Reimagining Vehicle Rescue and Extrication Methods

BY DAVID DALRYMPLE

In looking over the past 30-odd years I have been involved with vehicle rescue, I noticed the tool evolutions and methodologies for spacemaking to extricate injured vehicle occupants haven’t changed all that much. They have evolved along with tools and vehicle technologies, but sometimes we are behind the curve in both tools and vehicle technology. Trauma is a disease of time; vehicle extrication is a medical intervention.

NEXUS Study

Our need to rapidly access the injured occupants, safely create space or make a pathway to disengage them from the vehicle, and transport them to the appropriate medical facility has remained constant. However, even this has changed in the light of the NEXUS study^1,2 that has brought about the widespread use of selective spine clearance in the prehospital environment. This allows us to board and collar only those injured vehicle occupants requiring such treatment according to our patient assessments. Common sense coupled with focused patient assessment wins. Sadly, as a result, many emergency medical services (EMS) providers have become complacent and lax. Rather than allow rescue personnel to create a proper safe space to disentangle patients, these EMS providers choose to drag patients across vehicle center consoles and other obstacles; they can point to the NEXUS study that says the percentage of the chance of further injuries is nil. But how professional are these actions truly? Would you want them to do this to your family members?

Movement and Packaging

What are you using to move and package patients? Although adjustable C-collars are fine and justified, long spine boards are frowned on—why? If your assessment justifies their use, then use them. You can still use them as a transfer or movement device; there is nothing wrong with such applications. However, selective spinal clearance programs don’t want you to use the long spine board to transport patients to the appropriate medical facility.

What about other movement devices to assist you with disengaging your patients from the vehicle? The Kendrick Extrication Device® (KED) comes to mind for most rescuers. The KED has been around since the 1970s. It was designed for the vehicles of that time, in which the front driver’s seat had a large amount of space; large door openings; and a bench seat, the prevalent seating of the era. Many rescuers today do not even know what a bench seat is. Most vehicles today have four smaller doors, front bucket seats designed to keep you planted in the seat with a center console between the driver and front passenger, and much less interior space than ever, yet we still use a device unimproved for at least 45 years to do the same thing it was designed to do in the 1970s. If we put it on any patients in a vehicle today, it would physically entrap them if they weren’t already.

Better Movement Devices

There are much better movement devices on the market today. The key word is movement. Short or half-size boards and spoon boards are alternatives. Long spine board alternatives include the plastic take-apart scoop board and the vacuum mattress. Although vacuum mattresses are a bit awkward to use, training and practice is all you need.

Another movement device that has not taken off here in North America but is definitely something to try out is the rescue boa. It works much in the way as an endless webbing loop does for a drag or a hospital blanket roll for a lift but works much better than either device.

Techniques vs. Vehicles Today

Although I noted above why EMS providers must be hands-on inside the vehicle with the patient, we need to improve our on-scene time against trauma. The patient doesn’t have time on his side and neither do we; vehicle extrication is a medical intervention.

But many of the tool evolutions we use today are the same evolutions that have been used for the past 30 or 40 years, adjusted to the vehicles over time. Rescue technicians have to definitively adapt to today’s vehicles to gain time on the patient’s trauma clock. Sadly, in this area, we as rescuers or responders do not do any research, even casually. We only learn about new vehicle challenges when we get new vehicles to practice on or if we respond to an incident involving them.

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; even that will absorb crash energy and, to a certain extent, will drop onto the ground, which will transfer the crash energy to the ground, even flattening the tires 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 deflect any intrusion into the passenger area. Therefore, you should suspect an occupant injury if there is a six- or 12-inch intrusion into the side of the vehicle.

So, we must find a better way to create space in vehicles to disentangle patients. Today’s vehicles today are smaller; in many crashes, they will crush up even smaller. We need to use the vehicle to assist us in space creation and be more strategic.

We can release stored crash energy from the incident in the vehicle though strategic tool evolutions, progressively weakening the vehicle structure, or making it fail on purpose through our tool evolutions and actions.

Controlled Vehicle Relocation

Controlled vehicle relocation is not new; it involves moving the vehicle to a better location or reorienting it to facilitate space creation. This has a new life because of the selective spine clearance from the NEXUS study. This tool operation has been used for some time in the motorsports field and around the world. In some incidents with some vehicles and orientations, you have no other choice but to move the vehicle to facilitate driver removal. Under the safety officer’s supervision, it uses simple tool operations with simple cribbing or stabilization while EMS is treating the patient. Once the vehicle is moved into its new position, rescuers stabilize it and begin making space.

Strategic Tool Operations

In this, we look for ways to weaken the vehicle structure, release “trapped” crash energy absorbed by the vehicle structure, and make the vehicle structure work for us to help create space for access and patient disentanglement. One way is the fender “raus” or strip/removal evolution. The fender on the patient’s side of the vehicle is removed, but when it is done is key. It is done immediately after completion of stabilization and while glass management is in progess and EMS is inside with the patient. The very first tool evolution, it exposes the door hinges, the crush zone, and the damage to inside the wheel well. This will allow for easy access to remove doors and for observation of the patient’s feet and lower extremities for injuries and entrapment.

Other examples include the dash lift and the whole process of cross-ramming the vehicle structure. Today, rams, especially telescopic rams, are fantastic, dynamic tools for the process of reforming the vehicle’s interior back to its original size or to a size we require for patient disentanglement.

Total Side Removal

Door displacements or “pops” are a routine tool evolution; this needs to change. In the past, vehicle doors were larger and there were more two-door vehicles. Door displacements became the most common tool operation for patient access and for patient disentanglement. It made sense—easy access, easy removal—but not today.

Most vehicles (cars, SUVs, and pickup trucks) now have four doors. Although they are smaller and the outside materials are thin, flimsy, and weak, they are backed up by very strong advanced steel alloys and other materials. Simple door pops are gone, along with the easy access.

Now we must consider a total side removal, also called the B post tear or rip, the butterfly evolution, Noah’s Ark, and so forth. Look at the side of the vehicle and consider it as a single door or one large side opening—just another structural component to be displaced or removed.

Remember, we can create space in a variety of ways. Removal/relocation of vehicle components and stretching the vehicle structure are the primary ways to create space for access to disentangle patients from vehicles.

Today’s vehicle construction methodology using advanced steels and alloys in structural reinforcement adds a tool to our space creation process. In addition to being very strong, these materials have high tensile strength. High tensile strength alloys, if bent, will stay bent in the direction in which they were bent. This means that, using a power hydraulic rescue tool ram, rescuers can stretch and bend certain vehicle components (e.g., roofs) and even stretch them farther away by severing a roof post (e.g., an A post). This is also why a dash lift works well; since you are putting force under the dash reinforcement bar, you basically are making it into a class 1 lever. So instead of removing four doors and a roof and displacing a dash, you can today perform a fender raus or a total side removal, stretch/displace the vehicle roof upward, and lift the dash in much less time while using the vehicle structure to assist instead of resist.

Wire Boot Hole

Let’s reconsider the wire boot hole through which the wiring harness goes through from the dash to the door for two reasons. First, it’s an already-made hole, so we just have to push the harness and the boot out of the way. Second, this hole is prime real estate for a deep relief cut for a dash evolution. Insert one of your cutter blades on each cut in both directions—i.e., toward the occupant cell and away from it. Cutting toward the occupant cell is a simple snip, but the cut going toward 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 ways. One way is 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 of the lower A post. The second “no-relief cut” dash lift is to capture the inner end of the underside of the dash with one spreader tip/arm; 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 simple mechanical advantage in both cases.

Safety

Remember the key safety items that are still important. Strip/pull trim whenever cutting roof posts and roof edges. It’s a good practice not to blindly cut into a vehicle structure without looking at what we are cutting into. Use hard protection between tool evolutions and the patient and the interior rescuer. It’s more important than before because the advanced steels/alloys used in vehicles tend to create small pieces of debris when fractured during severing. Using soft protection to cover patients and the interior rescuers is equally important.

Power Isolation and Keys

Power isolation is critical. Remember to chock the wheels and set the parking brake. Shut the vehicle off and gather up all the keys. Find the 12-volt battery and double-cut both cables, the negative first then the positive, and document it. Keys today are almost always wireless fobs, but they are now trending toward a card and a smartphone app.

Keep keys 50 feet away from the vehicle, which is much farther than before. However, you can use a Faraday bag to block the key’s radio frequency identification signal to the vehicle.

More than 50 percent of 12-volt batteries today are outside the engine compartment; the next most likely location is in the rear of the vehicle. Consider vehicle damage and such in your vehicle survey when checking for the 12-volt battery.

Vehicle Hazard Information

Last but becoming extremely important is on-scene vehicle hazard information. Alternative-fueled vehicles have had emergency response guides from day one, but even if we had all these for all the vehicles on the street, even as an electronic PDF, it would be next to impossible to look up the relevant information in a timely manner. Fortunately, there are smartphone apps, and automotive manufacturers have installed QR code stickers on their vehicles to assist us on scene. They give us background information on vehicle hazards and concerns—e.g., how to shut down an alternative-fueled vehicle in various ways, firefighting tactics, and more.

These are just some of the concerns today’s vehicle rescue professional must consider; vehicle technology is changing so dynamically. Other emergency service segments are more proactive in researching the methods, issues, and concerns of their responders. Vehicle rescue and extrication should likewise research the who, what, where, when, and why of what we do on scene. To keep ahead of the trauma clock, we need to investigate new methodology and tools for space creation; better educational programs to facilitate patient care and rescue skills; and operational planning skills that blend patient management, rescue activities, and overall scene mitigation activities as a whole.

Endnotes

1. Hoffman JR, Wolfson AB, Todd K, Mower WR. “Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).” Ann Emerg Med. 1998 Oct;32(4):461-9. doi: 10.1016/s0196-0644(98)70176-3. PMID: 9774931.

2. Hoffman, Jerome. “NEXUS Criteria for C-Spine Imaging.” https://www.mdcalc.com/nexus-criteria-c-spine-imaging.

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DAVID DALRYMPLE has been involved with emergency services for 38 years. He has been teaching vehicle rescue for the past 27 years, educating on vehicle technology issues and concerns. He is involved with the Society of Automotive Engineers Task Force on electric, hybrid, and alternative-fueled vehicles for first and second responders. Dalrymple is the educator/rescue consultant for RoadwayRescue LLC and has taught at FDIC International since 2003.