chapter 39: vehicle extrication and special rescue

the equipment used and gear worn depends on what? what are some examples of protective gear? what type of gloves should you wear and when?

• equipment that is used and gear that is worn depends on

  • hazards you expect to encounter

  • what you observe during scene size up

• protective gear may include

  • turnout gear

  • helmet

  • hearing protection

  • fire extinguisher

• wear blood and fluid-impermeable gloves at all times during pt contact

• wear a pair of leather gloves over disposable gloves to protect you from injury when handling ropes, tools, broken glass, hot or cold objects, or sharp metal

what are shock absorbing bumpers? what happens to then after a crash? why should you not stand in front of them? where are airbags lcoated? what should you do if an airbag has not deployed before arrival on scene? how much space should you maintain around side-impact, driver-side, and passenger-side non-deployed airbags? what does eye protection and a mask do to protect you from airbags?

• shock-absorbing bumpers protect a vehicle during low-speed impact

  • after a front or rear end crash, shock absorbers may compress or “load”

  • avoid standing directly in front of such bumpers, and always approach vehicles from the side, because the shock absorbers can release and injury your knees and legs

• manufacturers are now mandated to incorporate supplemental restraint systems [airbags] into vehicles

  • located in steering wheel and dashboard in front of passenger, deploying when vehicle is struck from front or rear

  • side-impact airbags may be present to protect driver and passengers from side impacts; may be located in the doors or seats

  • airbags should normally deploy and deflate before arrival on scene, but if not, they may spontaneously inflate while you provide pt care, causing injury to you

  • use caution when working in damaged vehicles in which airbags have not deployed

    • maintain at least 5-inch clearance around side-impact airbags, a 10 inch clearance around driver-side airbags, and a 20 inch clearance around passenger-side airbags

• appropriate PPE reduces risk of eye or lung irritation from cornstarch or talcum power that manufacturers used to place on the airbags to prevent minor skin irritation

what is extrication? what is entrapment? what are the ten phases of extrication?

• extrication: removal of a patient from entrapment or from a dangerous situation or position [also called disentanglement]

• entrapment: condition in which a person is caught within a closed area with no way out or has a limb or other body part trapped

• ten phases of extrication:"

  • preparation

  • en route to scene

  • arrival and scene size-up

  • hazard control

  • support operations

  • gaining access

  • emergency care

  • removal of the pt

  • transfer of the pt

  • termination

what are the role of EMS providers at a vehicle extrication scene? what about the rescue team? what about law enforcement? what about firefighters?

• role of EMS providers at a vehicle extrication scene:

  • assess pts

  • provide immediate medical care

  • triage and package pts

  • provide additional assessment and care as needed once pts are removed

  • provide transport to ED

• role of rescue team at a vehicle extrication scene:

  • secure and stabilize vehicle

  • provide safe entrance and access to pts

  • safely extricate pts

  • provide adequate room so that pts can be removed properly

• role of law enforcement officers at a vehicle extrication scene:

  • control traffic

  • maintain order at the scene

  • establish and maintain a perimeter so that bystanders are kept at a safe distance

  • investigate the crash or crime scene

• role of firefighters at a vehicle extrication scene:

  • extinguish fire

  • prevent additional ignition

  • ensure scene safety

  • remove spilled fuel

when parking and positioning for the preparation, en route, and arrival phases, what should you do if your unit is the first to arrive to vehicle extrication scene? what lights should you use? how should you park/position your unit if law enforcement or fire units have blocked their roadway? why should you not park alongside an incident on an active roadway?

• if yours is the first unit to arrive, position ambulance to block scene from oncoming traffic

  • use only essential warning lights; too many will distract or confuse motorists

• do not park in an area where you will be blocked in

• if law enforcement or fire units have blocked the roadway, position your unit so that the back of the ambulance is pointing toward the scene to facilitate pt transport

• avoid adding a hazard to the scene by parking alongside the incident on an active roadway; this could increase the risk of your vehicle or responders being struck

when approaching the scene during preparation, en route, and arrival phases, what should you do if hazardous materials are present? what steps should you take to ensure safety of yourself and others?

• if hazardous materials [toxic, poisonous, radioactive, flammable, or explosive substances that can cause injury or death with exposure] are present, park uphill and upwind

• to ensure safety of yourself and others:

  • before exiting the vehicle, put on proper PPE

  • be alert for any vehicles that may cause injury to you

  • do not assume motorists will always heed warning lights

  • before proceeding, make sure the scene is properly marked and protected

  • request assistance from law enforcement and/or fire personnel, who should close the road or divert traffic safely around the scene with cones, flares, or barricade tape

  • ultimately, traffic control is handled by other public safety units

what should you look for during scene size up for vehicle extrication? what ar eunits that may possibly need to be called?

• most important responsibility of scene size-up is to determine what, if any, additional units are needed

• during your walk, look for:

  • MOI

  • downed power lines

  • leaking fuel or fluids

  • smoke or fire

  • broken glass

  • trapped or ejected patients

  • number of pts and vehicles involved

• use the info you have gathered to evaluate need for additional resources like:

  • extrication equipment

  • fire department

  • law enforcement

  • hazmat suit

  • utility company

  • ALS units

  • air transport

what does a bent steering wheel indicate? what do imprints in the dashboard indicate? why should you lift deployed airbags at a car crash scene? what happens if a pt was not restrained? how can you tell if a front seat occupant was unrestrained and thrown forward?

• assess physical damage

  • bent steering wheel → mech of injury can lead to significant face and thoracic trauma

  • imprints in dashboard → usually from knees striking it, indicating the potential for serious lower extremity injuries such as hip dislocations and fractures

  • lift deployed airbags to see if there is deformity to steering wheel or dashboard, indicating the pt struck the structure after airbag deflated

• determine whether pt was restrained

  • unrestrained pt may have contact injuries as well as secondary injuries

  • if unrestrained occupant in front seat is thrown forward, he or she mays trike the windshield with the head, resulting in a spider web pattern of shattered glass and possible head, face, and neck injuries

what additional hazards may you notice and document during scene size uo?

• include any findings related to vehicle damage in documentation and maintain high index of suspicion

• look for spilled fuel and other flammable substances

  • fires may trap the occupants of the vehicle and require fire suppression

• crashes that occur in the rain, sleet, or snow present an added hazard for rescue personnel and pts

  • crashes that occur on hills are harder to handle

  • uneven terrain increases roll over risk, requiring stabilization of vehicle prior to gaining access

• be alert for weapons

• communicate with members of the rescue team throughout extrication process

• report to the incident commander upon arrival

what should you do if power lines are downed? what is the danger zone/hot zone? what should you do if you arrive before the rescue team does? why is a vehicle on its side dangerous and what should be done to stabilize it?

• never attempt to move downed power lines

  • if they are touching or located in proximity to a vehicle involved in the crash, pts should be instructed to remain in the vehicle until power is shut off by utility company

  • you and ambulance should remain in the safety zone

• in the danger zone [hot zone], people can be exposed to sharp metal edges, broken glass, toxic substances, radiation, or explosion of hazardous materials

  • off-limits to bystanders

  • help set up and enforce this zone

• if you arrive before rescue team does, work with law enforcement to coordinate crowd control

• a vehicle that rests on its side or roof is unstable and can be dangerous

  • rescue personnel can stabilize the vehicle with a variety of jacks or cribbing [wooden blocks]

  • before attempting to gain access to the vehicle, put the vehicle in park, with the parking brake set and the ignition turned off

  • disconnect both battery cables, negative side first

where are batteries often located in alternative-fuel vehicles? how are hybrid batteries different from traditional batteries, and what caution should be exercised around their cables? what should you assume and do if you smell a strange odor from an alternative-fuel vehicle?

• in many alternative-fuel vehicles, batteries are not located in the engine, but rather other areas such as the trunk or under the seats

  • more than one battery may be present

• hybrid batteries have a higher voltage than traditional automotive batteries, and it may take up to 10 mins for a high-voltage system to de-energize after the main battery is turned off

  • avoid contact with high-voltage cables [typically orange] and components throughout the rescue

• damaged high-voltage batteries may give off toxic fumes

  • do not approach vehicle if there is an unusual odor, and retreat if you experience burning of eyes and throat

  • call dispatch to request additional assistance from fire department and/or hazmat team

what are 3 forms of support operations?

• lighting the scene

• establishing tool and equipment staging areas

• marking helicopter landing zones

what questions should you consider to determine exact location and position of the pt?

• to determine exact location and position of the pt, consider the following questions:

  • is pt in a vehicle or in some other structure?

  • is vehicle or structure severely damaged?

  • what hazards exist that pose a risk to the pt and responders

  • in what position is the vehicle?

  • on what type of surface

  • is the vehicle stable or is it likely to roll over?

what should you do during access and extrication phases to keep pt safe and calm?

• during access and extrication phases, make sure pt stays safe

  • cover pt with heavy, fire-resistant blanket or place a backboard between the windshield and pt to protect them from breaking glass, flying particles, tools, or other hazards

  • reassure the pt that everything possible is being done to help them

  • describe what you are going to do before you do it and while you do it

  • cervical spine immobilization or other care may be needed during extrication

  • rescue team should try to keep heat, noise, and force to a minimum and use only what is necessary to extricate the pt safely

  • depending on pt’s condition and scene safety, you and your team may have to use the rapid extrication technique to move a pt who is not entrapped from a sitting position inside a vehicle to a supine position on a long backboard

    • team of experienced EMTs should be able to do this in under a minute

what is simple access? what should you do if rescue team has not arrived and delayed access to pt can be life threatening? what should you attempt first before using methods of forced entry?

• simple access: involves trying to get to the pt as quickly and simply as possible without using any tools or force

• rescue team should provide entrance needed for you to gain access

  • if rescue team has not yet arrived and delayed access can be life threatening, simple hand tools [hammers, center punches, pry bars, and hacksaws] are usually stored in ambulance for you to use

• whenever possible first try to unlock the doors [or ask the pt to unlock them], or roll down the windows

  • try to open every door using the handles to gain access before breaking any windows or using other methods of forced entry

• complex access: requires the use of special tools, such as pneumatic and/or hydraulic devices, and special training that includes breaking the windshield or removing the roof

• these advanced skills are typically performed by a specialized team rather than EMS providers and are listed below:

  • brake and gas pedal displacement

  • dashboard roll-up

  • door removal

  • roof opening and removal

  • seat displacement

  • steering column displacement

  • steering wheel cutting

what should you do for a primary assessment and provision of standard care prior to extrication?

• provide manual stabilization to protect cervical spine, as needed

• open the airway

• provide high-flow oxygen

• assist or provide for adequate ventilation

• control any significant external bleeding

• treat all critical injuries

what should you determine about a pt that needs to be extricated? what should you look for on a trapped limb?

• determine:

  • how urgently the pt must be extricated

  • where you should be positioned to best protect the pt during extrication

  • once the pt has been freed, how you can best move the pt from within the vehicle onto the backboard and onto the stretcher

• carefully examine the exposed area of the limb or other part of the pt that is trapped to determine the extent of injury and whether there is a possibility of hidden bleeding

  • if possible, evaluate sensation in the trapped area so you know whether increased pain indicates an object pressing on or impaling the pt during extrication

how does your input help the rescue team? what should you reevaluate? how can extremity injuries be supported and stabilized during removal? what should be determined after an extrication plan has been devised and everyone understands their role?

• rescue team assesses exactly how the pt is trapped and determines safest, easiest way to extricate them → your input is essential

• reevaluate whether pt needs to be immediately removed via manual stabilization and rapid extrication technique, or whether team can apply spinal immobilization device before pt is moved further

• in most cases, it is impractical and difficult to properly apply extremity splints within the vehicle

  • extremity injuries can generally be rapidly supported and stabilized while the pt is being removed by securing an injured arm to the body and, if a leg is injured, by securing one leg to the other

  • this will be adequate until the pt is placed on the immobilization device or until time permits a more detailed assessment and splinting of each injury

• once the extrication plan has been devised and everyone understands what will be done, determine how to best protect the pt

  • often, you or your partner will be placed in the vehicle alongside the pt to monitor their condition as the vehicle is being pried open

  • be sure to wear proper PPE

how do you avoid injuring yourself, team members, or pt? how should the pt be moved? what are the general guidelines to transferring the pt from the vehicle to the ambulance?

• to avoid injuring yourself, your team members, or the pt, ensure that each EMT is positioned so that he or she can lift and carry properly at all times

• move the pt in a series of smooth, slow, controlled steps, with designated stops to allow for repositioning and adjustments

  • make sure a sufficient number of team members are available for the move

• when moving pt from the vehicle to the ambulance, follow these guidelines

  • one EMT should be in charge, planning and verbalizing exact steps that you will follow to move pt from sitting in the vehicle to lying supine on backboard or stretcher

  • choose a path that requires the least manipulation of pt and equipment

  • move only on the team leader’s command, and move the pt as a unit

  • while transferring the pt, continue to protect them from hazards

  • once pt is on the stretcher, continue with any additional assessment and treatment

  • if environment is extremely hot or cold, raining, or snowing, load the stretcher and pt into the ambulance before continuing assessment and treatment

  • if pt requires immediate transport, provide only the additional care necessary to package the pt and perform the remaining steps en route to the hospital

what is entailed in the termination phase?

• during the termination phase, all equipment used on the scene, including hydraulic, electric, and hand tools, must be checked before reloading them on the vehicle

  • you must also check the ambulance thoroughly, replacing used supplies and decontaminating the unit as required by blood-borne pathogen standards

• rescue units and medical units will be required to complete all necessary reports

what are specialized rescue situations?

• cave rescue

• confined space rescue

• cross-field and trail rescue [park rangers]

• dive rescue

• missing person search and rescue

• mine rescue

• mountain-, rock-, and ice-climbing rescue

• ski slope and cross-country or trail snow rescue [ski patrol]

• structural collapse rescue

• special weapons and tactics [SWAT]

• technical rope rescue [low and high-angle rescue

• trench rescue

• water and small craft rescue

• white water rescue

what is a technical rescue situation? what are technical rescue groups and what do they do/what care do they provide? what should you do if the technical rescue group is not present upon your arrival? what is a staging area and what should you do if the staging area is some distance from the road?

• technical rescue situations: may contain hidden dangers, and it is unsafe to include personnel who do not have necessary training and experience

• many members of a technical rescue group are also trained as EMRs or EMTs so that they can provide necessary immediate care upon reaching the pt

  • even when the technical rescue group includes a paramedic or physician, only essential care is provided until the group members can bring pt to the nearest safe and stable setting [staging area]

• if a technical rescue group is necessary but is not present when you arrive, immediately check with the incident commander to make sure the group has been summoned and is en route to your location

• when you arrive at the rescue site, identify the designated staging area and set up your equipment there

• if the staging area is some distance from the road, you may need to leave the ambulance on the road

  • take a backboard and/or basket stretcher [or similar rescue stretcher] to carry the pt back to the ambulance

  • take all of the jump kits and other equipment you may need to treat and immobilize the pt at the staging area

• as soon as the technical rescue group brings the pt to the staging area, perform a primary assessment and proper treatment, then package pt without delay

what should you do after arrival and briefing on the situation? where should carry-in equipment be left and why? what should occur once a missing person has been found? how can you decrease time and effort needed to reach and carry out the pt?

• as soon as you arrive to the command post and have been briefed on the situation, isolate and prep equipment you will need to carry to pt’s location

  • this saves time once pt has been found or if a member of the search team has been injured

• carry-in equipment [including backboard or other devices needed to immobilize the pt] should be left in the back of the ambulance until it is needed, so that it is protected from the weather

  • if it needs to be relocated, the equipment will not need to be reloaded and will not be left behind

• once missing person has been found, you will be guided by search personnel to that location or a prearranged meeting point where the pt will be carried, allowing treatment to begin quicker

  • consider relocating the ambulance or, if one is available, using a four-wheel drive, all-terrain vehicle [ATV], or snowmobile to decrease the time and effort needed to reach and carry out the pt

  • make sure the equipment is evenly distributed among personnel and that everyone can stay together easily

what is a trench collapse and how much does dirt weigh? at what distance from the scene should response vehicles park? why should the vehicles be turned off? what are other hazards often associated with trench collapses? when should rescue personnel not enter a trench? who provides most medical care during extrication?

• collapses usually involve large areas of falling dirt; weighs approximately 100 lbs per cubic foot

• when arriving on the scene of a cave-in or trench collapse, response vehicles should park at least 500 ft from the scene

• because vibration is a primary cause of secondary collapse, all vehicles, including on-scene construction equipment, should be turned off

• all roads should ve diverted from the 500 ft safety area

• other hazards include:

  • exposed or downed electric wires

  • broken gas or water lines

  • construction equipment at the collapse, which may be unstable and could fall into the cave-in or trench site

• identify any witnesses to the incident

  • may provide valuable info about the number of victims and their location within the collapsed area

• assist any nontrapped people from the area

• at no time should medical or rescue personnel enter a trench deeper than 4 feet without proper shoring in place

• during extrication of any survivors, trained medical personnel will provide most medical care

  • be prepared to receive pts once they have been extricated

what are situations/incidents that pose increased risk to emergency responders, and what units are required for them? how do EMS providers for the SWAT team differ from regular EMS providers? what should you do when called to the scene of a law enforcement tactical situation?

• incidents that pose increased risk to emergency responders include hostage incidents, barricaded subjects, and snipers

  • they require the use of specialized law enforcement tactical units or the SWAT team

• many communities have incorporated specially trained EMTs, paramedics, nurses, and even physicians into their SWAT units

  • these EMS providers provide a special level of care to the sick and injured, and their training goes well beyond the practices seen in standard emergency medical care

• altered standards of care are similar to those used by military EMS providers on the battlefield and are not used in standard EMT situations

what should you do when called to the scene of a law enforcement tactical situation? what should the incident commander do in these situations? what should tactical EMS providers and officers do in this situation?

• when called to the scene of a law enforcement tactical situation

  • determine the location of the command post and report to the incident commander for instructions

  • turn off ambulance’s lights and siren when nearing the scene

  • do not use outside radio speakers

  • the command post is usually located in an area that cannot be seen by the suspect and is out of range of possible gunfire

    • remain in this area and do not roam beyond this site

• what is the role of the incident commander?

  • have incident commander identify specific location of incident

  • incident commander should determine a staging area where you can meat SWAT team or tactical EMS providers should an injury occur

    • incident commander should determine a safe route to this point

• what is the role of tactical EMS providers or officers?

  • tactical EMS providers or officers will remove the pt to this staging area for continued treatment and transport to a medical facility

    • to save time in critical situations, designate primary and secondary helicopter landing zones if your region uses aeromedical evacuation

    • identify the closest hospital, burn center, and trauma center and note the route of travel to these facilities

what is the mnemonic FAILURE stand for for rescue failure?

• FAILURE mnemonic summarizes reasons for rescue failure

  • F - failure to understand environment or underestimating it

  • A - additional medical problems not considered

  • I - inadequate rescue skills

  • L - lack of teamwork or experience

  • U - underestimating the logistics of the incident

  • R - rescue versus recovery mode not considered

  • E - equipment not mastered

what is a structure fire? where should the ambulance be parked upon arrival and what should be considered concerning the ambulance? who does search and rescue, and what equipment is used? where should you remain during search and rescue? when should you leave the scene?

• structure fire: a fire in a house or other building

• when responding to a major fire scene, determine whether any special route is necessary to reach the scene

• once you arrive at the scene, ask the incident commander where the ambulance should be staged

  • park far enough away from the fire that it will be safe from the fire itself or a collapsing building

  • ensure the ambulance:

    • will not block or hinder other arriving units or be blocked in by other equipment or hose lines

    • will be close enough to be visible and pts can be brought to it easily

• determine whether there are any injured pts or whether you are on standby

• search and rescue operations are performed by teams of firefighters wearing full turnout gear and self-contained breathing apparatus [SCBA] and carrying tools and fully charged hose lines

• unless otherwise stated, stay with ambulance

• do not leave scene even after fire is out, as you may need to treat an injured firefighter

  • ambulance should only leave the scene if transporting a pt or if the incident commander has released it