Vehicle Extrication and Special Rescue

Chapter 39 Vehicle Extrication and Special Rescue Unit Summary After students complete this chapter and the related course work, they will be able to describe and apply, in context, EMS rescue operations, including vehicle extrication and its 10 phases. Additionally, they will be able to describe various specialized components of EMS operations, including tactical EMS, trench rescue, high-angle rescue, and the EMT’s role in these operations. The safety aspects of these operations are also discussed. National EMS Education Standards Competencies EMS Operations Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Vehicle Extrication • Safe vehicle extrication (pp 1464–1475) • Use of simple hand tools (p 1472) Knowledge Objectives 1. Explain the responsibilities of an EMT in patient rescue and vehicle extrication. (p 1464) 2. Discuss how to ensure safety at the scene of a rescue incident, including scene size-up and the selection of the proper personal protective equipment and additional necessary gear. (pp 1464–1469) 3. Describe examples of vehicle safety components that may be hazardous to both EMTs and patients following a collision and how to mitigate their dangers. (pp 1464–1465) 4. Define the terms extrication and entrapment. (p 1465) 5. Describe the 10 phases of vehicle extrication and the role of the EMT during each one. (pp 1466–1475) 6. Discuss the various factors related to ensuring situational safety at the site of a vehicle extrication, including controlling traffic flow, performing a 360-degree assessment, stabilizing the vehicle, dealing with unique hazards, and evaluating the need for additional resources. (pp 1466–1470) 7. Describe the special precautions the EMT should follow to protect the patient during a vehicle extrication. (pp 1470–1472) 1 8. Explain the different factors that must be considered before attempting to gain access to the patient during an incident that requires extrication. (pp 1470–1472) 9. Explain the difference between simple access and complex access in vehicle extrication. (p 1472) 10. Discuss patient care considerations related to assisting with rapid extrication, providing emergency care to a trapped patient, and removing and transferring a patient. (pp 1473–1475) 11. Describe examples of situations that would require special technical rescue teams and the EMT’s role in these situations. (pp 1475–1479) Skills Objectives There are no skills objectives for this chapter. Readings and Preparations: Review all instructional materials including Emergency Care and Transportation of the Sick and Injured, Twelfth Edition, Chapter 39, and all related presentation support materials. Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation Enhancements • Direct students to visit Navigate. • Content connections: Chapter 2, Workforce Safety and Wellness, provides very relevant information that can be related to the extrication process. Chapter 10, Patient Assessment, provides useful information on how to assess individual patients. Chapter 25, Trauma Overview, and the rest of the trauma section cover very specific injuries that may be encountered when taking part in an extrication emergency. Chapter 8, Lifting and Moving Patients, relates information that will be needed during the extrication process. Teaching Tips • Discuss the need for personal safety equipment and what may be needed for vehicle entry and protection from sharp edges, broken glass, and fuel spills. • Stress the importance of having knowledge about alternative fuel vehicles as well as airbag deployment characteristics. 2 • Demonstrate and discuss certain personal safety situations and how to deploy a “360° look” at an environment to ensure personnel safety when responding to a potential hostile environment. Unit Activities Writing assignments: Have each student pick a certain rescue operation and detail what training is required as well as how EMS is involved. Student presentations: Break into small groups and have students research a recent disaster that involved some aspect of technical rescue and the EMS role, as well as some of the lessons learned. Examples include: • Hurricane Katrina • Earthquake in Haiti • Northridge earthquake • Red River floods • Local automobile accidents with multiple fatalities requiring extrication Group activities: Discuss the 10 phases of extrication and what each one entails. What are some of the tools an ambulance may carry and use, and what training is involved? Medical terminology: Create a matching activity using the terms and definitions found in the Vital Vocabulary section of the chapter. Pre-Lecture You are the Provider “You are the Provider” is a progressive case study that encourages critical thinking skills. Instructor Directions 1. Direct students to read the “You are the Provider” scenario found throughout Chapter 39. 2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. 3. You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture 3 I. Introduction A. You will usually not be responsible for rescue; you may assist with extrication. 1. Rescue requires training beyond the EMT level. II. Safety A. Extrication requires mental and physical preparation. 1. Priority is to provide patient care. 2. Personal safety and that of your team must be addressed before patient care is initiated. 3. The equipment that you use and the gear that you wear will depend on the hazards you expect to encounter, as well as what you observe during your scene size-up. III. Vehicle Safety Systems A. Vehicle safety systems can become hazards after a collision. 1. Shock-absorbing bumpers may be compressed or “loaded” following a front- or rear-end collision. a. Approach vehicles from the side. b. They can release and injure your knees and legs. 2. Manufacturers are required to install supplemental restraints or airbags in all new cars. a. Airbags fill with a nonharmful gas on impact and quickly deflate after the crash. b. Airbags are located in the steering wheel and the dash in front of the passenger. i. Side-impact airbags may be located in the doors or seats. c. Nondeployed airbags may spontaneously inflate while you provide patient care; maintain at least: i. 5-inch clearance around side-impact airbags that have not deployed ii. 10-inch clearance around driver-side airbags that have not deployed iii. 20-inch clearance around passenger-side airbags that have not deployed d. Haze inside vehicles in which the airbags have deployed is caused by cornstarch or talc. e. Appropriate protective gear, including eye protection, will reduce the risk of eye or lung irritation. IV. Fundamentals of Extrication A. Your primary concern is safety. 4 1. Your primary roles are to: a. Provide emergency medical care. b. Prevent further injury to the patient. 2. You may provide care as extrication goes on around you. 3. Extrication: the removal from entrapment or from a dangerous situation or position. 4. Entrapment: a condition in which a person is caught within a closed area with no way out or has a limb or other body part trapped. B. Roles and responsibilities 1. EMS providers are responsible for: a. Assessing and providing medical care b. Triaging and packaging patients c. Providing additional assessment and care as needed once patients are removed d. Providing transport to the emergency department 2. The rescue team is responsible for: a. Securing and stabilizing the vehicle b. Providing safe entrance and access to the patients c. Extricating any patients 3. Law enforcement officers are responsible for: a. Controlling traffic b. Maintaining order at the scene c. Establishing and maintaining a perimeter 4. Firefighters are responsible for: a. Extinguishing fire b. Preventing additional ignition c. Ensuring that the scene is safe d. Removing spilled fuel 5. Roles and responsibilities often vary based on jurisdiction and available agencies. 6. Good communication among team members and clear leadership are essential to safe, efficient provision of proper emergency care. C. Preparation 1. Preparing for an incident requiring extrication involves preincident training with rescue personnel for the various types of rescue situations to which you might respond. 2. Rescue personnel must routinely check the extrication tools and their response vehicles. D. En route to the scene 5 1. Procedures and safety precautions similar to those in the phases of an ambulance call are used when responding to a rescue incident. E. Arrival and scene size-up 1. Position the ambulance to block the scene from oncoming traffic. a. Use only essential warning lights. b. Choose a location that will allow safe access to the scene while leaving a way to drive your ambulance out. 2. Put on PPE and look for passing cars before exiting your vehicle. 3. Make sure the scene is properly marked and protected. 4. Size-up is the ongoing process of scene assessment to determine appropriate strategies and tactics to manage an emergency. 5. Evaluate the hazards and determine the number of patients by doing a 360° walk around of the scene. a. Look for the following: i. ii. iii. iv. v. vi. vii. Mechanism of injury Downed power lines Leaking fuels or fluids Smoke or fire Broken glass Trapped or ejected patients Number of patients and vehicles involved b. While looking at the vehicle or vehicles involved in a motor vehicle collision, note the damage. i. Bent steering wheel may indicate significant face and/or thoracic trauma. ii. Imprints in the dashboard may indicate lower extremity injuries such as fractures and possible hip dislocations and fractures. iii. Lift deployed airbags to see if there is deformity to the steering wheel or dashboard, which indicates the patient struck the structure after the airbag deflated. iv. Unrestrained patient may have contact injuries as well as secondary injuries; check windshield for a spider-web pattern of shattered glass indicating possible head, face, or neck injuries. v. Include findings in your documentation; use the information to maintain a high index of suspicion. c. d. e. f. Evaluate the need for additional resources Look for spilled fuel and other flammable substances. Rain, sleet, or snow can present an added hazard for rescue. Crashes that occur on hills are harder to handle than those that occur on level ground. g. Some crash scenes may present threats of violence. 6. Coordinate your efforts with rescue teams and law enforcement. 6 a. Communicate with members of the rescue team throughout extrication. i. Start talking to the incident commander as soon as you arrive. ii. You will enter the vehicle and provide care for the patient(s) when approved by the incident commander. F. Hazard control 1. Downed electrical lines are a common hazard at vehicle crash scenes. a. Never attempt to move downed electrical lines. b. If power lines are close to a vehicle involved in a crash, instruct the patient to remain in the vehicle until power is shut off. c. Remain in the safe zone, outside of the danger zone (hot zone). 2. Family members and bystanders can also create hazards. 3. The vehicle can be a hazard. a. An unstable automobile on its side or roof can be a danger to you. i. Rescue personnel can stabilize the car with a variety of jacks or cribbing. b. Ensure that the car is in “park” with the parking brake set and the ignition turned off. c. Both battery cables should be disconnected to minimize the possibility of sparks or fire. 4. Alternative fuel vehicles a. Vehicles may be powered by electricity and electricity/gasoline hybrids, or fuels such as propane, natural gas, methanol, or hydrogen. i. Disconnect the battery. ii. In more than 40% of today’s alternative fuel vehicles, the batteries are located in the trunk or under the seats, not in the engine compartment. iii. There may be more than one battery present. b. Hybrid vehicle systems i. Hybrid batteries have a higher voltage than traditional automotive batteries. ii. It may take up to 10 minutes for a high voltage system to deenergize after the main battery is turned off. iii. Avoid high-voltage cables (typically orange) and components. iv. Damaged high-voltage batteries may give off toxic fumes. v. Do not approach the vehicle if unusual odor is detected, and retreat if you experience burning in your eyes or throat. G. Support operations 1. Support operations include: a. Lighting the scene b. Establishing tool and equipment staging areas c. Marking helicopter landing zones 2. Fire and rescue personnel will work together to accomplish these functions. H. Gaining access 7 1. Make sure that the vehicle is stable, and hazards are eliminated or controlled. 2. The exact way to gain access to a patient depends on the situation. 3. To determine the exact location and position of the patient, consider the following questions: a. Is the patient in a vehicle or in some other structure? b. Is the vehicle or structure severely damaged? c. What hazards exist that pose a risk to the patient and rescuers? d. In what position is the vehicle? On what type of surface? Is the vehicle stable or is it apt to roll or tip? 4. Rapid extrication may be needed to quickly remove a patient if the environment is threatening or if the patient needs resuscitation. a. A team of experienced EMTs should be able to perform rapid extrication in 1 minute or less. 5. During the access and extrication phases, make sure the patient remains safe. a. A heavy, fire-resistant blanket can be used to protect the patient from flying glass or other objects. b. Always describe what you are going to do before you do it and as you are doing it, even if you think the patient is unresponsive. c. Try to keep heat, noise, and force to a minimum. 6. Access a. The first step is simple access, or trying to get to the patient as quickly and simply as possible without using any tools or breaking any glass. b. Complex access requires special tools, such as pneumatic and hydraulic devices. I. Emergency care 1. Providing medical care to a patient who is trapped in a vehicle is essentially the same as for any other patient. 2. Once entrance and access to the patient have been provided and the scene is safe, perform a primary assessment and provide care before further extrication begins. a. Address any exsanguinating hemorrhage with direct pressure or a tourniquet if appropriate. b. Provide manual stabilization to protect the cervical spine, as needed. c. Open the airway. d. Provide high-flow oxygen. e. Assist or provide for adequate ventilation. f. Control any significant external bleeding. g. Treat all critical injuries. J. Removal of the patient 1. Rescue personnel should coordinate with you to determine the best removal route. 2. You should participate in the preparation for patient removal. 8 a. Determine how urgently the patient must be extricated. b. Determine where you should be positioned to best protect the patient. c. After the patient has been extricated, determine how you will move the patient to the backboard and then to the stretcher. d. Your input is essential to so that the rescue team plans an extrication that protects the patient from further harm. i. Reevaluate whether the patient needs rapid extrication. 3. Often you will be placed in the vehicle with the patient. a. Be sure to wear proper protective equipment. K. Transfer of the patient 1. Perform a primary assessment once the patient has been freed. a. Make certain that the spine is manually stabilized. 2. Move the patient in a series of smooth, slow, controlled steps, with designated stops to allow for repositioning and adjustments. a. One person should be in charge of the move. i. ii. iii. iv. v. Choose a path that requires the least manipulation of the patient and equipment. Ensure that everyone understands the steps and is ready. Move only on the team leader’s command. Move the patient as a unit. Continue to protect the patient from any hazards. 3. Once the patient has been placed on the stretcher, continue with any additional assessment and treatment that was deferred. 4. Move only on the team leader’s command and move the patient as a unit. L. Termination 1. Termination involves returning emergency units to service. a. All equipment used on the scene must be checked before reloading it on the apparatus. b. Check and clean the ambulance thoroughly, replacing used supplies. c. Rescue and medical units are required to complete all necessary reports. V. Specialized Rescue Situations A. Sometimes a patient can be reached only by teams trained in special technical rescues. 1. Specialized skills of these teams include the following: a. Cave rescue b. Confined space rescue c. Cross-field and trail rescue (park rangers) d. Dive rescue 9 e. f. g. h. i. j. k. l. m. n. Missing person search and rescue Mine rescue Mountain-, rock-, and ice-climbing rescue Ski slope and cross-country or trail snow rescue (ski patrol) Structural collapse rescue Special weapons and tactics (SWAT) team Technical rope rescue (low- and high-angle rescue) Trench rescue Water and small craft rescue White water rescue B. Technical rescue situations 1. Require specialized skills and equipment to safely enter and move around a. It is not safe to include personnel who have not been trained. 2. Many members of technical rescue groups are also trained as emergency medical responders (EMRs) or EMTs. 3. Ensure the technical rescue team has been summoned and is en route. 4. When you arrive at a technical rescue scene, you will be directed or led to the staging area. a. Set up your equipment at the staging area, a stable location where you will be able to treat the patient. b. Perform an assessment and initiate care as soon as the rescue team brings the patient to you. c. Packaging and carrying the patient back to the ambulance requires a joint effort between EMTs and the technical rescue team. C. Search and rescue 1. An ambulance is usually summoned to the incident command post when a person is lost outdoors, and a search effort is initiated. a. Your role is to stand by at the command post until the missing person or persons have been found. 2. You may be asked to stay with family members of the lost individual. a. Gather any medical history and communicate to those in charge. b. Only the incident commander should communicate any news or progress of the search to the family. i. Set your radio to a discreet volume. 3. Once the missing person is found, you will be guided by search personnel to the location where you can begin treatment. a. Time and effort can sometimes be decreased by relocating the ambulance or by using an all-terrain vehicle. D. Trench rescue 10 1. Many cave-ins and trench collapses have poor outcomes for victims. a. Collapses usually involve large areas of falling dirt that weigh approximately 100 lb per cubic foot. b. Victims with thousands of pounds of dirt on their chests cannot fully expand their lungs and may become hypoxic. 2. The risk of a secondary collapse is a concern to rescue personnel and EMTs. a. Response vehicles should be parked at least 500 feet from the scene. b. All vehicles should be turned off to avoid a secondary collapse caused by vibration. c. All road traffic should be diverted from the 500-foot safety area. d. Construction equipment at the collapse site may be unstable and could fall into the cave-in or trench site. 3. At no time should medical or rescue personnel enter a trench without proper shoring in place. 4. During the extrication of any survivors, medical personnel trained in cave-in and trench collapse rescue will provide most medical care. a. You should be prepared to receive patients once they have been extricated from the site. E. Tactical emergency medical support 1. A steady increase in violence throughout the country has resulted in EMTs taking precautions to ensure personal safety. 2. When the potential for violence exists, responding units should wait until the scene is secured by law enforcement officers. a. Sometimes a special weapons and tactics (SWAT) team is needed to secure an area. b. Many communities have incorporated specially trained EMTs, paramedics, nurses, and even physicians into police SWAT units. 3. When called to the scene of a law enforcement tactical situation, report to the incident commander for direction. a. Lights and siren should be turned off, and outside radio speakers should not be used when nearing the scene. b. The command post is usually located in an area that cannot be seen by the suspect and is out of range of possible gunfire. i. Remain in this area. c. Planning measures are key in these situations. F. Structure fires 1. In most areas, an ambulance is dispatched with the fire department to any structure fire. a. Ask the incident commander where the ambulance should be staged. 11 b. Determine if there are any injured patients or whether you have been called to stand by. 2. Search and rescue in a burning building requires special training and equipment. a. Operations are performed by teams of firefighters wearing full turnout gear and self-contained breathing apparatus (SCBA). 3. Sometimes a scene may be further complicated by the presence of hazardous materials. Post-Lecture Assessment in Action A. Assessment in Action is available in the Navigate course. 12