As several of you may know already, I’ve been spending a lot more time in the pre-hospital environment in the last few years. Despite many years working in busy emergency departments seeing many of the same patients that are seen by pre-hospital teams it’s been fascinating to see the complexity of some of the decisions that are made in the pre-hospital environment. One such area of complexity relates to the extrication of patients from vehicle accidents. Traditionally the approach has been to be highly risk averse for spinal injury (though not risk averse overall as we can discuss later). It was the case that protection of the spinal column seemed to have primacy in the treatment of patients and every effort and device was used to absolutely minimise spinal movement.
As the article below suggests, this led to some rather interesting practice.
In recent years I have seen a move towards a less invasive approach to extrication. Locally, patients are now encouraged to self extricate where possible and this has undoubtedly led to faster scene times and better patient care in my opinion. This trend has been informed by a number of papers and consensus statements that have some common themes.
Trends in extrication science
1. Assisted extrication does not result in a reduced spinal movement as compared to self extrication and may even result in more spinal movement
2. Many patients can self extricate
3. Self extrication is faster than assisted extrication
4. Unstable spinal injury is relatively rare
5. If spinal cord injury is to occur then it will probably have occured at the point of impact and during extrication which inevitably has a lower kinetic energy peak
The evidence is far from comprehensive though, and this has contributed to a slow adoption of some of the principles, and thus a resulting variation in practice. We covered an important paper in this areas some years ago on the blog.
I still attend RTCs where there is a reluctance amongst some services/individuals to allow self extrication or gentle handling at the preference of cutting up cars and using spine boards. It is therefore helpful to see a paper published that brings together the science, combined with expert opinion to help guide clinical practice. Such a paper is now published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
What kind of paper is this?
This is described as a Delphi study (Ed – albeit a highly modified one). Delphis are a technique that attempts to quantify expert opinion in areas where other forms of methodology are difficult or impractical. I’ve used Delphi techniques a lot in major incident management and if it is used wisely and in areas where there is no quantifiable assessment then it can be a powerful tool.
Delphis have several key features
- Reiteration (in a series of rounds where group and own answers are reviewed)
The two biggest questions I ask when looking at Delphi studies are whether this is the right technique for the topic and who did they include as experts. In this case the Delphi approach seems to be right method based on the current evidence base (not strong) and the need to bring a range of opinions together from a broad group of specialists.
Who was studied (or in this case involved)?
This is a key question in a Delphi method. In this study expertise was defined by identifying stakeholder groups, but it does not look especially systematic, rather it appears to be based around the opinions of the steering group. In many Delphis this is not uncommon. In a perfect world there would be clear water between the authors, participants and steering groups in determining expertise, but in small subject areas such as this that is rarely possible. It does mean that there may be bias here, as in many studies the steering group/authors will define expertise through availability, familiarity and perhaps prior knowledge of aligned thinking.
60 subject matter experts were included in the study. Authors/steering group members did not join the Delphi, but they did create the initial statements. That’s not quite the same as a traditional Delphi where the round 1 statements are themselves constructed from the group. In this regard I think this study is more of a structured approach to agreement than a traditional Delphi method. In effect, the authors/steering group performed a review and created a series of statements, these were then tested amongst the 60 subject matter experts to see if there was agreement.
The steering group created 88 statements. After this it’s tricky to follow as between rounds some questions were dropped, rewritten or reconstructed. Ultimately 91 statements were considered (so the number grew over time which is not like a traditional Delphi). It’s unclear to me from the paper how this revision and recycling of questions between rounds took place. I imagine that it’s the steering group that did it, but I can’t be sure from the data in the journal.
What did they find?
You will need to read the full paper in order to get these, but having said that the main themes that I’m taking away into practice are as follows.
- Self extrication where practicable is the appropriate method for patients.
- Awake and able to follow instruction
- Able to stand on one leg
- Gentle handling rather than strict immobilisation if assistance needed.
- Inappropriate spinal immobilisation risks the delayed diagnosis of other time critical conditions.
- Interventions when entrapped should be minimised to those that are absolutely essential.
- Entrapment times should be minimised.
- Patients who need to be disentangled are at high risk of time critical injury and therefore they are also at risk if extrication is delayed.
Although I think the methodology is not a traditional Delphi model, and there are some questions about process that are not reported in the published document, I think there are some interesting and helpful findings here. The full tables are well worth a read I think the principles above, now backed by a broad consensus of experts are helpful in guiding me and my colleagues in determining the clinical and extrication priorities for patients at scene.
What I would also love to see is some consensus of who then gets immobilised for their trip to hospital. There are clearly a group of patients who are now encouraged to self extricate, but who are then immobilised on scoops/blocks/collars for transport to hospital. There is another question that may further benefit patients.
- Nutbeam, T., Fenwick, R., Smith, J.E. et al. A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision. Scand J Trauma Resusc Emerg Med 30, 41 (2022). https://doi.org/10.1186/s13049-022-01029-x
- Simon Carley, “JC: Self extrication vs. assisted extrication. St.Emlyn’s,” in St.Emlyn’s, September 19, 2015, https://www.stemlynsblog.org/jc-self-extrication-vs-assisted-extrication-st-emlyns/.