A true revised mindset on vehicle rescue and extrication

In looking over my career in emergency services, both as a provider and as an educator, involved with vehicle rescue, much of the tool evolutions or the methodology of how we have made space to disentangle injured vehicle occupants has not really changed all that much. It has kept pace with the tools that have come onto the market as well as the vehicles and their technology concerns. Most times we have been behind the curve, either tool or vehicle wise or even both! 

Rescuers – let’s look at space making evolutions. While we know why EMS providers need to be hands-on with the patient inside the vehicle, we need to improve our on-scene time against trauma. Remember, trauma is the disease of time. The patient doesn’t have time on their side and neither do we, and vehicle extrication is a medical intervention. That’s not a question, it’s a statement folks. But many of the tool evolutions we use today are the very same tool evolutions that have been used in the past 30 or 40 years, perhaps adjusting to the vehicles of the time. 

But what have we done as rescue technicians to make a definitive change to adapt to the vehicles of today and to gain time on the patient’s trauma clock? Sadly, this is one area where we as rescuers or responders do not actively perform research or even casual research. We are faced with casual observation when we are able to get new vehicles to practise on and from actual incidents themselves.

Today’s vehicles absorb crash energy two different ways. Front and rear, vehicles will readily absorb crash energy and crush easily. The front end includes the driveline and even that will absorb crash energy and to a certain extent it will drop onto the ground and that will transfer it to the ground even flattening the tyres in the process. However, the sides of the vehicle are a totally different matter. The side of the vehicle is designed to repel crash energy or to deflect any intrusion into the passenger cell of the vehicle. This is why even 6in or a foot of intrusion in the side of a vehicle with an occupant is a significant clue to suspect injury.

So, as rescuers we need to strive to find a better way to create space in vehicles to disentangle patients. Vehicles today are smaller than in the past and in many crashes they will crash and crush up even smaller. What we need to do today is to use the vehicle to assist us with our space-creation evolutions and we need to make a significant change in our methodology to create space, perhaps more strategic than in the past and in the process of weakening the structure of the vehicle as well. In addition, it also releases stored crash energy in the vehicle from the incident by the process of strategic tool evolutions, progressively weakening the vehicle structure and making it fail on purpose and in the direction we want by the tool evolutions and actions we as rescuers are performing.

The first concept is that of Strategic Tool Operations. Basically, we are going to look for ways to weaken the vehicle structure, release ‘trapped’ crash energy that has been absorbed by the vehicle structure and make the vehicle structure work for us to help create space for access and disentanglement of our patients. One simple way is the Fender ‘Raus’ or strip/removal evolution. This evolution is the removal of the fender on the side of the vehicle where the patient is but when it is done is key. This is done right after stabilization is complete, glass management is being done and EMS is inside with the patient. It is the very first tool evolution and exposes the door hinges, the crush zone and the damage to the inside of the wheel well. This will allow for easy access to remove doors, then to observe feet and lower extremities for injuries and or entrapment.

More examples of this strategic process are dash lift and, even better, the whole process of cross ramming the vehicle structure. Rams today, especially telescopic rams are fantastic dynamic tools for this process of reforming the interior of the vehicle back to its original size or actually to a size we desire and require for patient disentanglement.

The next concept is thinking of ‘more than just a door’. Door displacements or ‘pops’ are a routine common tool evolution. And in many ways, this needs to change. Doors on vehicles in years past were larger by nature and this led to door displacements becoming the most common tool operation for both patient access and patient disentanglement. And it made sense. Easy access, easy removal, easy peasy. However, not so easy today. First off, most vehicles today are four doors, be it a car, SUV or even pickup truck. Doors are smaller and the outside materials are thin, flimsy and weak but are backed up by super-strong advanced steel alloys and other materials. Those days of simple door pops are gone and easy access with it. There are lots of ways to call it: B Post tear, B Post rip, Butterfly evolution, Noah’s Arc, etc. But basically, I want you as a rescue technician to look at the side of the vehicle and see it as a total side removal. One door, one side opening. One structural component of that vehicle to be displaced or removed.

Along with this side removal action we really need to look at the whole process of removal of the vehicle’s damaged components and maybe rethink and relook at removal and just simple movement. Space is simple in that it can be created in a variety of different ways. Removal of vehicle components, relocation of vehicle components, stretching of vehicle structure are the primary ways we could create space to access and disentangle patients from vehicles post collision. Now with today’s vehicle construction methodology and usage of advanced steels and alloys as structural reinforcements, this adds an interesting tool to our space-creation process. High tensile strength alloy materials are strong, but if they are bent, they will stay bent in the direction they were bent in. This is important, rescuers! This means certain vehicle components like roofs for example can be stretched and bent by using a power hydraulic rescue tool ram and even stretched further away by simply severing a roof post such as an A post. This is also why a dash lift works well since you are putting force under the dash reinforcement bar, basically turning it into a class 1 lever. So instead of removing four doors, a roof and displacing a dash we can today perform a fender raus, total side removal, stretch and displace the vehicle roof upwards and lift the dash in much less time while using the vehicle structure to actually help us instead of fighting us.

Part of this ‘stretching’ of vehicle components such as the dash lift evolution is a refocus towards the wire boot hole that goes from the dash to the door. Along with the fender raus or removal this focus on the wire boot is twofold. First off, we are after the actual hole created by that boot and wiring so just push the wire and boot out of the way. Second, this hole is prime real estate for a deep relief cut for a dash evolution. How so? Well easy, insert one of your cutter blades on each cut in both directions. The direction towards the occupant cell is a simple snip but the cut going towards the firewall/wheel well allows you to open the cutter wide and the other blade to grab into the wheel well. Another option is to use your spreader to perform a ‘no relief cut’ dash lift in two different ways. One way is basically to insert your spreader tips into the wire boot hole and open the tool vertically, ‘ripping’ the hole open as the arms open. Adjust the tool as the spreader lifts the dash, you might need to grab more of the dash or the lower A post. The other way of the ‘no relief cut’ dash lift is to capture the inner end of the underside of the dash with one tip/arm of your spreader and the other tip/arm goes against the footwell. As the tool opens up and lifts, it stretches the dash. The dash reinforcement bar acts like a class 1 lever as a simple mechanical advantage in both cases.

An important concept to look at is controlled vehicle relocation. This is not a new tool operation nor one that is power hydraulic rescue tool based. The concept is to move the vehicle to a better location or orientation for facilitating space creation for the patient. This has a new life due to selective spine clearance from the NEXUS study; however, this tool operation has been around for some time in motorsport and different parts of the world. In some vehicles and orientations, you have no other choice but to move the vehicle to facilitate the driver removal. How do we accomplish controlled vehicle relocation? Basically, simple tool operations in conjunction with simple cribbing or stabilization while being observed and over watched by a safety officer while the patient is being treated by EMS. Once the vehicle has been moved into its new position, it is stabilized and final space creation is commenced.

So, Rescuers remember these statements:

ν ‘Trauma is the disease of time’

ν ‘Vehicle extrication is a medical intervention’

What has stayed constant is our need to rapidly access and then safely and rapidly create space or a pathway for the injured occupants to be removed from the vehicle. However, even this has changed in the light of the NEXUS study, which has brought about the widespread use of selective spine clearance in the pre-hospital environment. This allows us to not automatically board and collar all injured vehicle occupants, only those who need such treatment due to our patient assessments. Common sense coupled with focused patient assessment wins! Sadly, this has led many EMS providers to become complacent and lazy. Rather than allow Rescue to create proper safe space to disentangle patients, these providers choose to drag patients across centre consoles and other obstacles since they can point to the NEXUS study and state the chance of further injuries is null. But would you like to have this done to your family members, and how professional are these actions truly?

So, let’s look at what is being used to move and package patients. Adjustable C-collars are fine and justified but what else is available today? Long spine boards are frowned upon but, really, why? If your assessment justifies its use then use it. But you can still use it as a transfer or movement device. There’s nothing wrong with it being used in these applications. Selective spinal clearance programmes only want you not to transport patients to the appropriate medical facility on a long spine board. Then what of other movement devices to assist you with disengagement of your patients from the vehicle? The first device that comes to mind for most rescuers is a KED device. The KED has been around a very long time, since the 1970s. It was designed for the vehicles of that time, with a large amount of space with large door openings and for the prevalent seating arrangement of the time, a bench seat. Many rescuers today do not know even what a bench seat is. So, what are most vehicles today? Four smaller doors, bucket seats designed to keep you planted into the seat with a centre console between the driver and front passenger and much less interior space than ever. Yet we are still using a device unimproved for at least 45 years to do the same job it was intended to do in the 1970s. If we put it on a patient in a vehicle today it will physically entrap them, if they were not before. See a problem here? There are much better movement devices on the market today. The key word here is movement device. Speedboard is one. Ferno XT is another. MED spoon board is yet another. And for long spine board alternatives, a plastic take-apart scoop board is great and so is a vacuum mattress. Another movement device that has not taken off here in North America, but is a definite look at and try out, is the PAX Rescue Boa. It works much like an endless webbing loop for a drag or a hospital blanket roll for a lift but works so much better than both devices. It’s an awesome piece of kit!

Even with all this, we still need to remember key safety items that are important today. We need to strip/pull trim whenever we cut roof posts and roof edges. Actually, it’s a good practice to not blindly cut into the vehicle structure without looking at what we are cutting into. Use of hard protection between tool evolutions and the patient and interior rescuer is more important than before. This is due the amount of advanced steel and alloy present in vehicles and their tendency to create small pieces of debris when fractured during severing. Along with hard protection, soft protection covering our patients and interior rescuers is equally important. And last but definitely not least, power isolation is critical today. Remember to:

ν Chock wheels – set the E brake

ν Shut the vehicle off – Gather up all the keys

ν Find the 12V battery and double cut both cables – negative then positive 

ν Document it

Remember that keys today are almost always wireless fobs, but the trend is going to a card and an app on a smartphone. Also, today’s keys need to be kept 50ft away from the vehicle, much farther than before. However, you can use a device called a Faraday bag that blocks the key’s RDIF signal to the vehicle. Also, over 50% of 12V batteries today live outside of the engine compartment, the next most likely location being in the rear of the vehicle. Consider vehicle damage and such in your vehicle survey when checking for the 12V battery.

The last item, but one that is rapidly becoming extremely important, is on-scene vehicle hazard information. Luckily, we have smartphone apps and automotive manufacturers now install QR code stickers on vehicles to assist us on scene. While space prohibits me going into depth on these items, they give us background information on vehicle hazards and concerns. How to shut down alternative-fuelled vehicles in various ways, firefighting tactics and much more. Depending on where you are in the world, these smartphone/tablet apps can be Moditech CRS, NCAP Rescue Sheets, AUSCAP Rescue Sheets, or Rescue Code, for example. All of these plus the OEM ERGs are important information for your response and training. Use them!

This is all part of the mindset and methodology that today’s vehicle rescue needs to evolve into. We are faced with a constantly changing dynamic, of both the vehicle and its technology. Other parts of what we deal with in Emergency Services have a higher-level learning and educational process, which includes research into the various activities, methods and methodology, concerns and issues faced by responders. Perhaps it is time that Vehicle Rescue and Extrication joins Fire Science that has research into the process of the who, what, why and because of what we do on scene. In order to keep ahead of the trauma clock, we need to investigate ways to develop new methodology for space creation, better tools to create such space, better educational programmes to facilitate both patient care and rescue skills and finally operational planning skills that blend both patient management and rescue activities as well as overall scene mitigation activities as a whole.

For more information, email carslayer@roadwayrescue.com