In my previous blog post 'Vehicle relocation for trapped patients; is our cautious approach harming the 99.3%?', I mentioned some CPD activities which included watching vehicle relocation examples online.
I recently spent some time in South Wales representing the United Kingdom Rescue Organisation (UKRO) as a Road Traffic Collision (RTC) Team Educator and worked as part of a multi-disciplinary team to help facilitate a package of extrication research known as the Extrication in Trauma ('EXIT') project. This research is lead by Dr Tim Nutbeam, a consultant in emergency medicine and prehospital emergency medicine, and involves applying scientific methodology to the process of extrication and post collision response.
We created a range of RTC scenarios and replicated multiple extraction techniques to gain biomechanical analysis from a simulated 'injured passenger'. See this recent article published by The Guardian for more information.
One of the extrication strategies used was vehicle relocation with an injured patient still in situ. I have subsequently created five short videos from this recent EXIT research to demonstrate various vehicle relocation techniques.
1. Vehicle relocation: car on four wheels - controlled manoeuvre
Learning points
The simplest of all of the relocation manoeuvres, this controlled roll requires approximately 5 rescuers including the Commander.
The Commander co-ordinates their crew to relocate the vehicle safely. The medic inside is responsible for releasing and applying the handbrake (parking brake) while the rescuers prepare to relocate. The medic should remain in the vehicle wherever possible, their role is to let the patient know what is going on at all times and communicate with the Commander outside the vehicle should they need to stop for the patient.
Top tip: Use wedges under the wheels both before and after relocating to prevent any uncontrolled movement.
2. Vehicle relocation: car on side - controlled roll.
Learning points
If there is nothing to spread or ram away from, the winch might be your next best option. A good example of this might be a vehicle resting against a hedge where access is very difficult. The benefit of relocating onto all 4 wheels makes it more likely the patient will be able to safely self-extricate under the guidance and supervision of the medic.
The commander will need to coordinate this manoeuvre with the winch operator and the medic inside the vehicle.
Winch and strop location will vary depending on positioning of the vehicle, However you attach the strops or chains, ensure that there won’t be any uncontrolled part of the controlled roll. Have appropriate stability ready to put in position once the manoeuvre is complete. This might include struts and large wedges and or blocks. Be ready to wedge the wheels straight after too.
The medic should remain in the vehicle wherever possible, their role is to let the patient know what is going on at all times and communicate with the Commander outside the vehicle should they need to stop for the patient.
Top tip: Make sure the handbrake is applied before you start the manoeuvre, if this cant be confirmed, then lay out a couple of large sleepers by the wheels to act as wedges once the relocation has been completed.
3. Vehicle relocation: car on its side - spread and ram
Learning points
Stability is important with this manoeuvre. Initial stability needs to be put in place first, with consideration given to relocating after this is done.
When putting the struts on place, don’t tighten them up fully as you will need these to slide freely when relocating.
The Commander will need to coordinate the relocation and position themselves so they can see the movement and be able to communicate with the medic inside the vehicle. Rescuers start by using a spreader against a strong part of the vehicle and spread gently away from the obstacle, all the time another rescuer must follow this up with appropriate stability should the spreader slip for any reason, thus protecting the rescuers and those inside the vehicle. Once full range of the spreader has been achieved, it is possible to follow up with the ram to create even more space.
On the underside of the vehicle, one rescuer is responsible for watching the struts and ensuring they slide effectively. Once vehicle is in it’s final position, tighten up the struts to ensure the vehicle is stabilised.
The medic should remain in the vehicle wherever possible, their role is to let the patient know what is going on at all times and communicate with the Commander outside the vehicle should they need to stop for the patient.
Top tip: Try placing a tear drop under the struts to reduce friction for the relocation part of the manoeuvre.
4. Vehicle relocation: car on four wheels - winch away from obstruction
Learning points
This manoeuvre may be required in the event the vehicle will not roll on its wheels. This could be for a number of reasons including damaged wheels, handbrake will not release and vehicle stuck in gear or electric motor prevents it from rolling.
Apply the strops or chains around the wheels or axle and take them to a focal point where you connect the winch. This angle should not exceed 90 degrees. Keeping the pull low helps prevent the vehicle from digging in and allows for a more efficient pull.
Have wedges ready to put in position once the manoeuvre is complete The medic should remain in the vehicle wherever possible, their role is to let the patient know what is going on at all times and communicate with the Commander outside the vehicle should they need to stop for the patient.
Top tip: Ensure the handbrake is applied before moving and make sure the wheels are as straight as possible as the winching may change the angle.
5. Vehicle relocation: car on its side - winch away from obstruction
Learning points
If there is nothing to spread or ram away from, the winch might be your next best option. A good example of this might be a vehicle resting against a hedge where access is very difficult.
The commander will need to coordinate this manoeuvre with the winch operator and the medic inside the vehicle. Apply the strops or chains around the lower and upper wheels or axles and take them to a focal point where you connect the winch. This angle should not exceed 90 degrees. Keeping the pull low helps prevent the vehicle from digging in and allows for a more efficient pull.
Have appropriate stability ready to put in position once the manoeuvre is complete. This might include struts and large wedges. The medic should remain in the vehicle wherever possible, their role is to let the patient know what is going on at all times and communicate with the Commander outside the vehicle should they need to stop for the patient.
Top tip: Keep the winching cable low to the ground to reduce the chance or pulling the vehicle over onto all 4 wheels in an uncontrolled way.
Why consider vehicle relocation with a patient still in situ?
Relocating a vehicle with a patient inside at an RTC is a fairly new concept being supported by UKRO. 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 by Tim Nutbeam and his colleagues 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). I have written more about this here.
When should you consider vehicle relocation with a patient still in situ as an option?
I would suggest that the following three conditions need to be satisfied before vehicle relocation is attempted:
The overall incident would be made safer.
Relocating the vehicle makes the incident safer for rescuers to work on or in the vehicle.
Relocating benefits the patient and a successful extrication could be achieved quicker.
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.
Does UKFRS National Operational Guidance support this?
Yes, a recent change in National Operational Guidance for Fire and rescue services states:
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.
Final thoughts
Vehicle relocation 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 appropriate 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.
Ultimately, the main purpose of this blog is to give examples of vehicle relocation strategies and to encourage responders to look seriously at the merits of relocating a vehicle at RTCs. Please discuss this rescue solution further, debrief incidents attended and watch more relocation videos online. Then have a practice; start in the training area, create simple relocation scenarios and build from there.
Let’s get the wheels rolling on improving extrication strategies and subsequent patient survival rates.
Where can I learn more?
Similar to last year, the UKRO RTC education team (including myself) will be running vehicle relocation workshops for UKFRS extrication teams at the UKRO Challenge: West Midlands Festival of Rescue on 29th Sept – 1st October 2022 at Smithfield, Birmingham.
For more information about this event, contact: UKRO@wmfs.net
If you have any further questions in the meantime, please don't hesitate to contact me at jcoomber@UKRO.org