Rollover Extrication: Upside Down with Nowhere to Go


Automotive design changes have increased the frequency of vehicle rollovers in which the vehicle ends up resting on its roof with the patients still belted into their seats. When confronting this difficult upside-down patient situation, there are a number of patient and rescuer considerations.

Vehicle manufacturers have engineered more aerodynamic vehicles to increase vehicle fuel efficiency, with a more rounded, streamlined appearance in contrast to the boxy shape of older cars. As a result, when a vehicle rolls, it tends to roll over more times and come to rest on the flat roof section rather than on the rounded sides of the vehicle.

Physics is another factor contributing to the increased number of rollovers. SUVs and pickup trucks have higher centers of gravity, and their popularity has increased the potential for rollovers. Manufacturers are now installing electronic stability control (ESC) in many of the newer models, including SUVs. ESC uses a variety of sensors along with automatic braking of individual wheels to help the driver maintain control of the vehicle. This technology also helps drivers maintain control during hard cornering and on slippery roads by keeping the vehicle headed in the intended direction, even when the vehicle approaches or exceeds the limits of road traction. ESC can also detect when a car is entering a skid or nearing a rollover and make the necessary corrections. Although ESC does help drivers avoid loss of control that could lead to a collision and is an exciting new safety feature, it does not replace driver prudence and attention while behind the wheel. Driver error remains the number one reason people are hurt or killed in crashes.


Often, when you find patients still belted in their seating positions in a rollover incident, they may be unconscious or injured seriously enough that they make little or no attempt to remove themselves from their uncomfortable predicament. A variety of rescue methods have been proposed for extracting patients found in this compromising position.

Some rescuers access the patient by opening the doors and attempting to support the weight of the patient at the torso while releasing the seat belt. They then twist, turn, and maneuver the patient into a position so that the person can be placed on a backboard. This practice is effective for small, lightweight patients but puts rescue personnel in awkward positions not very conducive to proper body positioning while lifting patients. There is also considerable risk of dropping patients using this method. It is extremely impractical when confronted with larger or heavier patients.


A preferred option to assist rescuers in safely moving a patient in this situation uses two backboards for added patient and rescuer safety. For photo purposes, certain vehicle components normally in place have been removed to provide a better view of the procedure. Also, EMS providers who would normally be in place providing C-spine stabilization have been removed. Always provide proper immobilization of obvious or suspected injuries.

Begin by ensuring all department accident scene protocols are followed regarding scene size-up, safety, vehicle stabilization, air bag and supplemental restraint system awareness, and using hard protection between cutting/spreading tools and patients.

In this procedure, assume there is one stable patient with no entrapment in the driver’s seat position of an overturned vehicle—in this case, a two-door hatchback (photo 1).

(1) Photos by author unless otherwise noted.

Click here to enlarge image

First, gain access to the passenger compartment to assess patient condition, determine the degree of entrapment, and perform other interior rescuer duties (e.g., turning the ignition off, unlocking doors, and opening windows).

Next, locate the recline lever on the side of the seat. Depending on the vehicle make and model, it may be on either side of the seat bottom—in this particular vehicle, the seat back recline lever is on the inside of the lower seat cushion toward the center console area of the vehicle. If the front passenger seat is unoccupied, you may easily identify and locate that seat’s recline lever, which may give you a clue as to the location of the occupied seat’s lever. Remember that in this inverted position, the seat back will provide the patient with little or no torso/lumbar support. Also, the two-inch-wide lap seat belt will be supporting nearly all of the patient’s weight, which is extremely uncomfortable for the patient.

Open and overextend driver and passenger doors, or remove them completely if necessary. Open the hatchback door and let it rest on the ground. Alternatively, you can leave it closed and just break out the glass if the window area is large enough to provide adequate access. However, you will have more room to work if you remove it completely, since it won’t be in your way. Use whatever method is appropriate for the situation (photo 2).


Next, insert a long backboard (orange in photo) transversely through the vehicle passenger compartment so the foot end is accessible to rescue personnel positioned at the passenger side vehicle door. The board should pass under the middle of the patient’s thighs. This allows rescue personnel to support both ends of the backboard (photo 3).


From the rear of the vehicle, insert another long backboard (yellow in photo) in line with the patient. Place the foot end of the backboard near the patient’s head, not quite under it, at a slight angle initially, in a ready position to slide it directly under the patient (photo 4). Once this board is in place, the interior rescuer releases the recline lever so that the driver’s side seat back can be pushed to its fully reclined position. The front passenger seat back should also be fully reclined at this point to allow more space for patient maneuverability. The headrest in most vehicles may also be removed to gain another four to five inches of clearance, if needed (photo 5). Assist the patient’s torso with some support.




With assistance, the interior rescuer carefully positions the patient’s torso back to create room for the yellow spine board that is to be inserted under the patient with the foot end following through to the patient’s foot area. If possible, insert the foot end into the lower portion of the steering wheel for support, or rest it on the dashboard if the patient is in the passenger seat (photo 6).


This will bring the board closer to the legs to better accommodate the lowering of the patient. Ensure that a rescuer remains supporting the head end of the yellow backboard.

The patient is now ready to be released from the seat belt. Carefully raise the other backboard (orange) to the patient’s thighs, take his weight, and release the seat belt buckle or cut the seat belt (photo 7).


Lower the patient carefully onto the bottom (yellow) backboard, paying close attention to C-spine and airway patency. Ensure the patient’s airway remains open by supporting the head and neck; do not allow it to overextend and possibly compromise his breathing (photo 8). The patient will now be resting prone on the bottom yellow backboard (photo 9). Next, carefully remove the top (orange) backboard from the vehicle.




Remove and support the foot end of the backboard out of the steering wheel and coordinate a careful, smooth shuffling motion out toward the rear of the vehicle (photo 10).


Once the patient has been moved to a safe location away from the vehicle, position the original (orange) backboard or a scoop stretcher next to the patient, check him for injuries, and logroll the patient onto the remaining board into a supine position for proper care and packaging (photos 11, 12).




The vehicle used in these photos is a hatchback. For vehicles that have a trunk or smaller rear exit areas, create a quick large egress point with a hydraulic ram or spreader. Insert the ram/spreader into the rear window, near the center; spread/push until there is compression of the trunk bulkhead and the roof starts to tent in the middle; continue to spread until there is sufficient room to remove the patient out of the rear window area (photo 13).




Some advantages of the two-backboard method follow:

  • It decreases manipulation of the patient’s spine by not requiring twisting or turning the patient’s body for removal out the side of the vehicle.
  • It eases the rescuers’ workload by not forcing them into compromising lifting positions.
  • It reduces the risk of responders’ inadvertently dropping the patient.

Depending on the damage and type of vehicle, you can perform the two-backboard extrication method without forcefully removing the vehicle’s components by possibly opening rear hatches and doors.


Some disadvantages of the two-backboard method follow:

  • It will not work well if the vehicle is a truck (pickup or older SUVs and minivans with nonremovable second and third seats) without removing or relocating large amounts of metal or other components. However, most newer minivans and SUVs have removable bench seats or captain’s chairs. When these seats are removed, it is easy to enter through the rear of the vehicle.
  • It is more time consuming if the vehicle’s seat backs do not recline and have to be removed with tools.
  • It requires a minimum of four rescue personnel.


The two-backboard method of removing a patient belted into his seat from a rolled-over vehicle is one means available. No single procedure will work for every situation. The more tools we have available in our arsenal, the more proficient we can be at the variety of rescue situations we encounter.

RANDY SCHMITZ is a firefighter and an extrication instructor for Calgary Fire Department in Alberta, Canada. He is chairman of the Alberta Vehicle Extrication Association and educational chairman for Transport Emergency Rescue Committee (TERC) Canada and has served as a judge at TERC international extrication competitions. Schmitz teaches extrication courses and new vehicle technology programs across Canada and the United States.

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