BY DAVE DALRYMPLE
Vehicle extrication rescue is a patient care-driven skill. We all know this and it is reiterated in the educational programs we teach and attend. Otherwise, it would just be an exercise of going to a salvage yard and cutting vehicles apart. But let’s rethink this.
 (1, 2) Photos by author unless otherwise noted. |
Many times, our extrication training programs focus on tool skills and evolutions. As part of that, we visualize how our patients could be disentangled and packaged. But let’s consider a concept that takes a different approach: space making and strategic cutting/spreading to make patient pathways.
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Why? Is it really all that different from simple tool evolutions? Many times, we force or “pop” doors for access to our patients and use the pathway created to remove the patient. Or we cut or displace the vehicle’s roof and remove the patient vertically or toward the rear of the vehicle. If our patient is physically entrapped by the dashboard or footwall area, we will need to move or displace the dash to remove the patient.
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Our patients are either physically entrapped (usually as in the above situation, since the dash area or footwell area has collapsed or crumpled around them) or “medically” entrapped because of the nature of their actual or potential injuries and how the vehicle structure is displaced or crushed around them (photos 1, 2). Considering all the concerns about new vehicle technology (safety systems, vehicle construction and materials), we should refocus our tool evolutions into strategically creating pathways to remove patients to ensure our safety and to produce better patient outcomes. We should also consider cutting or displacing vehicle components/areas so as to weaken other vehicle components to assist in displacement or removal, if not actually creating a patient removal pathway.
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Let’s take a look at the vehicle itself. How easy is it today to perform a simple door displacement? Doors shred and tear pretty easily today, which leaves us little or nothing to push against for displacement. This transforms the evolution into a cutting operation; how many power hydraulic cutters are up to the task of cutting the hinges and latches of today’s vehicles? Will this provide the space you need to remove that patient?
Here’s a question I often ask my students, “Where do people sit in vehicles today-in front of, in line with, or behind the B-post?” Think about it; go for a drive and observe for yourself. Overwhelmingly, I find that most occupants sit either in line with or behind the B-post structure of the vehicle.
So what? With the B-post in the way, if the occupants are seated there, the patient would need to be moved forward before he could be moved sideways out of the vehicle. Why not just remove that B-post altogether? This makes the operation go more smoothly and safely, and it’s better for the patient, too. It also gives you almost the same amount of space as a roof removal evolution (photos 3, 4). Consider this: Most side removal/displacement evolutions, such as a B-post tear/rip, actually will go faster than a traditional door pop since we are (1) working away from most of the hardened vehicle components such as door latching/ securing devices and hinges; and (2) we are defeating the way the vehicle was originally constructed. Remember, however, that safety system components (e.g., side curtain airbag, gas generators, and seat belt pretensioners) can and do exist in the B- post today, so you need to remove interior trim to take a look before cutting and displacing the B-post.
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Finally, think of the vehicles of today that have different door configurations. Minivans sometimes have sliding doors; some maxicab pickup trucks, the Honda Element SUV, and other vehicles have facing doors that open in opposite directions (photo 5). What problems do they present for side removal pathways?
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Let’s look at the roof structure. Removing or displacing the vehicle’s roof usually gives us the largest removal pathway and also is usually the easiest of all the vehicle components to remove. However, as with the B- post, the presence of safety system components is a big concern. Side curtain gas generators and sometimes seat belt pretensionsers may be located in any of the roof posts and interior roof edges. Thus, we may need to displace not only interior post trim but that of the interior roof edge as well (photo 6).
 7 Photo courtesy of Volvo of North America. |
Also, high-strength materials may be used for roof reinforcements and may also be tied into side impact protection. These lighter-weight vehicle reinforcements strengthen the vehicle’s structure and also assist in the movement or dispersal of energy in a crash. Other reinforcement materials such as polyester foams may be used to fill the post/structure voids (photo 7).
Finally, consider the size and construction of vehicle roofs. The popular sport utility vehicles (SUVs) and minivans of today have larger roof structures and may also be higher off the ground.
Can our cutting tools handle these materials? Today, all power hydraulic tool manufacturers make cutters that provide more than 100,000 pounds of cutting force. Although the amount of cutting force was aimed at cutting crash beams, some of the same materials used in these beams are now also found in roof reinforcements. Various manufacturers also produce reciprocal saw blades that are specifically designed for extrication operations and are needed to cut the high-strength materials used in vehicles today.
So is it really the easiest pathway today? Although car roofs have become smaller so that displacing/removing them is physically easier, you need to consider the concerns above. With the current popularity of SUVs, minivans, and pickup trucks, we need to address these concerns. Maybe our easiest pathway now has become more of an option instead of an absolute.
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Since the last major vehicle component we displace in extrication is the dashboard and footwell area, we must remember that all of today’s vehicles have dashboard reinforcements that not only tie each side together but also tie into the floor and forward into the firewall. Add to it that same concern about vehicle design and construction that absorbs crash energy and displaces and channels it around the vehicle. Recall the recent motor vehicle crashes to which you have responded. Note how the vehicle’s nose crushes rearward and “balls” up (photo 8). Concerning these two issues, how would you displace the dash? Would a traditional dash roll evolution work well, or would newer techniques such as the dash lift work better? To make these tool evolutions faster and more effective, we need to add an additional tool operation such a fender evolution. Fender evolutions are nothing more than a tool evolution that facilitates strategic cutting and displacement in a vehicle structure to enhance other tool evolutions (photo 9).
 9 Photo by Denyal Cusimano. |
Since we are now discussing strategic cutting/displacement evolutions, how about the concept of cross-ramming? In this evolution, we place a power hydraulic ram into the vehicle interior and extend it to force a crushed roof structure upward or to widen the passenger compartment or footwell (photo 10). We really haven’t had to consider this too much in the past, but as vehicle designs get smaller and structurally stronger, when they are crushed or displaced inward in a crash, we might need to visit that concept more often in the future.
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It’s time to rethink our current tool operations. How does the patient need to be disentangled from the vehicle? What potential injuries are present, and how might they affect removal? What about the pathway for removal-what options are available? Blending our tool evolutions with our knowledge of vehicle concerns, hazards, and issues is necessary in today’s rescue evolutions. Applying that knowledge is helpful in answering all of the above questions. Knowledge is truly power, especially for today’s rescue technician.
DAVE DALRYMPLE is a career EMS provider for Robert Wood Johnson University Hospital Emergency Services in New Brunswick, New Jersey. He is also a firefighter/EMT/rescue technician and former rescue services captain of the Clinton (NJ) Rescue Squad. Dalrymple is the education chair of the Transportation Emergency Rescue Committee-US and serves on the Expert Technical Advisory Board of the International Emergency Technical Rescue Institute as the road traffic accident advisor.
