Deep side-impact extrication: 2 options for quick access and extrication
A step-by-step guide to removing a patient when the driver’s side door won’t open
The infamous T-bone – a high-velocity collision where one vehicle slams head on into the side of another vehicle, naturally, forming a “T” shape.
These impacts are not only lethal, they present unique challenges for rescuers attempting access and extrication. There are many techniques to pull this off, but there are just as many variables that contribute directly to the success or failure of those techniques.
To try and keep this discussion on point, I am not going to attempt to discuss all of the techniques and variables. I’ll instead focus on one specific vehicle presentation and provide two technical approaches that I believe offer the highest margins for both success and speed.
Setting the stage: Side-impact vehicle presentation
You arrive on scene to find a late-model four-door vehicle with significant sidewall intrusion. Primary impact is to the driver’s side of the vehicle, and the driver is entrapped. The driver’s side door does not open naturally due to damage and impingement. The driver is significantly injured.
Your goal: Gain access in less than two minutes and have the patient extricated in less than five minutes.
Ready, set, GO!
Scene perspective: Macro, micro and back to macro
This scenario and those benchmarks can be pretty overwhelming – and probably sound unrealistic to a lot of rescuers. However, with proper training and resources, it is very attainable. Let’s establish that safety assessments and actions have been conducted and the vehicle is stabilized and de-energized.
Before we shift into the extrication sequence, I want to discuss a quick theory in decision-making and prioritizing actions, roles and responsibilities. I have in the past discussed scene analysis as macro to micro and back to macro assessment, so let’s go through that approach again focusing on this scenario.
As the in-charge rescuer, look at the vehicle from a macro, aka big picture, perspective:
- Determine how many victims, and the nature of injuries and lifesaving resources required; and
- Consider basic impact and entrapment assessment, analyze the energy behind the impact, the vehicle design and damage, and the entrapment caused to the victim(s).
Now zoom in on the focused picture – the micro assessment:
- Map out an access plan, get EMS personnel to the victim with the resources to provide appropriate care;
- Map out the extrication plan: How are we going to move the metal away from the victim and remove the victim from the victim in a way that affords the best possible outcome?
- Conduct a final resource check: Do we have what we need to pull off the plans?
Now go back to macro, big picture, perspective:
- Communicate the overall plan with established benchmarks;
- Assign roles and responsibilities – and get after it; and
- Continuously evaluate all of the pieces of the puzzle to ensure the desired objectives are being met, and establish Plan B and Plan C as continencies for predicted obstacles and unforeseen challenges.
Now we are ready to get to work.
Challenges prevent standard quick fixes
The first major challenge we face with these types of accidents is placement positions for tools. In most cases, the B-post and the doors are pushed into the passenger compartment, creating a giant dimple that has racked the seats on that side and either pinned the patient between the door and seat or driven the front passengers to the middle consoles. Patients have also often incurred head injuries from the B-post displacement.
We typically can’t get away with just blowing the front door hinges and rear door latch and popping the doors because the manipulation of the doors often pushes inward, initially making the patients situation worse.
A normal quick fix is the window spread move in which we position the spreaders in the window opening and draw the door outward and away from the patient first. This is usually a no-go as a standalone technique in this scenario because of the positioning available. Remember, the push points on the doors are crushed toward the interior, which means that they are oriented inward of the roof line. The roof line is our posting point for the spreaders in a window spread. This means that doing the window spread in this scenario is only going to drive the doors deeper toward the interior.
This leaves us with two quick options: exterior drawdowns and interior cross-ramming.
Option 1: Exterior drawdowns
There are a several tools that can be used to accomplish this, but we will discuss one of the simplest and most available ones to ensure every firefighter reading this has a good option.
Step by step:
- Wrap the B-post with a connector. A connector can be a short section chain, heavy 2-inch webbing, or a ratchet strap.
- Establish a ground level anchor across from the B-post at an appropriate distance for the extrication sequence and environment. This can be the guard rail, an apparatus wheel or hitch base, vehicle frame of another vehicle, or even pickets.
- Establish another quick connector on the anchor you have chosen.
- Connect a ratchet strap or multiple ratchet straps between the connectors. A chain hoist, grip hoist, or winch can also be implemented here.
- Start tensioning the system and apply preload to the B post. This should not be an excessive amount of force initially, just enough to tension the system and the B post.
Option 2: Interior cross-ramming
Establish a posting point on the inside of the vehicle. This is commonly done by accessing the opposing or unoccupied side of the vehicle, working through the windshield opening or the back glass opening.
Take a piece of cribbing, position it under the roof of the vehicle against the roof liner and compress it into position with a spreader. The spreader will act as a vice or clamp to keep the cribbing in position as an interior anchor. You want to make sure that you line up the cribbing and spreader properly. The end goal is to position a telescoping ram between the B-post and this interior cribbing anchor and pretension the B-post. In order for this to be secure and work properly, imagine creating a cross with good right angles in which the cribbing is the horizontal member of the cross, the ram is the long vertical member of the cross, and the spreader is the short vertical member of the top of the cross. When you place the ram, make sure the fixed tip of the ram is in line with the spreader arms and tips on the cribbing and extend the ram until the piston tip is about six inches below the roof line on the B-post. This will allow proper access to the top of the B-post for a cut.
Getting down to business
Now that we have pretensioned with one of these two techniques, we really only have two primary moves left to perform in order to get the entire side of the vehicle out and away from our patient.
Move 1: Cut the upper B-post. This can be accomplished with an adequate high-strength cutter or a reciprocating saw. Once the cut is made, the B-post should drift out and away from the victim because of the pretension that has already been applied. We can now continue with that movement or drift by either continuing to ratchet our straps (or hoist or winch) or keep extending our interior ram.
Move 2: Place a telescoping ram: As soon as the doors and B-post are positioned outside of the roof line, we can convert to our second essential movement, which is an exterior placement of a telescoping ram between the roof line and the B-post. If you don’t have the space to position the ram the way you want, you may need some spreader work initially to create an opening big enough to place your exterior ram.
At this point, we can stick the essential movement of the ram and simply apply corrective actions as needed. The rams will eventually drive the side of the vehicle all the way down to the ground if it has enough stroke and power. Corrective actions are applied based on resistance and compromise of the posting point.
In this phase of the evolution, the posting point is the roofline where the fixed end of the ram is positioned and the pushing point is the B-post where the piston end of the ram is positioned. If the ram posting point starts to compromise and the B-post stalls out in movement, that is an indication of too much resistance on the door connections. This is resolved by cutting or spreading the front door hinges and the rear door latch, which will allow the B-post to travel unrestricted.
Make sure you check out the attached video for more details on how to perform this rapid side access.
Stay safe and train hard!!