When does an extrication rise to the level of a technical rescue? Most of us know it when we see it. We arrive at a complicated incident, and then we realize our training, talent, and tools will be taken to task. The answer is short and simple: when specialized tools and skills must be used to perform—or at least attempt—a successful rescue.
The next question is: What are the extra challenges and considerations laid out before us in a technical rescue? We often find ourselves having to work smoothly with other agencies. We must tailor-make an incident action plan quickly, one that fits the incident. Contingencies must be considered. And having the ability to think three moves ahead will benefit us immensely.
On the morning of October 18, 2021, the Ozark (MO) Fire Protection District (OFPD) responded to something more than a routine extrication; it was, undeniably, a technical rescue. We employed our specialized tools and skills to undertake this challenging technical rescue. However, performing a technical rescue and performing a successful technical rescue are not necessarily the same thing.
At 0814 hours, during rush-hour traffic, OFPD’s Engine 11 and Battalion 11 responded to a report of a pickup truck rollover on a divided highway. While en route, the dispatcher relayed more information: The heavily damaged pickup was standing straight up on its front bumper and wedged against a rock bluff, and the driver was trapped inside.
(1) Fire crews had to place stabilization struts to ensure the vehicle would not shift as the patient was disentangled from the vehicle. The patient’s positioning within the vehicle as well as the patient’s size were challenges for all involved. (Photo by Eleazar Soto.)
(2) Cutters, spreaders, and a ram were needed to remove the patient from the vehicle. One crew is working on EMS stabilization of the patient, while another crew member prepares to use the hydraulic ram to attempt to free the patient. In the foreground, law enforcement units were used for traffic assistance, and a safety officer assisted in visually monitoring the stabilization of the vehicle as the extrication continued. (Photo by Eleazar Soto.)
In less than five minutes, I arrived to exactly what our dispatcher said. A heavily damaged pickup truck stood almost straight up on its front bumper, the crushed roof pressed against a rock bluff. The bumper rested on soft ground and was clearly unstable. Bystanders milled around the balanced truck, some trying to get inside. Other bystanders frantically waved me closer, pointing and yelling, “Someone’s inside there!”
Based on the precarious way the pickup truck was balanced, and the entrapped patient being about eight feet above the ground, I knew we would need more resources than what was en route. Before stepping out of my battalion SUV, I requested a second engine company equipped with additional extrication tools and a basket stretcher. I then directed the bystanders to move away from the vehicle.
Before Engine 11 arrived, I climbed the rock bluff and accessed the patient through the broken window. Crawling into an unstable vehicle was a risk—risk a little to save a little, risk a lot to save a lot. All the air bags had already deployed, presumably on impact. The truck’s roof had been crushed against the tops of the seats, leaving just enough room for one person; the driver lay at an angle between the driver’s and passenger’s front bucket seats. The dashboard had been smashed down and forward, pinning both legs. The steering column had been shoved firmly between his legs as if he were straddling it. His feet were not visible. I did the “ABCs.” The patient had a viable airway, was breathing, and had a bounding carotid pulse. He groaned in pain. A viable patient lay trapped inside, in desperate need of advanced life support.
When Engine 11 arrived, they were given a few brief orders and went to work. First, they pulled a charged attack line. There was no sign of fire and, thankfully, we made it through the incident without even a spark. However, with a compromised vehicle and extrication imminent, we never tore into vehicles without a charged line handy. Next, the crew brought their battery-powered cutters, spreaders, and ram to the vehicle. They were ready to work.
(3) EMS personnel (lower left and upper right) provide advanced life support interventions to the patient while the extrication continues. Tow company operators can be an additional resource in extrication because of their knowledge of vehicles and can be an invaluable asset if available. (Photo by Eleazar Soto.)
While they advanced the line and prepped their extrication tools, the second engine company arrived. A one-word order was issued to the crew: “Struts!” Engine 13 quickly, efficiently, and properly deployed the vehicle stabilization struts to the undercarriage of the pickup truck, which prevented the truck from moving laterally and falling forward. The truck had been secured, and extrication could begin.
After I directed the bystanders to again move back, Engine 11’s crew was directed to pry open the passenger’s side front door, leaving the hinges intact. This would allow better access and would become the patient’s exit. Engine 13 was tasked to completely remove the driver’s side front door so we could get a full understanding of how the patient’s feet were trapped and entangled.
While the two engine companies were busy with their extrication tools, I coordinated with paramedics and one off-duty emergency room nurse on scene. Without getting in the way, without putting themselves in danger, and without compromising the stability of the vehicle, I needed them to continually monitor the patient. Paramedics hooked the patient to a monitor, took his blood pressure, measured his blood sugar, and determined a cervical collar could not be placed on him without compromising his airway. So, we used manual spinal immobilization until the patient could be extricated.
After the driver’s door was removed, we found the collapsed dashboard pinning the patient’s feet to the floor and his shins to the seat. The seat wouldn’t move back any farther. Of course, there was no play in the dash or steering column, but we must try before we pry.
The strategy was simple: move the dash off the patient’s legs. The tactics were challenging. Engine 13 would use the short rescue ram to inch the collapsed dashboard forward. However, this posed another potential problem of moving the dashboard up on one side only to drive it down on the other side. We didn’t want to free the patient’s left leg only to crush his right. The two crews had to work together, communicating and cribbing ¼ inch at a time.
(4) Secondary accidents because of driver inattention can complicate a response to a critical incident. In this picture, inattentive drivers led to a secondary accident that pulled resources away from the main scene. (Photo by Eleazar Soto.)
Within a few minutes, the crews had freed the patient’s legs and feet. At last, we would be able to remove him from his crushed pickup truck. However, removing the patient posed a whole other set of logistical challenges. The patient weighed about 260 pounds and did not have the ability to move himself at all. The crushed roof had limited the cab space, making it impossible to apply a Kendrick extrication device or insert a backboard beneath the patient. Rescue crews had to operate about eight feet above the ground, balancing themselves on a rock bluff.
I consulted with the EMS supervisor on the scene, and we decided to keep the patient in line, pulling him straight out one of the exits that had been created. One paramedic held the C-spine, while our fire crews cradled the limbs and carefully manipulated the patient out of the vehicle. He was placed in a cervical collar and strapped to a backboard for spinal immobilization, and then all hands lowered him to ground level and onto a cot. Patient care was transferred to emergency medical services (EMS), who transported him to a full-trauma emergency room. He had multiple broken bones but was expected to recover.
Bystanders can be helpful, especially when relaying information about what happened and how many patients are involved. However, they can get in the way when there is work to be done. They can slow operations and may unwittingly put themselves and others in danger. We directed our bystanders to step back, and we had to ask law enforcement to remind them several times.
Traffic also poses a challenge. Although traffic had been controlled on our side of the divided highway, the other side had onlookers becoming distracted by the extrication. Two rear-end style accidents occurred on the opposing side of the highway, and law enforcement had to investigate each one to determine if there were any injuries. We were lucky; neither accident resulted in injury.
A technical rescue often has multiple agencies responding to the scene. Unified command is a necessity. OFPD worked smoothly with EMS and law enforcement. Each agency understood their roles and responsibilities. The success of our unified command can be attributed to communicating the incident action plan to everyone.
(5) Civilian bystanders can complicate a scene, despite their best intentions. Here, the person in the red coat was asked several times to move away from and stop leaning on the vehicle. The female above the white-helmeted chief is an off-duty trauma nurse crews used to stabilize the patient. [Photo courtesy of Ozark (MO) Fire Protection District.]
(6) Following extrication, significant intrusion into the cab area can be seen. The lack of a seat belt worn by the driver led to his unusual positioning within the cab. [Photo courtesy of Ozark (MO) Fire Protection District.]
(7) After the tow company had pulled the truck off the bluff, the full extent of the intrusion into the passenger compartment became clear. [Photo courtesy of Ozark (MO) Fire Protection District.]
An IAP needs to be detailed. Simply stating the IAP is to “extricate the patient” tells everyone nothing they don’t already know. However, the IAP doesn’t need to be an exercise in micromanagement, either. We were specific and detailed in developing and communicating our IAP, which included doing the following tasks:
Contingency planning is a large part of developing an IAP. We had to consider what to do if the vehicle lost stability, if pushing the dash would not free the patient, if the patient’s vital signs began to crash, if a firefighter or paramedic sustained an injury during operations, and many other “ifs.” As an incident commander (IC), one must be judicious in communicating contingencies; they can muddy the water. Responders might get the contingency plan mixed up with the IAP. A good practice is to think a lot about—but not talk a lot about—contingencies. Communicate them on an as-needed basis.
Whether it’s a routine extrication or a technical rescue (or any other incident, for that matter), scene safety is paramount. We don’t want to make a bad situation worse through negligence, complacency, poor training, or mismanagement. Our goal is not to increase the number of injuries on any given scene.
We have trained together so that we can work together safely and efficiently. The skilled engine companies knew their tools and their limitations. They knew how to stabilize and open up a vehicle, regardless of the way the vehicle was situated. They trained many times on how to safely remove a patient from a crushed vehicle.
Some things may appear out of the IC’s control. How do you move bystanders back who are insistent on lending a helping hand? The answer is, do it firmly, continually, and as politely as possible. It certainly helped having law enforcement close by to deny entry. Still, a few bystanders kept creeping back into our warm and hot zones. Regardless of the bystanders’ poor judgment and careless actions, their safety is still our concern.
In tasking nonfirefighting paramedics with patient care, we had to place them in our hot zone. Working with the EMS supervisor, we managed to place the paramedics close enough to the patient to be effective while also keeping them out of harm’s way. Good communication played a major role in ensuring no responders were injured.
We rely on our specialized skills and tools to perform a technical rescue, but we rely on much more to make it successful. We have trained and built a rapport with each other, where we can issue, understand, and carry out one-word orders (“Struts!”). You must develop and communicate a solid IAP to all necessary parties and cultivate a strong, positive relationship with your partners in emergency response. Only then will you improve your odds of a successful outcome.
SHAWN MARTIN is a 26-year fire service veteran and a battalion chief with the Ozark (MO) Fire Protection District. Martin began his career in Springfield, Missouri, where he served as a technical rescue team leader. He now commands a platoon of firefighters in all aspects of fire and rescue operations.