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CRF 11.05.23 Road Traffic Collision (RTC) Extrication - Casualty Centred Rescues, Mr Dominic Morgan

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Summary

This on-demand teaching session is designed to educate medical professionals on a concept that is often misunderstood - casualty-centered rescues. Led by Danek Morgan, Director of Operations at Foreign Spiral Health, the session will focus on over the bonnet techniques and Integrated Emergency Management. It will discuss the different types of entrapment, the global death rates for road traffic collisions, and the concept of relative and actual entrapment. There will be a demonstration video of a car fire and a discussion of the different types of ignition sources. All of this will be delivered with the goal of keeping the casualty at the center of every response.
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Learning objectives

Learning Objectives: 1. Demonstrate an understanding of casualty-centered rescues and how it can ensure the best interests of a casualty. 2. Explain the different types of entrapment in a pre-hospital environment. 3. Compare global death rates of road traffic collisions across high and low/middle income countries. 4. Recognize the components of a triangle fire (oxidizing agent, ignition source and fuel source). 5. Articulate the need for quick response time when recognizing a potential fire in a pre-hospital environment.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

I all that. Welcome to join it already. Uh My name is Danek Morgan on Director of Operations, Foreign Spiral Health uh Assistant Days on RTC education and casually sent rescues. I'm going to share my screen, Emily. Can you enable shared screen? But okay, hopefully you'll be able to see uh this as it says, it's Cashews centered rescues education and we're going to go straight into it because it's quite a long session. This session was done for Imperial College, London for the Innovation on Surgery for David Knots MSC uh by Imperial College in London. So I delivered it there. So you're getting exactly the same presentation has delivered on that MSC course. Okay. Well, what do we mean by casualty centered rescues? Uh that's often, often misunderstood what you mean by casual center rescues. Uh But I'm going to explain it to you in a way that hopefully is going to uh really put in your mind. What happens in the pre hospital field when it comes to casualty centered rescues? Um I'm going to apologize in advance. We've got a problem with one of my teeth. So I'm just gonna take actually something out and then I can be able to talk normally, I suspect. Oh, that's better. Ok. Casual center of rescues, what does it really mean? What it means is that all organizations as part of responding to a casualty in a pre hospital field only act in the best interest of the casualty. Now, that makes common sense, but actually, in reality, that's not what used to happen. And what we mean by that is each organization would come to an incident with their own priorities. The police priority would be to see if there was a crime. Therefore, they would be interested in securing evidence. Let's see whether a crime has been committed because they would have to carry the post incident, invest investigation out. The fire service's main responsibility was for fire and rescue. And therefore they would be very fixated on the rescue. Element of the extrication was the ambulance service obviously is designed uh responsible to save life. So we would be very conscious on the casualty. However, those three things sometimes worked against each other. So what happened in the eighties in the UK was there was development called incident Emergency Management. And what that basically meant was that they recognized this problem of organizations coming with their own organizational priorities to some major incidents. And in the debriefs that occurred in these things like Kings cross clap and rail train crash, it was recognized that there were different priorities were being set and that did not mean that the casualties were putting in the center of what was being done. So, a change was instigated. Uh And it is absolutely vital that these things are practiced that multi agency training together is done to place a casualty at the center of any rescue. And it's only by training together. Do you really get that ethos and experience? Right. So there are different types of entrapment. So first of all, we're gonna quickly talk about with the type of entrapment, their workplace, home, the leisure environment, someone might have their hands stuck, you might have your head stuck. I think of a, you know, child in a railing. There are doing structural collapse where the building, urban search and rescue, where the building has collapsed. Uh And that may be due to many factors, gas explosion, things of that nature. And then the most actual common form of entrapment is um road traffic collisions, what we call our tcs and we call them collisions, not accidents because the police determine some time ago in the UK that there was no such thing as an accident. There was always a cause to a collision. Uh that may not be necessarily human cause. It may be just road design, it maybe environmental uh road traffic conditions, all all these factors play into what could be a road traffic collision, but it was never just an accident. So the most common cause of both traumatic injuries and entrapment is road traffic collisions and that's not just in the UK, that is everywhere. Urban search and rescue is where the buildings have collapsed. And as we said before, that could be due to many reasons such as explosions and things of this nature that is urban center and rescue is what we do in the UK when that collapses happened within the UK. Uh and we are trained with in the fire service and the ambulance service to do that. And I've spent 20 years in the fire service uh just as long in the ambulance service and international disaster response. And all of that training goes towards urban search and rescue and also international search and rescue, which is called A PSA which is when we do go abroad and supply resources and, and personnel to respond to international disasters, which I have done on three occasions. So emergency integrated emergency management. What does it actually mean? Well, it was built on a really simple concept and that concept is called over the bonnet. And what that means is exactly what it says. It's a requirement on the leaders of the three main agencies attending, but any agency attending a road traffic collision to get to find the nearest vehicle, literally find the nearest vehicle and get over the bonnet of it and then set out a plan in real time, putting the casualty at the center of this plan. If that does not occur, then we'll go back to the old way of doing things where people are doing their own organizational priorities and that in itself can cause major instances and major problems for the casualties. So the requirement of the over Bonnet is to develop a plan in real time in the now. And each agency recognizing its part within the plan and then going away and carrying out its part in conjunction with the other agencies ensuring that the casualty remains at the center of everything. We do. Road traffic collisions result in deaths of approximately 1.35 million people around the world each year 20 to 50 million people with non fatal injuries. So that numbers are extremely high. The young are particularly vulnerable to injuries leading cause of death for Children and young adults aged between five and 29 internationally is road traffic collisions and young males under the age of 25 are more likely to be involved in road traffic collisions than uh females with 73% of all road traffic collisions occurring among young males in that age. Developing economies recording higher rates of road traffic injuries with 93% of fatalities coming from low and middle income countries. So if you are joining us from a lower middle income country, you are already susceptible to a higher degree of road traffic injuries and deaths. These are the RTC global death rates where the latest data, I think it's 2018 was collated and as you can see, uh the UK is not exempted for 5400 UK. Trauma deaths associated with road traffic collisions in that in that one year. But you will see there is a big disparity between what occurs around the world with high income countries, particularly North America, Western Europe, Australasia, and some countries in South America and some isolated countries having a high level of response to road traffic collisions and reducing their fatalities in our place is lower, middle income countries, particularly as you can see in Africa have a very high level of death rate in mortality rates when it comes to road traffic collisions. And there's a reason for that and we'll come to that as we go on. So what is an entrapment? Well, we class entrapments is free, basic things. The first one is physical and that means that you're not necessary entrapped by an injury, but you're unable to educate yourself because of the damage sustained. So the vehicle itself is stopping you from getting out of the vehicle door, maybe jam uh more than one door, maybe jam the level of damage just not allowing you to use a normal exit routes from a vehicle. And then we call what's known as medically trapped and medically in tract means that you have an injury which stops you from getting out of the vehicle. So you may have a neck injury, you may have a spinal injury. You may have a long bone injury which doesn't allow you to extricate yourself in the vehicle. And then we have the most serious which is medically and physically threat. Uh, and this basically means that you are impeded by the vehicle, but you are also impeded by injuries and that's the most severe and the most likely to cause fatalities. There's another term that we use for that, it's called relative and actual entrapments. And what we mean by that is relatively strapped by the virtue of your injuries and actual tracked by the structure, the vehicles depending on what terminology use in your country. You may hear both of these terminology is being used but all actual treatments or what we call physical uh entrapments, physical and medical entrapments are a high risk of having severe significant transfers of energy and therefore we increased risk of severe injury and loss of life. And more so, would you believe with newer vehicles? And the reason for that is that actually the safety devices in newer vehicles means it's less likely that you will be actually trapped by the vehicle because of the way the safety devices have been designed. Therefore, if you are trapped by the vehicle in a newer vehicle, you have sustained a significant amount of energy transfer. It's important that you understand what we mean by the triangular fire by requires free conditions to create a chemical reaction of fire as an oxidizing agent. O2 in the air hydrogen halogen a gas of some type. But oxygen being the most common it requires an ignition source. A lot of people think that ignition source is petrol, but actually it's not the emission sources. Normally something like electrical and particularly in road traffic accidents can be electrical or it can be a spark with the vehicle coming into contact with a road metal coming into contact with hard surfaces can cause sparks. And that's often the ignition source in a road traffic collision, but it needs a fuel and fuel obviously is held in most vehicles, petrol, diesel, gas, etcetera. But even electrical batteries can provide fuel for road traffic collisions now, which can start fire. So it's really important that uh that you understand that fire is a constant risk in road traffic collisions. Not just because when you get there, the vehicle might be on fire, but actually it might develop fire while you're there and some of your actions may lead to fire. So it's something the fire service are constantly aware of when they're in uh attending a road traffic collision. And it's their responsibility to make sure that that does not occur. So you will often see some actions taken by the fire brigade straight away to try to resolve that issue and make sure fire doesn't start. I'm going to play you a video. You may not hear the sound, but it's not that important that you don't hear the sound. What's important is that the timing that's involved? Yeah. At this point, I'm going to stop the video. Essentially. What you've just watched in real time is a fire starting from smoke issuing to being fully involved in the space of about two minutes. That's how quick a car can burn fire service know this. And so do, um, prehospital conditions know that actually a fire in a, in a vehicle is one of the most dangerous fires that you can have. And the reason for that is there are so many different types of material involved in the manufacture of a car. In fact, there's more carcinogenic in a in the vehicle uh fire than in any other known fire because it has such a wide range of uh materials in its manufacture. So it's extremely toxic. A fire involved following an RTC can fully engulf the vehicle within about two minutes. And that means as you saw pretty much in this video, but the fire was nearly fully involved before the fire service even got in attendance. So that's how quickly it can occur. And it is an unfortunate reality that in the pre hospital bill, we have to deal with fire when it comes to road traffic collisions. And some of those can be quite significant. This is one on a UK motorway and as you can see, there's a pile up that's occurred. I think this particular incident, 32 people died, many of those people died because of smoke inhalation due to fire because they were trapped and we couldn't be removed from the vehicles and that occurred very, very quickly. So it can be a very traumatic incident for responders to have to deal with. But also from a medical perspective, when we think about casualty scented rescues, burns are a highly likely cause of injuries to people involved in road traffic collisions where clearly there's a fire been involved. So a lot of people, a lot of preoperative missions don't recognize that in the first instance, but actually it's something that occurs quite commonly. So what do we do in the in the pre hospital bill? Well, I'm sure many of you have heard of the golden hour and the gold now was first described in Baltimore in the 19 sixties. And it was basically recognized that the sooner that trauma patient's reach definitive care and what we mean by definitive care is a hospital somewhere, there is a trauma center somewhere they were just capable of dealing with trauma, the quicker that you can get that person to definitive care, the better chance to have survival. And although these figures are quite old, they're actually still relatively true the time to injury. If it's an hour, if you can get someone to definitive care over 10% mortality rate that rises quite drastically. The longer the time goes on. If you look at 10 hours, it's 75% because that person who does not have the care that they require. So the golden hour is a realistic guide for vehicle entrapments. We try to aim to get that vehicle, that person out of that vehicle and to definitive care within one hour. And that's why it's called the Golden Hour. That is not always possible. Believe me, when I say that it is not always possible, but it is the aim that we are all collectively trying to achieve. When we come together over the Bonnet, we're trying to achieve that golden hour. It requires a significant collaboration for multi efficiencies to be able to do that. And it's, it's required for three main reasons. One because it's more efficient and effective prehospital care if we collaborate. But actually beyond that, there's a legal duty in some countries such as in North America, but also in the UK in Europe, it's actually a legal duty, you know, in many countries, it's not. And it would be something I would ask you to consider, especially as conditions leading the developments in your own countries is that there is a legal requirement now for us to actually do something. And of course, there's a moral duty for us to work together to be able to effectively make an extrication efficient for the benefit of the casualty. Uh in order for us to collaborate emergency service, another local national parties increase the efficiency and effectiveness of the service they provide. And this is actually written down in section 21 of the Fire Service Act in 2004. So you can see in 2004, the UK developed the Fire Service Act and laid down specific requirements for collaboration and it also laid down specific requirements for rescue, which is why the fire and rescue services now in the UK are called fire and rescue and not fire service because they are actually required by the Fire Service Act in 2004 to rescue people from the road traffic collisions and other types of entrapment. And as you can see, it's set out in law. So this is actually legislation. So it's copied directly from the legislation. And it's not only are we responsible for rescuing people and protecting people from serious harm, but we're actually responsible for securing the provision of personnel services and equipment necessary to meet all those normal requirements, secure the training of personnel to make arrangements for dealing with calls and summering personnel, obtain information needed for the purpose and mentioned above. So in other words, we know how many road traffic collisions where they're gonna occur. What's the average for a road, what's the average for an area? And therefore we take reasonable steps to make sure we have the equipment, the sighting of vehicles, the training of personnel to be able to carry out these rescues. So we are no longer in the UK Fire and rescue service. Uh Fire service. We are fire and rescue services. And that means that we take these responsibilities uh effectively under law to make sure that we can carry out our statutory duty. I mean, as I said, many countries do not have this yet, but some countries do particularly in high income countries because there's a lot of money involved with having to do this. But it makes a significant difference as well. See to the survivability from road traffic collisions. So we all have different types of roles. So the emergency medic role is that we assume responsibility for the triage casualty treatment and what we call disposal to hospitals, transfer to definitive care. So that obviously includes in the UK, ambulance paramedics, as well as ambulance, air paramedics and staff. And we also have what's known as basics and swift doctors which are GPS and doctors which are taking additional training and are prepared to respond outside of GP surgeries to significant incidents. Uh And we have a lot of that in the UK and they're mainly volunteers and they will get notified when there's a serious entrapment as well. And they will choose whether they can, whether they can come as well and uh extremely useful because they have a higher grade of clinical intervention that they can provide at the scene, which often helps us uh extricate much more easily. And then as I said, transport to an appropriate medical facility remains the responsibility of the of us as emergency medics the fire service roles is they assume overall responsibility of an incident. When a fire is involved, simple as that, if a fire is involved, they have overall responsibility when there is no fire involved, they issue responsibility for carrying out rescue's. There is very clearly defined, the police have ultimate responsibility for any incident. There is a terrorist incident, they have primacy what it's called primacy over the incident. But obviously they work in conjunction with the fire service, no ambulance service to affect rescues and care, casually centered rescues where casualties are involved, the fire service run what's known as, as the whole team approach. And this is really the hallmark of efficient effective rescue from an RTC. And this is what's developed over a number of years in the seventies, eighties and nineties around many of the high income countries. And it's really achieved by one simple methodology, it's simultaneous activity. So rather than waiting for something to happen in serious, similar same as activity is occurs through medical and physical activities to make sure that we can get to a point of explication as quick as we possibly can because obviously, we need to reduce the time because we're trying to remain to the golden hour to achieve the golden hour. So these things are occurring in real time at the same time, safety and seen assessment, stability and initial access. And what we mean by initial access is that the medics have to have access to the casualty. If we haven't got access to the casualty, then it's not a casualty centered rescue. So if you see medics standing over one side in a road traffic collision waiting for access, then if this isn't a casualty centered rescue, casually centered rescue requires a medic to get in as quickly as possible to be able to open an airway, what we call a patent airway to make sure that the passion that the the the casualty can survive. If you can't breathe, you're not going to survive. So we have to have initial access. But also because the assessment may deem that things change during the the the actual education and where therefore we need to be able to have an option of getting a casualty out much quicker than we would not like to because the situation in the casualty may not be stable. Glass management occurs pretty much straight away because glass is always a hazard it seems and we have to create an area which is safe as possible. It's a glass management is basically where we break the glass and take it away, remove the glass from the vehicles. So what we're less with this is a vehicle without glass. Space creation is what is used by the tools and that is where we create space and sometimes that space needs to be created to get the medic in, not just to get the casualty out. So it's something that occurs very early on within a whole team approach for a road traffic collision by the fire service, full access is where we are not restricted any, any longer by any access by the vehicle itself. And that is created that is the ideal opportunity to get, take the the the casualty out the vehicle in the right way, which involves immobilization and extrication. And as it states, the safety of the casualty and the rescue team remains the overriding principle of all extrication. So everyone is responsible for scenes for the safety of everyone at the scene. And there's a reason for that is because it's so complicated, it cannot be down to one person or one organization to take that responsibility. Everyone at that scene has to take responsibility for that. There are stages to an RTC and there are six natural stages to an RTC in the whole system approach. And uh as it says, urgency must be maintained throughout the rescue phase. So this is a very urgent requirement right the way through the whole of the road traffic collision, six stages. So prehospital continuous prehospital life support. Ph TLS is vital throughout the rescue to ensure the education remains casually centered for out. So everything that the fire service do, everything that the police do, everything the ambulance service does has to be based on a casualty in a way that is related to the other services is through the medics, through the paramedics, they will determine what time is available to carry out the education and what therefore what type of education can actually be achieved? The fire service will offer what they can do and the ambulance service will choose based on the casualties position. What is, what is the right course of action? So rapid intervention is the first part and the first is, as we said, seen, assessment and safety. That's absolutely vital. That scene assessment is carried out and we'll come to that in a second stabilization and initial accent, as we said, vehicles are very unstable when they've been involved in a road traffic collision. If somebody has a spinal industry, just getting in the vehicle potentially could cause them permanent damage. So the requirement for us to stabilize the vehicle uh is clear and evident right in the beginning and that is the responsibility of the fire service glass management as we says occurs in the rapid intervention side. So we don't wait to be asked to be to manage the glass. It occurs simultaneously because we know it's a hazard. It will only add to the problems of the rescue and also broken glass potentially can infect wounds and getting two wounds and making treatment for the casualty, much more difficult with glass in lots. Once we've done a rapid intervention, although these things are continuous medical and physical rescue, then we come up with what's known as the main plan so that this is the extrication plan. So we will look at what space needs to be created. What allows us to get to full access? What is the mobilization extrication? And that is the second three phases of a road traffic whole team approach. That is in conjunction particularly between the two services of the ambulance service and the fire service. We were determined what it's time, we had to be able to achieve those three things. And it's also vitally important that every single road traffic collision there is a multi agency hot debrief and there are two types of debrief to occur. One is a hot debrief which occurs at the scene in real time once the casualty has been transported. So once the casualty as a casualty, central rescue is no longer the responsibility of those at the scene. Then at that moment, we will call a multi agency hot debrief in real time to make sure that we learn the lessons that have just occurred. And there are always lessons to learn from road traffic collisions and from any type of rescue. So it's vitally important that we hold that Debrett's, if it's determined that something is much more strategic and actually there needs to be a wider debrief, then we will hold that in slower time and we will ask agencies to come back together at another time and place and consider their ports and bring their observations back. So we can look at things in a much more strategic way and that's how some of these elements like whole team approach were developed through multi agency debriefs which recognized the failings of all organizations at the scene and worked to overcome those failings. So we now have this type of approach. The unseen roles and responsibilities are different, but they are split essentially between different parts of the fire service and the ambulance service. So the ambulance, the fire service will essentially have an incident commander. They were responsible for the whole of the incident responsible essentially for the health and safety of everyone at the scene. And again will come to y days uh important. Uh And why it's the fire safety is roll the fire service's role, there will be someone that's responsible for seen safety. They will actually be looking purposely just at that area. So there'll be a safety officer, someone that's actually looking at the scene and as you can see from the picture standing back and looking at the scene. So you've got an officer in charge an incident commander, but you've got someone even further back looking at the whole incident. And, and the reason for that is we'll come to it is called tunnel vision. And then we'll have a technical operator, somebody that will be on the tools. Uh and you'll have more than one, normally two and then you'll have a medic or technical back up. The reason we have a split role there is sometimes the fire service get there before the ambulance service. So therefore, the requirement is to intervene with the casualty straight away and to make sure the casualty can survive during that rapid intervention phase. And therefore sometimes that requires a fire sir, this personnel to do that and they are trained in basic trauma. So it's not PHTLS, they don't have the equipment, they don't have the drugs, but they do have some basic equipment such as bag and mask and valve and resuscitate. Er and they can and they have things like flu can eclair ways so they can open an airway and stabilize the patient before the virus before the ambulance service gets there. And then the ambulance service, the paramedic is responsible for casualty care and that is the person is the highest grade condition of the ambulance service that turns up and that is always the case. So the most qualified condition is responsible for casualty care. And then we normally have either a second paramedic or what we call an EC A in the UK, but someone that supports the paramedic and again, the ambulance service is responsible ultimately for the casualty and the fire service responsible ultimately for the rescue. The, oh I see does what's known as an unseen 360 degree review and we talked about this earlier, but this is really, really important uh and it doesn't happen very often but it does occur, road traffic collisions are highly complex environments and one of the worst things that can happen is that you spent a lot of time working on an extrication only to find that actually somebody else was involved and that you never realize they were involved and somebody could be extricated from a vehicle. Uh, only to find that somebody had actually been thrown out of the vehicle sometime before and you hadn't found them. And that has occurred particularly, uh, I've seen it in real time where we went to an incident where there were four people involved and we didn't find the first person straight away, but we found them by doing the 360 dynamic risk assessment and they were down there bank lying in some stinging nettles. But if we hadn't done that, we wouldn't have found them. So it's vitally important that often charged as a 360 dynamic risk assessments looks at the whole thing and goes around the whole of the incident to ensure that every single person that potentially could be a casualty has been identified. The name of that is to save life and reduce harm, harm and to establish a safe working environment for the fire crews and other respondents. We have to know where are working area is going to be the objectives of that 360 degree review. Our to identify the number of casualties required medical attention and instigate an immediate triage process. Identify what could cause injury or illness to you. Your team and the casualty hazards and decide how likely it is that somebody could be harmed and how serious that harm could be the risk. So we try to eliminate the hazard. If this is not possible, we try to control the risk and that again, like I said, ultimately, the responsibility of everyone at the scene, not just a fire service, we also go further because we like to stabilize any life threatening injuries or conditions and maintain that casualty care. We have to do with any immediate and ongoing fire risk. So even if there isn't immediate fire, we have to recognize that fire risk, it has now been created. So things like running out a hose reel to make sure that we have immediate water available to us. If the fire is started, we can intervene straight away from the fire service, expect it. We have to create that immediate release that emergency and full extrication plans. And there are free plans that and we'll come to that in a moment, we'll stabilize the vehicle and create that initial access to the casualties because as we said, airway management has to be done right from the beginning when it comes to casualties, but more than airway management. And again, we'll come to that in a set. Uh, can we have to control the management of any glass that may affect, adversely affect rescue operations? And we have to reveal hidden areas. So I'd aid aid identification of components. Now, that is vitally important with newer vehicles because newer vehicles have explosive devices on them such as airbags, uh safety restraints systems which are explosive. And if we don't know where they are, we could inadvertently cut those things while we're doing the extrication and quickly, that would not be uh sensible and extremely dangerous. We have to escape the casualty consider there are injuries in the overall threat to life. And again, that means casually centered rescue, that means that it's a casualties position and the injuries which determine what type of rescue we're going to do and we have to secure the scene to ensure evidence is preserved for investigations. So again, even though that's responsibility of the police service in the UK, it is still our responsibility to recognize where we might have intervened. So if we let down a tire to create a stable platform for a road traffic collision, extrication, we will write on the tire in chalk fire. So the police know that it was us that let the tire down. It was not that the tire was let down prior to the incident. And a dynamic risk assessment is an ongoing process and requires regularly updating throughout the incident. Risk assessments remains the responsibility of all rescues due to the unique and conflicts natives RTC and that dynamic risk assessment is just ongoing continuously until the scene has been closed. So it never stops until the whole scene has been stood down. So as you can see is quite a significant responsibility for those involved in doing the dynamic risk assessment. We have to stabilize the incident right from the beginning and what we call uh stabilizing is recognizing those hazards. And as you can see, just from this picture, there are significant hazards involved in a road traffic collision. There's a road itself, there's other vehicles on the road, there are other emergency service vehicles. Some of these vehicles are very big. Some of these vehicles uh create hazards in themselves. Some of those hazards are from the vehicle itself. Some of them are we've created from cutting things from the vehicle. We've now created new hazards. So it's an ongoing recognition of hazards going on around us in the road traffic collision and the extrication. So it is not a static environment. It's constantly changing, including us, creating more hazards as we do the extrication, the environmental conditions can be highly challenging a road traffic collision. Some of the aspects of the site itself will present significant as it's just depending on way where the incident occurs. We could have slippery and even ground conditions that can lead to slips, trips and falls. We can only worse by wreckage and debris on the floor, which is why we do things in a certain way or visibility may have been the reason why there was a road traffic collision in the first place. We create a lot of noise particularly fire engines and extrication equipment. So that's something that needs to be considered for out extrication. You can't have people working in these environments, particularly the casualties. So if you're wearing something, the rule is if you're wearing ear defenders because of the noise and you're wearing goggles because of the glass, then the casualty requires the same. And that's how we determine that whatever you're wearing, whatever protection you're using, the casualty requires the same toxic fumes from the vehicles and generators used to run equipment, fumes can build up very quickly, particularly in vehicles. So we need to make sure that they are cited correctly. But also that we're fully aware that toxic fumes are being created. The feature of the roadways themselves can be involved and particularly things like crash barriers, statement back mints by adults. Street furniture, even drain access can cause issues when it comes to a road traffic collision and all parts of hazards that need to be considered an recorded and recognized weather conditions themselves. It could be extremely hot, cold, rain, snow. Some of these weather conditions may have led to the road traffic collision in the first place, but they all now impact on all of the rescuers and the casual when it comes to the extrication extrication planning. You've heard this term, immediate release, emergency education and fall. We'll get to full extrication. And what that means is, as we've said, immediate release where medical assistance cannot be performed what a casual remains inside the vehicle, ie airway management or chest compressions. If you cannot manage an airway of a casualty in a vehicle, they come out of that vehicle straightaway. Irrespective of what happens. Irrespective if that causes a spinal injury because this is a life over limb situation. This is a life overall situation. They will not survive if they stay in that vehicle. Now, you may think that's quite rare, but actually, it's common for us to make that decision. Uh And sometimes it's the only decision you can make, taking the risk of spinal injuries, but it's a decision to keep the casualty alive. And that is often made by not the fire service that made by the paramedics, by the by the casualty care. Those of us responding from an ambulance perspective, we will make the decision that this is immediate release. The respect of what the fire service want to do is the casualty. Now, that's important because we're going to lose their life. Unless we take action. Now, then there's the emergency extra cations and this is following the primary survey. So the patient is stable enough for us to do a primary survey. And during that primary survey, we may recognize there is now a need for rapid extrication and we're looking at injuries which can deteriorate very quickly. So we've recognized there's an injury that could deteriorate very quickly and we recognize that actually we don't get this patient out they are on that road to deterioration very quickly. So for medical intervention to be able to continue, we need to get that person out during an emergency extrication, we try to minimize spinal rotation as much as we possibly can. Because even though it's a rapid extrication, we still recognize that this is not immediately life threatening, this is an emergency. So therefore, we can take that a little bit of time to make sure that spinal rotation is controlled because as you know, spinal injuries can cause significant long term injuries and death to a patient and then what's known as full extrication. Now, this is following the primary survey and we've had time to do a secondary survey and the casual remains relatively medically stable for our and therefore there sufficient time for a full extrication. Now, this is what the fire service want to do. This is the gold standard, this is what they, what they turn up thinking, this is what we're gonna do. We're gonna do a full extrication. That is we're going to, we're going to create an appropriate amount of space where the casualty should be kept completely in line straight and therefore minimising any rotation to the spinal pelvis. Ideally, it should take no longer than 20 minutes and less it possible. And the principle of a full extrication is that we do not remove the casualty from a vehicle, we remove the vehicle from the casualty. So effectively, we create the space all around the casualty to take that casualty out in neutral alignment, protecting their spine for our. And then there's what's known as self extrication. Uh And this is really following recent evidence over the last few years of the overuse of Power College, which themselves can cause significant injuries if they've been on for some significant time. So there is an option now to do what's known as a self extrication. And that is only a final immobilization has been low pulled out and we'll come to the guidelines for that. But once a spinal injury has been ruled out, we could ask somebody to extricate themselves if it's, if they're able to, able to step out of the vehicle with no significant injuries and the spinal injuries been ruled out, then we could ask them to do that to aid us in extrication. But it may be that we create a bit space for them and then ask them to do self extrication. We use a systematic approach to all our tcs and the basic principles of these remain the same. All our tcs. The first thing that we do is we protect the scene using actually the vehicles that we respond in. So you'll see what's no, not to fend off position. And that is where the vehicle is part in a way that if another vehicle comes along the road and hasn't seen the road traffic collision, it will actually hit one of our vehicles and be bounced off away from the RTC. And it's called a fend off procedure procedure. And that is normally undertaken by the fire service, but sometimes by the, by the ambulance service where the vehicle is parked sufficiently far away, not to encroach on the RT, see if it's impacted by another vehicle. Now, you may think that, you know, everyone sees a road traffic collision and they should see all these vehicles, But you'd be surprised how many vehicles are run into by other people who are essentially looking at the road traffic collision and not really looking at what's going on or not seen it at all. And we have to establish an in accordance and this is really only for emergency personnel. So no one else is allowed within the in accordance. So that includes members of the public, including family members, having family members close to a road traffic collision. Education is extremely dangerous. We're using highly sensitive pieces of equipment, highly mechanized, loud, sharp, dangerous pieces of extrication going on and we'll come through some of that and we'll show you what, what that means. But essentially we have to have that area clear so we can carry out the extrication. So it's only emergency personnel and we have to create an area where we put all of our talks because there's enough debris at the scene already. So we have a tool staging area and when we cut something of the vehicle we have a part stump where we take all of those parts and their place away outside of the in accordance. And they are only there to collect all of the bits again, decreasing there, hazards at the scene, increasing the safety for everyone that's involved in the rescue. So we have to ensure that and then we establish what's known as a hot side and the hot zone is really about 3 to 5 m around the vehicles themselves. And they are essentially only where the personnel that are directly involved in the rescue are. So if you're the officer in charge, you're not directly involved in the, in the rescue, you'll be in the in accordance watching what's going on because that's your job. Once you touch something, you're no longer in charge. If you pick up a tool, you're no longer in charge. Your job is not to pick up anything is not to have your hands on any of the tools is to be only in charge. And therefore you can do that from the, from the in according. And you don't necessarily need to be right up next to the vehicle. There are sometimes when that changes, particularly when the technicians are out in the fire service are using the tools themselves to an effect rescue very close to the casualty in those circumstances. We do look very closely at what's going on. The main element of uh study that we do at an incident is the mechanism of injury. And that will tell us a lot of how many forces have been applied to uh the human body. An incident. If you remember, I'm sure you do from, from sciences, energy cannot be created, it can only be transferred. So in a road traffic collision, the nature of the mechanism of injury will tell you how much of energy and give you a very good indication of the sort of injuries that you should expect with that casualty. And often actually, it's the mechanism of injury that determines that, that, that injury may occur because we may not have seen the sign of the injury, uh particularly if it's a very rapid extrication and we will pass that on to the medical receiving services. So if you're a doctor in a hospital, you should expect the mechanism of injury to be passed on to you, expect us to tell you that what we think has happened from the mechanism of injury, vehicle collisions, uh what we call kinematics. And that is basically the forces that have been transferred. And there are three types of forces that are transferred into a vehicle uh during a road traffic collision and their attention flexion and talk shin. Now, that's quite a significant amount of forces which are being applied to the vehicle shape itself, uh and they can cause significant injury to rescuers and casualties. Once we start to cut the vehicle, as you can see, a vehicle under those types of types of forces in itself is a hazard cutting, it will release those forces and that makes it a significant hazard to everyone involved. So, what do we do with that? Well, before we come to what we do, if it were going to mention one significant thing, because it's really important that if an occupant is expelled from a vehicle, they have a highly, extremely high chance of mortality just from being expelled from the vehicle alone. So if you see someone expelled from a vehicle, they're not in the vehicle, when you arrive at the scene, their chances of survival are literally about 80% of mortality. So about 20% survival purely because the forces involved in expelling them from the vehicle side impact. And you can see a couple of examples of side impact here are significant reason for that is because the neck is not really designed to go sideways. It's very good at going backwards and forwards with extension flexion, but it's not very good at going sideways. And if you have a side impact, you have a high degree of suspicion of c spine injuries, particularly as as the neck and the c spine is loose. So therefore, it's not a lot of stabilization but also spinal injuries further down. So you need to be, this is what we, what we call a high index of suspicion. So we looked at the kinematics, we can see a high index of suspicion of what type of injuries we should expect. Roll over collisions are even more complicated because there are many forces involved. They can be frontal impacts, they can be side impacts, they can be rollovers and all of those injuries can now occur. So you can see if you turn up to an incident where there's been clear evidence of roll over collusion that multiple injuries are likely to be involved with the casualty under runs and crush incidents are extremely complex. Extrication is particularly because they tend to involve larger vehicles and they can, they can take a long time to get someone out even if we wanted to get someone out very quickly. Often under these circumstances, we do not have that option. We have to go through extrication process just to get them out and hope that the casualties survives and that we can do everything for the casualty until we can get them out. Stabilization can be extremely complex when it comes to the vehicle, particularly vehicles on its side. And you can see that we use different techniques in the buyer service in particular to try to stabilize the vehicle. And then we have a range of techniques available to us, including things like using these props to be able to stabilize the vehicle before we start getting in the vehicle, cutting the vehicle ourselves. This is a video of cross ramming. I'm not going to show it. All right. The reason for showing you this is really important is because when we come to extrication, one of the things we try to achieve very early on is what's known as cross ramen. And the reason for that is we try to put the vehicle back into its original date. And the reason for that is to remove those forces and reduce those forces attention toss and in flexion. So if we can put the vehicle back to its similar shape before we start cutting the vehicle, we have less chance of the vehicle springing less chance of movement in the vehicle, particularly if the casualties trapped in the vehicle. If you can imagine them trapped with the engine on top of them legs underneath any type of forces involved in, in that we release as part of the education can be extremely dangerous. There are different types of procedures that we use for our and we're gonna quickly just run through these as door inside removal. In this case, we have not taken the roof off. There is no requirement and it's quicker. There's a dash role which would be a video, but I'm not going to show it because of time and a dash roll essentially is where we literally roll the dash off the pace of the casualties. So we cut down the side of the doors and we use the ram to push the whole front end of the vehicle and roll literally the dash away from the vehicle, taking the engine of the lower limbs of the vehicle is a very common technique and very often involved in frontal collisions. There are other types of procedures where we will use the roof to our advantage such as a roof flat. So rather than cut it off and take it out the way we will flap it down and bring the casualty out on the roof. You will see that's part of the procedures. We cover up all of the extreme edges that we've cut because these are now sharp and they will involve injury to the casualties and to the rescuers, but we cover them up as procedures and you'll see that sheets over where the windscreen has been cut. You'll see uh elements over the post, the A B and C posts to try to protect ourselves and the casually. And you will also see in this picture that there is a device which has been put over the steering and that is to stop the airbag from initiating airbags can initiate after an RTC because they have condensers in them that can hold enough power to actually cause the explosion in the device and that can happen after the batteries being connected disconnected. So we have to protect particularly casualties trapped from a frontal collision by the steering wheel. We have to make sure that that's not going to go off in the casualty space. We talked about before about tunnel vision, a tunnel vision is something that's really important and it's something we have to understand when we're doing extrication. People are very keen to get the person out of the vehicle and what can happen is they get pulled into the, to the situation. They get frustrated, they want to make it work, they want to make it work. And often you'll see people taking, getting pulled into the situation. Now it can occur straight away. So somebody screaming, you get pulled towards the casualty, not completing your 360 degrees seen assessment. And then you may find out later that you've actually missed somebody. So it's important that while one person goes to the casualty, the often charged us a 360 assessment. So we don't get drawn in. We don't get tunnel vision and we have to, we have to do this as part of the ongoing management of the scene because what we want to do is to make sure that the ongoing responders and rescuers know what we, what we require. So we have to do this ongoing assessment, make sure that we're standing back, make sure we understand all of the resources we need, what the situation we got the number of casualties, the types of entrapment. Therefore, what are the resources we need at this scene? What is already coming? Why, what do we need to request and their while we're doing the extrication, which somebody gets frustrated and they're on the tools and I get tunnel vision and they're looking at that often. What we'll do is we'll take them out. We'll take, we'll literally swap personnel and say right time to swap, they don't like it at times, but it's what you'd have to do to reduce tunnel vision and to make sure that we're all seeing a bigger picture and to make sure that the rescue is casualty centered, this is about 80 less and I'm not going to go through the whole video because we haven't got the time. But essentially a TLS was developed in 1976 and it was James Strider. It was an orthopedic surgeon was flying his own plane and that plane crashed and he realized something, he realized that that the care that he got at the scene that he, that he could provide himself was better than he received at the hospital. And that started the process of advanced trauma life support. He came back with a colleague after that in 1976 and decided that actually there shouldn't be a difference when you, when you were involved in trauma, everyone should be following exactly the same tried and tested methodology, advanced trauma, life support or prehospital life support as a trauma, life support as we say in the ambulance service. So we're all following a TLS advanced trauma life support. And this was developed as said by James Stridor. Why is it important? Well, if you look at the figures remember the figures that we showed initially a road traffic collisions and you'll see where the mortality rates are higher in red and where they're blue, they're much lower. And you can see this is mortality rates for 100,000 and there's a significant difference. And then you look at where prehospital trauma, life support phds. A TLS is now performed around the world. And you can see predominantly in North America, South America, Western Europe, some other countries, Australasia, South Africa, you can see that there is significant ph TLS. There are some anomalies such as South Africa, but there are reasons for that but essentially where there is good uh phtlsatls being practiced by the pre hospital services. There is a significant reduction in trauma mortality, associate with road traffic collisions. And as you can see, particularly in Africa, there's a high level of where it's not conducted. So if you're in a country that is not running 80 less and not running P hdls regularly, it should be something that you as conditions should be pushing for to make sure that it is understood and practiced in the pre hospital field. Former emergencies require very simple methodologies yourself the scene and the casualty in that order. But the casualty remains the center of all casualty centered rescues. We follow um anomic called seen which allows us safety, the cause recognition of the mechanism of injury, environment, number of casualties, x resources needed. We go through that process. And then that allows us to come up with what we need and allows us to effectively planned what we're going to do next. We're, we've got two minutes of this session list. So I'm going to make it quite quick. Rtc's can be very complicated. But one question you have to ask yourself and the Austrian charges asking himself this question constant is what are we trying to achieve here? What is it that we're trying to achieve? And if it's not driven by the casualty, then we shouldn't be doing it. We do use the primary survey and I'm not going to teach you the primary survey because as conditions you should already be, Rian taught this. Uh but you'll recognize a good primary survey should only take 60 to 90 seconds. And it has changed over recent time because of our experience in dealing with trauma from the battle bill where catastrophic hemorrhage now takes place is before airway. And that means essentially it's just as important because if somebody is bleeding out and they're going to bleed out within a minute, it doesn't matter whether they got an airway because they haven't got blood, which is going to transfer their oxygen to the brain and whatever anyone tells you, there's only one reason why people die and that is lack of oxygen to their brain. There's many reasons why that could occur. But the only reason people die of lack of oxygen to their brain So we run through the process of a primary survey and catastrophic hemorrhage algorithm to make sure that we can manage bleeding. This is all conducted in the pre hospital field. We always do c spine control and airway management. And then we run through what is breathing and we use the Masonic 12. And again, I'm not gonna, can't go through this because this is quite detailed intervention in the pre hospital field. But if it's something you're interested in, you should research it further because particularly if you're a condition that's going to receive some of these casualties, you will see how we get to the point of recognizing how much blood is lost, significant types of injuries that we're going to find and how we find those injuries and make sure that we can make sure we can pass that information on to you and, and stabilize casually before it gets you. We do use a poo in the pre hospital field. But we also move to a Glasgow coma scale very quickly because we can use the major trauma tool which will tell us whether this person needs to go to a trauma center or just a hospital. I'm going to run through these last elements of it. But the major trauma to was now used in pre hospital services across the UK. And that is four steps and allows us to determine whether this person meets the criteria, should go to a trauma center and we do pass on information, which is we use the ATMOS process, which is the age type of incident mechanism, injuries, uh injuries that we've discovered or suspected signs and symptoms and treatment. And don't forget to give an 80 a estimated time of arrival. And that is in time. Don't say 10 minutes, say I'm going to be there by this time because that can get lost transfer. We do do prehospital spinal injury assessments. And again, if you want to know more about that, we use what's known as the Canadian C spine rule. And if you follow that, that was determined whether this person has a potential spinal injury and allows us to make decisions based on what we do next when it comes to extrication, right? If you've got any further questions, uh I'm hoping that you've sent them in and we can answer those questions for you is a very quick overview of what we do in the pre hospital field. The question you should be asking yourself is two things. One, what's the type of casualty I'm going to receive here and what's happened in the pre hospital field to allow these casual to survive to them to get to me. So by the time they get to you that you're going to be the particularly doctors, you're going to be the people that are going to intervene in this casualty in definitive care. And the second thing you should be asking yourself is if this level of expertise does not exist in your country, in your area, you don't see this, you don't see this level of training, this level of expertise, equipment and perhaps even statutory duty, maybe it's something you should be asking yourself as conditions, should we be leading change here? Okay. That's my presentation. I hope that's been useful to you, particularly for those people that are gonna find themselves in the front end of our hospitals in the accident emergency. So you have a good understanding of what happens in the pre hospital bill. Thank you. Thank you so much for your time. Thanks.

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