Most extrication incidents can be mitigated with common initial plans, including some form of a side, roof or tunnel tactic. But when those initial plans fail to provide a suitable path of egress, you’ll need to put into action your secondary disentanglement plan. The development of these plans should begin with the dispatch information provided and continue throughout the incident, adjusting to fit responders’ needs.
One potential secondary disentanglement plan involves moving the patient vehicle before the patient is extricated. Although this tactic is seldom required, when it is needed, it can prove invaluable.
When to Move
There are several scenarios for which this tactic should be considered.
Path of egress concerns: Vehicles involved in collisions may come to rest in positions where there are simply no access/egress points for responders. Or, there may be access points that allow a medic to maneuver into the vehicle, but no option for an appropriate path of egress. If we cause additional injury to the patient by grossly manipulating them through an opening, then we’ve provided an inferior level of service.
Secondary entrapment: Victims sometimes have a secondary entrapment of an extremity outside the patient compartment. The extremity could either be trapped underneath the vehicle or in between the vehicle and an immovable object. In these situations, responders almost always need to move the vehicle in some manner to relieve the entrapment while also completing common disentanglement procedures.
Side-resting vehicle with patient entrapped on the low side: Arguably one of the most difficult extrication scenarios that responders face is a side-resting vehicle with a patient entrapped on the low side by the dash—the result of an initial frontal collision. Responders may rely on relieving the dash impingement with a dash pull or dash displacement from the interior. These tactics will need to be completed with the low side door in place and little relief of the vehicle’s structural components. If these tactics don’t provide enough relief, the only remaining option is to move the vehicle to access the low side.
Under-rides: Some under-ride situations may require lifting the top vehicle to complete extrication tactics. Equipment needed includes lift bags, lifting struts, recovery vehicles, etc., and responders should take precautions during the lift to limit any unexpected movement. There are certainly inherent risks due to various factors, such as weight capacity of equipment and cribbing, load shifts and structural integrity of the lifted vehicle. But moving the patient vehicle from under the load after the lift can sometimes help ensure the safety of the patient and personnel.
Vehicle in the water: Vehicles may come to rest in bodies of water, including canals, swamps, rivers, lakes, etc. Rescuing patients from a vehicle that is either submerged or partially submerged can be very difficult and hazardous to everyone involved. In certain cases, it may be easier and safer to pull the vehicle from the water first.
A note about safety: It’s critical that responders understand the potential risks involved with moving the patient vehicle. The incident commander (IC) and disentanglement supervisor should identify, assess and prioritize the risks and then apply and coordinate resources to maximize results.
Advantages to Patient Vehicle Movement
The potential advantages to patient vehicle movement include improved access for EMS personnel, an improved path of egress and decreased extrication time.
One key to successful vehicle extrication is the quick access of interior medics to allow for an appropriate level of patient care and, of course, ensuring that the medic can exit the work area safely. If early access can’t be made, then rescuers will only be able to make voice contact with the patient. In situations where there are insufficient access points, moving the patient vehicle may allow the medic to position themselves closer to the patient and provide more hands-on care.
In some situations, responders must weigh the option of moving the vehicle against the option of removing a patient through an unacceptable path of egress. Moving a vehicle may be the more appropriate choice if it will provide a more acceptable path of egress.
When discussing tactics used to move patient vehicles, rescuers are often concerned that these complicated tactics increase the overall extrication time. However, during training sessions, students have quickly been able to grasp these tactics and put them into operation. In fact, with practice, the disentanglement group can complete an appropriate move that allows a suitable and safe path of egress in just a few minutes.
Disadvantages to Patient Vehicle Movement
As with any tactic, there are potential downsides to moving the patient vehicle. Chief among them: the challenge of stabilizing the patient during movement.
When moving a vehicle occupied by a patient, consideration must be given to maintaining patient stabilization. Responders should be realistic and understand that the patient will need to be moved in some manner to a long spine board, loaded in an ambulance and transported to a hospital. To believe that the car cannot be moved while holding the patient stationary is a limiting perspective; however, holding the patient stationary provides its own set of challenges. Hopefully, the patient’s position and the vehicle damage that’s causing the entrapment will actually assist with preventing patient movement. This may require strapping a front seat patient to the seat and/or assigning responders to hold the patient. It is important to maintain in-line spinal stabilization for any patients with potential spinal injuries.
Another disadvantage: Responders may have an impression from watching wrecker crews that vehicle movement should be rough and quick. But removing a vehicle from the roadway after an accident is cleared is very different from moving a vehicle with a patient still inside. Recovery vehicle operators don’t need to show concern for patients; we do. Finesse and care should be the hallmarks of our operation.
Finally, whenever you move a vehicle with the patient inside, there’s always a degree of uncertainty and risk. Certainly, moving an already damaged vehicle could result in injury to the patient or responders. But this must be weighed against the probable patient outcome if the vehicle is not moved.
Step by Step
Responders should initially treat the incident like any other vehicle collision. Take the necessary steps to establish incident command, survey the scene carefully, call resources as necessary, control hazards and stabilize the vehicle in the position found. Initial stabilization is the key to ensure the safety of responders and victims. It provides a secure base to make subsequent decisions and begin to manage the incident. Careful attention should be given when placing the stabilization equipment to ensure that it is positioned in a manner that allows a smooth transition to vehicle movement. Conduct stabilization checks throughout the process to ensure that the vehicle is as stable as possible.
Movement of the patient vehicle typically requires a high level of skill. Command personnel must trust that their personnel and equipment can accomplish the determined tactic in a proficient manner. This is a situation where a disentanglement supervisor can use a responder who is mechanically minded (whether it’s in general automotive, mechanical advantage systems, lifting and shoring or something similar) to help in the decision-making process.
These types of incidents require a well established incident command structure that includes an IC, safety officer, disentanglement group and possibly a lifting/movement group. The lifting/movement group is responsible for set-up and lifting operations during the incident. The disentanglement group can then concentrate on the necessary tactics required to free the occupant(s). Two groups of three or four rescuers working in coordination with each other should be able to establish initial access and an appropriate path of egress in a timely manner.
To Move or Not?
The movement of the patient vehicle has been the center of a lot of controversy over the years. It’s important for responders to be open-minded as to the effectiveness of these tactics under the right conditions. Moving a vehicle with a patient inside may not be the initial plan, but it must be considered early in an incident. It may be as simple as setting up typical stabilization equipment in preparation for later movement, or as complicated as calling additional resources and working with outside agencies, such as recovery vehicles. This thought process should be determined by command personnel and communicated to all responders.
The key to a successful operation is having an understanding of the resources available. The IC also needs to know that their personnel have the training and skills to complete the movement in a controlled manner and improve the patient’s outcome. In future articles, I’ll discuss specific tactics to complete this movement.
Quick Cribbing Tips
No matter how big or small the incident, a responder must evaluate and address the vehicle’s stabilization needs to properly execute victim disentanglement. Following are a few cribbing tips:
Come with cribbing. Some responders make their own wooden step chocks. A local high school wood shop class may cut your wood cribbing as a project. Another option: commercially made metal or plastic step chocks.
Prioritize your cribbing around your patient. If the driver is the sole occupant of the vehicle, focus on the A- and B-posts. I recommend B-posts before C-posts in this example because they support the vehicle body more effectively if you need to take the doors and roof. As more cribbing arrives, you can expand from there.
Check and recheck. Give the cribbing a “love tap” with a wedge or Halligan bar, for example. Snug it up. Put your hands on the struts and straps to confirm they are tight. Don’t just look at it and assume it’s good. Also, check the strut straps. Are they wrapped around sharp edges? Are they contacting hot or greasy parts?
Cater to the strengths of the vehicle. Whether using struts or wooden cribbing, avoid moving parts, wheels and suspension. Remove plastic trim to find a suitable stabilization location.
—Todd Meyer, FireRescue’s “Make the Cut” Columnist