By Brendon Morris
From the second a vehicle collision occurs, the medical wellbeing of a trapped and injured patient will begin to worsen. Approximately 50 percent of all road traffic deaths occur at the crash scene. The patient’s need for definitive treatment in a hospital as soon as possible is essential to increase the chances of survival. To this end we tend to invest much time and money developing well-run ambulance services that can carry the patient to the hospital safely and efficiently. What we cannot forget is the importance of not harming the patient further while freeing him.
During the past several years, developments in vehicle design have required us to modify our rescue techniques. The automotive industry’s focus on increased occupant safety and the issues this focus poses to firefighters cannot be ignored. This focus has resulted in the strengthening of the passenger cell with high-tech metals as well as passenger protection systems such as side airbags, inflatable side curtains, and pretensioners. New car technology affects every rescuer. Ignoring these developments or not adapting our techniques to them should no longer be acceptable.
A number of basic extrication techniques may be used together to complete the extrication process as a whole. These techniques must be used and developed considering two areas:
- Is this technique likely to lead to a reaction in the vehicle that may put me (the rescuer) or my patient at risk of further injury?
- Is this technique the most effective and efficient way of achieving the goals of stabilization, creating access, space, or patient removal route?
If we take time to consider these points, we come to realize that various techniques of the past may no longer be the safest, most effective, efficient, patient-focused way of getting the job done. Let’s take a look at some examples of techniques that have evolved or become obsolete.
Stabilization
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If practiced, the time required to stabilize a vehicle properly is minimal, but the potential benefit can be huge. |
As we all know, stabilization is the platform on which we build the entire extrication. It’s the first step in taking control of the vehicle. Basic vehicle stabilization is something that should no longer be overlooked. If practiced, the time required to do it properly is minimal, but the potential benefit can be huge. If we don’t take the time to do this properly from the beginning, there is every chance that it will come back to haunt us later during the job. One major change in the way cars are built today is the use of unibody construction. Vehicles are not built onto rigid substructures as they were in the past. Now the substructures are integral parts of the vehicles. If we begin to cut into the roof of an unstabilized vehicle that has structural damage, it is likely that the vehicle will react in such a way that increased entrapment results. By performing good stabilization at the beginning of an extrication, we remove this reaction force.
Creating Initial Insertion Points
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Do not ram spreader tips to create an access point. The Fender Squeeze technique is one way to create an insertion point for Spreaders or cutters. |
After stabilization, consider the way we create initial insertion points for spreaders when performing a door removal. Before you even consider how to remove a door, always ask yourself if it is necessary to do so. In many countries it is now common practice to leave the doors in place if there is no significant dash impingement or foot entrapment. The roof is simply removed or folded forward and the patient is removed inline up a hard board.
If you do need to create an opening to remove a door, keep in mind that the days of ramming the spreader into the side of the door to create a purchase point are gone, or at least should be gone. Using the “battering ram” technique completely overlooks what is best for patients. We only have to consider the hazard of activating faulty side impact protection systems to see why this technique should clearly be a “no go”. The other important matter to consider is the entrapped, and most likely traumatized, patient’s wellbeing. Lateral movement of a compromised spine carries high risk for exacerbations of that injury, even when collar and inline supports are in place. Another reason to avoid this spreader-ramming technique is because there are so many safer alternatives to create an insertion point. Consider the front fender squeeze or simply making use of a halligan bar to create the necessary insertion point for the tips of a spreader: much more control.
Door Removal
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Using a spreader to expose the hinges and then cutting them gives the rescuer more control of the door removal operation, and helps avoid accidentally triggering a pyrotechnic device. |
With an insertion point now created, the next area to consider is the door removal technique. The option of removing the door starting at the hinge side of the door versus the latch is becoming increasingly popular. On today’s modern vehicles, the B-Pillar is the common location for the trigger mechanism for side impact airbags, as well as the hiding place for seatbelt pretensioners. Using a spreader to expose the hinges and then cutting them gives the rescuer more control of the door removal operation, and helps avoid accidentally triggering a pyrotechnic device. Spreading is also far more likely to lead to uncontrolled (read that: unsafe) breaking, particularly in heavy vehicle rescue where doors are higher and heavier. Think about it: we used to say “blow the door off” or “pop the door” off – it doesn’t exactly imply control does it? So why should we now consider cutting hinges if we have always managed in the past with simply “popping” the door off with the spreader only? There are a couple very good reasons. One is simply: because we can. Also, in most cases, spreading takes longer, especially if sheet metal begins tearing. Another disadvantage of uncontrolled breaking is that it sometimes leads to movement of the vehicle, despite proper stabilization.
A further, increasingly important, matter to consider is the existence of various passive safety systems, such as side impact airbags often mounted inside the doors. By removing the door from the hinge side, one can remove the hazard of these devices earlier, (as soon as the wiring is cut) and from a safer position (outside the door). There is another advantage of working from outside of the door: one is not standing in the position between the open door and the vehicle while trying to pop the hinges after spreading the door off the latch. When you are standing in this position you are obviously at greater risk of safety systems such as side impact protection systems mounted in the side of the seats. Before employing this technique, ensure that your cutter can be used on hinges. Old cutter models, and in some cases even new makes of cutters, cannot be used on hinge materials without damage or failure.
Moving the Dash
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A ram can be used for the traditional dash roll or a spreader can be used to perform a dashboard lift, shown here. |
Now you have the door off and you find that there is significant dash displacement entrapping the driver. In the past, the first thing we would do is reach for the chains. The use of chain adapters on a spreader pulling on a chain wrapped around the steering wheel is a well known technique. It has a long history of use especially in the days when rams were not commonplace. However, this technique poses a high level of risk and gives you very little control over movement. The risk of the steering wheel failing is increased exponentially with the new design of front wheel drive vehicles. Most every front wheel drive vehicle has a joint along the steering column that is at risk of breaking allowing the column to be swung up into your unsuspecting patient. The risk of steering column failure during pulling techniques increases with the advent of adjustable steering columns now standard on many vehicles. The message here is avoid this technique at all costs. In some countries, due to nasty experiences, it has been completely outlawed and not even taught for history’s sake.
So if we are not using the spreader and chains for dash and steering wheel displacement, what should we be using to get the dash off our patient’s lap? Use a ram or a spreader. Either tool will give you the rescuer a far greater level of control during this operation. A ram can be used for the traditional dash roll or a spreader can be used to perform a dashboard lift. Bear in mind if you are performing a dash roll that the sequence of ram placement before making the relief cut has become increasingly important. The added reaction strength found in modern vehicles means that there is more chance of downward movement following a relief cut in the base of the A-pillar. If our patient is trapped by the steering wheel or dash we of course must avoid any downward movement. To mitigate this, it is important that your ram is positioned first before the relief cut is made. With the ram in place any downward movement is prevented, and you can begin the pushing operation. In some Nordic countries where there are many new vehicles on the road, the standard approach of using a ram down the center of the vehicle before even removing the doors is commonplace.
Cutting Pillars
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Strip away internal trim or covers that cover the pillars before you cut through them. By doing this you will instantly be able to see where any cylinders are and avoid cutting them. |
The final point to discuss involves cutting pillars. Side impact protection systems have to overcome some complications that are not a problem for frontal impact airbags. The main difference in requirement is the speed at which these airbags need to inflate. The reason for this is that there is very little space between the outside of the car and the occupant in a side impact. This means that the deployment of these side mounted airbags needs to be much faster than the frontal impact types. To make this fast inflation possible, the manufacturers make use of compressed stores of gas that are released into the bag at impact. These mini gas cylinders can be found in numerous places, especially in the pillars and roof rails where we need to cut to remove or flap a roof. When you cut through these pillars, there is a chance that you may be cutting through a gas cylinder with 2900-4350psi (200-300bar) of compressed gas inside it.
Unfortunately we cannot just stop cutting all car pillars or roof rails and car manufacturers are not going to stop manufacturing such systems. For this reason it would be good practice to adopt a cautious approach to cutting by employing an “expose and investigate” method. This does not have to mean dramatically increasing the time you will take to finish the extrication job. All that is necessary is to strip away internal trim or covers that cover the pillars before you cut through them. By doing this you will instantly be able to see where any cylinders are and avoid cutting them. As an added safety feature, always consider placing a flexible cutting shield around the area you will be cutting.
Conclusion
This is the end of this whistle stop tour through the many areas where extrication techniques are (or should be) changing or becoming obsolete. Hopefully you have found this information helpful and will be able to use it practically in your everyday extrication efforts. Holding on to the past is simply no way to ensure that we are performing the safest, most effective, and most efficient extrication rescue possible. Being involved in a crash is a traumatic event. The least we can do for those who have gone through this terrible ordeal is to be the best we can at what we do.
Brandon Morris is a rescue paramedic currently employed as a Consultation and Training Manager for Holmatro Rescue Equipment. His responsibilities include training Holmatro users and dealers worldwide on best rescue practices as well as researching rescue disciplines to ensure that Holmatro keeps pace with future rescue needs.
