Trapped passengers and drivers: what to do?
Around 136,000 people are injured in road accidents each year. 28,000 have serious injuries. 1,700 die. Drivers and passengers can be trapped in their damaged cars for some time. Emergency services then have to balance the risks. Is it best to get people out quickly? They may need life-saving treatment. Or is the risk of getting them out too high? If they have unstable spinal injuries, moving them may cause lifelong paralysis.
The ways of getting people out of vehicles have improved over the last 70 years. Rescue services have faster and more powerful cutting equipment. However, one thing did not change. This was the thinking that you should move people as little as possible – ‘movement minimisation’. The risks of exacerbating a spinal injury were considered too high. The risks were thought to outweigh the benefits of getting people out – and being able to treat them – quickly. The importance of not moving injured people became embedded in the thinking of rescue services. Their guidelines and manuals required it. Everyone thought we should not try to move trapped people out until it was absolutely safe to do so.
The downside was that people were left trapped for longer. Many were in distress. Some were bleeding. Some needed life-saving treatment and didn’t get it. Some suffered worse injuries or even died as a result. And no one really knew whether ‘movement minimisation’ was actually for the best. There was simply no good evidence one way or the other.
The EXIT Project: the research
Back in 2007, 2 clinicians, Dr Tim Nutbeam (consultant in Accident and Emergency) and Rob Fenwick (consultant nurse) started the EXIT project. They aimed to find out what was the best thing to do for people trapped in vehicles and develop guidance, based on evidence. The Road Safety Trust funded the project. Over a number of years, they carried out 10 detailed studies. These included:
- Comparing injuries for people trapped in vehicles and those who were not. In particular, they looked at spinal injuries and ‘time-dependent injuries’ – those which get worse the longer they are left.
- Looking at how different ways of getting people out of vehicles apply forces to their bodies differently. For instance, how far were different methods likely to cause an unstable spine to move and risk injury to the spinal cord?
- Finding out what the people themselves thought. How distressing was it being trapped in a car? What was their experience and what did they want?
- Finding out what experts, such as paramedics and rescue services thought of the evidence.
The EXIT Project: results
Their findings were surprising and challenged the way things have been done for 70 years.
- There was no evidence of that getting people out of vehicles caused injuries to their spine or even death.
- Only very few people who were extricated had spinal injuries that might be made worse by movement – 0.7%;
- Trapped patients are more likely to serious injuries or die. (This may sound obvious because a crash bad enough to trap drivers and passengers is likely to be serious.) It also may mean that getting them out is a priority.
- Women are more likely to be trapped than men;
- Men and women tend to suffer different injuries. Women are more likely to have injuries to the spine and pelvis. Men are more likely to have head, chest, arm and leg injuries.
- Neck collars reduced neck movement for people who got themselves out.
- Ways of getting people out that were supposed to reduce movement didn’t actually do so;
- People who got themselves out had less neck movement that those who didn’t.
- It was really important to trapped people that someone was there talking to and reassuring them. This reduced their distress.
The EXIT Project: conclusions
In short, the received wisdom was wrong and we urgently needed a change in practice. Leaving people trapped in vehicles until they could be got out ‘safely’ was doing more harm than good. The risk of getting people out quickly – and of them getting themselves out – was lower than anyone thought.
New guidance
New guidance is being brought in for paramedics, ambulance crews and fire and rescue services. The guidance recommends a change in practice. The emphasis now is on helping people to get out of their vehicles more quickly. The aim is to reduce harm from road accidents.
Conclusions
Accidents will still happen and people will still sadly be injured on our roads. People will still suffer serious fractures, spinal injuries and internal injuries. Some injuries were worse because people were left in their vehicles for too long. New guidelines should ensure people are extricated more quickly, reducing the harm from road accidents.
