The case against extrication in motorsport: Reforming the deployment method

The case against current regulations for extrication

In 2013, there were numerous accidents during the World Rally Championship, but only six required deployment of extrication teams and all occupants were able to self-extricate without the help of the extrication teams. There was one RE required during the World Endurance Championship on the only activation of the extrication team. Thus, the 2013 World Rally season saw only seven extrications, with no formal extrication at all.

This current setup mandates separate teams for extrication in Formula 1 and GP2, with a large, and we would argue surplus, manpower requirement, as the manpower is required to undertake formal extrication, which we believe is unnecessary.

Formal extrication usually takes between 5 and 7 min to undertake which carries the real risk of decompensation over time, iatrogenic pain, spinal movement and airway compromise. This is of paramount importance as in the pre-hospital environment time to definitive care is a critical factor. Most drivers are fine after an accident and self-extricate.

Dixon et al. ³ undertook biomechanical analysis of spinal immobilisation during pre-hospital extrication. Sensors were placed on patients and extricated by a six-man team in nine different variations including slow formal extrication. Their results demonstrated that conventional extraction techniques record up to four times more cervical spine movement during extrication when compared to controlled self-extrication. The main area of concern using the formal extrication method is that the principle behind the extricable seat design and formal extrication process is flawed, as the car is almost never on all four wheels and there is hardly ever any surrounding space for manoeuvre, absence of fire hazard or seat damage and the car is often, buried in Armco (protective impact barriers).

It has been estimated that up to one-quarter of spinal cord injuries may be significantly worsened during transport or early treatment. Hence, the American College of Surgeons recommends full spinal immobilisation during extrication after a motor vehicle accident. ⁴ However, this recommendation does not take into account the potential detrimental effects of iatrogenic injury caused by immobilisation during extrication, especially as Dixon et al.’s ³ study demonstrates the amount of movement that occurs during formal extrication.

Two main principles are followed during the extrication process to prevent motion of the spine and further injury: maintain spinal alignment and minimise body twisting.

The same study by Engsberg et al., ⁴ demonstrated that the least cervical spine movement occurred when the driver was allowed to extricate themselves without assistance with cervical spine collar in place.

Shafer and Naunheim ⁵ have undertaken extensive experimentation on models to determine the extent of cervical spine motion during extrication. Volunteer patients were marked with an infrared motion capture system and extricated from a vehicle by experienced paramedics. The least movement was demonstrated to occur when the driver had a cervical collar applied and was allowed to extricate themselves from the vehicle on their own and lay down on a back board. Ben-Galim et al., ⁶ demonstrated that even cervical spine collars can be detrimental when applied. They provided evidence that extrication collars can result in abnormal distraction within the upper cervical spine in the presence of a severe injury. However, they did not demonstrate any evidence of instability or neurological compromise.

It is now recognised that the most vulnerable part of the driver in F1 cars is the head and neck as it is in this area where the most serious injuries in the past few years have been seen. Karbi et al. ⁷ studied the extrication, immobilisation and radiological findings of patients with cervical spine injuries; one-third of patients had injuries to C1 or C2 vertebrae where any movement could lead to paralysis or death. The authors concluded that the most effective way to deal with spinal injury was prevention.

Head injury has also been noted to cause agitation, and in this scenario forced head restraint or manual fixation of the head can cause further injury and it may be necessary to remove the fixation.

From the authors’ experience in both Formula 1 and rally cars, nearly all drivers can be extricated with a simple short board or a KED and there is almost never a need to cut the roof off the car which translates to less cutting at the roadside on a normal motor vehicle collision (MVC). Historically, the removal of the roof has been undertaken by the firecrew and is medically unjustified in nearly all cases. Cutting gear should be for disentanglement only.

Indycar experience over the past 25 years shows a simple short board behind the driver, with a simple thoracic strap and neck collar, is both similar in technique and results described by Cline et al. ⁸ Extrication from these cars takes less than a minute and there has been no associated paralysis in the 25 years this technique has been utilised. This, therefore, contradicts the rationale behind formal extrication using a full seat and extricable seat, reinforced by the fact that studies have demonstrated that drivers who self-extricate move less than when they are manhandled by an extrication team.

In Norway, the KED device has been removed from all ambulances and collar usage is limited to where a driver complains of neck pain. All are encouraged to self-extricate with no apparent increase in morbidity. Pre-hospital entrapment is a risk factor for complications and delays transport to the hospital. The RE method, described by the Norwegian Air Ambulance, combines winching and cutting of both front reinforcement poles in the car and using two larger vehicles to pull car wreckage apart to extricate patients. Previous studies indicate that RE is an efficient alternative to previously existing methods.^9,10

Proposal for extrication

At any accident scene, rapid removal of the casualty to hospital improves their chances of survival. The term the ‘Golden Hour’ was first introduced in 1961, but because of misinterpretation as to what period this actually referred to, a second concept, the ‘Platinum Ten Minutes’ was proposed as the time taken to move a casualty to the ambulance. To achieve this rapid removal, the ambulance and medical personnel must work in harmony with the rescue personnel to secure the scene and remove the casualty safely without causing injury either to the casualty or other personnel on the scene. ¹¹

The authors recommend the removal of the requirement for separate extrication teams. The skills required for extrication and disincarceration can be combined alongside a core medical skill set into one or two vehicles removing the need for a separate extrication vehicle with all personnel trained in extrication and rescue (Figure 4). This would result in a decrease in both manpower and vehicle requirement. OPEN IN VIEWER