In my previous article I spoke about the role of the Incident Commander at an RTC or Extrication Challenge but also touched on how important the team approach is. As I have stated, for the Team to be effective there is a lot of pre planning and training that must take place in the classroom and drill yard but everyone must know the stages inside out for all crews to be truly effective.
The team approach is well documented in the Fire and Rescue Manual (Incidents Involving rescues from Road Vehicles) and more recently in the excellent publication from Ian Dunbar (Vehicle Extrication Techniques) which offers more modern techniques in line with today’s vehicles. In both publications the team approach is still the same and focuses on the 6 key elements of a structured rescue.
- Safety and Scene Assessment
- Stability and Initial access
- Glass Management
- Space Creation
- Full Access
- Immobilisation and Extrication
I am going to look at each of these areas and going to give some practical tips and techniques on each area that have always served me well both on the road and at Challenges. These will all be applicable for a crew or extrication team and can be used with 4, 5 or 6 people depending on how many you have on the appliance/team. Obviously the less people on the first appliance then you will have to adapt as required though the most important thing to remember throughout the whole evolution is that it must be “patient focussed”.
The roles at an RTC are as follows:
- Incident Commander
- Technical Operator 1
- Technical Operator 2
- Medic/tech back up
The beauty of the Team Approach is that it allows everyone to know each other’s roles and if anyone has a particular skill such as extra medical experience then is doesn’t matter where they are on the appliance, your specific pre planning will allow them to fit seamlessly into that role.
You may well find that due to any number of reasons such as access or the patient injuries that the order cannot be followed prescriptively. This doesn’t matter as long as you remember to consider them all at some point as this will ensure nothing is missed.
For the sections below I am going to assume that there is no paramedic in attendance however, if there is, you just incorporate them into your plan and must still have the same discussions/information gathering conversations with them.
Safety & Scene Assessment
As soon as you arrive, the team approach takes over. The IC must complete a full 360 outer survey taking the medic with him if possible, as this will ensure you both see all the hazards, the location of the patients and an idea of the kinematics. Look at the vehicles involved; are they old cars with glass that will cut out and a couple of airbags or new BMW’s with a vast range of SRS and difficult glass. Are they hybrid, LPG or single fuel, are they on their roof/sides or is there anything else involved.
Once this is completed, hold your medic at an appropriate point where they can communicate with the patient, then carry out a very brief inner survey to look for further hazards. By completing an inner and outer survey, you will gain maximum info to start forming a plan. Briefly confirm hazards with the medic and get them to work making sure you get a name, any injuries and entrapment as soon as possible!! Now brief your techs on the hazards, who will have the correct stabilisation ready and waiting and get them to work. This should all happen within a minute or so!
Stabilisation & Initial Access
Pre-planning will ensure that the tech operators must have a systematic approach to stabilising the vehicle whether it is on its roof, side or wheels. There are many ways and techniques to stabilise vehicles, however, the key is being able to use what you have in your FRS efficiently and again Ian Dunbar’s book makes good reference to these.
While they are stabilising, it is also a good time for them to gather anymore information that will assist them and my plan. My pre-planning on this is that one would do the inner survey and one would do the outer survey and to me this is vital as and I would be looking for:
- Confirmation of fuel type
- Glass type
- Boot and battery access
- Any openings both doors and windows
- Confirm entrapment (see below)
- Seating plan and any intrusions (see below)
- Confirm all SRS
- Boot and bonnet releases
Any entrapment must be confirmed along with a technical solution, this is vital and if not considered early by all can hamper the plan later on. Just as important is the seating plan. By this, I need to know are the seats electric/manual, do they/can they recline, is the B post in the way, are there airbags in the seats. All these will have a bearing on my plan and final extrication pathway.
Whilst this is happening, it gives you time to get any further information from the medic and to start formulating a plan around this, depending on what access is available. Access may have to be a priority and have to be achieved at the same time as stabilisation. When talking about initial access, at this point it is for the medic to get an airway or at least hands on. As part of this he should also look at where he wants/needs to be after discussion with the IC.
As soon as stabilisation is finished and checked you should call everyone in, receive their inner and outer survey reports, factor these in and then deliver your plan. If your crew are well trained, communicating the plan is easy and only needs to consist of the main plan and emergency exit, as well as any space creation that is required to ensure this is viable i.e. roof off and plan ‘B’.
It is always worth asking if anyone has any other ideas as there may be something you have missed.
On delivering the plan I always like to see the tech team discuss who is doing what as depending on the plan not all glass needs to be removed, just managed. By using tools available today such as Packexe Smash and Speedings Ltd glass and door sheets and the Rhyno cutter, this has never been easier. Having said that, there is great skill in using all of these and they must be rehearsed regularly!
As an example if you are taking a post off with the door still on you can wind the glass into the window and put tape over it or just Packexe it and leave it in situ. This just saves time and prevents the glass becoming a hazard.
This is a key area which is often misunderstood and ideally must be incorporated into the plan. This is purely around taking away any entrapment for the patient and may be as simple as removal of a door but may be more complex such as cross ramming or a dash roll.
I always look at this in two ways not only for the patient but also for the medics in the vehicle and again I will use manual space creation and that created by using tools.
My first attempt at this is when I get the medic into the vehicle. If appropriate, I would expect him to spend 30 seconds on opening/unlocking doors, pulling boot/bonnet releases, getting the keys and winding any seats down. This will save a lot of time and effort for the technical crews.
Your space creation should start to become your full plan and ideally if you have enough crew this must be carried out simultaneously. The nature of removing any entrapment from around a patient often needs to be carried quickly and the ram is excellent for this. Often due to a lack of space this can be awkward, so try using straps to hold it in place (piece of old seatbelt is fine) and if you can’t get a block in, just go off the seat cushion, there will be metal underneath somewhere!
Although we have a vast amount of hydraulic tools at our disposal don’t forget the old school methods of pedal removal by using the seatbelt and the door!
Once we have an emergency exit and have created space for this to be viable it is onto full access.
The question is often asked “well how much space should we create?”
There are key factors which define this, the most important being the patient’s injuries and it is vital that you as the IC and all the team are aware of these. The injuries, coupled with the position they are in will generally dictate, as the rule of thumb is to take them out in line wherever possible. This will be balanced with the actual amount of space you can create as with a car on its side up against an immovable structure there is only so much you can achieve and it may mean ‘tunnelling out!’
What should be taken into consideration is that the more space you have, the easier it is to manage the board work and if you are able to create enough space to get your crews either side of the board then you should aim to do so!
Immobilisation & Extrication
This is all about the safe removal of the patient via the long board and generally straight to the waiting stretcher and handed over to the attending paramedics. Immobilising the patient can mean using collars and KED’s etc. Not all FRS carry these and there is now good guidance on the use of collars on the UKRO website.
As the IC you should lower the tempo, ensure all generators are off and that tool belts are removed. Those in contact with the patient must be wearing medical gloves, check all the sharps are covered, the patient is uncovered from the casualty sheet and that the oxygen has a clear pathway out. At this point hand over to the medic. The medic must confirm all injuries with the team and confirm that everyone is in place and are aware of the pathway out.
To me, this is the final part of the team approach and extremely important and if you have not fully trained on this so everyone is fully aware of their roles, then you can undo all your previous good work.
That is a brief look at the team approach from my perspective and I have used it to great success both on the road and in UKRO/WRO Challenges. It is straightforward but only if you pre plan and train hard, but not only will you benefit from it but so will the public that we all serve!
For further information, go to www.ukro.org
This will be balanced with the actual amount of space you can create as with a car on its side up against an immovable structure there is only so much you can achieve and it may mean ‘tunnelling out’!