As much as emergency medical service (EMS) has become the predominant response of many fire departments, motor vehicle collisions are a large part of EMS and fire response that call on our abilities to do medical and rescue operations simultaneously.
That requires establishing a safe scene to work in, gaining access for medical personnel and removing the vehicles from the patients so that we can treat and remove them. Getting this done calls for an understanding of the principles of extrication, knowing what resources are available, and being able to apply the principles to any given situation with the resources on hand.
Whether you're trained to the awareness level or are an experienced rescue technician, all responders should be familiar with the principles of extrication in order to accomplish their roles at the scene.
To ensure expedient and safe operations, incident command must be established to make the scene safe and to coordinate operations. Numerous hazards are present at motor vehicle collisions from fire, fuel and other volatile fluids, wreckage that can cut or tangle rescuers and new hazards presented by active restrains such as air bags and electrical hazards in hybrid vehicles.
I'll mention training again later, but the changing dynamics of the vehicles we drive require training updates to enable us to safely work on these new vehicles. An important element of safety is personal protective equipment (PPE). I still see ambulance personnel pulling patients from vehicles wearing nothing more than basically street clothes. This is not appropriate and if ambulance personnel do not have appropriate protective clothing, rescue personnel should deliver the patient to them.
Access To Patients
Once command is established and the scene is made safe (this includes of course making sure that rescuers are in proper gear to work in and around the vehicle) the next order of business is to gain access to the patients.
The goal here is to get rescuers into the vehicle to make an assessment of their patient's condition. In some situations, this may not be possible until a substantial amount of work is done to remove obstructions and create space for the rescuers to get in.
With all of our equipment and training, there will still be situations in which we can't get to the victim without some serious preliminary work. This is the phase we are all familiar with that defines extrication as "removing the vehicle from the patient." This is a means of emphasizing not forcing the patient through the opening we have, but making an opening to accommodate getting the patient out safely. If possible, we will get a rescuer in to assist the patient as much as possible and comfort the patient while the vehicle is removed from around them.
As the vehicle is cleared away sufficiently to create adequate space, we remove the patient while protecting the patient from further injury by limiting movement and contact with sharp edges or other hazards.
In order to follow the principles of extrication, there are a wide variety of resources available to us, ranging from simple hand tools to hydraulic and pneumatic tools. It's important to first to plan and equip yourselves as best you can and to know what resources you have and how they can be applied.
Not all crashes require complex rescue. In some cases simply opening a door and pushing it out of the way will gain access. In other situations, simple hand tools like belt cutters to release restraints or punches to break tempered glass may be all that is needed.
In more complex situations, which require considerable force to be applied to the vehicle, stabilizing the vehicle is important. Ensuring that the vehicle does not move during operation can be as simple as ensuring it is in park gear or as complex as using cribbing or rope and cables to keep a vehicle from sliding down a hill. Cribbing has improved in recent years in a variety of sizes and in weight and strength making it easier and safer to employ.
Evolution Of Tools
Come-alongs and other devices are available for moving a part of the vehicle out of the way and securing it in place. Rescue air bags or rugged bags that can be filled with compressed air can also lift and help stabilize a vehicle.
While there are multiple manufacturers that provide hydraulic cutters, spreaders and rams to us now, when I was a young firefighter, Haligan tools and pry bars were what was employed to get into most vehicles. I still enjoy watching rescuers, who with pride, can demonstrate how quickly they can get a door open with hand tools.
The first mechanical addition we saw were pneumatic tools designed for body shops. Air-powered chisels and cutters helped us get through tough situations that required more muscle. Hand pumps powered the first ones I used, and later tools used compressed air.
These tools have been refined specific to our use over the years and are still employed by many rescuers. The last 20 years have seen the development of hydraulic cutters, spreaders and rams. These powerful tools make short work of getting to the patients and creating openings for removal. The technology over the years has made them lighter, more powerful and improvements in power generation have made them easier to deploy on scene.
If we begin with principles, and we've evaluated our resources, that brings us to the most important part - application. This is the actual work.
Our ability to apply knowledge and resources in skillful safe practice depends on education and training. Education provides the theory in order to make the principles of extrication a part of the way we think. It enables us to review the inventory of tools at our disposal so we know what they are capable of so we may call upon them for use on the street.
The actual work, however, has its best chance of good outcomes if the rescuers are confident in their ability to perform the task. This requires training.
Confidence comes through experience, to be sure, but in gaining that experience it is fundamentally important to train with all of our tools in a variety of situations, challenging ourselves to solve technical problems. This practice will build that confidence and create a kind of library of experiences in extrication enabling us to apply a personal experience to a new situation with high expectations of success.
Most departments include extrication on their training schedule. That is helpful, but in becoming a rescue specialist, one should take advantage of every opportunity to perfect the craft. There are opportunities outside of your regular training schedule.
One example is through EMS training. Part of emergency medical technician training requires an extrication demonstration that allows the students to experience the noise and commotion of a crash scene and gives them an opportunity to practice working on patients in a crash.
Look into your local EMS training programs and see what you can do to participate in their training including the extrication drills. Another opportunity would be to become a trainer yourself or at least volunteer to assist with the extrication trainers.
Local colleges and academies have extrication courses going throughout their schedules, and they are always looking for help getting the demonstrations set up, preparing the equipment and monitoring the students. One of the best ways to improve your skills is to teach others.
Early in my career, I began teaching because in preparing my presentations I felt that I was making myself better at my job. In all aspects of our work there are elements that we seldom use that require practice to be able to employ.
Becoming an instructor or trainer's aide gives us that opportunity to practice all of our skills, not just the ones our call volume give us the opportunity to use most frequently.
This column is offered as an outline defining principles, resources and applications as the three elements to efficient and safe extrication, not an extrication refresher.
I'd like to make the point that you need to understand your own resources and your ability to apply the principles, using the resources available to you, with confidence. That confidence comes from practice. Give yourself the opportunity to gain experience that can be called upon at 2 a.m. in the cold and sleet when your patient needs you.
Finally, take a look at the tools you have and keep your eyes open for new technology in magazines and at trade shows.
See what else may be out there that will help you in your mission.
Editor's Note: Will Chapleau, who has 30 years of EMS experience, is the Advanced Trauma Life Support (ATLS) program manager for the American College of Surgeons. He is the former chief of the Chicago Heights (Ill.) Fire Department, has served since 1996 as the chairperson for the Prehospital Trauma Life Support (PHTLS) program of the National Association of Emergency Medical Technicians and has been a member of its international faculty since 1984. He is a board member of the National Association of EMS Educators.