IMPROVING PATIENT ACCESS AT EXTRICATION SCENES

By Mike Daley

Early on a cool October eve-ning, you are dispatched to a reported smoking vehicle, resulting from an accident. On arrival, you find the situation is not what you had expected: Two vehicles were involved in a high-speed collision. One car, a 1999 four-door sedan, came to rest in the middle of the intersection after striking a 1996 four-door sedan in the two driver’s side doors, sending the 1996 vehicle up on the front lawn of a residence on the corner, coming to rest after rolling over several times. The 1999 sedan sustained significant damage: The front of the vehicle was driven down to the road surface from the impact, and the passenger compartment was shortened from the impact, jamming all four doors and trapping all three occupants in the cab. A view from the side showed that this vehicle was actually bent upward in the center of the passenger compartment at the B post. The 1996 sedan sustained significant damage on the driver’s side, entrapping the driver and partially ejecting the occupant in the front passenger seat before the vehicle came to rest upside down.

Quick access to most of the patients is paramount. The primary focus is to select tactics that will allow rescuers to access and remove as many victims as possible. To accomplish this, you need a technique that will open up as much room as possible. One such technique is a full side removal.

FULL SIDE REMOVAL

The full side removal has many advantages compared with other extrication techniques. First, it creates more space for patient care and accessibility instead of removing only one door. On most four-door vehicles, passenger doors are much smaller than doors commonly found on two-door vehicles, thus allowing less room if you remove only the one door closest to the victim. Second, removing the entire side of the vehicle creates a safer working area for victim removal instead of flapping the side of the vehicle down to the ground. Although many rescuers use the full side flap technique successfully, they must still traverse the remaining doors and B post to remove the patient, making for a treacherous walking surface. Also, the full side removal allows the EMS provider to continue performing C-spine immobilization without pausing to transfer head and neck stabilization to someone outside the vehicle to get past the B post. Taking these points into consideration, you can see why this is a more efficient technique to gain access inside the vehicle.

Safety Considerations

As with any extrication technique, you must address a few safety concerns before performing this maneuver.

You must complete the inner and outer circle surveys to ensure all hazards around the scene—such as involved utilities, hazardous-materials leaks, and other damaged property—have been removed or stabilized.

You must stabilize the vehicle the best you can to avoid its unnecessary movement, which would result in patient movement. Stabilization is performed three ways: horizontal (not allowing the vehicle to move forward and back); vertical (not allowing the vehicle to move up and down); and interior (securing the vehicle by putting the vehicle in park, setting the brake, removing the ignition key and placing it on the dashboard, disconnecting the battery, and so on). Stabilization is assigned to a rescuer at the incident, whose job it is to continually check stabilization and stop the operation if the stabilization requires adjusting.

If hazards require, have a charged handline capable of flowing the required gpm necessary for extinguishment standing by.

Note the model years of the vehicles involved. Newer vehicles have supplemental restraining devices, such as air bags and seat belt pretensioners, so the inner circle survey includes looking for markings that would indicate the presence of such devices. It also is necessary to remove the interior trim around all posts and headliner areas, to locate these devices to prevent cutting through them during the maneuver. Another good practice is to locate the vehicle in Holmatro’s The Rescuer’s Guide to Vehicle Safety Systems guidebook, which aids in locating such items as batteries, deployment sensors, and air bags. If you find these inflation devices, take proper precautionary measures to avoid cutting through them during operations.

Protect the patient during any maneuver; this is critical. Place a short board, backboard, blankets, or even a salvage cover between the work area and the victim. If you use a covering material, it is important that the BLS provider performing C-spine immobilization stay covered with the victim to protect and calm the victim. This might be your 100th extrication, but it probably is the victim’s first!

Completely remove the window glass before spreading the doors. The tempered glass found in most side windows will shatter when you remove the door because the window tracks are modified during the spreading operation. If you can, lower the glass into the door, which will help collect the glass inside the door panel instead of its becoming a flying hazard to you and the victim.


(1) To begin the full side removal, separate the rear door from the nader/striker pin. (Photos by Joe Kotora Sr.)

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(2) After you have opened the rear door, prepare the B post for removal by cutting the seat belt and removing the trim from the interior of the post to check for any supplemental restraints and seat belt pretensioner devices.

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(3) After ensuring no hazards are present in the B post, cut the post at the top.

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Performing the Maneuver

After you complete the circle surveys and abate all hazards, you can perform the maneuver.

Obtain a purchase point above the rear door nader pin or striker pin assembly. The nader pin resembles a U-shaped loop of steel and is attached to the vehicle body; the door latches onto it. The striker pin resembles a cylindrical pin and is threaded into the post with which the striker latch mates to close the door.

Place the spreader tips in the point, and separate the rear door from the nader pin or striker pin assembly.

Prepare the B post for removal if you have not already done so. Cut or disconnect the seat belt, and remove the trim around the post to find any hazards associated with possible supplemental restraining devices.

Remove the B post. Cut it at the highest area possible to avoid any supplemental restraining devices; this may mean making a V cut in the roof as close to the B post as possible. Cut the bottom of the post at the lowest point, as close to the rocker channel as possible. Place the outside spreader arm against the bottom door hinge, place the inner spreader arm against the outside of the rocker channel, and spread the B post up and away from the vehicle.

If, during spreading, the rocker channel begins to displace, moving toward the ground, place a box crib or other suitable cribbing under the point of spreading, which will help you remove the B post from the rocker channel.

Remove the front door at the hinges. Gain a purchase point above the top hinge, and insert the spreader points to spread the door away from the vehicle and parallel to the ground. (If you apply the spreading force in a downward direction, you may displace the doors into the ground and lift the vehicle up off its stabilization points.) Place the spreader over the lower hinge, and apply the same force to separate the doors and B post from the vehicle.

Cut or remove any wiring that connects the doors to the passenger compartment, if necessary. These wires may operate the door locks, window motors, mirror controls, or door air bags. Make sure you have disconnected the battery prior to cutting any wire. Also, be aware of sharp edges created by removal of the B post. In addition, be sure you have enough space to remove the entire side assembly from the operations arena.


(4) Make a relief cut at the base of the B post, and

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(5) spread the post up and away from the rocker channel.

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(6) The post is separated from the vehicle.

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(7) After the B post is separated, the crew goes to work on the front door hinges.

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(8) Wiring for power door locks and windows may be in between the door hinges, so have a sharp cutting tool on hand to cut through the harness. Prior to cutting, reaffirm that the battery is disconnected.

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(9) The full side assembly is removed at the front hinges.

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Full Side Flap

The full side removal technique produces an opening at the side of the vehicle that makes patient access and re-moval much more efficient. If damage to the vehicle or accessibility hinders this operation, an alternative could be to perform a full side flap and then remove the B post with a cutting tool. This procedure can be used on many applications, in-cluding vehicles on their roofs. However, when a vehicle is on its roof, take extreme care to ensure stabilization techniques are truly supporting the vehicle. Use wood cribbing, step chocks, and static stabilization struts to ensure the vehicle is stabilized horizontally, vertically, and internally.

OYSTER CRACKER TECHNIQUE

Often, the roof and posts have been compromised from the force of the impact between the roof and the ground, which can have catastrophic results when you remove a door or post. In addition, when a vehicle’s roof has been compromised in such an accident, the actual working space inside the vehicle may be limited and may need to be increased. If that is the case, after you have performed the full side removal, you can tilt-lift the vehicle from one side using the oyster cracker technique. During your size-up and initial scene survey, where you place the initial stabilization is vital to the success of this maneuver.

When stabilizing the vehicle on its roof, identify the side on which you will perform the maneuver. On the opposite side of the maneuver, place the box cribbing in a position to be axially loaded when the vehicle is tilt-lifted. Optimum placement will result in the edge of the vehicle’s fenders resting in the center of the box crib.


(10) The resulting space in the vehicle will allow for easier patient access and removal.

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(11) A full side removal is required at the start of the oyster cracker technique. Note the static stabilization struts in place. The struts are required to support the load as the A and C posts are cut.

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Perform the full side removal, as outlined above. Once completed, the side of the vehicle will have the A and C posts remaining.

Separate the front windshield from the dashboard. Remove the rear window, if you have not done so already.

Cut the A and C posts close to the dashboard and trunk area, respectively. It is important to note, however, that the weight of this vehicle will be transferred to the roof and posts in the event of a rollover, so it is imperative to continue adjusting stabilization as necessary. Remember the rule of stabilization: If you lift an inch, then crib an inch! Your operations may include box cribbing with wedges and static support struts that are ready to be put into action as you lift.

Prepare the vehicle for lifting. Place a 4 2 4 timber that spans the length of the roof onto the headliner of the roof, as close to the post edge as possible. Put another 4 2 4 at the rocker channel area, on the inside of the post area.


(12) The C post is cut, and the roof line and rocker channel are prepped for separation with 4 2 4 timbers.

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(13) A hydraulic ram is placed in between the 4 2 4 timber, and crews are ready to adjust stabilization as they “open” the car.

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(14) Open the car by extending the ram, and adjust the static struts as you spread the car from the roof line.

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(15) On the opposite side of the maneuver, stabilization consists of box cribbing that is axially loaded at the front and rear fender edges. These cribs provide a point on which the vehicle can pivot as you lift it.

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Prior to lifting, stabilize the corners of the vehicle. The stabilization on the side you are lifting will require modification once lifting has started. If you use box cribbing, have an adequate amount of cribbing on hand, and have wedges available to maximize surface contact area. If you use struts, adjust them as you lift the vehicle. Monitor the box cribs on the opposite side of the lift to make sure the vehicle is loading properly on the box. Again, optimum loading would result in the pivot point of the vehicle’s resting in the center of the box crib.

In between the timber, place a hydraulic ram vertically, and open it to make contact with both timbers. This will provide the lift for the vehicle. Continue lifting until patient access and removal are possible. Then cease lifting, and complete final adjustments on stabilization. Take care when tilt-lifting to an angle above 307: The vehicle can become unpredictable at this height. Once you have stabilized the vehicle in place, remove the hydraulic ram and timbers to help facilitate victim removal.


(16) The finished maneuver. Note the lower right corner of the photo. Initially, that step chock was providing stabilization at the front of the vehicle. At the end of this lift, the space between the chock and the car was more than 17 inches. This maneuver provides more space for victim removal when the vehicle’s roof has sustained crushing damage.

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The scenario at the beginning of this article was part of an actual response that occurred in our district. We applied these maneuvers to the vehicles on-scene. In a time span of approximately 45 minutes, we removed five victims from the extrication scene; sadly, one victim did not survive his injuries. However, as you can see, being able to access and remove the most patients within the “Golden Hour” helps to improve the percentage of successful rescues at motor vehicle extrication scenes. Maneuvers such as the full side removal and the oyster cracker are important parts of our tool cache; use them to help increase your efficiency on-scene.

MIKE DALEY, a 16-year veteran of the fire service, is a lieutenant and training officer with Monroe Township (NJ) Fire District #3 and a rescue specialist with New Jersey Task Force 1, Urban Search and Rescue. He is an instructor with the Middlesex County (NJ) Fire Academy, where he has developed many rescue curriculum classes, including motor vehicle extrication training. He is also an FDIC and FDIC West H.O.T. instructor and has lectured at the FDIC.

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