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

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

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.

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.

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

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

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

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.

Simple Definition: Removal of a trapped patient

Goal of Extrication

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anatomy of the airbag AIRBAG NUMBERS - 206 million cars have airbags, with 1 million new cars added each month. - Frontal airbags have been required since 1995-6. - Frontal airbags have been required in sport utility vehicles and light duty trucks since 1996-7. - 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 200-300 mph. - Depowered airbags deploy between 100-200 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 12-14 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 20-24 inches long X 24 inches wide. - Bench seat cars (6 passenger) deploy out 24-30 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 12-15 inches X 2 inches thick. Mention OOPS, out of position seating

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

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

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

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

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

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.

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)

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

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

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!”

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.

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.

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

Side Flap

Roof Removal Dash Lift

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

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.

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)

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

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

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

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.

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

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.