, what is the priority here. You do not smell gasoline or see evidence of fluid leakage from the fuel tank which is towards the rear of the vehicle. It's true gasoline can be leaking and surely there are enough sources of ignition present just by the nature of the crash.

    Here's your calculated risk that must be taken by YOU as OIC. If you stretch a handline and assign a person to it, that task alone might tie up both the person at the nozzle and someone at the pump. Because your paramedic has to get inside to make patient contact, stabilization of the vehicle also becomes important. You don't want your crew member climbing inside an unstabilized vehicle.

    The question for you in situations such as this is 'Can a 20lb dry chem be effective enough fire safety initially so stabilization can be accomplished?' You could standby with that as your two crew members spend about a minute to stabilize the vehicle. Then possibly, a handline could be stretched.

    There's no always right or always wrong answer for all situations. Use these images and this incident to stimulate consideration of what can be accomplished and by whom in those vital first few moments of a crash.

    Sometimes being "First-Due' sucks!
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    In the third decision point, there is a hidden teaching point that I want to bring to your attention. Make sure that you and your rescue crew know that a dash can be "Rolled" or a dash can be "Jacked" with the roof still ON the car. All that is needed is for a chunk of the front A-pillar to be removed.

    Ideally, the dash job works best after total roof removal but that is NOT a requirement! Make sure you are aware of this. Practice your dash assignments with an intact roof and a missing A-pillar. It works.
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    All good points.What about the "third door tactic"?I read it on this vehicle as adding very little time to the job and a whole lot more space.T.C.

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    All good points Ron....

    I am surprised that the majority of "Officers-In-Charge" of You Make the Call #16 ordered full deployment of a handline before ordering stabilization.
    I don't think this has come from being distracted- I think this comes from a safety stand point. I wouldn't have any members working around, and especially IN any vehicle without fire protection in place first. This includes any member placing stabilisation.

    surely there are enough sources of ignition present just by the nature of the crash.
    You've answered this one yourself....

    What about the "third door tactic"?
    Hey 101, don't get the terminology mixed up. A third door conversion is performed on a TWO door car. We're creating a third door where there isn't a door.

    If on the other hand you're referring to the removal of the side of the car, then I would see merit it in it if time allowed again. If we insist on removing out the side of a vehicle, then lets make room to move....
    Luke

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    Hehehe,Big grin as I throw out the bait!Trolling for lutans!Time?What time?Back door already opens!Blow front hinges,three slice,drop side!Third door, fifth door,Terms not my strong point;unlimited acess for my Med crew is.I like lots of room and I don't know a quicker way to get it.If you do,start shaking the moths out and show me!Sheesh, this is even your kinda car,small and bent;not like your average 'merican rolling apartment house.Now lessee,what kind bait do I use to catch Kiwis? T.C.

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