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The EMT's and Paramedic's Role in Vehicle FEATURED JOBS

Extrication Paramedic

Mon, Jun 8, 2015 By Bill Hallinan, RN, MSBA Sunstar Paramedics -   LOOKING

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Motor vehicle crashes (MVCs) continue to be a source of severe injury Rise in Azerbaijan
and death in the United States. In 2013, the National Highway Tra c
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Safety Association (NHTSA) reported 32,719 fatalities and 2,313,000 DUFFEL
injuries from MVCs.1 This is a downward trend in the fatality of the over 5 million total crashes each year. Of Grass Fire Causes Evacuations in
occupants in fatal crashes, 49% were unrestrained, and alcohol-impaired fatalities accounted for 31% of the Colorado
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However, changes in personal behavior, overall health of citizens and vehicle design changes are making the
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rescue and treatment of survivors of MVCs more di cult for EMS.
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More than one-third (78.6 million) of U.S. adults are obese.2 Obese and morbidly obese drivers have a 50%
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and 80% increased risk of death in an MVC, respectively.3 Survivors with advanced age, anticoagulants and Video: Arrival Video of DCFD
complex medical conditions all make the initial triage and medical care of patients in MVCs more challenging. Companies at an Apartment Fire

Vehicle design changes and changes in emergency spinal care guidelines would appear to reduce the
challenges of vehicle extrication, but in fact have created more challenges for EMS, re and rescue teams. A
vehicle occupant with a properly functioning restraint system will have a greater chance of being alive with
severe but survivable injuries than they were a decade ago, but will often require a very coordinated
extrication uninhibited by the complexity of a modern vehicle.

Emergency crews must work together to balance the priorities of rescuer and patient safety, utilization of
resources, tactical decision-making, and patient care in the continued race to bring a patient to a trauma
team as quickly as possible. Crews are encouraged to get patients to critical trauma care within the "Golden
Hour"--a term credited to famous University of Maryland shock trauma surgeon R Adams Cowley, MD--which
is the rst 60 minutes after their injury. The Golden Hour will likely never see a randomized trial, but trauma
teams across the nation continue to work to shorten the time patients experience the progressive decline
toward death brought on by hemorrhagic injuries and shock.

Despite awareness of the time sensitivity of the severely injured trauma patient, barriers can still occur that
add time to the clock. Rescue teams with inadequate resources and training, delays in extrication because of
safety concerns, lengthening the extrication time because of needing to modify a rescue plan, lack of
preparation to quickly transition from treatment to transport, and underuse of air medical resources or poor
communication from rescue to transport crews can all prolong the time it takes for a patient to reach
de nitive surgical care and negatively impact the patient's outcome.

Damage Control Extrication

Changes in how severely injured trauma patients are treated by trauma teams can be applied to how vehicle
extrication is performed by rescue teams. Over the past 20 years, trauma teams have applied the concepts of
damage control to performing surgical interventions on polytrauma patients.4

Damage control surgery means trauma teams perform only the necessary maneuvers to stop bleeding and
resuscitate the patient. The patient is then allowed to stabilize before undergoing additional surgery to
completely repair their injuries.

The concept "damage control extrication" (DCEx) was rst described by trauma surgeon Mark Gestring, MD,
director of the Kessler Trauma Center at the University of Rochester.5 DCEx requires teams to assess the
complexity of the rescue scenario and develop an integrated rescue and medical plan that incorporates
tactics that balance the patient's injuries, time and risk to the survivor and team. The goal of DCEx is to
improve survival through teamwork, e ective tactics and a stronger focus on the patient than the accident.

This concept has created a framework for rescuers and emergency medical professionals to increase
education, discuss common strategies and tactics, de ne roles and expectations and train together to
improve patient care.

For responders who have the luxury of working with cross-trained rescue and medical personnel daily, this
may not be a di cult challenge. But for the thousands of responders who work in isolation from their peers
in the rescue services, the DCEx platform is an opportunity to come together. The DCEx process should be
used when there's been a high-energy impact and inadequate use of restraint systems or failure of the
patient compartment, thoracic or lower extremity trauma (including pelvis), or a complex extrication (more
than three multi-step maneuvers).

Each rescue maneuver (door removal, roof removal, etc.) should take less than ve minutes. After
size-up, a rescue team should have a good idea of how many maneuvers it should take. Photo
courtesy John Spaulding

To participate in vehicle extrication, EMTs and paramedics should have more than the obligatory extrication
demonstration. To integrate into the rescue team, a provider must understand the following:

Crash mechanics, force and velocity;

Injury pro les;
Restraint systems bene ts and limitations;
The team's "rescue playbook";
Their de ned role in the rescue team;
The appropriate personal protective equipment (PPE) to wear; and
The process to communicate with the rescue supervisor.
When confusion and con ict occur between medical and rescue priorities, it's the patient who su ers.

Understanding injury pro les is the rst step in adding value to the extrication process. The crashworthiness
of vehicles is based on a detailed assessment of many factors. Translating this information into the initial and
ongoing size-up for rescue teams can be intimidating. Begin by considering what the typical crashworthiness
test is and make a determination if the impact the survivor compartment sustained was beyond that.

This high index of suspicion for severe injuries will lead the EMT, paramedic or rst responder to consider
what severe injuries may be involved. For frontal or o set collisions with a combined speed of greater than
75 miles per hour with damage and intrusion to the survivor compartment, or with failure or inadequate use
of restraints, medics must consider that these patients have severe injury.6 (See Table 1 above.)

Frontal impact protection reduces head and cervical injury but signi cant thoracic, lumbar, pelvis and lower
extremity injury can still persist.7,8 Side impact or lateral collisions o er very little space to displace or
absorb the energy of the collision.

Chest wall, lung, and pelvis injuries can easily occur along with the head impacting the B post if there's no
side curtain airbag. In side impact crashes, despite modern vehicle design, a 30-cm (11.8-inch) intrusion is
associated with a 20-fold increase risk of pelvic fractures, and in the elderly there's a 70% increase risk of
pelvic fracture.9

In rollover crashes, ejection of occupants continues to be a major risk. But belted, non-ejected occupants in
rollover crashes account for 1/3 of serious spinal cord injuries and 42% of spine injuries occurred with roof
intrusion of less than 5.8 cm.10


EMS units should always position their vehicles to consider routes of travel to the hospital, protection from
tra c, upwind and uphill hazard separation, and allowing rescue and re suppression equipment adequate

Vehicle extrications pose many hazards to rescuers and survivors. Teams should operate within the hot,
warm and cold zone safety elds. Hazards from re, electricity, jagged metal, projectiles, falls, biological
contaminants and inhalation of dust and fumes are present at every crash.

The hot zone should generally be a 15-foot parameter around the vehicle, and everyone in that zone should
have proper PPE that includes footwear, long pants, jackets, eye protection, gloves and respiratory protection
as needed.

Emergency medical providers trained in extrication can add a great deal of value to a rescue team. The
approach to a crash involves a detailed 360-degree size up, scene safety measures, ongoing vehicle
stabilization, safe patient access, disentanglement of the vehicle from the patient and extrication of the
patient from the vehicle. (See Table 2 above.)

Scene size-up should include looking for evidence the driver was alert and reactive at the time of the accident
through steering or braking maneuvers. Gathering information about posted and observed speeds of those
involved should be obtained in conversation with law enforcement.

First-arriving EMS resources that may not be able to participate in the hot zone of the rescue can provide
important information to the rescuers by using gathering information about fuel, battery locations and
restraint systems.

Patient protection should include both hard and soft material. Hard material such as polycarbonate (lexan)
will shield the patient from impact debris and tools, and soft material such as a tarp will protect the patient
from glass. If sparking tools are used, a non- ammable blanket should be used for protection. Crews should
also be able to provide dust protection to the patient as needed. The stance of crews operating in the hot
zone should be down in a crouch with a reduced pro le,standing only to perform an extrication maneuver.
This is an easy way to separate the spectators from the workers.

EMS on the Inside

Patient access should be performed as soon as the vehicle is stable and any external hazards are controlled.
Consider that doors una ected by the crash may open normally. When breaking glass is required, it should
be done farthest from the patient until they're adequately protected.

The inside medic (EMT or paramedic) should be prepared with safety equipment, ashlights, hemorrhage
control supplies, spinal immobilization equipment and patient lifting straps. A dedicated outside medic
should stay in constant communication with the inside medic to provide any additional equipment, direct the
preparation of treatment and transport equipment, and provide updates to the receiving trauma team.

The inside medic should perform an initial focused exam of the survivor and vehicle, provide psychological
rst aid and perform any treatment that doesn't interfere with the rescue. The inside medic should account
for all occupants in the vehicle, determine seat position and function and damage to the interior
compartment. They should also identify red or un red air bags and determine if the patient was restrained.

The presence of un red restraint systems should be communicated with the team leader. Managing risk and
providing protection to all team members and the patient are critical to permitting the rescue to proceed at
an appropriate speed. If the patient has an adequate airway and ventilation, an early priority will be to
determine the extent of the entrapment and communicate this in detail to the rescue team leader.

The inside medic's ability to determine and communicate the internal entrapment and possibly remove
debris will improve the speed of the rescue. The extent of entrapment will vary based on impact direction,
survivor characteristics and vehicle type. In many cases the lower extremities will simply disappear below the
dash and their status is unknown.

If the limbs can be located and it's determined the entrapment is a focal entrapment by a pedal or oor pan
wrapped around the foot, the rescue team strategy should change appropriately. A rescue group supervisor
may be planning to lift the entire dash when a focal entrapment only requires a relief cut and displacing
some material. In modern vehicles, the entrapment can occur from a large amount of plastic debris.
Although rigid, this material can often be fractured and removed internally, freeing lower limbs.

An overweight or obese patient will also impact the strategy. The larger patient generally is entrapped by
pressure in all directions and requires access from 360 degrees to allow team members adequate access to
lift without risking injury.

Rescue group supervisors encountering an overweight patient should consider using a second tool team to
remove opposing vehicle side walls and seats to allow proper access. Even when the patient will be removed
horizontally, lifting straps or large webbing can permit adequate and safe points for rescuers.

The ongoing assessment of the trapped survivor will yield vital information that can reduce delays after
extrication. Pertinent medical history of cardiac or endocrine diseases or neurological disorders are
important ndings to communicate to the transport team. The Centers for Disease Control and Prevention
2011 Field Triage Guidelines for Injured Patients includes patients on anticoagulants or with bleeding
disorders as criteria for a trauma center.

The primary goal should be to get the patient to the de nitive care of the trauma team. Good communication
between the rescue supervisor and the inside medic will determine if an extended extrication may warrant
escalating patient care.

Each rescue maneuver (door removal, dash removal, roof removal, etc.) should take less than ve minutes.
After size-up, a rescue team should have a good idea of how many maneuvers it should take.

A rescue e ort lasting longer than four major maneuvers or 20 minutes should be considered an extended
extrication. During extended extrications, the medical concerns for hypothermia, pain control or volume
resuscitation may warrant additional management. Even mild hypothermia (34–36 degrees F) can give
patients cold-induced coagulopathy, which will worsen any bleeding or shock state.11

Crews transporting multi-trauma patients should have hypothermia management kits for any patient with a
delayed rescue or who may be receiving volume resuscitation. Pain control or sedation during extrication
should be administered with clear communication with the rescue team and cautious titration that permits
the patient to remain conscious and allows for an accurate exam to identify possible injuries. Agents like
ketamine, fentanyl and midazolam have been shown to be administered safely and e ectively intranasal in
hospitalized patients as well as in prehospital settings.12,13

Scene size-up should include looking for evidence the driver was alert and reactive at the time of the
accident through sterring or braking maneuvers. Photo courtesy Bill Hallinan

The disentanglement maneuvers used by rescue groups should have prede ned names and steps known to
all responding agencies. Even in the most mangled vehicle, standard steps for cutting, spreading, relief
gapping and displacing material should be used.

Many disentanglement procedures can be ine ective if there aren't proper relief gaps or if the material is
displaced against the suspension system of the vehicle. Another barrier to e ective disentanglement is
tunnel vision, which prevents teams from seeing the strong points from which material can be pushed.

Teams can lose valuable time trying to make small e orts to get "just enough room," when what may seem
like a larger maneuver can displace a lot of material more quickly and provide the team greater access to
extricate the survivor. In complex or extended extrications, rescue group leaders should request enough
resources to operate several plans simultaneously. (See Table 3 below.)

For example, the damaged side may seem like a direct path to a patient in a side impact collision, but a full
sidewall, seat and center console removal can create a faster extrication path because crews aren't working
against the impact of the collision.

For rescue groups with limited equipment or manpower, knowing when to stop a plan that's struggling is a
di cult challenge. Even if resources for simultaneous operations aren't available, a leader can be identi ed
who will be working on a backup plan, monitoring the primary plan for progress and be empowered to
discuss changing plans with the rescue group supervisor. The crews working on the primary plan will often
continue without consideration for a change in direction.


The transition from disentanglement to extrication should be seamless. The decisions to remove a survivor
horizontally or vertically will depend on the manpower available, access to the patient, suspected injuries and
resources for lifting. Extrication of patients with severe limb injuries can be a painful experience for the
patient and uncomfortable for the EMT or paramedic. Angulated limbs can be returned to a neutral position
when the patient is extricated. Delaying extrication for a limb that's free but requires manipulation puts the
patient at further risk of hypothermia, bleeding, limb ischemia and injury.

The rescue, treatment and transport groups must all understand they share the same precious eld time
allotted to the prehospital team. Opportunities to reduce on-scene time include the outside medic keeping
transport teams updated on the progress of the rescue, transport teams being available and ready to
transport the patient after extrication, and reducing repetition in patient assessments.

An e ective means of producing a seamless, accurate and timely transition to transport is to keep the inside
medic with the patient until hando to the trauma team at the hospital. During hando , accurate facts are
often lost that would paint an important picture for the members of the trauma team. Transporting medical
crews must be ready to receive the patient after extrication. Have ambulances well-positioned, gurneys and
immobilization devices ready, infusion lines primed, and adjuncts to keep the patient warm and secure.

With proper education and training, EMS can improve outcomes for critically injured trauma patients. The
integration of high-quality medical care, quick and e cient rescue plans, and timely transport can give
trauma teams the time to provide de nitive care.  


1. U.S. Department of Transportation National Highway Tra c Safety Administration. (December 2014.) 2013
motor vehicle crashes: Overview. Retrieved Jan. 15, 2015, from

2. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011–
2012. JAMA. 2014;311(8):806–814.

3. Jehle D, Gemme S, Jehle C. In uence of obesity on mortality of drivers in severe motor vehicle crashes. Am
J Emerg Med. 2012;30(1):191–195.

4. Hussmann B, Lendemans S. Pre-hospital and early in- hospital management of severe injuries: Changes
and trends. Injury. 2014;45(Suppl 3):S39–S42.

5. Gestring M. Damage control extrication [lecture]. Studies of Trauma and Emergencies Project (STEP)
Conference: Rochester, N.Y., March 2009.

6. Stucki SL, Hollowell WT, NHTSA R&D, et al. Determination of frontal o set test conditions based on crash
data [white paper]. National Highway Tra c Safety Administration: Washington, D.C.

7. Rao RD, Berry CA, Yoganandan N, et al. Occupant and crash characteristics in thoracic and lumbar spine
injuries resulting from motor vehicle collisions. Spine J. 2014;14(10):2355–2365.

8. Müller CW, Otte D, Decker S, et al. Vertebral fractures in motor vehicle accidents--A medical and technical
analysis of 33,015 injured front-seat occupants. Accid Anal Prev. 2014;66:15–19.

9. Schi MA, Tencer AF, Mack CD. Risk factors for pelvic fractures in lateral impact motor vehicle crashes.
Accid Anal Prev. 2008;40(1):387–391.

10. Bambach MR, Grzebieta RH, McIntosh AS, et al. Cervical and thoracic spine injury from interactions with
vehicle roofs in pure rollover crashes. Accid Anal Prev. 2013;50:34–43.

11. Kaafarani HM, Velmahos GC. Damage control resuscitation in trauma. Scand J Surg. 2014;103(2):81–88.

12. Borland M, Jacobs I, King B, et al. A randomized controlled trial comparing intranasal fentanyl to
intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med.

13. Riediger C, Haschke M, Bitter C, et al. The analgesic e ect of combined treatment with intranasal S-
ketamine and intranasal midazolam compared with morphine patient-controlled analgesia in spinal surgery
patients: A pilot study. J Pain Res. 2015;8:87–94.


Bill Hallinan, RN, MSBA

Bill Hallinan, RN, MSBA, is a captain with the Spencerport Fire District. He has over 20 years
of experience as a New York state paramedic and is a member of the Monroe County Special
Operations Unit and New York state disaster medical assistance team 6. He's also the clinical
director of the University of Rochester's Arti cial Heart Program. Contact him at

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Gert Petzer Sep 13, 2017

If the vehicles are equipped with this technology then the cost of extrication equipment will be drastically reduced.

Extrication AEES (Auto Emergency Extrication System) Technology for new build vehicles

Like Reply

David Miller from Facebook Feb 13, 2016

This agency seems to do just fine at providing medically directed rescue to a mid sized city...

Like Reply

Jeff Kelly from Facebook Feb 13, 2016

Thank you Mr. Bane for your non progressive thinking. Next your going to tell me that only the FD should handle things like forcible entry and
water rescues. Without a patient, there is no rescue. It is ALL about the patient!!

Like Reply

Todd Bane from Facebook Feb 12, 2016

I strongly disagree with you Jeff. More training WITH EMS and paramedics is a better idea.

Like Reply

Donnie DuVall from Facebook Feb 11, 2016

Great stuff coming out of my home region!

Like Reply

Jeff Reim from Facebook Feb 11, 2016

Ideally the EMS service and paramedics should be doing rescue and not fire departments as this allows for easy implementation of what is
described in the article. Of course, this is not always possible and is rarely the case in the United States. Good article.

Like Reply


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