COMPLEX EXTRICATION SAVES WORKER

By Sandy Bogucki, MD, Ph.D. and David C. Cone, MD

At about 7:30 a.m. on March 17, 2001, a 63-year-old male employee of a nursery and landscaping business was using a screwdriver to chip out crusted product that had hardened onto a corkscrew conveyor. This apparatus consisted of a 12-inch-wide rounded trough containing an auger-conveyor mechanism. It was used to propel powdered lime from ground level under a metal holding tower upward through a hole in a corrugated metal building to a height of 12 feet, where it emptied the lime into a soil-mixing bin. The conveyor system was accidentally engaged, the blade apparently caught the worker’s heavy work shirt and undershirt, and his right arm was pulled into the apparatus to the level of his shoulder. The conveyor automatically shut down within a few seconds from the resistance generated by the wedged arm impeding its forward motion. A co-worker witnessed the incident and immediately called 9-1-1.


The victim was pinned against the building exterior. His arm was drawn into and trapped by the conveyor assembly. {Photos courtesy of authors.}

The Clinton (CT) Volunteer Fire Department (CVFD) was dispatched to the scene along with the Clinton Police Department, which shares EMS first-response duty with the fire department. In addition to fire suppression and rescue, the CVFD provides basic life support (BLS)-level EMS transport. When required, hospital-based paramedics (Middlesex Medics) respond to provide advanced life support (ALS) for Clinton and nearby towns. LifeStar is the only medical helicopter service in the state, operated by Hartford Hospital, about 40 miles away. The nearest Level 1 Trauma Center is Yale-New Haven Hospital, 25 miles from the site of the incident.


The victim on a stretcher in the ambulance with his arm still entrapped in the conveyor assembly. Note the vertical 4×4 supporting cribbing between the stretcher and the attendant bench.

Clinton’s Dispatch Center received the 9-1-1 call at 7:41 a.m. The first crew and a chief officer arrived on-scene at 7:46 a.m. They found the victim tightly pinned in a standing position against the exterior wall of a corrugated metal building, with his right arm trapped in the chute where it passed into the building for mixing. The temperature was in the high 30s7F; there was a five- to 20-mph gusting wind. The day was sunny, but the ground surrounding the patient and involved equipment was deep mud with standing water from recent rains and heavy snowmelt.

CVFD Chief Hugh “Oscar” Allen established command on his arrival and sized up the incident. Assessing scene safety, he verified that the circuit breaker to the electrically powered conveyor had also been tripped when it automatically shut down, so there was no risk of inadvertent activation of the machine. It was clear that the worker’s right arm was seriously injured-possibly not savable-but its condition could not be directly assessed because it was wedged in the chute by the auger blade and a wide, transverse metal plate spanning the open side of the trough. It was also clear that extrication was going to be technically difficult and might ultimately require amputation of the arm at the shoulder to free the worker.


The victim attended by Emergency Department staff and the trauma team at Yale. The conveyor chute is resting on a second stretcher positioned parallel to the one holding the victim and is immoblized by Squad 2’s cribbing.

Allen designated Assistant Chief Scott Andrews as operations officer to oversee extrication efforts and EMS Deputy Chief John Brymer as EMS officer. Brymer advised requesting additional medical resources early, in case of medical complications or other technical problems with extrication. Middlesex Medic 2 had been requested with the original assignment and arrived at 8:04 a.m. LifeStar helicopter was summoned, and CVFD personnel established a landing zone on-site. In addition, the IC requested an amputation-capable physician team from the Emergency Department (ED) at Yale-New Haven Hospital.

The victim was initially covered with a salvage tarp for protection from the elements and subsequent extrication-related hazards. One firefighter-EMT provided continuous physical support, since the height at which his arm was trapped in the chute prevented the victim from sitting or lying down. Oxygen was delivered by facemask, and the paramedic established I.V. access for fluid resuscitation if needed. The victim remained alert, with acceptable vital signs throughout the rescue/extrication.


The 1/4 inch transverse steel plate holding the conveyor in place and helping to revent deformation of the metal trough containing the augur assembly. The victim’s elbow has been drawn beyond the opposite side of the plate from his hand by the underlying blade (blacked out here out of consideration for the victim and his family).

The operations officer determined that the victim could not be rescued in a one-step process because the arm actually passed through the corrugated metal building wall containing the chute. The conveyor was a direct-drive type, suggesting that expeditious disconnection of the auger from the drive to manually reverse the blade would not be feasible. The operations officer concluded that the rigid, metal chute with its auger-conveyor mechanism would need to be severed both below the victim (outside the structure) and above the victim (inside the structure). Cuts would need to be made far enough from the victim so that heat from the cutting tool blades would not be conducted by the metal structures to the victim. The resulting length of machinery, still containing the arm, could then be passed through the hole to the exterior of the building. This would allow EMS to more fully evaluate the arm and place the victim in a supine position.


In the Yale-New Haven Hospital OR, a member of Squad 2 cuts the transverse metal plate with an air-powered pneumatic cutoff tool while others pour sterile water for cooling and spark control.

The operations officer stationed himself in the nearby doorway where he could simultaneously monitor interior and exterior sections of the conveyor assembly. He then assigned Engine Company 1 to interior extrication and Engine Company 2 to exterior extrication efforts. Both crews proceeded to crib and shore the conveyor-chute assembly in preparation for cutting, as there were no structural supports between its origin under the lime tower and its suspension over the mixing bin. Prior to cutting, teams of firefighters were also stationed at points along the conveyor chute where cribbing was not practical to minimize movement of the segment containing the arm as it separated from the rest of the assembly. Hydraulic cutting tools were used on the thick metal trough inside and outside the building. The metal shaft of the auger-conveyor mechanism was found to be hollow and was cut separately using a reciprocating saw.

When cutting was complete, a roughly five-foot segment of the heavy, metal trough containing the corkscrew conveyor assembly and the arm was backed out of the building. At 8:30 a.m., the victim was assisted to a waiting EMS stretcher with his right arm still trapped by the blade in the trough.


Spreading tools are used to expose the arm after the transverse metal plate and underlying spacer arm have been cut through.

In the meantime, the LifeStar helicopter had landed at the scene at 8:11 a.m., and the first EMS physician dispatched by Yale had arrived at 8:22. Two additional physicians and a trauma nurse from the Yale ED were also on-scene with surgical equipment prior to victim extrication. Medical evaluation at this point revealed that the victim’s gloved right hand was pinned next to his shoulder, and his elbow had entered the corkscrew mechanism, sustaining an unknown extent of injury to the middle of his arm. Bleeding had occurred, turning the lime in the chute to shades ranging from bright red to pink, but because the blood had been absorbed by the lime, the extent of the bleeding was difficult to assess. Bone fragments were also mixed in with the lime. The patient was still alert and had some sensation in his right hand.

In consultation with the medical staff on-scene, the IC decided against further extrication efforts. They were concerned about potentially uncontrollable bleeding when the external compression being applied by the conveyor mechanism was released. It was impossible to gauge whether the limb was savable, but any remote chances would be improved by the earliest feasible surgical intervention. In addition, further extrication work in the cold and mud could result in hypothermia and increase the likelihood of infection of the injured arm.

Because of the size and weight of the apparatus still attached to the victim, he could not be transported to the trauma center by helicopter. He was moved to a stretcher, then loaded into the CVFD ambulance; firefighters supported the heavy and unwieldy segment of trough. Using additional cribbing materials, firefighters quickly constructed another support inside the patient compartment of the ambulance. At 8:53 a.m., the nurse-paramedic and another paramedic from LifeStar, Middlesex Medic 2, and two of the Yale physicians accompanied the victim into the Yale-New Haven Hospital.

While the ambulance patient compartment was being modified to accommodate the victim and his hardware, he received I.V. narcotic pain medications; his vital signs remained stable. Yale medical personnel at the scene also radioed ahead, requesting that New Haven (CT) Fire Department (NHFD) Squad 2 and Division Officer Captain Thomas Heins be dispatched to the ED to assist in the second stage of the extrication.

On arrival of the CVFD ambulance at the Yale ED, the NHFD personnel climbed aboard to support the conveyor assembly as it was lifted off the cribbing in the patient compartment. The stretcher was brought out of the ambulance, and the arm-containing machinery was handed from the firefighters onboard to four firefighters on the ground. The victim was brought into the ED’s trauma bay, where he was carefully transferred onto a hospital stretcher. A second stretcher, at the same height, was positioned parallel to the first to hold the segment of conveyor. The Squad 2 firefighters provided cribbing on the second stretcher to immobilize the heavy apparatus and prevent any movement that might further threaten the victim’s arm.

After initial evaluation, it was determined that the victim did not have any other life-threatening injury. He was intubated, placed under heavy sedation for pain control, and maintained on continuous cardiac and respiratory monitors. With the victim medically stabilized, the trauma team turned back to the fire-rescue personnel for advice regarding the final phase of extrication of the victim’s arm from the machinery.

NHFD Assistant Chief Michael Grant arrived in the trauma facility at this time and assumed command of the extrication operation. The Squad 2 engine had been positioned in the ambulance bay and portable generators set up outside. Hydraulic cutting and spreading tools had been carried through a direct-access doorway and placed inside the trauma room, ready for use. A 13/4-inch hoseline was also stretched from the apparatus to the trauma room in preparation for use of the hydraulic tools.

A preliminary attempt at dismantling the apparatus by loosening the bolts holding the transverse metal plate across the open side of the chute using hand tools was unsuccessful. Years of product buildup and corrosion of the through-bolts had permanently frozen them in place.

Grant conferred with the chief of trauma surgery, who was directing medical care. Preparation for use of the hydraulic tools included changing the victim’s ventilator settings to ambient air, to avoid the hazard of cutting and spreading in an oxygen-enriched atmosphere. This was medically acceptable since the victim had never been hypoxic and the sole reason for his being intubated was to allow heavy sedation and, eventually, general anesthesia. Further discussion between the participants in this unified command again addressed the likelihood of uncontrolled bleeding when the arm was decompressed by removal of the machinery. The trauma chief inquired whether the tools could be brought to the surgical suite instead of being used in the ED and was assured that portable tools were available.

Several additional NHFD companies were then requested to support the extrication effort that was becoming substantially more complex. In the operating room (OR), which is located on the third floor of the hospital, both oxygen and anesthetic gases could be required, and spark generation by the cutting tools was inevitable. Squad 1, Truck 2, Engine 11, and the Air Supply Unit responded to the scene. They were commanded by Deputy Chief Pat Ryan, who assigned Engine 11 to hook up to the standpipe system on the floor below the OR. Truck 2 provided a portable power pack with a 20-foot hydraulic line and spreaders; Squad 1 supplied additional SCBA air cylinders for operation of pneumatic tools and personnel who could work in rotation with Squad 2 should they require relief. A logistics area was established outside the clean environment of the OR that had been prepared for the victim, and the logistics officer served as liaison between the crew inside the OR and the various supporting units. The Engine 11 crew stretched its hoseline from the standpipe to the OR doorway.

Inside the OR, Grant explained the approach that would be taken and the tools that would be required. Generally, extrication from an auger entails dismantling or cutting and spreading the shroud, freeing up the blade and any entrapped body parts. Since the corkscrew-conveyor had a similar structure, the strategy adopted was to cut through the center of the transverse metal plate, then spread the sides of the trough to expose, then extricate, the victim’s arm. The orthopedic and trauma surgeons again emphasized their goal of saving as much of the entrapped arm as possible. Since the victim had sensation in his hand on arrival in the ED, there was still some hope that the entire arm might be saved. If that could not be accomplished, however, it would be important to salvage as much of the upper arm as possible so that an upper extremity prosthesis could be fitted to the stump after the acute injury healed. It was agreed that after firefighters completed each part of the extrication, they would step back from the operating table and allow the surgeons to reassess the extent of injury, look for evidence of new or uncontrolled bleeding, and attempt to manually dislodge the arm.

An abbreviated surgical prep was performed by the medical team because of the presence of the nonsterile conveyor apparatus and rescue tools in the room. Grant and the Squad 2 crew donned surgical scrub suits over their boots, bunker pants, and uniform shirts, including nonconductive footwear, caps, facemasks with built-in transparent eye protection, and nitrile gloves. Once again, the oxygen to the victim’s ventilator was turned off at the wall regulator, and only ambient air was administered. No flammable gases were used to maintain anesthesia. The victim was covered with thick, absorbent pads that were soaked using bottles of sterile water and saline. Additional firefighters stood by with one-liter bottles of sterile water or saline to continuously wet down the area and extinguish the shower of sparks that would be generated as the metal was cut. Additional bottles were shuttled in by the OR staff to preclude any interruption in cooling and wetting over the victim while the power tools were in use. Grant helped supervise the procedure from the opposite side of the table while the firefighters began cutting.

An air-powered pneumatic cutoff tool with an aluminum oxide blade was selected to cut through the transverse metal plate (see photos 9, 10). This tool was chosen to maximize control of the blade depth in hopes of preventing further injury to the arm tightly pressed against the underside of the transverse plate. It took about 20 minutes of cutting to divide the 1/4-inch metal plate. Another, even thicker metal strip was discovered directly under the wider, transverse plate. The underlying strip was part of the spacer arm assembly centering the blade in the trough. Cutting through this strip required the use of a second aluminum oxide blade and was accomplished by the officers from the opposite side of the table. Because of the orientation of the strip, they had a better angle for visualizing and cutting. The entire cutting operation took more than three-quarters of an hour.

Once the two metal retaining structures had been transected, a purchase point for spreading was obtained using a hydraulic ram (see photos 11, 12) and a small wooden wedge. Then the portable hydraulic spreader was used to completely open the plates spanning the trough. After spreading, a wood step chock was inserted to maintain the opening, and the squad stepped back, affording the medical staff their first unobstructed look at the victim’s arm.

It was immediately clear to the surgical team that the machinery had mangled the elbow and middle section of the arm beyond any hope of repair, sparing only a short length of humerus below the shoulder and the hand, which was now no longer viable. Essentially, it had already been amputated at mid-humerus. The firefighters carefully elevated the corkscrew mechanism from the base of the trough and slowly rotated it opposite its normal direction while the surgeons extricated the little tissue that still connected the humerus to the hand.

Squad 2 members then handed their equipment to the transition zone for cleaning, withdrew their hoselines, and exited the surgical suite. After their departure, the victim was fully surgically prepped and oxygen was reinstated in the ventilator’s supply line. The orthopedic team completed the amputation at the level of the proximal humerus. Nonviable tissue was cleaned away surgically, and the bone stump was covered with remaining muscle and tissue. Wound closure required skin grafting. The victim remained clinically stable throughout the procedure and stayed in the hospital only a few days following his surgery.

LESSONS LEARNED

The fire service is well accustomed to requesting and providing mutual aid for neighboring communities when incident requirements for staffing, equipment, or technical expertise exceed a local department’s resources. It is customary, however, to deliver the resources to the site of the incident, not to send the incident to the site of the resources. This has been particularly emphasized in mass-casualty and haz-mat situations, where responders are trained not to simply transport their “disaster” downstream to other emergency providers or medical facilities. The present case illustrates the fact that there are some situations that may best be handled by only partial mitigation at the scene, followed by the most expeditious transport possible to a more controlled setting.

From a medical perspective, it is not rare to see victims transported to hospitals by field providers with various objects still impaled in various parts of the body. It is reasonable to assume that internal damage, especially bleeding, may be difficult to control or even worsened by removal of the object. Transportation of a large piece of machinery containing an entrapped body part is much less common. One explanation for this might be an understanding on the part of emergency response personnel that hospital staff are generally neither equipped nor trained to operate the hydraulic rescue tools necessary to complete an extrication like the one described here. In addition, the hospital may be a particularly hazardous environment in which to operate such tools. Although they are known to generate sparks when used on metal structures, they are generally used outdoors, where temporary concentrations of vapors from volatile fuels or gases that may be flammable or explosive are more readily dissipated. Even under these more favorable conditions, a hoseline is always stretched and staffed during cutting or spreading operations.

The incident described here shares a number of features commonly seen in agricultural machinery injuries. Victims are frequently older males, and injuries overwhelmingly involve upper extremities. Many incidents are caused by attempts to unclog product from moving mechanisms and are initiated when clothing is caught and drawn into the machine. Extrications from augers used in agricultural applications are particularly difficult. These conveyor assemblies are typically exposed to the elements and a variety of products leading to corrosion of structural components, making it impossible to dismantle them during emergencies. They also tend to be constructed of heavy-gauge metals that challenge even hydraulic cutting tools. Extrication of body parts from augers can sometimes be accomplished with relative ease, usually depending on the type of drive powering it. In the present case, the auger had a direct-drive mechanism, so the shaft and blade assembly could not be freed up simply by cutting a V-belt. Furthermore, that approach would not have worked even if it were possible because of the position of the arm with respect to the trough, blade, and transverse metal plates. There were no viable options available to the operations officer other than cutting the trough and auger above and below the victim.

One of the overriding considerations at the scene was speed of extrication. In complex operations involving agricultural machinery, it can be difficult to accomplish more than one task at a time because of the risk of destabilizing a piece, resulting in further injury to the victim. At this scene, adequate equipment and personnel were available to permit appropriate cribbing and shoring of the chute followed by simultaneous cutting by interior and exterior crews. By having the operations officer stationed where he could direct extrication efforts while continuously monitoring both interior and exterior aspects of the chute, simultaneous cutting was safely completed, markedly decreasing total scene time.

The decision to transport the victim prior to completion of the extrication was made by the CVFD IC in consultation with on-scene medical staff from the closest trauma center. At the time this decision had to be made, the extent of damage to the arm could not be fully assessed, and there was some optimism that more of it could be saved than was subsequently possible. There was concern about potentially uncontrollable bleeding when the external compression being applied by the machinery was relieved by extrication. According to the chief trauma surgeon at Yale, fatal hemorrhage from the wound was a significant possibility given its location and severity. The decision not to free the arm from its mechanical “tourniquet” may have been life-saving in view of the distance from the scene to the trauma center.

Had a field amputation been deemed the best way to hasten extrication of the victim, the position of the arm in the machinery would not have allowed preservation of any of the humerus. In turn, that would have precluded future fitting for a prosthetic arm.

Finally, the environmental conditions at the scene of the incident were not conducive to a protracted extrication effort. Rescuers were working in deep mud and standing water. It was cold and windy, raising fears that the victim’s blood loss would be complicated by hypothermia. He had already been shirtless and pinned in a standing position for more than an hour at this point.

One extraordinary challenge was that the patient had to be transported in such a way that his arm would not sustain further damage from the auger-chute assembly. The segment containing his arm was more than five feet long and very heavy. If it suddenly dropped or fell away from the victim, it would complete what was assumed to be a partial amputation of his arm, break more bone, or even disarticulate his shoulder. Accordingly, each time he was transferred to a new location, a column of at least four firefighters walked alongside his stretcher, supporting the trough at the level of his shoulder. The victim compartment of the ambulance was modified with cribbing to immobilize and support the trough at stretcher height between the stretcher and the attendant’s bench. Although it added substantial minutes to the 25-mile ride to the trauma center, the ambulance never exceeded 35 to 40 mph to minimize movement en route.

Another extraordinary challenge was definitive extrication of the arm from the machinery once the victim had arrived at the medical center. This was accomplished by officers and personnel from the NHFD who responded to Yale’s request for assistance with the task. It was made more complex by the trauma team’s decision to do the work in the OR rather than the ED. The victim care considerations were similar to those contemplated by the initial rescuers in the field, but the decision to move to the OR added significantly to the logistical burden for the NHFD. Additional personnel were needed to shuttle supplies from the rescue apparatus to the OR three stories above. Water supply had to be established and hoses stretched to protect the OR where hydraulic and pneumatic tools were operated as well as vulnerable, high-risk exposures within the facility. Oxygen and anesthetic gases were shut off at wall regulators, and the room was ventilated prior to initiation of metal-on-metal cutting. Thick, absorbent mattress pads were soaked with water and used to cover the victim during cutting and spreading, and the operating table was surrounded by personnel continuously pouring sterile water or saline to control sparks generated by the cutting tool.

Squad 2 personnel wore OR scrubs and protective garb including nonconductive footwear, caps, face masks with eye protection, and nitrile gloves to work inside the OR. Portable pneumatic cutting and hydraulic spreading tools were chosen so that SCBA air cylinders could be used in place of a generator for this interior operation. The air-powered pneumatic cutoff tool was selected for cutting because of its small size and heft to optimize control while cutting through the thick metal plates that had the victim’s hand pressed against their undersides.

Each fire department established incident command to facilitate its own operations. In both cases, command functions were administered according to a unified command model, with medical and rescue operational officers forming consensus regarding all major, tactical decisions. In both venues, victim access was choreographed according to the victim’s care priorities and alternated in an orderly fashion between extrication and medical teams. Given the extent of the initial injury, salvaging a humerus stump that should be amenable to the future use of a prosthesis was the best possible outcome for this patient. It would not have happened without this two-tiered extrication effort by two fire departments.

Sandy Bogucki, MD, Ph.D., is an EMS physician in the Yale University Section of Emergency Medicine. She is a state-certified firefighter as well as an EMS medical director. She is associate medical director for the New Haven and Branford (CT) Fire Departments and a fire surgeon in Branford. She was on-scene for the field and hospital phases of this rescue-extrication.

David C. Cone, MD, is an EMS physician in the Yale University Section of Emergency Medicine. He is a state-certified firefighter as well as an EMS medical director. He is the EMS division chief at Yale, the associate medical director of Madison EMS, and a member of the North Madison (CT) Volunteer Fire Company. He was on-scene for the field and hospital phases of this rescue-extrication.

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