Could more people be saved from car wrecks?
Meanwhile, back down here on Earth you probably assume that our emergency services, those tasked with getting us out of harm’s way, were always working with the full weight of scientific medical evidence behind them; if so, this story might come as something of a shock. This is because, in the case of rescue from car wrecks, research has outlined that the current approach, designed to minimise the movement of patients to guard against exacerbating spinal injuries, is counter productive. And it’s not marginal. In over 99% of cases, spinal injuries are not the main problem for the patient, while extending the amount of time they spend trapped in the car could render other injuries, where every second that treatment is delayed counts, potentially fatal. Speaking with James Tytko, Tim Nutbeam, an Emergency Medicine Consultant for the NHS, estimates that hundreds of people in this country, and many more worldwide, might have been saved if a scientifically driven approach had sooner been applied to car wreck rescue efforts…
Tim- The principles of current fire and rescue techniques are based around what we call absolute movement minimisation. So, when you suffer an injury to your spine, there is a concern that further movements might exacerbate that injury and make the primary injury worse, and we call that secondary spinal injury. That has been the paradigm, the focus of extrication techniques and how they've developed, particularly over the last 40 or 50 years.
James- What are the flaws with this approach?
Tim- It's a, a single consideration in a complex environment, and we need to have an understanding of what injuries patients have and make sure that we've weighed all those into balance to work out what is best for that patient and that particular extrication. We set out to fill in some of the gaps in the relevant scientific evidence, and then to re-evaluate - is what we are doing correct? And if it's not, what are the next steps?
James- What was the result of that re-evaluation? What did you find?
Tim- So we went back and looked at all the history, all the farm rescue manuals, and tried to work out where this paradigm of movement minimization had evolved from, and if it had a historical evidence base. We could find no evidence of that. There was never any underlying scientific evidence in terms of frequency of injuries or type of injuries, or a specific reason why that, that paradigm might have been chosen over, say, a head injury or a chest injury or an abdominal injury. The second part of the project was looking at the different injuries which these patients suffer and we worked with the trauma audit research network and is the biggest trauma database in Europe. What we did is we looked at patients who were trapped and patients who weren't trapped and then looked at what injuries they suffered and then reported those injuries and also used modelling techniques to see if being trapped led to more deaths than it should.
Tim- What we demonstrated was the rate of spinal injury, or spinal cord injury, was very low, less than 0.7%. All the other patients - so this is looking at majorly injured patients - had other significant injuries. Normally it's the head or the chest or the abdomen with spinal injuries right down at the bottom of this list of injury frequency. We also found that being trapped was associated with more deaths than it should be. So once we took into account people's age, their comorbidities, that's the other things that they've got wrong with them, and the injuries that they suffered, we found that being trapped was an independent predictor of mortality. So there's something about being trapped that kills you.
James- Is it fair to ask why this has taken so long for people to look at the way we deal with these accidents and to re-assess how we should be dealing with them?
Tim- Yeah, I think there's a number of different challenges to that. One is around, I guess, patient ownership. Who is responsible for casualties or patients when they are actually trapped? Are they actually a patient or are they a casualty which is the responsibility of the fire and rescue services? And I think these areas of shared ownership lead to potential difficulties in delivering research in that area.
James- I definitely appreciate what you're saying, but when you've outlined the situation as clearly as you have, how does it stand up to people out there who, obviously have my deep sympathies, maybe they've lost someone to an accident who might have stood a far better chance had their injuries been treated sooner, giving an updated approach, which moves away from the movement minimization way of dealing with things.
Tim- I think that's a difficult question to, to answer. I think the important thing is, is that we've identified that what we are doing could be better and we are working with all the right stakeholders to make sure that that information rapidly and efficiently translated into practice. It's a shame that we've not looked at this sooner, but now that we have, we seem to have captured momentum and the buy-in and support of all these stakeholders to ensure that this translates rapidly into not only guidance, but into the practice that we deliver on a day to day basis, moving forward. We've already seen some changes or results and, and that's really fantastic to see.
James- Yeah, that's good to hear. When it comes to this transition, are there any major sticking points in the way that you envisage or could, could things move quite quickly from here?
Tim- I think it's important not to underestimate how difficult it is to overcome years of institutionalized practice and the fire rescue services have been taught for many years, that even a very small movement can lead to catastrophic consequences. I think it's important that this work has, it's not delivered by doctors and it's not delivered by fire rescue personnel. It's not delivered by a certain group of practitioners, but it's been genuinely developed and delivered by a multidisciplinary group of stakeholders. I think, in the past, we've perhaps gone wrong by doctors telling people how to do things. And I think the principles of regularly revisiting this guidance and ensuring that what we're doing is patient centred and patient injury centred that we can continue to refine and get better at this area of practice and all those other areas of shared multidisciplinary practice.