2. Gaining Access & Vehicle Extrication
The Role of EMS During Patient Extrication or Rescue

3. Introduction
The number of transportation, agricultural, environmental and residential accidents are increasing throughout the world, resulting in higher numbers of serious injuries and deaths.

4. Introduction Con’t
In Manitoba we have a vast area to cover as EMS providers. With accidents increasing we as EMS providers should be concerned. Being prepared when accidents occur throughout our province takes preparation and dedication from members of rural EMS.

5. Introduction Cont’d
Develop loosely defined roles for responding EMS crew to assess accident scene and confirm level of response needed.
EMS crews should be aware of any responding agencies roles and responsabilities.

6. Objectives Define extrication and goals Roles of agencies at scene
Placement of vehicles at scene
Scene assessment / Scene size-up

7. Objectives Stabilization Access to patient Disentanglement of patient
Patient removal
Post call
Obviously you would transport between removal and post call, that is covered elsewhere

8. Objectives Define extrication and goals Roles of agencies at scene
Placement of vehicles at scene
Scene assessment / Scene size-up

9. Extrication
The removal of a person from a building, vehicle or area of danger. More specifically the removal from a damaged vehicle, collapsed structure, or other position of entrapment.

10. Simple Definition:
Removal of a trapped patient

11. Goal of Extrication

12. Goal of Extrication
To remove the victim from entrapment without further injury or unnecessary movement.

13. Primary EMS Unit Crew members responsibilities:
Safety first for themselves and their partner
Secondly safety to the patient
Determine need for addition resources
Plan of action to complete goals

14. Crew Safety PPE. Rescue Helmet Eye protection
Protective clothing (Jacket, Gloves)
Position of vehicle(s) in relation to traffic

15. Hazards!! Fire Fuel Leaks Downed Power Lines Hazardous Materials
Unstable Vehicle/Structure
Traffic
Crowds

16. Communications Communications:
Interagency communications must be available
Important to asses and update potential resources (Fire Dept., Additional EMS units, ER.Dept, Law Enforcement)
Communication between agencies is of the utmost importance

17. Communications Communications con’t:
Messages, whether sent via radio or in conversation, must be clear, concise and to the point
During major incidents members may be required to change to a different frequency on their radios so as not to hamper radio transmissions on a department’s primary channel. Secondary and tertiary channels should be established before or on arrival at the scene
Special codes or radio language should be common between all members (e.g. 10 codes)

18. Objectives Roles of agencies at scene Define extrication and goals
Placement of vehicles at scene
Scene assessment / Scene size-up

19. Different Agencies Law Enforcement Fire Department Rescue Hazmat Hydro
Gas (Natural Gas / Propane)

20. Role of Law Enforcement
Investigation of incident
Traffic control
Crowd control
Preserve scene for reconstruction and investigation

21. Role of Fire Dept. Extinguishing fires Preventing fires
Handling spills or leaks
Vehicle safety
Energy absorbing bumpers
Electrical system
Fuel system
Stabilization
Assist police and EMS

22. Role of EMS (That’s us) Patient contact throughout incident
Patient assessment(s)
Triage
Patient care
Assess need for disentanglement
Advise rescue of entrapment conditions
Packaging of injuries / patients
Transport patient

23. Role of Rescue
Rescue may be performed by a separate agency or may be a part of Fire Dept or EMS Duties.
Establish incident/scene command
Assess rescue needs/ ext’n techniques
Provide patient access
Disentanglement
Assist EMS
Scene safety

24. Role of Hazmat Advise command of risk / hazards Secure scene
Evacuation of area
Removal of patients at contaminated scene
Decontamination of patients

25. Role of Hydro / Gas Advise command of risk / hazards
Assist in securing scene

26. Scene Size-up Consists of two surveys. Outer circle survey
Inner circle survey

27. Scene Size-up Outer Circle Survey
Starts when arriving, includes ambulance parking.
Assess hazards
Medical Needs
Number of patients
Location of patients
Trapped or not
Rollover - search 300 ft or more for additional patients

28. Scene Size-up Assess Rescue needs. Require: Additional Manpower
Forcible entry
Tools for disentanglement
Tools for patients egress
Additional lighting
Additional Manpower
Call in other agencies
Vehicle size-up

29. Inner circle survey Close up look at crash Initial patient contact
Approach patient from in front
Identify patient condition(s)
Identify degree of entrapment
Find hidden hazards (Airbags/Bumpers)
Assess need for stabilization

30. Stabilization Stabilization:
Safety before approaching the vehicle. (is the vehicle still running, on fire, hazardous chemicals present, HYDRO lines downed etc.)
Vehicle should be stabilized before personnel enter vehicle using wooden blocks and deflating the tires, vetter mats, or using jacks
Personnel should be aware of possible un-deployed airbags
Traffic hazards

31. Stabilization Con’t: How many vehicles involved
Scene may require light - if so use intrinsically safe devices if available
Make use of vehicles own safety features such as placing vehicle in park or applying the emergency brake

32. Where are airbags? Driver side (steering wheel)
Passenger side (above glove box)

33. Where are airbags? Side impact In side of seat In ‘B’ post
Tubular across window
Curtain (guillotine)

34. Where are airbags?
Side impact
A Post
C Post
B Post

35. Anatomy of the airbag
AIRBAG NUMBERS million cars have airbags, with 1 million new cars added each month. - Frontal airbags have been required since Frontal airbags have been required in sport utility vehicles and light duty trucks since Since 1998 depowered airbags have been required. TODAY, SOME VEHICLES HAVE 8-10 AIRBAGS. - Over 7 million cars (in 185 models) have side impact airbags. AIRBAG POWER AND FORCE - Force of 4,000-6,000 lbs. per square inch results in the first few inches of an airbag deployment. The adult human chest can experience injury at 3,000 lbs per square inch. AIRBAG INFLATION - Most airbags use sodium aizide, the solid pellet form of a rocket propellent. - Some systems are compressed argon gas, helium or nitrocellulose. FRONTAL AIRBAG SPEED - Airbags have been clocked up to 300 mph. Most airbags depoloy at mph. - Depowered airbags deploy between mph. - Side airbags deploy 3 times the speed as frontal airbags. FRONTAL DRIVERS AIRBAG SIZE - Most older cars from 1974 to 1992 have full powered airbags. They deploy at inches long. - Most new cars and those after 1998 have tethered airbags that are 10 inches long. PASSENGER AIRBAG SIZE - Bucket seat bags (5 passenger) deploy out inches long X 24 inches wide. - Bench seat cars (6 passenger) deploy out inches,. They are 1 1/2-times (2.5 feet) as wide as the bucket seat airbag. They protect the right front and middle seat occupant. SIDE IMPACT AIRBAG SIZES - Door mounted airbags deploy into the vehicle 5 inches. - Seat mounted Thorax bags deploy along the side of the seat 5 inches. - Seat mounted Head-Thorax bags deploy out 5-9 inches wide, but are taller from the top of the seat to the seat base. - BMW's HPS airbag is 3 feet 6 inches long X 6 inches tubular shaped. - Side impact curtains are 5-6 feet long X inches X 2 inches thick.
Mention OOPS, out of position seating

36. Control Zones Hot, Warm, Cold Reduce congestion More efficient
Less confusion
Circular
Size depends on accident scene

37. Hot Zone Closest to extrication Access only to those performing
Patient care
Extrication
Keep unused equipment out of hot zone

38. Warm Zone Just outside of hot zone Access only to those
Helping workers in hot zone
Handling charged lines
Handling scene lighting
Treating patients
Treat patients prior to transport in warm zone if safe to do so

39. Cold Zone Outer circle Where equipment and manpower staged
Command post
Cordoned off

40. Patient Access When safe access the patient
If possible make the car safer / easier to access
Secure the keys
Remove or cut seatbelt if safe
Unlock doors and roll down windows
Assess patient injuries and entrapment
Cover patient

41. Patient Access “Try before you pry!”
First try simple access: attempt access without using tools. Open a door or go through an open window.
If this doesn’t work, you must try complex access.

42. Complex Access Tools are required to access patient
Break a window, open a door
Break a window, crawl in
Use hand tools to make a pathway through wreckage to patient
Have TOOL personnel create a pathway using hand tools or heavy hydraulics (jaws of life)

43. Laminated glass Formed of a layer of plastic between 2 layers of glass
Shatters, but glass stays in place
Found on vehicle windshields (front)

44. Tempered glass Single piece of hardened glass
Shatters into thousands of small pieces
Found on vehicle side and rear windows

45. Removing Laminated Glass
Try pulling out rubber seal around window, remove window intact
Cut windshield with saw, axe, or specialized tool
If cutting, USE DUST MASKS ON RESCUERS AND PATIENT! Let patient and other rescuers know you are “CUTTING GLASS!”

46. Removing Tempered Glass
Try rolling down side windows, try pulling rubber out around rear windows
Break window with a center punch (bottom corner) or pointed object
When possible, use farthest window
Pull glass out, possibly into tarp or sheet, then roll it up
Make sure patient and rescuers know you are “BREAKING GLASS!”, cover Pt.

47. Disentanglement Always use soft and hard protection
EMS must maintain patient contact
EMS must maintain contact with rescuers
Continue re-assessing patient
Treat patient accordingly, C-collar, KED, Splints, etc.

48. Extrication What’s happening around you!
Dash roll / dash lift / steering wheel lift
Cut steering wheel
Roof removal / Roof flap
Side takedown
“Pop” doors

49. Side Flap

50. Roof Removal Dash Lift

51. Caring For The Patient
Safety while treating the patient is paramount. If available, a safety officer should be established along with the IC. Safety can also be another roll the IC and his crew members, leaving the IC with the overall command.
Personnel should establish direct communication link between EMS involved with Pt. care and those performing extrication.
Always communicate to ensure safety of all involved

52. Caring For The Patient
Once the EMS has gained access, he or she acts as the eyes and ears. He or she must communicate with the extrication members, Pt., and additional EMS resources during extrication.
EMS also decides (and must recognize) load and go situations or stay and play situations.

53. Caring For The Patient For patient safety, here are a few tips:
Ensure the Pt’s airway and control C-spine
Assess the Pt’s breathing and pulse
Establish the Pt’s L.O.C. and re-evaluate
Scan the Pt. starting at the head
Control hemorrhage as you encounter severe bleeding
Treat for shock
Provide emotional first aid as well as physical first aid
Personnel should explain what is happening around the Pt.(e.g. we are going to be breaking the window across from you)

54. Patient removal
May require more disassembly, distortion, displacement or severing
Communicate with rescue team
Communicate with patient
Maintain spinal immobilization

55. Patient removal Out door, feet first onto long board
Out door, head first onto long board
Out top, tilt seat back slide patient up onto long board
Improvise!
Secure to board
Treat patient
Advise receiving facility of Pt. condition

56. Post call Determine need for CISM
Collect equipment, pick up people you left behind
Clean, test and restock equipment
Critique

57. Some info on non powered hand tools
Screwdrivers can be used to break glass, open trunks & remove vehicle’s cosmetics.
Socket set w/ratchet to remove nuts & bolts that hold seats, doors, etc.
Pliers to cut wires, remove cosmetics or pull valve stems.
Spring loaded center punch to break glass.
Bolt cutters to cut bolt & steering wheel ring.
Long & short board for pt’s protection, stabilization & packaging.

58. Non powered tools (continued)
Pike pole to help flop the roof
Pry bar to make a purchase point & force doors
Flat headed axe to cut windshield
Halligen to make a purchase point, remove trunk locks & break tempered glass
Pry axle can opener to cut windshield, make purchase point & cut sheet metal
2 X 4 & 4 X 4 cribbing & wedges to stabilize vehicle (used with come along)
Come along with chains to pull dashes & seats, displace doors, pull roof & stabilize vehicle

59. Non powered tools (continued)
Chains to wrap dashboard & seats, pull roof or displace doors
Pneumatic tools (air powered) to cut roof, make relief cuts, third door conversion & cut windshield
Air bags used for lifting, pulling & stabilizing
Reciprocating electric or air operated saw
Hand operated hydraulic tools
Spreader used to force doors, seats & pedals
Cutter used to cut posts, make relief cuts, cut steering wheel & roof.