welcome back everybody and i really appreciate you sticking with me through this journey um we're going to cover chapter 39 vehicle extrication and special rescues uh we're going to talk about safe vehicle extrication the use of simple hand tools so usually it's a fire department that's involved with the extrications but there are many places where the rescue is performed by emts or you assist in it it's going to take training above and beyond what you receive here with your emt training so why does it take extra training well there's mental mental and physical preparation that you have to have when it comes to extrication again it's something that you're going to have to have beyond emt class as an emt our priority is always been and always will be patient care as extrication is going on around you our care excuse me our emphasis is going to be on patient care during this extrication process the safety of yourself and your team come first then we have to also consider what's happening to our patient during this extrication and again the equipment and gear should be appropriate to the hazards and there in lies some of the issues why emts don't do extrication because typically we don't have the equipment or the gear or the protective equipment to wear during extrications now some places will but a lot don't so with vehicle safety systems this is kind of the issues that we just kind of touch on in the mt class but things like the shock absorbing bumpers okay when they're involved in extrication processes they might have been collapsed and all of a sudden they release and they shoot off the car and injure you so that's why we always approach vehicles from the side because bumpers may like even in a car fire they heat up and they expand and they shoot the bumpers off some cars uh airbags oh my gosh every car has airbags and if they haven't gone off yet and you're inside the car working on a patient they could go off and they could cause great harm to you so airbags in the steering wheel in the dash they're in the side impact doors they're in the roof there's so many places that you can have airbags nowadays you have to be careful and cognizant of the fact that these airbags could go off and hurt you haze inside the the vehicle at the time of the accident might be a basically a sign that you see that the airbags had gone off and that's the corn starch or the talcum powder that keeps the the airbag when it's compressed from sticking to itself again using protective gear eye protection even something over your mouth because you could inhale that cornstarch or that talcum powder so fundamentals of extrication number one your safety is the first concern and your primary role is emergency medical care and to protect your patient and you may provide care as extrication goes on even around you you may be inside that motor vehicle as they're cutting the roof off it because you're taking care of patient care and you're trying to calm your patient so extrication defined as the removal from entrapment or a dangerous situation or position an entrapment is a condition in which a person is caught within a closed area with no way out or has a limb or body part trapped so there's a difference between extrication and entrapment so there's phases of extrication and it starts with the preparation going to the scene you get to the scene you control the hazards uh you support other operations you're gained access you do emergency care you get your patient out of there you transfer the patient and then you terminate the extrication phase our job again is medical care our job is to triage and package the patient we might have more than one patient and again our additional assessment of care as needed once the patients have been extricated and then we provide transport to the emergency department the rescue team on the other hand they're responsible for securing stabilizing the vehicle providing safe entrance and access to the patients and then extricating any patients that's not our job that's the rescue team's job law enforcement has a role here too they're controlling traffic making sure we have ordered the scene with bystanders uh and establishing maintaining a perimeter so we don't have an intrusive gawker or onlooker come into the scene roles and responsibilities the firefighters are responsible for extinguishing any fires preventing fires ensuring scene safety maybe even removing or containing a spilled fuel so the preparation part again they're preparing for this by having training and they're checking their tools that they're going to use when they respond to vehicles uh the enroute so they're uh thinking about how they're gonna respond to this emergency arrival again position the ambulance to block the scene uh again we don't need all these lights going on every vehicle we can kind of back off a little bit on our warning lights again choose that location that has safe access and exit put on your ppe and my goodness look for cars coming up behind you before you get out of your ambulance make sure the scene is properly marked and protected get pd there if they're not already there we want to close off the road sometimes absolutely you have the authority and the power and sort of the police or the fire department to actually shut that road down if it's not safe for you again our job is patient care you might have to direct traffic though until pd gets there seeing size up is an ongoing process uh the so is seen safety it's an ongoing process do a 360 walk around looking at the vehicle looking thinking about the mechanism injury careful look for those down power lines look for the leaking fluids or fuels look for smoke fire obviously broken glass trapped or even ejected patients remember part of your patient assessment sheet is number of patients well in a motor vehicle accident you might have some patients ejected and won't have to look at the immediate area look at the vehicle so what we're looking for is really quickly things that might indicate the mechanism of injury you might see a bed steering wheel excuse me you might see a cracked windshield you might see airbags that have been deployed even after the airbag has been deployed lift up the airbag on the steering wheel to see if the steering wheel is intact or bent again unrestrained patients may have contact injuries as well as secondary injuries look for that windshield spidering you might even sometimes see hair stuck in the spider web of the shadow glass think about what you find as you document this later on because again we're telling the hospital we're telling the physician a scene we're painting a picture for them so they understand what happened so once you arrive at scene now we did remember that line in your your patient assessment sheets of additional resources that doesn't always mean paramedics that could mean hazmat team could be the power company it could be paramedics it could be a helicopter all kinds of different resources are available for you look for fill spilled fuel sorry uh maybe on the electrical short or damaged batteries going to cause a fire rain sleet snow hazards crashes that occur on hills be and what we're worried about are cars coming the other way now that don't see you uh that and they can't see that there's an accident ahead of them and so they crest over the hill and boom there you are i think about violence especially nowadays so we want to have a coordinated effort between the rescue team and law enforcement we want to communicate we want to start talking to the incident commander as soon as we get there and become and we're becoming integrated into that rescue team just like we talk about with nims down power lines gosh it's so sad we just had a firefighter killed in northern florida because he stepped out of a vehicle that he was working on at a motor vehicle collision stepped out of the back of a vehicle and stepped right on a power line i don't know how it happened uh but if you see it down power line don't attempt to move it tell your patient by using your your pa speaker on your ambulance it's it's part of your siren it's part of your radio package but you could flip it to pa and and tell the person stay in the vehicle don't touch anything don't attempt to get out until the power has been shut off and then we just kind of wait uh in this safe zone until we have it's safe for us to approach they talk about 500 feet i that's a long ways um but again fires that we as an ambulance in this situation there's nothing we can do for that patient until the power is turned off so stay back and stay safe family members bystanders yep absolutely they can create hazards because they could get in the way so the vehicle could be a hazard if it's on its side or roof the fire department has their job is to stabilize that vehicle so it doesn't roll over more or tip over or whatever that's their job the first job is to stabilize that car after they make sure the scene is safe if it's parked excuse me if it's on all four tires we want to make sure it's in park or the the parking brake set so it doesn't roll away um battery cables one of the first things the fire department's going to do when they get there is they're going to cut the battery cables so that's going to hopefully eliminate that possibility of sparks and fire this is the newest concern for fire departments alternative fuel vehicles these these hybrids these propane powered vehicles these all electric vehicles so it says disconnected battery in all cases there's so many batteries nowadays in these cars the batteries can be located anywhere and in some situations these electric cars if they cut the wrong cable they could actually become very uh injured themselves so it's it's a whole new education on how to do extrication from electric cars hybrids the batteries uh it might take up to 10 minutes to de-energize after the main battery is turned off that's why the fire department that's why the rescue crews are doing that stuff again see the worms where it says avoid the high voltage cables the orange ones yeah those are the bad ones damaged batteries give off toxic fumes again if there's an unusual order back off and then you might have to treat besides yourself with your eyes and throat burning but the patience as well so hybrid vehicles love them i think they're a great thing but they're very dangerous thing as it comes to play with the rescue situations so some of the supporting operations that's lighting the scene at night big light towers on these on the fire trucks um a tool and staging area so that they're they kind of spread out their tools so that they know what they have and what and and what tools to use and then maybe the fire department's even setting up a landing zone for the helicopter it does say fire and rescue people work together but typically in most situations the fire and rescue people are from the same service critical phase of extrication that we're making sure the vehicle's stable and hazards have been eliminated and controlled and then we can get access to our patient and again it has to be the safest most efficient way for us to do that this is an unusual situation it looks like they're hanging off a bridge and again the special equipment that they're using is they're using some type of end loader or some type of device to to dangle basically a rescue worker over the side of a bridge oh my gosh this is a crazy situation so we need to think about a couple things when we gain access is the patient in the vehicle or in some other structure this isn't always about car accidents this could be a house that collapsed after a tornado it could be a building that fell down i whatever it is but it's the vehicle or structured damage that makes it really um as a rescue worker that's very you have to be very cautious about these vehicles and structures that are damaged because again they could further deteriorate and cause injuries what hazards exist what position is the vehicle on what surface is it app to roll over or tip these are things that the rescue department or the rescue firefighters are going to have to think about if the patient's condition changes now we have to change to adapt to that so and maybe initially that patient is stable but then as the process is going on to get them out of this trapped vehicle their patient condition changes and and we're the ones that note that i mean that's our job is to monitor the patient so maybe we need to get them out quicker than we thought um there's all kinds of situations that can come to mind uh situations that involve cpr and we have to do cpr so we got to get this person out to do cpr and maybe we're not going to worry about the c-spine precautions anymore we're just going to get them out as quickly as possible we want to keep the patient safe and sometimes what we do then if the patient is trapped in the car we'll get into the car with them and cover them and us up in a heavy blanket and so we're underneath this blanket in the dark talking to our patients well all this activity is going on around you they're cutting off the roof they're popping glass windows chainsaws are going i mean all kinds of crazy stuff uh you could use a backboard as a shield sometimes it's typically that heavy rescue blanket is what we use talk to your patient tell them what's going on so they're going to be scared heck you're going to be scared but talk to them you're explaining to them what's happening so that hopefully that de-escalates the situation a little bit always explain everything you're doing to the patient and why uh so that they can become more calm sometimes it's simple access sometimes uh we we can get access without using tools or breaking glass the first thing that you're taught in extrication class as a firefighter is try the door before you pry the door try before you pry in other words sometimes those doors will just open up just normally maybe take a little more energy than normal but they'll open up before you have to pry or cut anything again every ambulance by state statute or state rules and regulations they dictate what ambulances have for rescue equipment on them again every state's going to vary and maybe you may not have any equipment on your ambulance to help try the door handles try to roll the window down before you break anything sometimes you you're gonna have to use special tools pneumatic and hydraulic tools again as a firefighter um one of the things that we're taught is uh how to do these extrications and tools change and techniques change and so that's why as an emt it's kind of above and beyond our scope of practice because it takes all this extra education so this is one of the devices it's a spreader it's a cutter there's all kinds of different ways that this is going to aid us in getting access to our patients so we're going to control any exaggerating hemorrhage stop the bleed we're going to stabilize the spine we're going to open up the airway we can give them oxygen while they're still stuck in the car that's okay we can assist or pry provide for adequate ventilation we might bag our patient while they're trapped in the car we can do this is a cool technique try to bag a person while sitting behind them control any bleeding treat all critical injuries we really do need to coordinate with the rescue personnel to figure out what is the best way to get our patient out of the car there's so many different ways we can they can have the roof cut off and we can pull them straight up and out they can cut the door off and we can pull them out the side whatever it's going to take and and we have to be able to be creative in the way we're thinking about this so some extrication techniques the gas and brake pedal a lot of times during major car crashes they'll get in the way of the patient's feet we can pull the dash up and off our patient we can cut the door off uh we can cut the roof off we can cut the bolts holding the seat and make the seat come free we can take the steering column and bend it up and out of the way we can cut the steering wheel off so as a firefighter there's all different types of techniques and tools that we can use to make access to the patients better again while you should participate in the preparation for the patient removal so what they're doing is we're getting close to getting that patient out now you need to think about how urgent do we need to get them out what's the best way to protect our patient how will you move the patient to the backboard into the stretcher and the extent of injuries sometimes because of the motor vehicle collision you'll get them onto a backboard and then you'll have to take them away from the scene before you can actually get them on a stretcher uh and then we need to be thinking about the extent of injuries on our patient your input is essential so that rescue team plans an extrication and protects the patient again you will often be placed in the vehicle alongside or behind that patient you can do a a complete primary survey once they're free uh make sure that we put a their spine is protected we can put a c collar on them and we now that we've got them out we don't have to necessarily rush and run it can be smooth and slow as long as the patient is the patient's condition dictates our urgency one person should be in charge when we transfer that patient choose a path that requires the least manipulation in other words we're trying to keep their spine in line make sure everybody understands what's going on let the team leader speak for the team we're going to move the patient as a unit and then we're going to continue to protect the patient from any hazards as we get them out we can make sure that we put the backboard behind them we can put the c collar on them um but then that's after we've done our assessment termination again termination involves returning everybody back to service so the rescue department or rescue service again must check all the equipment that they used we clean and check our ambulance and then we do the reports so everybody has a role uh after the termination of this rescue special rescue situations again not every firefighter is trained in all these rescue situations like cave rescues or confined space rescue cross field and trail rescues that's a interesting one that park rangers might be trained in and dive rescues missing person search and rescue mine rescues mountain rescues ice climbing ski rescues another big one is structural collapse rescues so like when a tornado wipes out a town every house has to be searched swat um i'm an ex-squad officer from wisconsin and uh the only reason i was the the swat medic was because i was the only emt on the team i was besides being law enforcement i was an emt so again special training there rope rescues high angle rescues trench rescues for for people who are digging water lines uh sewer lines water and small craft rescues white water rescue i mean that this list can be nearly unending so personnel need special training equipment and skills to do this it's not something that the untrained person can do so if you don't have training in that rescue please please please don't attempt it without the training um let the professionals do it that we're we're not going to have a rescue firefighter do patient care if they they're not an emt we're not going to ask them to do it so why should we be doing the things that they're trained to do again rescue groups uh a lot of times rescue groups are made up of more than one department having members on this team so it might be a regional team a state team you think about fema the emergency management from the feds those have rescue teams check with the incident commander again to see if any kind of technical rescue group has been summoned if you need them again that incident commander he's in charge or she's in charge of everything that happens there again we really need to have one person clearly in charge because that if we don't that's where we have a lot of confusion and communication issues if there's no incident commander present heck you might be the incident commander until you're relieved so when you get there you're going to be directed to the staging area so we get our backboard maybe that basket stretcher stokes basket our jump kit our first in bag other equipment and we go to the staging area and again we're going to do the primary assessment of our patient as soon as rescue team brings the patient to us they'll be able to transport that patient to you in the staging area and then we package that patient and get them back to the ambulance uh to transport again an ambulance is usually summoned to the command post when a person is lost outdoors and the search is initiated your role is to stand by at the command post until they find that person then once you know what's going on you can get your equipment ready and then again leave the prepared equipment in the back of the animals to protect it from weather in the snow the rain or whatever you might be asked to stay with the family of a lost individual now besides doing obviously first aid we're doing psychological first aid once they've been found you'll be guided by the search personnel to the location where you can begin treatment you might need to relocate the ambulance or use an all-terrain vehicle to get access to your patient again make sure that the equipment is evenly distributed and ensure a pace is maintained such that all can stay together we're not gonna hurry uh if somebody cannot do it with kate or excuse me with trench rescues i think of people in the construction industry that are digging uh large ditches to lay water pipes and stuff a lot of times what happens is those walls of the ditch cave in and they trap the workers and when they get trapped uh if it gets high enough uh it could impede with their breathing the the scary part would be a second collapse while you're working on the patient so again we need to make sure that the appropriate rescue personnel are there to make sure the scene is safe for you as well as the patients other hazards include downed electrical wires broken glass water lines construction equipment might be as unstable and fall into the uh cave-in or the trench again witnesses should be identified it's going to be good information we want to get everybody out of the area we don't want to enter the trench that is deeper than four feet without proper shoring or the supports and the sides of the trenches and then during extrication of survivors uh medical personnel trained in cave-in and trench collapse will provide the most medical care so the hopefully the rescuers that are trained are also emts with tactical ems this is a new and emerging service that we have in ems sometimes uh the swat team needs to have a an emt on the team or have the ambulance standing by while the swat team is doing something with hostage situation or barricaded or whatever but again a lot of emts paramedics nurses and even physicians are incorporated into swat teams when called to the scene we want to find out where the command post is we're going to turn off our lights and sirens again the command post is usually in a safe area so that you're not going to get shot at or anything and we're going to remain with the command post because it is in a safe area planning is huge planning is huge the incident commander should determine a safe location to meet up with the swat team if an injury does occur to your team members to the public or even the bad guy themselves we want to designate a helicopter landing zone if needed and again think about the quickest route to the closest hospital or trauma center or whatever we would need to figure out a route and we're pl pre-planning is what we're doing with structure fires a lot of times your ambulance is dispatched with the fire department it asks the the incident commander where you want the ambulance stage and determine if any injured patients uh or if you have been called to stand by so sometimes we stand by to assist with patients that are in the burning house sometimes it's the firefighter that might be injured search and rescue in a burning building that's fire department stuff and sometimes the scene may be further complicated by hazardous materials so it might be a factory fire when proper protective equipment will vary depending on the hazards encounter which piece of equipment should be utilized during all patient contacts okay turn out gear helmets blood and fluid and permeable gloves or goggles okay that should be a pretty easy one we're on chapter 39 folks yup it's the gloves what is the first phase of extrication arrival preparation scene size of gaining access what's our first phase indeed it's preparation again there's a lot of training that's involved in making sure our equipment is functioning properly as you approach an unconscious patient who is still in her wrecked vehicle you note that there is no oh sorry there is a power line entangled in the wreckage of the vehicle what should you do retreat until the power line has been removed or the power shut off carefully gain access without touching any metal objects don a pair of rubber gloves and carefully disentangle and remove the power line that's a good way to die or d call for a tow truck to lift the vehicle off the power line and then access the patient that's a good way to kill the tow truck driver so yes obviously it's eight we're not gonna do anything until the power is turned off and the scene is safe four a two door passenger car struck a tree while driving approximately 50 miles an hour the doors are badly damaged and jammed the driver appears to be unconscious inside the vehicle entering the vehicle by breaking the back window is an example of simple access complex access technical rescue or disentanglement so if we break the window the back window to get access to our patient what is that called complex simple access doesn't use or sorry does not use uh tools again simple might be just opening the door this is complex where we have to break something 30 year old semi-conscious man is pinned by a steering wheel of his badly wrecked vehicle once access has been gained to the patient the emt should have the fire department disentangle a patient and quickly remove him immediately up immediately apply high flow oxygen to the patient and then allow extrication to begin perform a primary assessment and provide any needed emergency care prior to extrication or d ensure the patient is not bleeding significantly before allowing the extrication process to commence so he's semi-conscious and pinned once access has been gained what should we do it's a good question let me read them all again how many of you thought of c and c is perform your primary assessment and provide any needed emergency care prior to extrication we're going to do the xabcs while on the emt is in the vehicle assessing the patient the rescue team should be assessing exactly how the patient is trapped and determine the safest way to extricate them awaiting further instructions from the emt how to proceed actively extricating the patient using whatever method is deemed necessary or preparing for a simple extrication process as the emt has obviously gained access to the patient so the eft is in the vehicle assessing the patient what should the rescue team be doing right they should be the a the a is again assessing how the patient is trapped and what's the safest way to get them out proper removal of a critically injured patient from an automobile involves a moving the patient in one fast continuous step b utilizing no more than two p two personnel to avoid crowding see moving the patient in a smooth slow controlled steps or d removing the patient by grasping the immobilization device i don't understand the removing the patient by grasping the immobilization no okay has everybody got c very good uh again we're going to move them as a unit it's controlled and slow so that we basically are making sure we're considering spinal immobilization eight a man has been sucked inside a bin of a grain silo and is trapped which of the following rescue teams is most appropriate a trench rescue high angle rescue the local fire department or it can find space rescue and if you're not sure what a grain bin is it's a large round uh cylinder where farmers will put grain in it and what happens a lot of times is if the person is working inside that grain silo that grain bin um they kind of it's just kind of like a trench rescue where the they kind of sink into the grain and they're trapped and they can't get out if you're not a farmer uh it's kind of hard to explain or you're not from a rural area so who are we gonna get yep d we're gonna do d the confined space rescue because it is a small space nine you respond to a wooden area to help search for a child who has been missing for 24 hours which of the following equipment should you leave in the ambulance radio flashlight jump kit backboard so he's lost child for 24 hours yep i don't know why we would take that backboard so again leave that in the ambulance 10. you are dispatched to a scene of a trench collapse upon arriving at the scene the ambulance should be parked how many feet away from the incident and again we're making sure that we leave room for the rescue operations to take place we want to make sure that even still we could create more of a collapse how far should your ambulance be parked away yep it's 500 feet again vibrations are the things that we're going to be most concerned with all right that was chapter 39 only two more to go