Vehicle Accident with Entrapment: Call a Physician to the Scene!

On February 16, 2006, a 20-year-old male was driving his car when it left the road while he was negotiating a series of curves. The vehicle struck a large tree at the driver’s door with two feet of intrusion into the passenger compartment. The driver was entrapped, but the passenger sitting in the front passenger seat was able to crawl out of the heavily damaged car. The Clayton County (GA) Fire Department responded.

Battalion Chief Blaine Clark established command on arrival and made the following initial size-up: There was no fuel spill and no electrical line hazard. The collision involved only a single vehicle, which was positioned 40 feet into the tree line. The driver was gravely injured and entrapped inside the heavily damaged passenger car. Another victim was sitting on the ground holding an injured hand, and traffic was backing up on the road, a major traffic artery, as emergency units arrived.

The initial dispatch included one advanced life support (ALS) transport ambulance, one ALS engine, and one truck company for extrication. Clark immediately requested an additional engine; an additional ALS transport ambulance; the county’s heavy rescue squad; an additional shift supervisor; and a medical evacuation helicopter, Rescue Air One.


(1) A tow truck pulled the vehicle away from the tree so the patient could be accessed from the driver’s side of the vehicle. The spreaders were used to pull the steering column up and away from the driver. Multiple rams were deployed in the passenger compartment. (Photos by Tim Berryman, Warren Bond Photography.)
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As the first-in units arrived and began their respective operations-patient care, vehicle stabilization, charged cover hoseline placement and staffing, extrication tool selection, and staging-it was apparent that this was going to be a most challenging extrication. The driver’s life was in peril, and time was working against him.

As the patient care and extrication sectors completed their initial assessment and started the planning to ensure they addressed the driver’s medical and rescue needs, other fire department units established a helicopter landing zone and relocated units for area coverage. Clayton County has four shift supervisors assigned to every 24-hour shift. Two supervisors were dedicated solely to this incident, a third assisted while also remaining in-service for other alarms, and the fourth supervisor managed the other alarms occurring within the county’s 144 square miles.

PATIENT TREATMENT AND EXTRICATION

The paramedics treating the patient found that his hips and legs had multiple fractures. Both of his lower legs were pinned, since the floor pan collapsed on impact with the tree. Fortunately, he was conscious, his vital signs were stable, but his pain scale rating was 10. Responders established spinal immobilization, oxygen delivery, and intravenous fluids administration.

Extrication was initially complicated by the car’s position; it was bent around the tree trunk, preventing access to the driver’s side door. After evaluating every option, the extrication officer called in a tow truck; it was hooked up to the car and slowly dragged the wreckage sideways six feet away from the tree. Although this is an extremely unusual approach, it was necessary to gain access to the driver’s seat. Rescuers began to remove the roof and driver’s side door. The incident commander (IC)’s decision to call for an additional extrication unit was critical; now two teams were working simultaneously and cooperatively under the direction of the single extrication sector officer.


(2) Standing behind the flight medic in the blue jumpsuit, Dr. Dukes cradles the patient’s head during an assessment. The patient has been intubated and the flight medic is supporting his breathing. The patient has a cervical collar and extrication device applied around his upper torso and neck.
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Once the roof and driver’s door were removed, it became obvious that the greatest challenge would be to free the patient’s legs. Both of his feet, from mid-calf down, were trapped within the wreckage. When the vehicle had left the road, it snapped a telephone pole in half about 15 feet off the ground before slamming into the tree. These multiple impacts caused the steering column and dashboard to collapse into the driver’s lap and pushed the engine compartment and floor pan underneath his legs and hips.


(3) The patient is lying supine on the backboard. His pelvis and hips are markedly swollen with blood from crushing injuries.
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The extrication was complicated: As extrication personnel tried to use the hydraulic spreaders and rams to move the entrapping debris to free the patient’s left leg, the debris compressed his right leg, and vice versa. When the medical helicopter crew arrived, after consulting with medical control, it was decided to place the victim in a chemical coma. This was necessary since even the slightest movement or use of the hydraulic tools caused him excruciating pain.

“START AN ER DOCTOR!”

As the extrication approached the 60-minute mark, the IC asked for an estimated time needed to free the patient. Extrication personnel reported they were making very slow progress and explained the difficulties in freeing the patient’s legs and could not estimate when he would be freed from the wreckage.

The IC then requested a patient status report. The medical sector officer reported that the patient’s vital signs were stable with good blood pressure provided by the intravenous fluids. He was receiving airway support and was still sedated. However, the medical officer anticipated that in the very near future the patient’s vital signs would deteriorate, and sacrificing his legs to save his life was a possibility. The medical officer requested that a physician respond to the scene.

The IC then contacted the department’s medical director, Dr. Richard Dukes, who was at fire department headquarters when he was alerted to respond. A training officer drove him with lights and sirens to the scene. When Dukes arrived, he assessed the patient’s condition, ordered additional medications, and found him gravely injured but stable. There were some initial discussions of what the plan was if the patient’s condition started to deteriorate and extrication was still not imminent. Was amputating a leg an option to save the patient’s life? Dukes replied that it had not reached that point yet but might soon.

As the incident passed 90 minutes, the helicopter medical team alerted dispatch to place a trauma surgeon on standby. The surgeon could be on the scene in less than eight minutes using a second helicopter, providing a second physician on-scene for patient care. Dukes considered the 120-minute mark a critical point at which to evaluate all medical options for freeing the patient from the wreckage. Less than five minutes before this point, the extrication sector asked that the backboard and stretcher be made ready for patient removal. The driver was quickly moved by ALS ambulance to the helicopter landing zone and transported to Atlanta’s Grady Memorial Hospital’s trauma center.


(4) This view of the driver’s seat area after patient removal shows the conditions that the extrication crews had to overcome to free the patient.
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The driver suffered six fractures, spent 31 days in the hospital, and underwent nine surgeries. He is able to walk but has limited use of his right hand, wrist, and arm.

LESSONS LEARNED

  • Dual-certified firefighter/paramedics providing both rescue and medical treatment were an advantage. Each responder was familiar with each other’s skills, and there was a unified command structure for all sectors.
  • The IC’s call for additional medical and rescue resources and a medical evacuation helicopter immediately after completing his initial scene assessment greatly enhanced operations.
  • The IC received from the various sector officers regular situation reports that included timeline benchmarks. The reports were critical in rotating fatigued personnel and measuring incident benchmarks to reallocate resources.
  • Rarely does an IC request a physician to respond to a scene. However, for those complex and life-threatening incidents with extended timelines, it’s an available option. In the past, either a fire department shift supervisor or law enforcement officer would respond to the hospital to pick up the doctor.
  • Every fire department should establish policies and procedures covering the circumstances in which a physician would be called to a scene. This should include designating physicians to call and arranging transport to the scene. Preparing beforehand will expedite response when needed.
  • Although this incident happened at noon, in the postincident discussion, participants wondered, “What if this incident had occurred after dark?” Since the vehicle was well off the road into the tree line, the response would have required portable high-intensity lights. Even with the portable scene lighting the department carries, additional lighting would have been needed for the fine detail work setting the rams and spreaders.
  • Some of the extrication and medical treatment personnel were not wearing full personal protective equipment including eye protection. Additionally, nonfire department personnel (e.g., medical doctors, flight medics) who assist at incidents need some level of PPE.

ALEX COHILAS is chief and emergency management director for Clayton County (GA) Fire Department, where he has worked for 31 years. He has extensive experience with administrative and operational issues. Previously, he served as the president of the department’s largest employee organization for 10 years. He has had extensive experience as an investigator with a prominent law firm specializing in public administration law. He is a National Fire Service Staff and Command graduate and a frequent writer on fire service management.

JEFF HOOD, EMT-P, is a deputy chief who supervises all fire suppression and EMS operations for the Clayton County (GA) Fire Department, where he has worked for 28 years. He is a Georgia-certified EMT/paramedic instructor and received Georgia Governor’s Valor Proclamation for rescuing a police officer shot during a hostage standoff. Hood is a National Fire Service Staff and Command graduate.

BILL LOWE, EFO, EMT-P, is a captain/shift supervisor with the Clayton County (GA) Fire Department, where he has worked for 28 years. He has a doctorate in human resource management and is a graduate of the National Fire Academy’s Executive Fire Officer (EFO) Program.

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