Gaining Access

1. Chapter 32 Gaining Access

2. Case History You respond to a motor vehicle crash and find two teenagers trapped in a burning car. The fire is contained to the engine compartment but the flames are widespread and pose a threat to the occupants.

3. Rescue and Extrication • Rescue is a specialized field in prehospital care. • EMTs must work closely with rescue teams. • Primary responsibility is patient care. • Some systems include dual clinical and rescue responsibilities.

4. Situations That May Require Rescue • Motor vehicle crashes • High-angle incidents • Confined space incidents • Water incidents • Collapsed buildings

5. Role of the Non-Rescue EMT • Administer necessary care to the patient before extrication. • Ensure that the patient is removed in a way to minimize further injury. • Patient care precedes extrication. • Unless delayed movement would endanger life of the patient or rescuer

6. Role of the Non-Rescue EMT • Working with others • Work together with the rescue providers. • Cooperate with the activities of the rescuers. • Do not allow their activities to interfere with patient care.

7. Rescue EMS • EMS providers may serve as rescue providers. • Chain of command should be established to ensure priorities. • Administer necessary care to the patient before extrication.

8. Rescue EMS • Ensure that the patient is removed in a way to minimize further injury. • Patient care precedes extrication. • Unless delayed movement would endanger life of the patient or rescuer

9. Approach to the Scene • Approach hazardous scenes 100 feet, uphill, and upwind. • Observe scene. • How many vehicles are involved? • How many patients are present? • What additional resources do you need? • Perform risk/benefit analysis. • Will scene pose undue risk to you or other rescuers? • If so, consider waiting for appropriate resources (e.g., hazmat team).

10. Windshield Survey • Are the patients moving? • Are they conscious? • Are they attempting to exit vehicle? • Check for downed electrical wires. • If present, do not touch anything. • Retreat to position of safety. • Advise occupants not to exit.

11. Evaluate Vehicle Stability • Can vehicle be entered safely? • Will vehicle turn over? • Is vehicle on its side or wheels? • Is it in a secure position? • Does vehicle rock? • Block frame of vehicle, if needed. • Ensure stabilization.

12. The 12 “Nevers” • Never enter a potentially hazardous rescue scene without appropriate PPE. • Never operate on an active roadway until traffic flow has been controlled. • Never enter an unstable vehicle until it has been appropriately stabilized. • Never enter a fire scene unless directed by fire rescue.

13. The 12 “Nevers” • Never enter a confined space unless directed by rescue. • Never attempt deep water rescue without support of water rescue personnel. • Never enter a toxic scene until cleared by fire and rescue personnel. • Never enter a structural collapse unless directed by rescue personnel.

14. The 12 “Nevers” • Never enter a violent scene before arrival of police. • Never attempt rescue from height without high-angle rescue team. • Never approach an electrical hazard unless cleared by appropriate rescue or utility personnel. • Never proceed with any potentially hazardous rescue until you are fully assured that the scene is safe.

15. Traffic Control • Park vehicle to “fend off” oncoming vehicles. • Wear highly reflective traffic vests. • Use reflective traffic cones or road flares at night. • Never use flares where flammable vapors or liquids are present.

16. Personal Protection –Turnout Gear • Headgear • Eye protection • Respiratory protection, if required • Gloves • Boots • Coat

17. Respiratory Protection • Must have before entering smoke conditions or a potentially toxic environment • Self-contained breathing apparatus (SCBA) • Restricted to individuals who have had hands-on training

18. Patient and Bystander Safety • Use of rescue blanket • Needed when shards of glass or metal edges are present at rescue scene • Bystanders should be kept at a safe distance. • Victims should be prepared for loud sounds and activities for rescue process. • Psychological first aid is an important part of management.

19. Stabilizing the Vehicle • Prevents unwanted or dangerous movement of vehicle • Ensures structural integrity of vehicle is not compromised during rescue effort • Never lift a vehicle using bystanders and other rescue personnel.

20. Airbag for Stabilization

21. Cribbing for Stabilization

22. Gaining Access • Access should be gained in most expedient manner possible. • Route for access may not be the same as removal of patient. • Objective is to provide lifesaving care and stabilization.

23. Types of Access • Simple access • Access in which tools are not required • Complex access • When tools and other specializedequipment are necessary for access

24. Access with Slim Jim

25. Access with Spring-Loaded Punch

26. Door Access • Door provides a good place to enter vehicle and remove patient. • Door openings may have to be widened by “walking” the door back. • Ensure vehicle is stabilized before “walking” door back. • One or two rescuers push body weight against door and slowly push beyond its normal operating range.

27. Freeing the Driver • Steering wheel may trap driver. • Moving seat back is simplest method for freeing driver. • Always disconnect battery during extrication. • Modern vehicles may have one or more undeployed airbags that are ready to fire.

28. Supplemental Restraints –Airbags • Virtually every vehicle built since 1990 has one or more airbags. • Once airbag deploys, it rapidly deflates. • Types of airbags • Driver’s bag deploys from steering wheel. • Passenger bag deploys from the dash. • Side impact airbags can fire from back of front seat, roof rail area, or from the door. • Un-deployed airbags represent a hazard to rescuers.

29. 5-10-20 Safety Rule • Keep back 5 inches from side bag. • Keep back 10 inches from driver’s airbag. • Keep back 20 inches from passenger’s airbag.

30. Patient Safety • Priorities (in order) 1. Provider safety 2. Patient safety • Inform patient of the unique aspects of extrication. • Patient should be protected from • Broken glass • Sharp metal • Other hazards