Patient Extrication: the “Linear” Approach

By Jon Graziani

Patient extrication should be a fluid process that efficiently and effectively removes an injured patient without causing further injury or harm to him or us–sounds easy enough, right? If your agency is like most, the “go/no-go” rule to perform advanced extrication is based primarily on using “sick/not sick” status and is significantly associated with patient entrapment. The fire service is great at making the right decisions as to when to be aggressive at removing vehicles from around and on top of the patients.

1) Photos by author.

But what about the patients who are not sick but are complaining of significant neck and back pain? Not every motor vehicle accident (MVA) to which you respond will require advanced patient extrication techniques. In fact, most of the “routine” MVAs to which you respond result in patients complaining of minor to moderate neck and back pain with minimal vehicle damage.

Unfortunately, we tend to approach these “routine” incidents with a lackadaisical attitude that will eventually result in breaking the cardinal rule of emergency medical technicians (EMTs): cause no harm. This gray area is where you need to create a little property damage to prevent further injury to the patient. The property conservation philosophy is causing damage in the wrong area when it comes to patient care. The well-intentioned, overzealous crew twists, turns, and pulls the patient from the slightly damaged vehicle, all the while exacerbating what started as a minor neck and back injury into a potentially incapacitating injury. Although this is not a “bad” extrication procedure, the likelihood of maintaining inline stabilization without jeopardizing the patient’s spinal immobilization is limited at best.

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The linear approach to patient extraction simplifies removing a patient from the MVA in a straight line. Think of the patient as a six-foot-long piece of 4 × 4 wood; it would be impossible to remove this piece from a vehicle without (1) placing some hinge points in the wood and (2) removing one or two doors and the entire roof structure. This linear approach offers a systematic method of extracting patients in a way that maintains inline stabilization. Linear extraction that requires full or partial roof removal is performed routinely during serious MVAs. The fundamentals are the same, minus the sick, entrapped patient requiring advanced extrication procedures.

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Approach every MVA as we do the “Linear Rain Man”; draw an imaginary 4 × 4 × 6 linear axis plane at three main access/egress points of the vehicle–the roof, the driver/passenger doors, and the rear window. When mitigating the routine MVA where the patient is complaining of minor to moderate neck and back pain, the first access point you should consider is the rear window. In terms of a linear-axis extraction, removing a patient through the rear window is as linear as it gets. Well-trained crews can safely and effectively remove a patient through the rear window opening with minimal effort, resulting in a shorter extrication time. The only spinal movement required of the patient is when the high back seat is reclined and the backboard is guided in from behind the patient. From this point on, the patient is moved onto the backboard in a linear, fluid motion. You can remove the patient through the rear window by performing these simple steps in the following extrication training scenario:

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Remove and clear the rear window glass (photo 1). Removing the rear window is the only property damage we create to the vehicle. Follow department policy when clearing glass, wear proper personal protective equipment, and use the proper tool for the job. A window punch is more than adequate; the pick of the halligan works great and provides a tool to clear the glass from the frame.

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When clearing glass, protect the patient with a tarp. Tarps work better than blankets because they shed the glass shards from the patient. Glass shards can become imbedded in blankets, rendering them useless after the alarm. So, place a tarp over the rear window on the speaker panel (photo 2); this will protect the patient and the rescuer from glass shards. (The remainder of this article is viewed through a “maxi-side wall removal” for illustrating the extraction steps. When performing this operation on scene, the driver/passenger doors are to remain intact.)

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Rescuer 1 is positioned opposite the patient’s position in the vehicle. He faces the patient and maintains manual C-spine (photo 3). Rescuer 2 then captures the patient’s torso (identical to the steps when applying a Kendrick Extrication Device). Rescuer 4 positions himself on the rear trunk lid in a crouching or kneeling position; this position is necessary when capturing C-spine while the patient is moved up the backboard and out of the vehicle. Rescuer 3 reclines the seat back to the most reclined setting.

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Rescuer 4 slides the backboard through the rear window opening and behind the patient (photo 4). If the vehicle’s seats are electric, recline them prior to terminating the electrical system, if and when you accomplish that task.

Rescuer 1 maintains C-spine and ensures all rescuers are ready prior to starting the operation. On their count, the patient is reclined onto the backboard (photo 5). After this, Rescuer 3 captures C-spine. Rescuer 1 takes the patient’s left and right upper torso at the underarms to prevent downward movement. Rescuer 2 then frees the lower extremities; this rescuer must keep control of them during the next movement. Rescuer 1 and 2 move the patient approximately halfway up the backboard in a fluid motion.

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When Rescuer 4 can safely maintain C-spine without compromising the safety of the patient or the operation, he reaches through the rear window opening and captures C-spine from Rescuer 3.

On Rescuer 4’s count, the patient is moved up the backboard. Rescuers 1 and 3 slide the patient farther up the board once more to ensure balance on the backboard. The patient is held at this position while Rescuer 2 lifts the patient’s foot onto the backboard into a level position, eliminating any further downward movement. Rescuer 2 should encapsulate the lower extremities while grasping both sides of the backboard; this prevents the lower extremities from slipping off either side of the backboard. Rescuer 2 will now support the patient and the backboard; the head of the backboard will be resting on the top of the rear passenger seats and the speaker lid.

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Rescuers 1 and 3 reposition themselves to a more manageable position; this will assist with moving the backboard out through the rear window. On Rescuer 4’s command, the patient is slid out through the rear window in a controlled and fluid motion (photo 6). The patient will be positioned approximately one-half to three-quarters of the way out of the rear window with the remainder of the backboard staying within the vehicle.

On Rescuer 4’s count, the rescuers direct and guide the patient/backboard out of the rear window opening and onto the trunk lid (photo 7). They use the rear speaker lid and trunk to support the patient/backboard, requiring lifting/balancing support from rescuers (photo 8). Rescuers 1, 2, and 3 go to the rear of the vehicle and assist with pivoting the patient/backboard into a parallel position with the trunk (photo 9). They tend to the patient’s feet during the move, ensuring they are not caught on a pillar or the roof assembly. All four rescuers begin securing the patient to the backboard following local protocol.

They place a gurney at either side or the rear of the vehicle; now, the patient can be slid onto the gurney and loaded into the transport unit. There will be some stop-and-go movements when changing positions in and around the vehicle. Proper communication and teamwork ensure a fluid operation. Prior to beginning this operation, make sure the patient understands what is about to happen. Direct the patient to cross his arms and hold them close to his body during all movements. Last, but not least, encourage the patient to relax, and discourage him from “helping.” Sometimes, NOT helping is the same thing as helping.

Today’s fire service has made great strides in attempting to keep pace with the many challenging demands of our profession. With so much specific and detailed training in tactical/manipulative skill, it is sometimes important to step back and reevaluate your strategies, to see the bigger picture, and to ensure that you are still making decisions with a clear and concise priority: the patient. You may initially feel that the linear extrication operation is a bit convoluted. Through training and repetition, you can use the rear window extrication to shorten extrication time while maintaining the integrity of the linear position, minimizing negative spinal movement.

JON GRAZIANI is a 21-year fire service veteran and a firefighter with King County (WA) Fire District #43. He has a degree in fire command and administration and is pursuing a bachelor of science in fire service administration. Graziani is an adjunct instructor with First Due Training, an emergency medical services instructor for North Seattle College, a certified Instructor I and II with the International Fire Service Accreditation Congress, and an auto extrication specialist and lead instructor.

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