Extrication Is But 1 of 10 Phases of Vehicle Rescue System
Most emergency service units in this country are actively participating in training programs designed to provide the means for better initial care for the sick and injured. The programs range in depth from the first aid courses of the American Red Cross to the nationally recommended emergency medical technician training courses to the extensive courses used to prepare paramedics. Never before have fire fighters, ambulance attendants, rescue squadmen and police officers been as well prepared to handle medical emergencies, nor have they been better equipped.
The effect of proper emergency care training has been most dramatic. More people are reaching hospitals in better condition. Likewise, training has transformed fire fighting from a mere water-squirting procedure into a science of complex activities. Now we must assure that vehicular rescue operations be equally improved if the upgrading of the emergency sendees is to be complete. We must move away from the all too familiar “snatch and run” type of care at an accident scene—an operation in which the victims are pulled from the wreckage and rushed to a hospital with little consideration for anything but speed in clearing the roadway.
The lesson plans for the wide variety of emergency care training courses generally have one thing in common: they contain a segment devoted to teaching extrication. In many cases, the time allotted for that segment is only three hours or less. Therein lies a problem!
The word “extrication” is defined in many dictionaries as the release from entanglement or difficulty. Can this be considered an adequate description of the wide spectrum of accident scene activities? Not likely! Extrication is only one part of a series of operations that must be carried out in a logical sequence if the overall effort is to be successful—operations that are included in a system known as vehicle rescue. As a system, vehicle rescue can be easily compared to another system-structural fire fighting. A welltrained fire fighter knows that there are many phases in a structural fire fighting operation, including rescue, exposure protection, attack, ventilation, confinement, extinguishment, salvage and overhaul. Similarly, the 10 phases of vehicle rescue can be identified as readiness, response, assessment, hazard control, support operations, gaining access, emergency care, disentanglement, removal and transfer, and termination. It is vitally important that all emergency service personnel— not just rescue squadmen—be familiar with all the activities that make up the system, and especially with their significance to the overall operation. It is equally important that training programs include every activity, not just extrication.
There are many types of “systems.” There are computer systems, construction systems, health delivery systems, and so on. While each system has a different reason for being, each has certain similarities. For example, each system is made of men, machines and techniques, and in each system, efficiency depends on how well its elements work together. Nowhere is this more important than in the system that provides for vehicle rescue operations.
Needless to say, the machine part of the vehicle rescue system—the apparatus, tools and equipment—must be ready at all times if the system is to function at all. Moreover, the machine parts must be selected to fit the rescue needs of a community, whether light, medium or heavy. The tools must be sufficient to handle at least the “usual” transportation accidents that are typical to the service area. Equipment carried on the squad vehicle should complement—not duplicate— that which is carried on the fire fighting vehicles.
Rescue squad personnel—and all other emergency service members— must also be prepared. Training must be extensive in every area of vehicle rescue operations, and must be continuous if proficiency in rescue skills is to be maintained. And, of course, there must be properly prepared officers to coordinate the men, machines and techniques.
How quickly and efficiently the system is put into operation depends to a great extent on the quality of the initial information received about the incident. Those persons who receive emergency calls—whether central dispatchers or housemen—should always endeavor to learn such details as the numbers and types of vehicles involved, the number of persons injured, and the known hazards. This information will often influence the initial response, and thus, time and lives may be saved. At the very least, detailed information will better prepare rescuers for the task at hand.
Once the system is in motion, the same factors that affect the response of fire apparatus to alarms will also affect the response of rescue vehicles to a transportation incident. Response routes should always be carefully chosen, and where there is a possibility of congestion, hazards due to weather, detours or road construction, alternate routes should always be considered.
No competent fire officer would arrive on the scene of a structural fire and simply start to squirt water without first carefully sizing up the operation. By the same token, no welltrained rescue officer should start his on-the-scene operations until he has assessed the situation.
In this third phase of vehicle rescue, the officer must take a good look at both the problem and his capabilities. If he does so properly, he is able to match needs against available forces. In assessing a vehicular accident, a rescue officer must consider three things: First, he must consider the number and especially the types of vehicles involved and the damage. This will give him an idea on whether or not his equipment is sufficient for the job. Secondly, he must consider the number of people injured, and if the facts are immediately available, the extent of their injuries. This will tell him what the emergency medical requirements are. Third, he must consider the hazards, both the traffic and nontraffic variety. In considering hazards, he must also take into account the exposure problem that includes people and property. When he has developed this “box score” of the accident, he should be able to easily determine whether or not his initial force is capable of coping with the situation.
The one or two-car accident (unless there are unusual circumstances) presents few problems that the usual initial responding force of a rescue unit, an ambulance and an engine company cannot handle. But what of the accident that involves perhaps a tanker, or a dangerous commodity carrier, or a school bus? In these and many other situations it is likely that the officer will have to seek additional assistance.
Help is available in many forms and from many sources. Most rescuers think of assistance as that offered by additional ambulances, rescue units or fire apparatus. Other resources that may be both valuable and necessary include construction equipment, utility crews, wreckers, scuba teams, the humane society, medical teams, and so on. Rescue officers should maintain an active inventory of all their community’s resources that can be called upon at the time of emergency.
If, in his assessment, the rescue officer sees that a downed high-voltage wire is contacting the wreckage, he is faced with a dilemma. He can wait for utility crews, but the delay may well be fatal to persons trapped within the wreckage. He can order his personnel into action with makeshift equipment, in which case the rescuers might be added to the list of victims. Or, he can effectively control the dangerous situation with well-trained crews that have the proper equipment. The same applies in every hazardous situation.
Besides the obvious personal hazards of broken glass, twisted metal and spilled fuel, an accident often produces hazards that will severely challenge the abilities of officers and squadmen. The real problem is that in most instances, these hazards must be controlled before any rescue operations can begin, perhaps even before the injured persons can be approached. Cross training is the answer to hazard control. Rescuers—like fire fighters— must be able to recognize and deal with such hazards as downed wires, fire, dangerous materials, an unstable vehicle and debris that presents a hazard as well as an obstruction to rescue operations. Moreover, rescuers must be taught to appreciate the value of hazard control as it relates to their own safety.
5. Support operations
Many accident situations dictate that support operations be carried out before actual rescue operations are started. For example, it may be necessary to provide the trapped persons with some sort of protection, especially when power tools are to be used. Or, it may be necessary for rescue squad personnel to don some special sort of personal protection, as when they might be required to work in a hazardous atmosphere.
Other support operations, once started, might have to be continued all throughout the rescue operation. Perhaps the scene will need to be floodlighted. Warning and signaling devices may have to be set out, maintained, and moved as circumstances dictate. Most certainly, fire prevention operations will be required for as long as victims are still trapped in the wreckage.
These operations are often thought of as being secondary in a vehicle rescue operation, and there is a tendency for rescue officers to downgrade their significance. They should not be considered any less important than any of the other operations described. Remember the old saying, “for want of a nail, the horseshoe was lost, etc.”
6. Gaining access
This sixth phase of a vehicle rescue operation is often confused with the steps that are actually in the disentanglement phase. In far too many accident situations, rescuers devote their time and skills to one continuous operation in which they work to reach the victim, free him, and remove him from the wreckage. Often the procedure is time-consuming and valuable minutes are used up—minutes that could be spent on getting emergency care measures to the victim. If the gaining access phase and the disentanglement phase are separated as they should be, the time between the crash and when the aidman is able to care for the victim is substantially reduced.
The term “gaining access” is an accurate description of the activity. In essence, a hole is made in the wreckage just large enough for an EMT (or similarly qualified rescue squadman) to reach the victim’s side with a life support kit. The medical benefits are not the only ones to accrue to the victim when this procedure is used. The EMT or rescuer can also provide the victim with protection against flying objects or broken glass generated by subsequent disentanglement operations.
Access can be gained to trapped persons in three ways: through the doors, through the windows, and through the body of the vehicle, especially through the top. The operation may be as simple as merely opening one of the doors on the side opposite the damage, or it may be as complex as requiring the complete removal of the vehicle’s top. When techniques for gaining access require the removal of glass, or when power tools must be used, utmost consideration must be given to the protection of victims and rescuers alike. In extremely critical situations, rescuers may be unable to use power tools at all, perhaps because of spilled fuel or the proximity of the victim to the parts that must be cut. When this is the situation, squad personnel must be completely familiar with alternate manual methods for gaining access.
While it would be ideal to have all rescue squadmen trained to the level of the emergency medical technician, it is often simply not practical. However, the fact that he does not ride in an ambulance as part of his regular duties does not mean that a squadman should not be trained in the techniques of life support.
In many areas throughout this country, fire and rescue personnel arrive on the scene of a transportation accident before the ambulance. In some cases, an ambulance is not even called to respond before the rescue officer or fire chief has made his initial assessment. In situations like this, it is extremely important that rescuers know the techniques of life support that will keep the victim alive until the ambulance arrives. These techniques include the identification of injuries, maintenance of an airway, pulmonary and cardiopulmonary resuscitation, and the control of life-threatening hemorrhage.
When determining how much more than life support techniques should be learned by rescue squad personnel, one must consider his other tasks. Since rescuers have to move injured people, often under the worst of circumstances, they should be familiar with methods of immobilizing a person with spinal injuries and fractures. Since medical emergencies such as heart attack and stroke present themselves at accident scenes, rescuers should also know how to handle these situations and how to give the proper initial care. In reality, the gap between the EMT and t.he rescuer’s knowledge of emergency care procedures should be quite small and exists only because the EMT should be trained in more definitive care procedures. It is only when all emergency service personnel are trained in the basics of emergency care that the time between the crash and “first care” measures can be appreciably reduced and the saving of lives effected.
SYSTEMS ANALYSIS OF A VEHICULAR ACCIDENT
This phase of vehicle rescue operations may be looked upon in two ways: disentanglement of the victim from the wreckage, or disentanglement of the wreckage from the victim.
In the first case, the operation may be fairly uncomplicated, requiring that rescuers do little more than carefully manipulate the victim’s body parts around seats, posts, pedals and other obstructions in the effort to free him. As simple as it sounds, however, disentanglement in this fashion may not be so easy. Careful consideration must be given not only to the victim’s known and suspected injuries during the moving process. If it seems likely that the injuries may be complicated by manipulation, then rescuers must forego this procedure in favor of disentangling the wreckage from the victim. Techniques of disentanglement include removal of the steering wheel (or the entire column), seat removal, pedal displacement, and a variety of other techniques of severing, distorting, displacing or disassembling the vehicle’s components. Almost every tool in the inventory of equipment carried on the rescue unit—from the simplest hand tool to the most complex power toolmay be pressed into service in a disentanglement operation.
9. Removal and transfer
With regard for terminology, “removal” means the shifting of the patient from inside of the wreckage to a point outside, and “transfer” means the moving of the patient from the immediate accident site to the ambulance. Just as gaining access and disentanglement are two distinct operations, so are removal and transfer. While these two operations may often be uncomplicated, there will be other times that the removal and transfer operations will be as complex as the extrication effort.
In the “snatch and run” type of operation alluded to earlier, rescuers simply manhandle the victim from the wreckage. In a properly conducted operation, when the victim has become a patient under care, and when he has been properly “packaged” with a backboard and splints perhaps, the removal operation is tailored to the needs created by the accident. For example, when a spinal injury is suspected, extraordinary precautions must be taken so that the injury is not compromised. It may be necessary to use both a short spineboard and a long backboard to bring about removal, and it may be necessary to cut away the top of the vehicle and its doors so that removal is facilitated. The same applies for fractures that must be rigidly immobilized. Rescuers—and especially rescue officers— must be able to recognize the need for special removal techniques, and they must be able to provide them.
Transfer might involve nothing more than carrying the packaged patient a few feet to the waiting ambulance. Or, it may involve moving that patient 500 feet up a steep ravine. When squads operate in difficult terrain, techniques of transfer must be developed accordingly, using special harnesses, winches, rope hand holds, and perhaps aerial apparatus as a crane.
This last phase in vehicle operations, as the term implies, is the clean-up one. None the less, it is important to the overall operation. First, the officer must determine if the services of his squad are needed any longer. Obviously they are if continuing illumination is required, if hazard control must be maintained, or if further warning and signaling is indicated. Then he must assess the debris problems. Rescue squadmen are not expected to be street and sewer workers, but at times their expertise in handling dangerous materials, or their ability to use specialized mechanical equipment can assist public safety officers in getting the roadway open sooner.
Then, the final point. The rescue vehicle must be returned and serviced, and equipment must be put back into service or replaced. Without the final step, the system of men and machines will not be ready for the next assignment.
Now, how can all these points be put together in a smooth operation? One answer is obvious—training. But an effective vehicle rescue system does not necessarily start there. It starts with an appreciation of the value that the components of the system have to each other, or the man-machine relationship. Then, an appreciation must be gained by squadmen and officers of the many steps that make for an effective operation.
Realistically speaking, rescuers will probably never prevent accidents. What they can do, however, is to reduce the terrible toll in deaths and permanent disabilities that often result not from the accident itself, but from mishandling by emergency service personnel.