Relocating a vehicle with a patient inside at a Road Traffic Collision (RTC) is a fairly new concept being taught by the UK Rescue Organisation (UKRO). I have written about the introduction of this rescue option here.
Despite being placed into National Operational Guidance in 2021, this rescue solution is considered to be controversial by some within the UK Fire and Rescue Service (UKFRS) due to historical training around casualty management. Firefighters have previously been taught to assume that all patients involved in an RTC are likely to have suffered a ‘C’ spine injury (specifically a spinal cord injury) and that any movement of the vehicle (vertically or laterally) could potentially cause paralysis or worse. It is therefore understandable that concerns about moving a vehicle occupied by an injured patient are being expressed – surely it would risk further injury and potential litigation claims?
However, recently published evidence suggests otherwise. In fact, the clinical data actually goes as far to suggest that UKFRS may be inadvertently reducing patients’ chances of survival by not considering alternative extrication strategies (such as vehicle relocation).
In February 2021, Dr Tim Nutbeam and other clinicians produced a clinical paper titled “A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped.”
The paper analysed 63625 patients. 6983 patients were physically trapped and 56642 patients were not physically trapped.
“The injury severity score was greater in those who were physically trapped compared to those who were not. Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale. Trapped patients had more significant injuries of the head, chest, abdomen and spine and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax.”
The study concluded that trapped patients are more likely to die than those who are not trapped. A further very important addition to this finding was that spinal cord injuries were extremely rare; with a prevalence of just 0.7% in all patients extricated. We could therefore argue that our historically cautious approach to moving patients involved in RTCs actually negatively impacts around 99.3% of casualties encountered as their extrication is unnecessarily prolonged.
These findings are also in line with my own experiences of dealing with injured entrapped patients; the longer they remain in situ, the worse their outcomes tend to be. Without 360 access, ambulance staff often struggle to fully expose and assess the patients, resulting in injuries being missed or significant treatment delays. A classic example is a haemodynamically unstable casualty with a pelvic or femoral fracture – until that casualty is released from the vehicle, a pelvic binder or traction splint (designed to stop catastrophic haemorrhage) cannot be effectively applied resulting in prolonged blood loss. Entrapped patients also become cold very quickly, and this further negatively impacts on their ability to form blood clots if they are bleeding, again resulting in worsening outcomes.
In essence, the study concluded “improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.”
I believe the significant findings of this paper should lead us to review our team-based approach to all RTCs, with a key area of consideration being the relatively new option of relocating a vehicle with a patient still inside.
I believe vehicle relocation should be contemplated as a rescue option from the moment we are mobilised to an incident. To facilitate this, consideration must also be given to where we position our appliances at the scene. If we get too close to the RTC, we could accidently discount relocation as an option due to lack of space or there being too many resources and equipment being in the immediate area.
An additional consideration is the initial 360 assessment of the scene on arrival to identify all of the hazards. Whilst it is currently established practice for only Incident Commanders (IC) to fulfil this role, I believe that “All” rescuers should conduct their own assessment of the incident and feedback to their IC so they can add it to their plan for incident resolution.
Furthermore, I would suggest that the following three conditions need to be satisfied before vehicle relocation is attempted:
The overall incident would be safer
The relocated vehicle makes the incident safer for rescuers to work on/in
Relocating benefits the patient and a successful extrication could be achieved quicker
From a Fire and Rescue Service perspective, I think we are already well positioned to assess and evaluate the first two conditions. However I appreciate the third is an area where we might get a bit twitchy. To achieve this final condition, a clinical assessment must be conducted by an appropriately trained clinician to inform our rescue plans and decision making. In all reality, it is going to take several minutes to collate all of the information required before a joint decision between both Medical and Fire responders can be made.
Once these three conditions have been satisfied, vehicle relocation can be attempted. If you initially discount vehicle relocation as an option to begin with, don’t automatically discount it later as the incident develops. These types of incidents are dynamic and ever changing; they require a continuous evaluation process to ensure we make appropriate decisions that are in the best interests of the rescuers and the patient.
It sounds simple in principle, and in some cases it can be, but I do also acknowledge that it’s not always as easy as just rolling the vehicle away from the wall and hey presto. We need to consider other contributing factors to complete the relocation successfully. This includes training and competence, equipment and resources available, organisational policies and procedures and also the vehicle make and model, fuel type, impact damage etc. Whilst one vehicle may move in a way we want, another one in a similar impact may not.
Although I can’t help with all of these factors in a short article, I can highlight a change in our National Operational Guidance for Fire and rescue services:
Consideration should be given to relocating a mode of transport; this could be either the one containing the casualty or another one involved in the incident.
Ultimately, the main purpose of this article is to encourage responders to look seriously at the merits of relocating a vehicle at RTCs. Why not start with a discussion with your teams today, watch relocation videos online or debrief incidents attended? I have included some questions you could ask below:
· Did anyone consider vehicle relocation?
· Could we have relocated that/those vehicle(s)?
· Would it have made the incident safer?
· Would it have benefitted the patient to relocate?
· Would relocation have achieved a quicker extrication for the patient?
· Would it have made the rescue easier for us?
· What additional extrication solutions would have been available if we relocated?
· Do we communicate enough with the medical/fire responders?
The next step is to try it out for yourselves. Start off in the training area, create simple relocation scenarios and build on it from there. Let’s get the wheels rolling on improving our extrication strategies and subsequent patient survival rates.
Check out my next blog post 'Vehicle relocation videos: recent examples from the 'EXIT' project' for videos demonstrating a range of different RTC vehicle relocation strategies with helpful tips and guidance on how to perform the manoeuvres.
Here's an example video below: