Article and photos By Dave Dalrymple
In the previous column, I wrote about best practices in the first five minutes on arrival at a motor vehicle collision (MVC) and the tasks we must strive to complete in that time. Now let’s follow the path further and examine the next five minutes on scene, or to coin a phrase, the first 10 minutes.
Six Minutes …
At this point, the rescue/operations officer’s tactical extrication plan for creating a disentanglement pathway for the patient is well underway. The engine has a line stretched, charged, and staffed with self-contained breathing apparatus (SCBA) in place and is in the process of locating the 12v battery or batteries and disabling their power. Even they cannot access the batteries–either because of damage, access, or both–all personnel on scene are aware that the vehicle still has power in place even if the key is secured and back in the apparatus and ignition is off. In this case, we still need to continue our disentanglement process; however, we will need to work with caution. Initial stabilization would have been completed prior to emergency medical services (EMS) access to the patient, since most of our MVCs end upright on their wheels. However, even if the vehicle is not in this position, our stabilization will be in the process of wrapping up; the various strut systems we have access to today make short work of many of the situations we run into on the streets.
Seven Minutes …
EMS has started hands-on care already: the primary survey is done; the C-collar is in place, if practical and possible; and high-flow O2 in place. The patient condition has been passed along to the rescue crew and officer, and thus to the incident commeander (IC). Depending on what damage is found and what sort of pathway our tactical plan of action is calling for, glass management is underway. Depending on the vehicle involved, we might need to cut out the glass in our way; in general, our old friend, the center punch, will soon be less useful than ever before. Our patient is covered with soft protection during the glass management phase and, depending upon where the glass is removed, even hard protection or even some of the new glass management materials are being used. Tools are being prepped–power hydraulics tools, recip saws, air chisels, and hand tools.
Depending our patient’s condition, we might create space to improve our room to work on the patient. Or if we are dealing with a time-critical patient, we might be widening existing spaces to facilitate a rapid extrication. The rescue officer is in constant contact with the IC to ensure that the IC is on top of the incident mitigation and facilitating the right resources needed for the incident.
Eight Minutes ….
Recheck stabilization as our tools go to work. Remember, after every major action on scene–such as a vehicle component displacement or removal, glass management, or such–we should always recheck our stabilization, even if it is simply tapping the wedges or cribbing to ensure they stay tight. Unibody vehicles lose strength and move as you act on them. Stabilization keeps them solid and locked to the ground as best as we can by maximizing ground contact.
Our tactical plan should be to make a maximum space the first time around. Most times and in trying to keep our patient “head, belly, toes” in line, we will consider removing or displacing the roof structure. However, most of today’s vehicles give us another option which, if done on the same side of the patient, provides almost the same amount of room as a roof removal: a total side removal. Most modern vehicles, be it a car, SUV, or even a pickup truck, are four doors so that if we facilitate both doors and the B post, we have obtained a pathway without obstruction, and this has been secured much faster than a simple door displacement or “pop.” Regardless of the pathway we are creating, strive to multitask tool actions and ensure that you are using hard protection between your tool work and the patient and the EMS provider inside the vehicle. Also, remove interior trim wherever you are cutting, prying, or spreading into the vehicle’s interior.
Nine Minutes …
The EMS provider is keeping the patient in touch with what is going on around them. Have you ever been entrapped in a vehicle? Even if you know what is going to happen, it can be pretty scary (I know!), so imagine someone who is injured and has no idea of what all the noises are and such. It is important to keep that hands-on care for many reasons besides the obvious. If we have a patient status change we ALL need to know immediately. Our tactical plan needs to shift dramatically, resources need to be shifted, and the whole incident mitigation process needs to jump into a higher gear. At this point, examine two separate scenarios: one involving a time-critical patient and the other nontime-critical one (I’m not saying that a nontime-critical patient is less important; however, we have time on our side, to a certain extent, for our efforts on scene.)
EMS has signaled that our patient needs to be rapidly extricated. Although there is no physical entrapment, the patient is medically entrapped because of vehicle damage and potential injuries to the patient. Since we have access to the rear of the vehicle, the rescue/operations officer directs the rescue team to facilitate a “roof tent” evolution by making two small relief cuts inboard of the rear-most roof pillars. Then the rescue team places some cribbing onto the package shelf of the vehicle and places a power hydraulic spreader or a mini power hydraulic ram and extends or spreads the roof upward. This hyperextends the roof upward at least eight to 12 inches. As the tool evolution is operating, the rescue team places hard protection between the EMS provider and the tool work. As that is occurring, one of the rescue team members is facilitating the patient’s seatback in a slightly reclined position and stays in position with the patient and the seatback.
The rescue team has split into two teams to work simultainously on both sides of the roof. Besides multitasking with tools, the teams are also matching tools to optimize tool use to the posts they are cutting. After displacing the interior trim prior to cuts, cutting any wiring with hand tools and placing hard protection between the tool evolution and the patient and interior EMS provider, the power hydraulic cutters focus on the A and B posts while the reciprocating saws tackle the wider C posts.
Remember some basics in regards to cutting roof posts. Always cut at a 90° angle to the post regardless of what tool you are using. If it’s a power hydraulic cutter, let the tool do the work; don’t fight the tool and allow the tool to run through its entire operational cycle. If the post defeats the tool, stop, reposition, and try your cut again. Many times, depending on where the roof reinforcements are, sometimes moving an inch or two is all you need to get to weaker material. Reciprocating saws let the saw do the work. The saw should stay at zero miles per hour with the shoe of the tool firmly pressed against what is being cut. The blade is doing the work! If you are using a battery-powered reciprocating saw, make sure you have a space battery handy.
When cutting the B post, remember to reach in and find the adjustable seat belt bracket and cut above it or below it. Also, those of you who like to make a ‘pie” cut into the top of the B post, remember that many side curtain supplemental restraint systems (SRS) place the inflation module in that location and it is inside the bag itself.
The last two steps before the roof can come off entail (1) making a last post cut, the one closest to the patient’s head, to make sure the roof doesn’t come down onto the patient and( 2) make sure the seat belts are cut prior to moving the roof. There is nothing more frustrating than to start to move the roof off and get snagged because the roof is still attached by the seat belts.
Ten Minutes …
As the rescue team members remove the power hydraulic tool and cribbing, they cover up the sharp edges created by the tool evolution and the upper roof edge to protect the patient during movement. The EMS crew outside the vehicle has brought up a long spineboard and CID and facilitated sliding it through the widened rear window onto the top of the patient’s seatback. The interior EMS provider has moved to the side, and the rescue team outside next to the patient assists moving the patient’s seatback into a reclining position and sliding the board forward. A long blanket roll is placed under the patient’s arm as well as the EMS provider, and the rescue team member slide the patient carefully up the board. As the patient moves farther up the board, the outside EMS crew slides the board carefully out of the vehicle onto the rear of the vehicle. They attach the CID and strap the patient to the board and secure the O2 unit onto the board, then move the patient onto an ambulance stretcher for movement. As the patient is moved to a transport vehicle, the rescue team assists the interior EMS provider in exiting the vehicle and begins to secure the working area.
Now that the roof post is severed, lift and remove the roof in a controlled manner. As the team walks the roof away, it is placed in the warm zone in the part dump, “shiny” side down and fuzzy side up. Why? Think about it: Many times you are displacing and removing vehicle components like doors and roofs that have live undeployed SRS safety systems in them. Although the likelihood of an accidental deployment of side impact SRS systems is nil post-crash, they can be influenced by pressure, shock, and static charges–all of which can be triggered by your equipment. This hazard is something we really didn’t have to worry too much about a decade ago, but today’s vehicles are a different story. At least if the shiny or sheet metal side is against the ground, the undeployed SRS system is facing upward, not toward the ground.
The rescue team then secures the working area by covering up sharp edges and rechecking vehicle stabilization.
We have now reached our 10-minute mark after arrival on scene. Although I have tried to include most of the important things we will encounter, each MVC is different and the vehicle is the dynamic hazard out there. Time-critical patient rescuers need to strive for a 10-minute-or-less extrication time. Steve Kidd and John Czajkowski coined the phrase of the “platinum 10” back in the carbuster days, but it hold true even more so today. With the knowledge, training, and tools available today, we can check that 10 to 15- minute benchmark box more often than not. How do we get there? We need to stay on top of today’s hazards, look at new methodology, and try new tool evolutions that push the envelope. Next month, we’ll examine the first 15 minutes of an MVC.
DAVID DALRYMPLE is a career EMS provider for the RWJUH Emergency Medical Services in New Brunswick, New Jersey, and a volunteer firefighter/EMT/rescue technician for Clinton (NJ) EMS/Rescue. He has been actively involved with emergency services for 27 years. He is the education chair of the Transportation Emergency Rescue Committee-US (TERC), is a certified international level extrication assessor, and serves on the Expert Technical Advisory Board of the IETRI as their road traffic accident advisor. Certified as a NJ fire service instructor, he has been teaching transportation rescue topics for more than 16 years. He is the executive educator for Roadway Rescue LLC, an educational team for transportation rescue training. He is an ICET (Netherlands) certified registered International SAVER instructor. He writes on “Extrication Tactics” for Fire Engineering and contributed to Fire Engineering’s Handbook for Firefighter I and II (2009). He received the 2007 Harvey Grant award for excellence in rescue education. He is featured in “Training Minutes” on vehicle extrication on fireengineering.com.