Hello and welcome to Chapter 39, Vehicle Extrication and Special Rescue of the Emergency Care and Transportation of the Sick and Injured, 12th edition. After you complete this chapter and the related coursework, you will be able to describe and apply in context EMS rescue operations, including vehicle extrication and its 10 phases. Additionally, you will be able to describe various specialized components of EMS operations, including tactical EMS, trench rescue, high angle rescue, and the EMT's roles in these operations.
The safety aspect of these operations are also discussed. Okay, so let's dive right into it. So you will usually not be responsible for rescue.
But you may assist with extrication. Rescue requires training beyond the EMT level. Let's talk about safety.
Okay, so extrication requires mental and physical preparation. Priority is to provide patient care. And personal safety and that of your team must be addressed before patient care is initiated.
The equipment that you use and the gear that you wear will depend on the hazards you expect. encounter as well as what you observe during the scene size up. So first things first let's talk about vehicle safety systems.
So vehicle safety systems can become hazards after a collision. First is the shock absorbing bumpers and they may be compressed or loaded following a front or rear end collision. Approach the vehicles from the side They can release and injure your knees or legs. Also, manufacturers are required to install supplemental restraints or airbags in all cars now.
So airbags fill with a non-harmful gas on impact and quickly deflate after the crash. Airbags are located in the steering wheel and the dash in front of the passenger. You also could have side impact airbags and they may be located in the doors and seats.
When it comes to non-deployed airbags, they may spontaneously inflate while you are providing patient care. So you should maintain at least 5-inch clearance around side impact airbags that have not deployed and maintain at least 10-inch clearance around driver's side airbags that have not deployed. Also, maintain at least 20-inch clearance around passenger side airbags that have not deployed. Haze inside the vehicles in which the airbags have deployed is caused by cornstarch or talk.
So appropriate protective gear, including eye protection, will reduce the risk of eye or lung irritation from that substance. So let's talk about the fundamentals of extrication. And of course, as with anything, your primary concern is safety.
Your primary roles are to provide emergency medical care, prevent further injury to the patient. You may provide care as extrication is going on around you. So the definition of extrication is the removal from entrapment or from a dangerous situation or position.
Then the definition of entrapment is a condition in which a person is caught within a closed area with no way out. or has a limb or other body part in trouble. Let's talk about the roles and responsibilities. EMS providers are responsible for assessing and providing medical care, triaging and packaging patients, providing additional assistance and care as needed once patients are removed, and providing transport to the emergency department. The rescue team is responsible for securing and stabilizing the vehicle, providing safe entrance and access to the patients, and extricating any patients.
Law enforcement officers on scene are responsible for controlling traffic, maintaining order at the scene, and establishing and maintaining a perimeter. And then firefighters, they're responsible for extinguishing the fire, preventing additional ignition, ensuring that the vehicle is safe, and removing spilled fuel. Roles and responsibilities often are varied based on jurisdictions and available agencies.
Good communication among team members and clear leadership is essential to safe, efficient provision of proper emergency care. So the table on this slide shows the 10 phases of extrication, and that's what we're going to talk about next. The first phase is going to be preparation. Preparation is preparing for an incident requiring extrication. It involves pre-incident training with rescue personnel for the various types of rescue situations to which you might respond.
Rescue personnel. must routinely check the extrication tools and their responsible vehicles. And then next is the en route to the scene.
Procedures and safety precautions similar to those in the phase of an ambulance call are used when responding to a rescue incident. Next is the arrival and scene size up. So we want to position the ambulance to block.
the scene from oncoming traffic. We're going to use essential warning lights and choose a location that will allow safe access to the scene while leaving a way to drive the ambulance out. We need to put on PPE and look for passing cars before exiting the vehicle. We have to make sure the scene is properly marked and protected and the size up is an ongoing process of information gathering. and scene evaluation to determine appropriate strategies and tactics to maintain or to manage that emergency.
The next thing we're going to do in that arrival and scene size up is evaluate the hazards and determine the number of patients by doing a 360 walk around of the scene. And what we're going to be looking for is the mechanisms of injury, any downed electrical lines, or perhaps leaking fuels or fluids, smoke or fire, broken glass, any trapped or ejected patients, or the number of patients in the vehicles involved. And while we're looking at the vehicles involved in the motor vehicle collision, we want to note the damage to the vehicles because a bent steering wheel may indicate a significant face or thoracic area trauma.
Imprints on the dashboard may indicate lower extremity injuries, such as fractures or possible hip dislocations. And lift deployed airbags to see if there's some deformity to the steering wheel or dashboard. And because that may indicate that the patient struck the structure after the airbag deflated.
We want to also see if we could find out unrestrained patients. And they may have contact injuries. as well as secondary injuries.
So we want to check the windshield for a spider web pattern of shattered glass and this is indicating possible head, face, or neck injuries. And then include findings in our documentation. We're going to use the information to maintain a high index of suspicion.
All right, so we want to evaluate the need for additional resources during that scene size up, right? Because we might need extrication or fire or law, hazmat, utility, maybe advanced life care supports or some type of helicopter for transport. We need to look for spilled fuel and other flammable substances, right? Rain, sleet or snow can present an added hazard for the scene. Crashes that occur on hills are harder to handle than those that occur on level ground.
crashes, some crash scenes may present threats of violence. So we have to be aware of that. And we're going to coordinate our efforts with rescue teams and law enforcement.
We need to communicate with members of the rescue team throughout this extrication. Talking to the incident commander as soon as you arrive will help. So you will enter the vehicle and provide patient care for the patients when only when approved by the incident commander. Then there's hazard control. Okay, so hazard control can deal with downed electrical lines, and those are common hazards at vehicle crashes.
So we're never going to attempt to move a downed electrical line. If the power lines are close to the vehicle involved in the crash, we're going to instruct the patient to remain in the vehicle until the power is shut off. Remain in the safe zone.
outside of the danger zone. In the danger zone, we call the hot zone. Okay, so the illustration on this slide plays or displays the danger zone. Family members and bystanders can also create hazards. The vehicle also can be the hazard too.
So an unstable automobile on its roof or side can be a danger to you. Rescue personnel can stabilize the car with a variety of jacks and cribbing. So ensure that the car is in park with the parking brake set and the ignition turned off. Both battery cables should be disconnected to minimize the possibility of sparks or fire.
Next, we're going to talk about alternative fuel vehicles and the hazards that they might have on scene. So vehicles may be powered by electricity or some type of hybrid mix like electricity and gasoline mix or fuel such as propane, natural gas, gas, methanol or hydrogen. We're going to disconnect the battery to prevent further fire or explosion. 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.
There may be more than one battery present. In hybrid vehicle systems, hybrid batteries have a higher voltage than traditional automotive batteries. And it may take up to 10 minutes for a high voltage system to de-energize after the main battery is turned off. Avoid high voltage cables.
Those are typically orange. So damaged high voltage batteries may give off toxic fumes. Do not approach the vehicle if unusual odor is detected and retreat if you experience burning in your eyes or throat. Next, we're going to talk about support operations.
Okay, so this is important. Support operations include lighting the scene, establishing tool and equipment staging areas, or marking helicopter landing zones. Fire and rescue personnel will work together on these functions. Gaining access.
So gaining access to the patient is a critical phase of extrication. Make sure that the vehicle is stable and hazards are eliminated or controlled. The exact way to gain access to the patient depends on the situation you're having.
Okay, so the figure on this slide shows a motor vehicle collision. The exact way to gain access, just like we talked about, depends on the factors, including the terrain and the way in which the vehicle is situated. And also, don't forget the weather.
To determine the exact location and position of the patient, consider the following questions. So is the patient in the vehicle or some other structure? Is the vehicle or structure severely damaged? What hazards exist that pose a risk to the patient and the rescuers? And in what position is the vehicle?
Is it on top of some type of surface or what type of surface is it on top? And is the vehicle stable or is it apt to roll or tip? Let's talk about rapid vehicle extrication.
And this is important because rapid vehicle extrication may be needed to quickly remove a patient if the environment is threatening or it's a patient needs cardiopulmonary resuscitation, so CPR. A team of experienced EMTs should be able to perform a rapid extrication in one minute or less. During the assessment and extrication phases, make sure that the patient remains safe. Okay.
So a heavy fire resistant blanket can be used to protect the patient from breaking glass, flying particles, or tools and other hazards. Okay. So always describe what you're doing and what you're going to do before you do it. And as you're doing it, and even if you think the patient is unresponsive, try to keep heat, noise, and force to the minimum.
So the figure on this slide shows the EMS provider accessing the patient. Always explain to the patient why you are there and what you are doing. So we just had that rapid access.
This is a simple access when you're doing an extrication. So simple access is described as trying to get the patient out as quickly and possibly. simply as possible without using any tools or breaking glass.
So automobiles are built for ease. entry and exit, okay? It may be necessary to use forcible entry tools. The rescue team should provide the entrance you need to gain access to the patient.
If the rescue team has not arrived yet, use tools like hammers, center punches, pry bars, and hacksaws. They might be available on the ambulance. So gain access by trying to use the door handles or by rolling down the windows before breaking any glass. or using other methods of force entry.
And that's the simple access, okay? Now, when it comes to complex access, complex access requires special tools such as mnemonic or hydraulic devices, okay? And these require special training. It includes breaking windows and removing roofs. These advanced skills are typically performed by specialized teams.
So, on the figure on the slide shows an extrication process and this is a complex access and it's requiring the use of pneumatic or hydraulic devices okay you can see the spreaders right there in the photo all right so next we're going to talk about the emergency care the emergency care so providing emergency care to a patient who is trapped in the vehicle is essentially the same as for any other patient okay once entrance and access to the patient have been provided and the scene is safe, perform the primary assessment, and provide care before further extrication begins. You want to address any hemorrhaging with direct pressure or a tourniquet if appropriate, okay? And then provide manual stabilization to protect the cervical spine as needed. Then, of course, we're going to do that ABC. We're going to open the airway, give them high flow O2 if they need it, assist with ventilations if needed, and Like we said earlier, control any external bleeding and then treat all critical injuries.
Then the removal of the patient. So rescue personnel should coordinate with you to determine the best removal route. The table on this slide lists vehicle extrication techniques, including complex access.
Okay. You should participate in the preparation for patient removal. Okay, so determine how urgently the patient must be extricated.
Determine where you should be positioned to best protect the patient. After the patient has been extricated, determine how you will move the patient to the backboard and then to the stretcher. Your input is essential so that the rescue team plans an extrication that protects the patient from further harm.
Re-evaluate whether the patient needs rapid extrication. Often, you will be placed in the vehicle alongside the patient, so be sure to wear proper protective equipment. And then transfer the patient. So, perform a complete primary assessment once the patient has been freed.
Make certain that the spine has been manually stabilized and move the patient to a... Move the patient with a series of smooth, slow, controlled steps with designated stops to allow for repositioning and adjustments. One person should be in charge of the move, of course, and choose a path that requires the least manipulation of the patient and equipment.
Ensure that everyone understands the steps and is ready. And move only on the team leader's command. Move the patient as a unit.
continue to protect the patient from any hazards. And once the patient has been placed on the stretcher, continue with any additional assessment and treatment that was deferred. So move only on the team leader's command and move the patient as a unit.
Okay, so the figure on this slide shows the management of the patient during the extrication process. Once the patient has been assessed, rapidly reassess the patient. Stabilize the spine manually and apply a cervical collar if not done previously.
And then there's termination. So termination involves returning those emergency units to service. All equipment used on the scene must be checked before reloading them on the apparatus. Check and clean the ambulance thoroughly, replacing used supplies. And rescue and medical units are required to complete all necessary reports.
All right, so let's talk about specialized rescue situations. So sometimes a patient can be reached only by teams trained in special technical rescues. All right, so special skills of these teams include the following.
So you could have a cave rescue, confined space rescue, cross field and trail rescue, such as park rangers, and then dive rescue, missing person, search and rescue, mine rescue, mountain rock and or ice climbing rescues, ski slope and cross country or trail snow rescues like ski patrol. or structural collapse rescues, special weapons and tactics, that's a SWAT team, technical rope rescue, so high and low or high angle rescue, trans rescue, water and small craft rescue, and white water rescue, technical rescue situation. So let's talk about that.
A technical rescue situation requires special skills and equipment to safely enter and move around. It is not safe to include personnel who have not been trained. Many members of technical rescue groups are also trained as emergency medical responders, such as EMRs or EMTs.
Ensure the technical rescue team has been summoned and is en route. Okay. So you want to check with the incident commander to see if they have done so. Okay. And the incident commander is that overall command of the scene.
So. it's one person, they're clearly identified, and if there is no IC, you want to follow your local guidelines. When you arrive at a technical rescue scene, you will be directed or led to a staging area. What you want to do is you want to set up your equipment at that staging area, a stable location where you will be able to treat the patient.
You're going to perform a primary assessment as soon as a rescue team brings the patient to you. Packaging and carrying the patient back to the ambulance requires a joint effort between EMTs and the technical rescue team. Search and rescue. So an ambulance is usually summoned to the incident command post when the person is lost outdoors and a search effort is initiated. So your role is to stand by the command post until the missing person or persons.
have been found. You may be asked to stay with a family member of the lost individual. You want to gather any medical history and communicate to those in charge. Only the incident commander should communicate any news or progress of the search to the family.
So you want to set your radio at a discrete volume and once the missing person is found, you will be guided by the search personnel to the location where you're going to begin treatment. Time and effort can sometimes be decreased by relocating the ambulance or by using an altering vehicle. So let's talk about trench rescue. Okay, so many cave-ins and trench collapses have poor outcomes for victims.
Collapses usually involve large areas of falling dirt that weigh approximately 100 pounds per cubic foot, and victims with thousands of pounds of dirt on their chest cannot fully expand their lungs and may become hypoxic. The risk of a secondary collapse is also a concern. So response vehicles should be parked at least 500 feet from that scene.
All vehicles should be turned off to avoid a secondary collapse by vibration. So all road traffic should be diverted from the 500 foot safety area. Okay. And construction vehicles equipment at the collapse site may be unstable as well and could fall into that cave-in or trench site at no time no time at all should medical or rescue personnel ever enter the trench without proper shoring in place during the extrication of any survivors medical personnel trained in cave-in and trench collapses rescues will provide the most medical care you should be prepared to receive patients once they have been extricated from the site. Okay, then let's talk about the tactical emergency medical support for law enforcement officers.
Okay, so a steady increase in violence throughout the country has resulted in EMTs taking precautions to ensure personal safety. When the potential for violence exists, responding units should wait until the scene is secured by law enforcement officers. Sometimes the special weapons and tactics team, and you'll hear it called the SWAT team, is needed to secure an area. Many communities have incorporated specially trained EMTs, paramedics, nurses, and even physicians into police SWAT units.
When called to the scene of a law enforcement tactical situation, determine the location of the command post and report to the IC for instructions. Lights and sirens should be turned off. An outside radio speaker should not be used when nearing the scene. The command post is usually located in an area that cannot be seen by the suspect and is out of range of possible gunfire. Remain in this area.
Okay, so planning measures are key in these situations. You need to have the incident commander identify a location. The incident commander should determine when the scene is safe. designate helicopter landing zones, and identify quickest routes to the hospital, burn center, or perhaps the trauma center. All right, so next we're going to talk about structure fires.
All right, in most areas an ambulance is dispatched with the fire department to any structure fires, and what you want to do is ask the incident commander where you should park and state, and determine if there are any injured patients or whether you have been called just to stand by. Search and rescue in a burning building requires special training and equipment. Operations are performed by teams of firefighters wearing full turnout gear and self-contained breathing apparatus. So sometimes a scene may be further complicated by the presence of hazardous materials.
Okay, so that concludes Chapter 39, Vehicle Extrication and Special Rescue. And next we're going to see what we've learned. Okay, so let's see. Proper protective equipment will vary depending on hazards encountered.
So which piece of equipment should be utilized during all patient contacts? Hmm, helmet, blood, and non-perf, impermeable gloves. All right, I think they want us to say that the gloves, we don't want to have, so it's blood and fluid impermeable gloves is my guess. And we are right. All right.
What is the first phase of extrication? I think it's preparation, right? Yeah, because there's 10 phases and the first is to prepare. So we want to get ready and we need to have all the training of the various rescue situations. As you approach an unconscious patient who is still in the wrecked vehicle, you note that there's a power line entangled in the wreckage of the vehicle.
So what should we do? We're not going to go in. We're going to tell them to stay in the vehicle. So I think A is correct. It's going to be retreat until the power line has been removed or the power is shut off.
All right, so it's A. We do not want to make ourselves part of the problem. Okay, a two-door passenger truck.
struck a tree while driving 50 miles an hour. The doors are badly damaged and jammed and the driver appears to be unconscious inside the vehicle. Entering the vehicle by breaking the back window is an example of, and I think that is a simple access.
We know it's either a simple or a complex, and I'm pretty sure this is a simple. Ah, it says it's complex access because it requires the use of tools. All right, so.
Examples of simple access would be just rolling the window down. Okay, so we both learned. All right, so simple is just rolling the door, the window down.
So this makes it a complex access. A 30-year-old semi-conscious man is pinned by the steering wheel of the badly wrecked vehicle. Once access has been gained to the patient, the EMT should. Okay, we want to... perform that primary assessment and provide any needed emergency care?
I'm almost possible. I'm almost sure. Yeah. So just like, just like we would anybody else, once we get to the patient, we're going to start with that primary.
Okay. And when the EMT is in the vehicle assessing the patient, the rescue team should be, what should they be doing? A.
While the patient is being accessed, the rescue team should be assessing the degree of entrapment and determining the safest way to extricate. All right, proper removal of a critically injured patient from an automobile involves, how should we do it? All right, so slow and controlled steps as a unit. So it's going to be C, moving the patient in slow, smooth, controlled steps.
A man has been stuck. um sucked inside the bin of a grain silo in his trap which of the following rescue teams is most appropriate okay so i don't think we really talked about this but this is going to be a confined space rescue okay so confined space it's one of the technical rescue teams and grain sale silos are going to be confined spaces You respond to a wooded area to help search for a child who's been missing for 24 hours. Which of the following equipment should you leave in the ambulance?
Hmm. All right. So backboard. Um, it's not easy to carry and they say it should be left in the ambulance.
All right. And then finally, you are dispatched to the scene of a trance collapse. upon arriving at the senior ambulance should be parked at least.
And we know this is 500 feet from that incident, right? So 500 feet. Okay.
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