Maximum Access: Efficient Extrication Techniques for Making Space

Working within the “Golden Hour” and the “Platinum Ten” arena requires vehicle extrication operations to be quick, deliberate and safe. Four skills in particular can help rescuers to succeed on all three counts.

That said, keep in mind that these skills come into play only after numerous other steps already are completed: stabilization is established/on-going; the incident scene is secured; power supply to the vehicle(s) is secured; glass is removed where necessary; and patient care has commenced. Furthermore, the damage to the vehicle could require significant displacement of the vehicle’s components and would benefit from a wider access area for the patients; in some cases, it might require medical treatment and displacement operations to occur simultaneously.

Photo 1: Gaining access quickly to a rear seat patient might require unconventional skills.

Third-door-full-removal procedure

Two-door vehicles have limitations when it comes to rear seat access. There are times when accessing a patient in the rear seat area requires some unconventional thinking. Normal access for passengers to pass between the B-pillar and the front seat when getting to the rear seat won’t work when removing an injured patient (Photo 1). Therefore, you must make another access point, or “third door,” in the vehicle. Here, we combine removing the door along with the rear seat panel to save time and increase accessibility.

Photo 2: Removing the skin exposes the area to be cut from the panel.

The first step is to access the rear panel and B-pillar area, cutting the top of the B-pillar and removing any glass that’s in the rear seat area. Once that’s completed, an air chisel can be used to “skin” the panel for better visibility of the area to be cut and removed (Photo 2). The next step utilizes a reciprocating saw that has a good demolition blade to cut the rear panel along the outline of the rear seat, making sure that the cutting blade doesn’t come into contact with the patient in the rear seat (Photo 3). (Patient protection should be in place prior to cutting the panel.) The last cut is made in the bottom of the B-pillar, using either the reciprocating saw or the hydraulic cutters. The entire assembly is swung open to facilitate patient removal.

Photo 3: For the third-door-full-removal procedure, after “skinning” the rear panel of the vehicle to produce better visibility of the area to be cut and removed, use a reciprocating saw to cut the panel along the outline of the rear seat. A good blade can make the difference in the operation of a reciprocating saw.

If time and space permit, the entire assembly can be removed by attacking the hinges, but don’t delay patient care if the space that’s made facilitates patient removal (Photo 4).

Photo 4: When the third-door-full-removal procedure is employed, if time permits, the entire assembly can be removed by attacking the hinges.

Full side removal

Four-door vehicles pose a stabilization problem for rescuers when it comes to patient care. Medical personnel might be required to manipulate cervical stabilization around a displaced B-pillar in an accident. Furthermore, side-impact collisions might hinder access to center-door striker assemblies and hinge areas on sedans. It might be best to remove the entire side of the vehicle in one maneuver.

Begin at the Nader pin/door striker assembly area for the rear door and displace the door from the connection. Next, the cutters are utilized to cut completely through the top of the B-pillar and to place a relief cut in the bottom of the B-pillar, parallel to the rocker channel. Be sure to cut the seat belt, so the belt doesn’t hinder the removal of the post.

Photo 5: For the full-side-removal procedure, spreaders are used to displace the B-pillar from the vehicle by tearing the relief cut apart.

The next step requires rescuers to place the spreader tips into the lower relief cut in the B-pillar. In an outward/upward direction, displace the B-pillar from the vehicle (Photo 5). It’s necessary to support the rocker channel below the B-pillar to avoid pushing the channel assembly downward, instead of displacing the B-pillar.

There is debate about which cut to make first on the B-pillar, the top cut or the displace the relief cut. It has been my experience that the B-pillar displacement works much better when the top of the pillar is cut prior to displacement.

After the B-pillar is displaced from the vehicle, spread or cut the front door hinges, removing the entire side panel assembly from the vehicle (Photo 6). Be sure to have wire cutters on hand to cut any wiring for power accessories that might be in the door assemblies.

Photo 6: Removal of the entire side of a four-door vehicle facilitates greater maneuverability for patient access.

High dash displacement

Front-impact collisions can compound the problems that are found on the extrication scene. When two vehicles collide while traveling in opposite directions, the impact force can be increased exponentially. Moreover, recently, high-speed frontal collisions have resulted in more footwell entanglements, including pedal entanglement and lower firewall intrusion with the patient’s lower extremities. Additionally, when the vehicles come to rest, the front of the passenger compartment might be pushed down on the occupants, which hinders access. Furthermore, when the vehicle is up against a stationary object, it’s exceedingly difficult to displace the dashboard and firewall assembly off of the occupants. In this case, the high dash displacement is successful for disentanglement, because it allows for displacement without driving the front of the vehicle downward or into the object that the vehicle rests against.

(To execute this maneuver, the doors on the patient’s side of the vehicle must be removed, and the roof assembly must be either rolled back or removed completely.)

Make two parallel cuts into the A-pillar, one directly above the lower hinge and one directly below the lower hinge. Two more cuts are crucial in performing this maneuver: One cut is made from the lower side of the front wheel well, just behind the center of the wheel well, and the other cut is made from the top of the fender area, just behind the shock absorber/strut tower. Note: A structural metal fender channel is located in the vicinity of the top cut area, between the fender and the hood. It’s vital that this channel is cut through completely, or the dashboard won’t successfully displace.

Photo 7: For the high-dash-displacement procedure, after relief cuts are made and the spreader tips are set into place, additional cribbing/support should be put in place below the A-pillar.

Once these relief cuts are made, spreaders are used to first clamp onto the area that’s between the two parallel cuts in the lower hinge area and then bend the material out of the way. This allows for a large purchase point for the spreader tips to be set into place. At this time, additional cribbing/support should be put in place below the A-pillar, so the bottom of the channel doesn’t displace (Photo 7). The spreaders then are opened slowly, being sure to keep the handle of the tool parallel to the ground or tilted upward slightly. This increases the tool’s capability to lift the dashboard, instead of deflecting the lower region of the A-pillar outward. Lifting the A-pillar displaces the dashboard area while pivoting the fender assembly at the relief cut in front of the strut tower.

Inverted roof removal

Consider this: A vehicle extrication involves a vehicle that resulted in an inverted position (roof down) because of a significant rollover. Now, consider that the force of the impact to the ground caused the roof posts to completely fail, which compromises the passenger compartment significantly. Even after the doors are removed, there still might be limited room to access the patient. It might be necessary to remove the entire roof assembly from underneath the vehicle to access and remove the patient safely.

Stabilization is key here: The vehicle no longer will rely on the roof/pillars assembly to hold up the vehicle. The application of stabilization should be based on equipment availability and the direction of patient travel. If the patient is coming out of the vehicle through the rear window area, stabilization in that path of travel would be counterproductive.

If your department relies heavily on cribbing instead of struts and A-frame stabilization, your opportunities might be driven based on the limitations of your equipment. Either way, the significance of stabilization during this operation can’t be overstressed; it will make or break your operation.

Photo 8: For the inverted-roof-removal procedure, the windshield must be cut from A-pillar to A-pillar.

Once the vehicle is stabilized, cut the pillars of the vehicle, starting at the rear pillars. Relief cuts in front of the next sequential pillars might allow displacement of the roof to facilitate victim removal. If not, continue to cut the pillars in sequence until all of them are cut on each side of the vehicle. The windshield must be cut from A-pillar to A-pillar and can be removed with the roof assembly (Photo 8). The assembly is best suited to be removed to the side that’s opposite of the victim location.

Photo 9: Knowledge of capabilities of tools and equipment can lead to alternative solutions on scene.

Prior to the emergency

Being proficient on the rescue scene isn’t based upon brute strength alone. A high level of knowledge and understanding regarding the capabilities and limitations of all of the equipment that’s in the tool cache is what leads to success at the incident (Photos 9 and 10).

Photo 10: Patient accessibility can come from any direction, as dictated by the need of the incident. Tunneling through the floor and removing the seat allows for more access to the patient for removal.

It’s highly advisable to practice these skills on vehicles. Having the time and resources available to apply these skills prior to the emergency will increase the effectiveness and efficiency of the company when it’s called to respond.