1. #1
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    Default You Make The Call- T Bone

    Interesting "You Make The Call" when you look at the pictures provided and wonder why a rescue crew would lay the side down on the car when it would be quicker, easier and less work (Also, clinically speaking a better option given that there would be less spinal movement and twisting) to remove the casualty on a spine board, out the back window.

    CHECK IT OUT HERE


    For some further instruction and guidance on this- check out THIS LINK to a free, downloadable manual...
    Last edited by lutan1; 05-30-2005 at 06:19 PM.
    Luke

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    Sta22BeaverCoPA
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    Looking at pictures,
    1. was patient entrapped by door ?
    2. Was patient in cardiac arrest ?

    By impact vehicle was a "Total". One idea would be to cut "C" posts and cut the roof to do a to the front flap. Bring in long board and vertical extricate the patient. Patient is then removed straight line with no twisting of the spine.(I suggested this because of the suggestion to remove patient out rear window.)

    Another would be to remove whole roof and do vertical extrication of patient.

    If there was a need to do rapid extrication of this patient, then I would have to assume they thought this was the quickest.

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    I wouldn't have have folded the sidewall down, I would have removed it all at once so the crew doesn't have to step all over it while trying to get the patient out.

    I've never been a fan of the fold down just because it becomes a huge trip-hazard.......
    The comments made by me are my opinions only. They DO NOT reflect the opinions of my employer(s). If you have an issue with something I may say, take it up with me, either by posting in the forums, emailing me through my profile, or PMing me through my profile.
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    Default Call

    Looks like a body bag to me. Take your time and let the new guy play and cut the b post at the bottom for total removal....or open the door on the other side and take it out.
    If they were alive and dressed in a tyvex wrap for halloween take the roof and go vertical - Im with ya beav! We do this all the time, cant ask for better C-spine mobilization than vertical extraction. Just have to have the beef there if its a big one.
    Burn
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    Burn<br />LT/EMT/Inst />Central Mat-Su FD<br />Wasilla Alaska

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    I wouldn't have have folded the sidewall down, I would have removed it all at once so the crew doesn't have to step all over it while trying to get the patient out.
    Good point

    Looking at pictures,
    1. was patient entrapped by door ?
    Another good point, but can be easily overcome with a ram or similar.

    2. Was patient in cardiac arrest ?
    But that's a different thing where you probably wouldn't (Unless you had to due to a physical entrapment versus a "positional") move metal.

    By impact vehicle was a "Total". One idea would be to cut "C" posts and cut the roof to do a to the front flap. Bring in long board and vertical extricate the patient. Patient is then removed straight line with no twisting of the spine.(I suggested this because of the suggestion to remove patient out rear window.)
    It is another option, however I suggested out the rear window (If the patient will fit) becasue they said it was a high priority patient and by going out the back window, you don't need to move metal.
    Luke

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    I don't think it's a DOA, because in pic #1, someone is holding C-spine, and that's a blanket, not a body bag.

    From the pics provided, I would have done the same thing for the following reasons:
    1) there appears to severe intrusion into the passenger side. it is possible that the person was pinned between the car door and the center console

    2) if you are going to take someone out the back (something i've heard about but never done on a real call) you need to cut both C pillers and then fold the roof up. then you need to move the seats as far back (and remember you had the door in the way) to pull them out. with what was done here, all you need is to rotate them and put them on a board.

    however, due to the damage to the car, i would probably remove the door instead of leaving it lying there.
    If my basic HazMat training has taught me nothing else, it's that if you see a glowing green monkey running away from something, follow that monkey!

    FF/EMT/DBP

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    Not necessarily.Sometimes if your patient isn't too big you can just "blow" the back window and massage it a bit with the spreaders.With a lot of new vehicle seats having the ability to tilt way back,it's another "tool" for the toolbox. T.C.

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    Vehicle cutting is part of patient care. Therefore before making a decision on what to cut to allow the patient removal, patient care issues need to be taken into consideration.

    In regards to the egress decision (which is a patient care issue), egress is generally decided using two basic principles (ref 1-4):

    1. Maintain spinal alignment
    2. Minimise body twisting

    Therefore with the patient sitting in the drivers seat as in this case, egress is through the rear of the car, or alternatively using an option mentioned previously in this forum - the vertical lift. Side removal of the patient in this scenario is contra-indicated as it breaches the above two patient care principles.

    If anyone wants a freely downloadable manual on the patient removal techniques, go to www.neann.com/vet.pdf


    References:

    1. Department Of Human Services Victoria Australia
    Review Of Trauma & Emergency Services 1999: Final Report

    2. Royal Australasian College of Surgeons
    Management Of Acute Neurotrauma In Rural & Remote Locations: 2001

    4. Joint Royal Colleges Ambulance Liaison Committee
    Prehospital Clinical Guidelines: 2001 Spinal Trauma

    5. German Trauma Surgeons Task Force on Emergency Care
    Unfallchirurg 2002 105:10151021
    Algorithm for extrication and medical care in vehicular trauma

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    Default Out the back

    We did a drill we found in a Firehouse mag back a few months ago regarding a patient extrication through the back window. It wasn't just a matter of popping out the back window and squeeking him through, but instead you had to cut out the back pannel, the back seats and so on- which all in all wasn't that hard- and that opened up a tunnel... a huge tunnel. It'd definitely be an option- provided you had the time and needed to take care.

    I'm in full agreement about that side flap- but again, nobody said it would be easy. I suspect someone gave some serious thought to the amount of time it would take to cut away all together... armchair quarterbacking makes my fingers tired... phew.

    Another option I consider as I look at the photos is of the possibility of performing what we like to call a "two door rip-and-blitzer." Considering the crush /impact nature of the damage on the B-post, I'm not 100% on whether or not it could be performed... basically it's the lateral opening of both doors pivoting on the A post hinge. Effecting entry on the rear door, opening it enough that you can make a relief cut on the B pillar bottom and totally cut the top, using the jaws to break the rest of the B post= and swing the whole assembly out of the way... then pop the A hinge.

    AGAIN- not 100% sure if it's practical to do in this case- but it's something I'd have definitely investigated while on scene. It'd have all depended on whether or not I could swing that back door open enough to get the cutters in there to relief the B. If I can't do that then it's on to plan be- which could very well have been through the back window or flapping the sidewall as described here.

    I'm not confident that I'd have performed a vertical extrication in this case- but then we don't really practice it... so I'm not saying it's wrong- but that's why I wouldn't do it.

    (EDIT) Actually, we did do one vertical on a guy that was 6'4 and about 250 out of one of those little...Festiva type thing. And now that I think about it- it worked okay... He had bi-lateral femur fractures and a host of internal injuries- with the manual adjust seats it was possible- but with the battery laying out on the road it would have exacerbated the situation in the event the vehicle had electric adjustmenters.
    Last edited by Eno821; 08-01-2005 at 04:25 PM.
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    Hi Eno,

    Thanks for yur reply and comments on the rear window extrication. The rear window extrication does'nt actually however require removal of the rear seats and is super quick. Have a look at http://www.neann.com/lsb8d.htm which will show you the technique we teach in Australia, and offers a number of ways of opening the space, none of them requiring a tunnelling effect. The vertical spread is the quickest method if the window space is too small and takes about 2 minutes to complete at the most.

    From a Paramedic point of view, the side extrication of the patient is simply not an option and goes against all principles of patient care. It is time consuming (thus eating into the patient's Golden Hour) and requires twisting the patient's spine (clearly contra-indicated in this case). It should therefore only be used as a last resort.

    Finally from a OH&S point of view, rear window extrication is far safer for the Rescuers backs as compared to a side door extrication.

    Best Wishes
    Anthony

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    I understand where you're going with that and I think you're right... removal of the rear seats opens up an enormous area in the back, and cutting through that wall is very quick with the saws all. But yes, I concur with your assessment. Nice to talk shop... love it.

    I checked out that web page- and I can speak from experience (with that example I gave) on how that proceedure can work in real life. Even with the KED, getting the patient lifted up on that spineboard is quite a proceedure. I've got a good picture of our scenario at home that I will include later- I'm on the job right now and I don't have access to those photos at this moment. Not quite as easy as it sounds- because then you've got to hoist the guy up on the board- and while it's not "torquing" per se... it's not quite as easy on the core as you might hope.

    Just an additional note-
    Last edited by Eno821; 08-02-2005 at 02:43 PM.
    Ian "Eno" McLeod

    Train Hard, Fight Easy

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    Default KED + Rear window

    Hi neann1.

    Just reviewed the procedure from the website you posted.

    I'm curious about the clearance required to take patient out the rear window while wearing a KED. Its been my experience that a patients legs will not lay flat while immobilized in that device. Is it common practice for you to loosen the KED once you've got the patient slid up the backboard so the legs will lay flat? or, are you widening the rear window opening to accomodate the knee bend?


    Thanks.

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    Eno,While "tunneling"is a viable option,I'm guessing you haven't run into one of the several vehicles on the US market that I would regard as tunnel resistant.These have a fairly heavy HSS bulkhead that I would regard as anything BUT quick and easy to remove.Best advice:Keep your mind AND your option plate open.Choose the method that will give you the best patient access with the LEAST patient movement in the shortest time with the least labor.Now out of those items,at least one or two WON'T factor in your favor.But such is the laws of extrication. T.C.

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    I hear ya... 100%- I'm guessing you don't have the obesity problems that we do here in north america. Believe me when I say that we often need all the room we can get. Maaaaan... bring back any memories to the rest of you? Remember the largest person you've ever extricated? Any of you worried that the largest person you'll ever have to pull out (of a house or a vehicle) being a member of your own department?

    Now that is scary.
    Ian "Eno" McLeod

    Train Hard, Fight Easy

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    Something that I have found to ease in "lifting the patient onto a backboard for vertical or rear removal is to take a sheet and place it long ways across the victims chest, then take the excess and pull it through the underarms. Now you have a method of moving the patient that does not require you to be right beside the patient. Of course, this is not as good a move if there are chest injuries or, difficulty breathing associated.
    Shawn M. Cecula
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    IACOJ Division of Fire and EMS

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    Hi Guys

    Here's a few answers to the discussion.


    Hi Ruralfire,

    If you don't cross the straps on the KED, but instead buckle them onto the same side, and ensure the groin straps go in the gluteal fold during insertion (which far better secures the KED to the torso to prevent movement) then the legs can be straightened without crushing the patient's vital parts. Have a look at the application technique in page 94 of the Spinal Manual at http://www.neann.com/psc.pdf


    Hi Eno,

    There is no reason to get rid of the rear seat for the rear window extrication technique on this webpage. If the patient is large, place your spreaders on the rear seat and spread with the upper side of the spreaders contacting the roof. Spread the full width of your spreader. The seat will push down and the roof will lift up. The opening will be massive and no matter how obese the patient is, they will come out the hole. If extra room is required (for working inside the vehicle), the forward roof flap can be performed.

    In regards to sliding the patient up the Board, with A KED in place and a rope attached to the KEDs top handle, the procedure is very easy and quick. It is faster than you may think and far safer on your back than a side door extrication (not to mention the patients spine).

    These rear window techniques using the KED are by far the preferred method for those who have tried them. A study in Victoria conducted with 100 participants gave overwhelming preference to the rear window vs side door extrication. Infact no one gave preference to the side door in the study.


    Hi Lewiston2Capt

    I agree with you in this technique for the time critical patient requiring rapid extrication. Some use a rope, but I'm sure you have found like me this seems to be a bit painful for the patient if still conscious. The sheet is clearly the better option.


    Best wishes to all

    Anthony
    MICA Paramedic

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    i would have tried to do a complete sidewall removal by first taking the rear door from the latch. i would have then made a cut at the base of the b-pillar as far through as you can get. now spread from the rocker panel to where the hinges meet the b-pillar. this should start displacement of the b-pillar.cut all the way through base of b-pillar and then cut the top of b-pillar. the rear door,b-pillar, and front door should all be one unit that will swing forward on the front hinges. cut front hinges and total sidewall removal is complete. just my 2 cents.

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    i would have tried to do a complete sidewall removal by first taking the rear door from the latch. i would have then made a cut at the base of the b-pillar as far through as you can get. now spread from the rocker panel to where the hinges meet the b-pillar. this should start displacement of the b-pillar.cut all the way through base of b-pillar and then cut the top of b-pillar. the rear door,b-pillar, and front door should all be one unit that will swing forward on the front hinges. cut front hinges and total sidewall removal is complete. just my 2 cents.
    The issue there is that it does not address the casualty perspective in terms of minimal twisting of the spine during removal. If you read neann1's or my orignal post, I query this rescue based on the issue of casualty care. (If you haven't already done so, sit in the car and get removed via the side and then do one out the back window and see which one does the least amount of twisting and causes the least amount of discomfort)

    We often make cuts that work (Don't get me wrong, every call is different) but can often be time wasters, however we need to make sure that what we do does not imapct in a negative way on the casualties well being....
    Luke

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    Regardless, keep the nose and navel in alignment, to prevent spinal twisting. Simply maintains the axial skeleton in vertical alignment.
    Developer and Sr. Presenter, Team Xtreme
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    So let me play dumb for a second and see if I understand this right.

    Your saying that unless there is a reason to take doors and posts (ie legs under the dash needing a roll, etc) there is no reason to mess with the sides you should always approach with out the back window as you primary means of removing the patient? And even then, for the sake of spinal alignment you are saying that you should always TRY to go out the back as described in the link?

    Just confirming because of all the accidents I have been on in 11 years, I have only once removed the patient out the rear of the vehicle and that was because it was pinned between a very large truck and a very unmovable object with no HD tow trucks available to remove the truck and get working room.. We always slide the board under the patients butt and careful relocate them to the long board to remove to the stretcher.

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    As I think you'll find all over the Eastern seaboard and other areas of the US as well.The question remains:is the way we've been doing it for years the BEST way.In terms of efficiency OR patient care.Sometimes a seemingly innocent question can pay big dividends in results if it is practiced and utilized.Thoughts to ponder,T.C.

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    Your saying that unless there is a reason to take doors and posts (ie legs under the dash needing a roll, etc) there is no reason to mess with the sides you should always approach with out the back window as you primary means of removing the patient? And even then, for the sake of spinal alignment you are saying that you should always TRY to go out the back as described in the link?
    Not saying that it's primary way- we need to consult with the medics and assess the position of the casualty. BigRig summed it up well-
    Regardless, keep the nose and navel in alignment, to prevent spinal twisting. Simply maintains the axial skeleton in vertical alignment.
    If you download the full document, you'll see that it gives different options, however they ALL maintain spinal alignment.

    Just confirming because of all the accidents I have been on in 11 years, I have only once removed the patient out the rear of the vehicle and that was because it was pinned between a very large truck and a very unmovable object with no HD tow trucks available to remove the truck and get working room.. We always slide the board under the patients butt and careful relocate them to the long board to remove to the stretcher.
    There is no careful way to remove from the side of a car by rotating onto the spine board.


    Grandmaster 101 is spot on with his reply-
    As I think you'll find all over the Eastern seaboard and other areas of the US as well.The question remains:is the way we've been doing it for years the BEST way.In terms of efficiency OR patient care.Sometimes a seemingly innocent question can pay big dividends in results if it is practiced and utilized.Thoughts to ponder,T.C.
    "That's how we've always done it" is not necessarily the best way. It's a bit like rescue units who say you ALWAYS take the roof off- why? If you don't need to, why bother wasting time? Every accident needs to be taken on a case by case basis and the cuts that rescuers make need to be efficient and effective....
    Luke

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    Good points and let me clear up that although it may seem that way by how I phrased my question... I am far from set in the "we've always done it that way" rut. My line of questioning was more of a fishing expedition to arm me with more opinions and insights for when I face off with some of my members who ARE that rut let alone stuck in it.

    Me thinks my next training session we will do this evolution a few times and see how it goes. The fortunate thing is that those of us willing to experiment and continue the learning process are beginning to turn the corner and outnumber the others.

    Thanks for the insights.

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    The fortunate thing is that those of us willing to experiment and continue the learning process are beginning to turn the corner and outnumber the others.
    Woohoo!

    Unfortunately, it really is a big problem in the emergency services...
    Luke

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