David A. Greene

Published Writing - Spring 2007

 

(From Carolina Fire-Rescue EMS Journal - Spring 2007)

In the current days of high angle, confined space, trench, water and other types of technical rescues, it is very easy to forget one type of rescue, the more common but less glamorous, auto extrication. I begin every auto extrication class with a story about my father, who can define the changes in auto extrication that have occurred over the last fifty years very simply. He grew up in central Pennsylvania and would frequently be tasked with standing at the bottom of the driveway to the house where he grew up and watch for cars. He would waive his father down, when there weren’t any cars traveling on the highway, to drive their 1941 Chrysler (“The Gray Meteor”) as fast as he could down the hill to smash into the snow bank that was typically four feet tall and left by the passing snow plows on the highway blocking egress from their driveway. This would allow them to go “to town” but would have to be repeated several times a week during the winter. I would imagine performing this operation with a new model car today would leave you with a lot to explain to your insurance company.

Auto extrication has changed so significantly because the automobiles continue to change significantly. Gone are the days of connecting a chain to a wrecker on each side of the car and pulling until you can extricate the patient. New technologies such as airbags, electronic fuel injection systems, alternative fuels, and the like have left us constantly having to improvise, adapt and overcome tactically. Regardless of our approach and function at these types of incidents, we must constantly remind ourselves of the basics through training. 

First and foremost, we must be prepared. Preparation includes both the training on types of automobiles and their associated new technologies, as well as preventive maintenance on the equipment we use to perform at these types of calls. Obviously if we are not prepared, we are setting ourselves up to fail when called upon to perform.

Second we have response. Without writing another article, let us look at the statistics on serious firefighter injuries and deaths. A quick look at those statistics will show the need to drive safely. Furthermore, if we do not arrive at the incident, we haven’t even begun to solve the problem.

Third is Assessment. We have to follow the golden rule of any forcible entry technique, “Try before you pry.” Prior to assuming the advanced life support treatment and transport role, I fondly remember working diligently for long periods of time on the driver’s side of a vehicle while the paramedics extricate the patient through the passenger side of the vehicle. The lack of coordination at these types of incidents often lead to wasted time, further damage, and hurt feelings. Any auto extrication requires a strong incident commander. If you take two command officers that have relatively the same experience (let’s say 20 years) and put them at the same motor vehicle accident, they are likely to come up with two completely different ways to extricate the patient. The strong incident commander’s role is to keep everyone on track with the action plan and only allows changes or new ideas whenever the current plan isn’t working. Tactical changes that occur in the middle of the plan usually result in very long extrication times, and could be easily defined as nothing more than highly organized freelancing. Once command is established, the circle surveys can begin. Remember the inner circle is responsible for vehicle stabilization, hazards and patient situation while the outer circle survey looks for hazards and other patients. Assessment is also the step where most mistakes occur. In my department, we are considering writing a procedure that assigns the biggest, meanest, ugliest firefighter on the scene to protect and deny entry to the compartments on the Rescue truck that contain the extrication tools until the vehicle has been properly stabilized. How many times in your department does the hydraulic pump come off of the truck before the cribbing? Remember, the car has to be stabilized prior to cutting on it. If you were involved in a major traumatic event such as a high-speed collision with a fixed object associated with a rollover and partial ejection, chances are you would want to not move anymore once you came to a stop. Unfortunately, we have had some bad experiences with vehicles moving while cutting, and although most have only moved a few inches, a few have moved roughly the length it takes to get a first down. Assessment is also the time to think about how to deliver your patient to appropriate definitive care as quickly as possible. If you don’t have a Level One Trauma Center in your jurisdiction, it may be time to call for an air evacuation of your patient, weather permitting. If this is done early enough, the transport time can be reduced and the ultimate outcome for your patient improved.

Fourth is Hazard Control. Initially, traffic must be a paramount concern. In June of 2006, a Colleton County Fire-Rescue Firefighter/Paramedic assigned to an engine was struck by a tractor-trailer on Interstate 95, seconds after arriving at a medical call. Coordination must be sought with law enforcement to try to provide for traffic flow for the civilians (and me if I am stopped in my personal vehicle in your jurisdiction), but providing safety for those operating at the scene, outweighs traffic flow concerns everyday and twice on days in June. Other hazard control issues are fires, spills, hazardous materials, unstable vehicles, debris, and submerged vehicles.

Fifth is Support Operations. Will other Fire-Rescue companies be needed such as haz mat, more ambulances, more engines or maybe other agencies, such as the power company, gas company, or water company. 

Sixth is Gaining Access. This is where an access is made for a medically trained and properly protected individual to enter the vehicle to begin assessment and stabilization of the victim. The access should be large enough to allow access for the medically trained individual but should not involve massive amounts of work (or time or tools). 

Seventh is emergency medical care. I have seen this range in my department from an EMT-Basic holding C-spine on the patient until they are extricated to the patient having two large bore IV’s and intubated prior to being extricated. The individual assigned to gaining access can also provide valuable information to those working outside to any changes inside the vehicle or to the patient. This individual also gives our conscious, alert and oriented patients a friend or cohort so they are not alone in their new environment.

Eighth is disentanglement. Regardless of the manufacturer or types of tools that you possess, the disentanglement plan has to be followed. The incident commander should insure that any changes in the tactical operations only occur when we identify that the current plan is not working. I have been on an extrication that lasted 90 seconds. I have also been on an extrication that lasted two and a half hours, simply because we changed the operation every time a new idea was brought up and before we evaluated whether the current idea was working.

Finally, we have patient removal and transfer. Remember your National Registry Practicals? What are the first three letters out of your mouth at each station? BSI. We have to switch from structural gear or auto extrication gear to body substance isolation clothing, particularly gloves. Nothing makes the head of logistics in your department happier than the third time you go to see them for a replacement pair of turnout gloves because the last two pairs in the last two weeks have been soiled with blood. We must make sure the patient is ready to be moved and that we have enough people to move them safely. This would be the point where any special equipment (i.e. long spine boards, KED’s, ground ladders, stretchers, or anyone capable of levitation) becomes very useful. One of Chief Alan V. Brunacini’s timeless truths is: “There is a reason they don’t call natural laws natural suggestions (stuff like water vs. thermodynamics, everything about gravity, supply/demand, never tease a weasel, don’t tug on Superman’s cape, etc.” Use gravity to your advantage during patient removal and transfer, whenever possible.

Auto extrication continues to be a very dynamic form of rescue for the fire service.  Although the automobiles have changed significantly and new technologies force us to perform tactically different, the basics have not changed much over the years. By following the basics, we can continue to perform with poise, precision and professionalism as we go about the job of protecting our citizens. Be safe and do good.