Hands-on Vehicle Extrication Experience
Extrication (a complex, technically difficult and physically demanding task aimed at removing a critically injured victim from a tangled mess that once was a car) is a concept that is relatively clear and understood by a majority of Prehospital care providers. Exactly what is required to perform this task may not be fully understood or appreciated by a number of Emergency Physicians, who by and large work within the relatively sterile confines of a climate controlled Emergency Department (ED). As unwieldly as ED situations can become, they are rarely similar to anything that confronts EMS.
Vehicular trauma (often-needing extrication and spinal immobilization) may account for a majority of trauma patients presenting to our Emergency Department. In 1997, program coordinators identified a need to enhance the prehospital knowledge and interaction between Emergency Medicine residents and Emergency Medical Services (EMS) providers specifically looking at vehicle extrication. A decision was made to contact the city fire department for assistance.
The first year of this program, interns (first year residents) were sent to a large city fire department to observe extrication and vehicle rescue procedures. While this department provides excellent patient care and performs extrication at a superior level, all training was observation only. This was felt to be of minimal value to the interns. Emergency Medicine physicians are by nature "hands on" individuals who thrive on physical contact and interaction. Over the next two years a transition was made from the city fire department to a smaller, local, primarily volunteer department where hands on activity could be performed. The first transition class began in 1999 becoming full time in 2001. Currently, all Emergency Medicine residents in our program spend time at the Manlius Volunteer Fire Department learning the basics of vehicle extrication.
Providing direct personal experience at a 'scene' is designed to help residents better understand: mechanism of injury, personal safety at the crash scene, vehicle extrication equipment and methods, and difficulties associated with patient extrication and as a result to be better able to communicate with on-the-scene personnel.
For some interns, cervical spinal immobilization, cervical collars, short and long spinal immobilization devices are a new concept. The residency program currently spends a significant amount of time instructing how to assess and "clear" or evaluate for spinal injuries without reviewing the how and why patients are immobilized in the first place. Knowing the how and why patients are immobilized increases an understanding of injury patterns, underlying non-apparent trauma and appropriate means of removal.
Communication between EMS providers and Emergency Medicine physicians is paramount. Accuracy and precision combined with a concise evaluation of a patient's status is necessary for good patient care. The more relaxed and comfortable the individuals are communicating with each other the better the patient outcome. This program places a face with a name. No longer is the paramedic a bodiless face on a radio or another ambulance driver waiting to drop off another patient in an overcrowded ED. While it is true that these are only four paramedics from one fire department that are known by ten physicians, both groups gain an awareness and an interest in developing a more collegial atmosphere.
Anecdotal responses of the residents who have participated in the extrication program to this question have been overwhelmingly positive. They voice a new understanding of mechanism of injury and extrication. For some, this is their first exposure to cervical collars, KED extrication device, and long spine board immobilization. Both the residents and firefighter/paramedics develop a lasting understanding of each other's role and allows for a more collegial interaction in the future.
Between December 2005 and March 2006 an electronic and mail survey was undertaken to determine which Emergency Medicine Residency training programs offered a similar experience. 136 allopathic and 36 osteopathic training programs were contacted. A total of 107 (62.2%) were returned. Only 23 (21.5%) reported having a hands-on vehicle extrication training program.
Residents completing the program report new and significant understandings of factors related to safe vehicle extrication as well as implications for medical treatment in the ER. Likewise, firefighters and paramedics report that during subsequent patient transports they feel substantially more comfortable relaying information, requesting orders and obtaining follow-up from the residents who have completed the program.