1. Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Gaining Access Chapter 32

2. Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Case History You respond to a motor vehicle crash and find two teenagers trapped in a burning car. The fire is contained to the engine compartment but the flames are widespread and pose a threat to the occupants. You respond to a motor vehicle crash and find two teenagers trapped in a burning car. The fire is contained to the engine compartment but the flames are widespread and pose a threat to the occupants.

3. Slide 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Rescue and Extrication  Rescue is a specialized field in prehospital care.  EMTs must work closely with rescue teams.  Primary responsibility is patient care.  Some systems include dual clinical and rescue responsibilities.

4. Slide 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Situations That May Require Rescue  Motor vehicle crashes  High-angle incidents  Confined space incidents  Water incidents  Collapsed buildings

5. Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Role of the Non-Rescue EMT  Administer necessary care to the patient before extrication.  Ensure that the patient is removed in a way to minimize further injury.  Patient care precedes extrication.  Unless delayed movement would endanger life of the patient or rescuer

6. Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Role of the Non-Rescue EMT  Working with others  Work together with the rescue providers.  Cooperate with the activities of the rescuers.  Do not allow their activities to interfere with patient care.

7. Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Rescue EMS  EMS providers may serve as rescue providers.  Chain of command should be established to ensure priorities.  Administer necessary care to the patient before extrication.

8. Slide 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Rescue EMS  Ensure that the patient is removed in a way to minimize further injury.  Patient care precedes extrication.  Unless delayed movement would endanger life of the patient or rescuer

9. Slide 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Approach to the Scene  Approach hazardous scenes 100 feet, uphill, and upwind.  Observe scene.  How many vehicles are involved?  How many patients are present?  What additional resources do you need?  Perform risk/benefit analysis.  Will scene pose undue risk to you or other rescuers?  If so, consider waiting for appropriate resources (e.g., hazmat team).

10. Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Windshield Survey  Are the patients moving?  Are they conscious?  Are they attempting to exit vehicle?  Check for downed electrical wires.  If present, do not touch anything.  Retreat to position of safety.  Advise occupants not to exit.

11. Slide 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Evaluate Vehicle Stability  Can vehicle be entered safely?  Will vehicle turn over?  Is vehicle on its side or wheels?  Is it in a secure position?  Does vehicle rock?  Block frame of vehicle, if needed.  Ensure stabilization.

12. Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. The 12 “Nevers”  Never enter a potentially hazardous rescue scene without appropriate PPE.  Never operate on an active roadway until traffic flow has been controlled.  Never enter an unstable vehicle until it has been appropriately stabilized.  Never enter a fire scene unless directed by fire rescue.

13. Slide 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. The 12 “Nevers”  Never enter a confined space unless directed by rescue.  Never attempt deep water rescue without support of water rescue personnel.  Never enter a toxic scene until cleared by fire and rescue personnel.  Never enter a structural collapse unless directed by rescue personnel.

14. Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. The 12 “Nevers”  Never enter a violent scene before arrival of police.  Never attempt rescue from height without high-angle rescue team.  Never approach an electrical hazard unless cleared by appropriate rescue or utility personnel.  Never proceed with any potentially hazardous rescue until you are fully assured that the scene is safe.

15. Slide 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Traffic Control  Park vehicle to “fend off” oncoming vehicles.  Wear highly reflective traffic vests.  Use reflective traffic cones or road flares at night.  Never use flares where flammable vapors or liquids are present.

16. Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Personal Protection – Turnout Gear  Headgear  Eye protection  Respiratory protection, if required  Gloves  Boots  Coat

17. Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Respiratory Protection  Must have before entering smoke conditions or a potentially toxic environment  Self-contained breathing apparatus (SCBA)  Restricted to individuals who have had hands-on training

18. Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Patient and Bystander Safety  Use of rescue blanket  Needed when shards of glass or metal edges are present at rescue scene  Bystanders should be kept at a safe distance.  Victims should be prepared for loud sounds and activities for rescue process.  Psychological first aid is an important part of management.

19. Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Stabilizing the Vehicle  Prevents unwanted or dangerous movement of vehicle  Ensures structural integrity of vehicle is not compromised during rescue effort  Never lift a vehicle using bystanders and other rescue personnel.

20. Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Airbag for Stabilization

21. Slide 21 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cribbing for Stabilization

22. Slide 22 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Gaining Access  Access should be gained in most expedient manner possible.  Route for access may not be the same as removal of patient.  Objective is to provide lifesaving care and stabilization.

23. Slide 23 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Types of Access  Simple access  Access in which tools are not required  Complex access  When tools and other specialized equipment are necessary for access

24. Slide 24 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Access with Slim Jim

25. Slide 25 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Access with Spring-Loaded Punch

26. Slide 26 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Door Access  Door provides a good place to enter vehicle and remove patient.  Door openings may have to be widened by “walking” the door back.  Ensure vehicle is stabilized before “walking” door back.  One or two rescuers push body weight against door and slowly push beyond its normal operating range.

27. Slide 27 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Freeing the Driver  Steering wheel may trap driver.  Moving seat back is simplest method for freeing driver.  Always disconnect battery during extrication.  Modern vehicles may have one or more undeployed airbags that are ready to fire.

28. Slide 28 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Supplemental Restraints – Airbags  Virtually every vehicle built since 1990 has one or more airbags.  Once airbag deploys, it rapidly deflates.  Types of airbags  Driver’s bag deploys from steering wheel.  Passenger bag deploys from the dash.  Side impact airbags can fire from back of front seat, roof rail area, or from the door.  Un-deployed airbags represent a hazard to rescuers.

29. Slide 29 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 5-10-20 Safety Rule  Keep back 5 inches from side bag.  Keep back 10 inches from driver’s airbag.  Keep back 20 inches from passenger’s airbag.

30. Slide 30 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Patient Safety  Priorities (in order) 1. Provider safety 2. Patient safety  Inform patient of the unique aspects of extrication.  Patient should be protected from  Broken glass  Sharp metal  Other hazards