36: Gaining Access

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36 Gaining Access
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Cognitive Objectives (1 of 2)

• 7-2.1 Describe the purpose of extrication.
• 7-2.2 Describe the role of the EMT-B in
  extrication.
• 7-2.3 Identify what equipment for personal safety
  is required for the EMT-B.
• 7-2.4 Define the fundamental components of
  extrication.

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Cognitive Objectives (2 of 2)

• 7-2.5 State the steps that should be taken to
  protect the patient during extrication.
• 7-2.6 Evaluate various methods of gaining access
  to the patient.
• 7-2.7 Distinguish between simple and complex
  access.
• There are no affective or psychomotor objectives
  for this chapter.

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Safety

• Preparation
• Mental
• Physical

5
Vehicle Safety Systems

• Shock-absorbing bumpers
• Airbags

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Fundamentals of Extrication

• Extrication
• Removal from entrapment or a dangerous situation
  or position
• Entrapment
• To be caught within a closed area with no way out

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The 10 Phasesof Extrication (1 of 2)

• Preparation
• En route to the scene
• Arrival and scene size-up
• Hazard control
• Support operations

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The 10 Phasesof Extrication (2 of 2)

• Gaining access
• Emergency care
• Disentanglement
• Removal and transfer
• Termination

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Preparation

• Training
• Equipment maintenance

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En Route to the Scene

• Safe driving practices
• Good steering techniques
• Road positioning and cornering
• Controlled acceleration
• Controlled braking
• Laws and regulations

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Arrival and Scene Size-up

• Traffic hazards
• Additional resources
• Coordination within ICS
• Rescue team responsibilities
• EMS responsibilities

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Hazard Control

• Law enforcement
• Traffic control
• Investigation
• Scene control
• Fire fighters
• Extinguishment
• Spill control
• Rescue team
• Extrication

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Hazards

• Downed power lines
• Sharp metal
• Broken glass
• Toxic substances
• Hazardous substance ignition
• Unstable vehicles

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Support Operations

• Lighting
• Tool and equipment staging areas
• Helicopter landing zones

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Gaining Access (1 of 2)

• Is the patient in a vehicle or other structure?
• Is the vehicle or structure severely damaged?
• What hazards exist that pose risk to the patient
  and rescuers?
• What is the position of the vehicle?
• What type of surface is it on?
• Is it stable?

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Gaining Access (2 of 2)

• Simple access
• Access without the use of tools or force
• Complex access
• Requires the use of tools and force

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Emergency Care

• Provide manual immobilization to protect the
  cervical spine.
• Open the airway.
• Provide high-flow oxygen.
• Assist or provide for adequate ventilation.
• Control any significant external bleeding.
• Treat all critical injuries.

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Disentanglement

• Removal of the motor vehicle from around the
  patient
• Disentanglement techniques
• Brake and gas pedal displacement
• Dash roll-up
• Door removal
• Roof opening and removal
• Seat displacement
• Steering column displacement
• Steering wheel cutting

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Removal and Transfer (1 of 2)

• Determine urgency of move.
• Plan moves and communicate with the team.
• Once patient is freed, rapidly reassess and
  recheck vital signs.
• Make certain spine is immobilized.

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Removal and Transfer (2 of 2)

• Move the patient in slow, controlled steps.
• Choose a path that requires the least
  manipulation of the patient and equipment.
• Move the patient as a unit.
• If the patients condition is critical, perform
  remaining steps en route.

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Termination

• Check tools and equipment.
• Replace used supplies.
• Clean unit and conform to bloodborne pathogen
  standards.
• Complete all necessary reports.

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Specialized Rescue Situations (1 of 2)

• Cave rescue
• Confined space rescue
• Cross-field and trail rescue
• Dive rescue
• Lost person search and rescue
• Mine rescue
• Mountain, rock, and ice-climbing rescue

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Specialized Rescue Situations (2 of 2)

• Ski slope and cross-country or trail snow rescue
  (ski patrol)
• Structural collapse rescue
• Tactical emergency medical support (SWAT)
• Technical rope rescue (low- and high-angle
  rescue)
• Trench rescue
• Water and small craft rescue
• White-water rescue

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Lost Person Search and Rescue

• Primary role will be to take care of patient when
  found.
• Prepare equipment and stand by in area designated
  by incident command.
• Only incident command should deliver information
  to the family unless someone else is designated
  to do so.

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Trench Rescue

• Poor outcome for victims
• Risk of secondary collapse
• Proper safety reduces potential for injury.
• Stage response vehicles.

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Tactical Emergency Medical Support (1 of 2)

• EMT-Bs, paramedics, nurses, and physicians with
  specialized tactical and medical training
• Nonstandard medical procedures similar to
  battlefield medicine
• Examples of tactical situations
• Hostage situations
• Snipers
• Barricaded suspects

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Tactical Emergency Medical Support (2 of 2)

• Response procedures
• Shut off lights and siren when approaching the
  scene
• Report to the command post
• Planning
• Specific location of the incident
• Rally point with tactical EMS providers
• Helicopter landing zones
• Hospital locations and route of travel

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Structure Fires

• Ask incident command where the ambulance should
  be positioned.
• Do not block arriving equipment or become
  blocked.
• Only leave the scene if transporting a patient or
  cleared by incident command.

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Review

• A two-door passenger car struck a tree while
  driving approximately 50 MPH. The doors are badly
  damaged and jammed and the driver appears to be
  unconscious inside the vehicle. Entering the
  vehicle by breaking the back window is an example
  of
• A. simple access.
• B. complex access.
• C. technical rescue.
• D. disentanglement.

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Review

• Answer B
• Rationale Complex access requires the use of
  special tools and special training and includes
  breaking windows or other forcible entry. Simple
  access does not involve the use of any tools
  examples of simple access include opening a door
  or rolling down a window. Technical rescue
  involves the use of specialized teams (ie, trench
  rescue, high-angle rescue, swift water rescue).
  Disentanglement involves the removal of a motor
  vehicle from around the patient (ie, Jaws of
  Life).

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Review

• A two-door passenger car struck a tree while
  driving approximately 50 MPH. The doors are badly
  damaged and jammed and the driver appears to be
  unconscious inside the vehicle. Entering the
  vehicle by breaking the back window is an example
  of
• simple access.
• Rationale Simple access does not involve the use
  of any tools.
• B. complex access.
• Rationale Correct answer
• C. technical rescue.
• Rationale Technical rescue involves the use of
  specialized teams.
• D. disentanglement.
• Rationale Disentanglement involves the removal
  of the vehicle from around the patient.

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Review

• 2. What is the first phase of extrication?
• A. Arrival
• B. Preparation
• C. Scene size-up
• D. Gaining access

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Review

• Answer B
• Rationale There are ten phases of extrication
  preparation is the first. Preparing for an
  incident requiring extrication involves training
  for the various types of rescue situations your
  team might face. Just as you must check the
  equipment on the ambulance, rescue personnel must
  routinely check the extrication tools and their
  response vehicle to ensure proper operation.
  Preparation reduces the possibility of equipment
  failure at a scene.

34
Review

• 2. What is the first phase of extrication?
• Arrival
• Rationale This is part of the third phase of
  extrication.
• B. Preparation
• Rationale Correct answer
• C. Scene size-up
• Rationale This is part of the third phase of
  extrication.
• D. Gaining access
• Rationale This is part of the sixth phase of
  extrication.

35
Review

• 3. As you approach an unconscious patient who is
  still in her wrecked vehicle, you note that there
  is a power line entangled in the wreckage of the
  vehicle. You should
• A. retreat until the power line has been removed
  or the power is shut off.
• B. carefully gain access to the patient without
  touching any metal objects.
• C. don a pair of rubber gloves and carefully
  disentangle and remove the power line.
• D. call for a tow truck to lift the vehicle off
  of the power line and then access the patient.

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Review

• Answer A
• Rationale Never attempt to access a patient
  until you are certain that the vehicle is stable
  and that any hazards have been identified and
  removed. Common hazards at a motor-vehicle crash
  include leaking gasoline, power lines over the
  vehicle, and engine fires.

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Review (1 of 2)

• 3. As you approach an unconscious patient who is
  still in her wrecked vehicle, you note that there
  is a power line entangled in the wreckage of the
  vehicle. You should
• retreat until the power line has been removed or
  the power is shut off.
• Rationale Correct answer
• B. carefully gain access to the patient without
  touching any metal objects.
• Rationale Never attempt to gain access to the
  patient until all hazards have been removed.

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Review (2 of 2)

• 3. As you approach an unconscious patient who is
  still in her wrecked vehicle, you note that there
  is a power line entangled in the wreckage of the
  vehicle. You should
• C. don a pair of rubber gloves and carefully
  disentangle and remove the power line.
• Rationale Removal of electric line should be
  handled by experts in the power industry,
  typically electric company personnel.
• D. call for a tow truck to lift the vehicle off
  of the power line and then access the patient.
• Rationale Accessing the vehicle before the
  electrical hazards have been removed can and will
  result in additional injuries.

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Review

• 4. A man has been sucked inside the bin of a
  grain silo and is trapped. Which of the following
  rescue teams is the MOST appropriate to request?
• A. Trench rescue
• B. High-angle rescue
• C. Local fire department
• D. Confined space rescue

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Review

• Answer D
• Rationale Of the technical rescue teams listed,
  a confined rescue team would be the most
  appropriate to request for help. Grain silos are
  confined spaces that such teams are specially
  trained to operate in. Trench rescue teams are
  trained to deal with cave-ins and trench
  collapses. If your local fire department is
  trained in confined space rescue, they should be
  notified.

41
Review

• 4. A man has been sucked inside the bin of a
  grain silo and is trapped. Which of the following
  rescue teams is the MOST appropriate to request?
• Trench rescue
• Rationale These teams are trained for rescues
  from trench cave-ins.
• B. High-angle rescue
• Rationale These teams are trained for rescues on
  slopes greater than 45.
• C. Local fire department
• Rationale You must know the capabilities and
  limitations of your local fire departments.
  Confined space rescue is a specialized training
  course.
• D. Confined space rescue
• Rationale Correct answer

42
Review

• 5. You respond to a small plane crash in a corn
  field. Which of the following pieces of
  information would be the LEAST helpful in dealing
  with this incident?
• A. The severity of damage to the plane
• B. The position of the victims on board
• C. The location that the plane was flying to
• D. Whether or not hazardous materials are on board

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Review

• Answer C
• Rationale You should be thinking of where the
  patients are positioned in the plane what it
  will take to remove them, as noted by the
  severity of the damage to the plane and if there
  are any dangers to your team or the patients (ie,
  fuel leaks, hazardous materials). The planes
  destination is of no real consequence during the
  rescue phase.

44
Review

• 5. You respond to a small plane crash in a corn
  field. Which of the following pieces of
  information would be the LEAST helpful in dealing
  with this incident?
• The severity of damage to the plane
• Rationale This is an important piece of
  information.
• B. The position of the victims on board
• Rationale This is an important piece of
  information.
• C. The location that the plane was flying to
• Rationale Correct answer
• D. Whether or not hazardous materials are on
  board
• Rationale This is an important piece of
  information.

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Review

• 6. Proper removal of a critically injured patient
  from an automobile involves
• A. moving the patient in one fast, continuous
  step.
• B. utilizing no more than two personnel to avoid
  crowding.
• C. moving the patient in smooth, slow, controlled
  steps.
• D. removing the patient by grasping the
  immobilization device.

46
Review

• Answer C
• Rationale To ensure that each rescuer is
  positioned so he or she can lift and properly
  carry the patient at all times, move the patient
  in a series of smooth, slow, controlled steps,
  with stops designed in between to allow for any
  repositioning or adjustments as needed. Move the
  patient as a unit, and resist the temptation to
  move the immobilization device instead.

47
Review

• 6. Proper removal of a critically injured patient
  from an automobile involves
• moving the patient in one fast, continuous step.
• Rationale The removal should be smooth and slow.
• B. utilizing no more than two personnel to avoid
  crowding.
• Rationale Use the number of rescuers necessary
  to allow for a smooth and controlled removal.
• C. moving the patient in smooth, slow, controlled
  steps.
• Rationale Correct answer
• D. removing the patient by grasping the
  immobilization device.
• Rationale Do not grab or pull on immobilization
  devices. This will avoid the potential of
  loosening or dislodging the devices.

48
Review

• 7. You are dispatched to the scene of a trench
  collapse. Upon arriving at the scene, your
  ambulance should be parked at least _____ feet
  from the incident.
• A. 250
• B. 500
• C. 750
• D. 1000

49
Review

• Answer B
• Rationale When arriving at the scene of a
  cave-in or trench collapse, response vehicles
  should be parked at least 500 feet from the
  scene. Because vibration is a primary cause of
  secondary collapse, all vehicles, including
  on-scene construction equipment, should be turned
  off. In addition, all traffic should be diverted
  from the 500-foot safety area.

50
Review

• 7. You are dispatched to the scene of a trench
  collapse. Upon arriving at the scene, your
  ambulance should be parked at least _____ feet
  from the incident.
• 250
• Rationale 500 feet is the recommended distance.
• B. 500
• Rationale Correct answer
• C. 750
• Rationale 500 feet is the recommended distance.
• D. 1000
• Rationale 500 feet is the recommended distance.

51
Review

• 8. While the EMT-B is in a vehicle assessing the
  patient, the rescue team should be
• A. assessing exactly how the patient is trapped
  and determining the safest way to extricate.
• B. awaiting further instructions from the EMT-B
  regarding how to proceed with the extrication.
• C. actively extricating the patient using
  whichever rescue method is deemed necessary by
  the rescue leader.
• D. preparing for a simple extrication process as
  the EMT-B as obviously gained access to the
  patient.

52
Review

• Answer A
• Rationale While the patient is being assessed,
  the rescue team should be assessing the degree of
  entrapment and determining the safest, easiest
  way to extricate. Once the assessment of the
  patient is complete, the extrication can
  commence.

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Review (1 of 2)

• 8. While the EMT-B is in a vehicle assessing the
  patient, the rescue team should be
• assessing exactly how the patient is trapped and
  determining the safest way to extricate.
• Rationale Correct answer
• B. awaiting further instructions from the EMT-B
  regarding how to proceed with the extrication.
• Rationale Although the EMT-B may verbalize the
  patients injuries, which may help in deciding
  how the extrication can best be handled, the
  actual extrication is performed by the rescue
  team.

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Review (2 of 2)

• 8. While the EMT-B is in a vehicle assessing the
  patient, the rescue team should be
• C. actively extricating the patient using
  whichever rescue method is deemed necessary by
  the rescue leader.
• Rationale The decision on the extrication method
  must include the assessment of the patient, the
  degree of entrapment, and the determination of
  the safest extrication route.
• D. preparing for a simple extrication process as
  the EMT-B as obviously gained access to the
  patient.
• Rationale The rescue leader must consider all
  options the way the EMT came in may not be the
  best way for the patient to come out.

55
Review

• 9. You respond to a wooded area to help search
  for a child who has been missing for
  approximately 24 hours. Which of the following
  equipment should you leave in the ambulance?
• A. Radio
• B. Flashlight
• C. Jump kit
• D. Backboard

56
Review

• Answer D
• Rationale When participating in a search and
  rescue effort, large equipment that is not easily
  carried (ie, backboard, wheeled stretcher) should
  be left in the ambulance.

57
Review

• 9. You respond to a wooded area to help search
  for a child who has been missing for
  approximately 24 hours. Which of the following
  equipment should you leave in the ambulance?
• Radio
• Rationale Communications via radio in a search
  and rescue mission is extremely important.
• B. Flashlight
• Rationale Many rescue situations involve low
  light conditions and require a flashlight.
• C. Jump kit
• Rationale The jump kit is necessary for the
  initial treatment of life threatening situations,
  if and when the victim is found.
• D. Backboard
• Rationale Correct answer

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Review

• 10. A 30-year-old semiconscious man is pinned by
  the steering wheel of his badly wrecked vehicle.
  Once access has been gained to the patient, the
  EMT-B should
• A. have the fire department disentangle the
  patient and quickly remove him from the vehicle.
• B. immediately apply high-flow oxygen to the
  patient and then allow extrication to begin.
• C. perform an initial assessment and provide any
  needed emergency care prior to extrication.
• D. ensure that the patient is not bleeding
  significantly before allowing the extrication
  process to commence.

59
Review

• Answer C
• Rationale Unless there is an immediate threat of
  fire, explosion, or other danger, you should
  perform an initial assessment and treat all
  immediate life-threats as soon as you have gained
  access to the patient. After correcting any
  immediately life-threatening problems,
  extrication should begin.

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Review (1 of 2)

• 10. A 30-year-old semiconscious man is pinned by
  the steering wheel of his badly wrecked vehicle.
  Once access has been gained to the patient, the
  EMT-B should
• have the fire department disentangle the patient
  and quickly remove him from the vehicle.
• Rationale Do this only after correcting
  immediate life threats to the patient.
• B. immediately apply high-flow oxygen to the
  patient and then allow extrication to begin.
• Rationale Oxygen may be applied, but all life
  threats must be assessed and treated prior to
  extrication.

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Review (2 of 2)

• 10. A 30-year-old semiconscious man is pinned by
  the steering wheel of his badly wrecked vehicle.
  Once access has been gained to the patient, the
  EMT-B should
• C. perform an initial assessment and provide any
  needed emergency care prior to extrication.
• Rationale Correct answer
• D. ensure that the patient is not bleeding
  significantly before allowing the extrication
  process to commence.
• Rationale Bleeding is not the only immediate
  life threat airway and breathing must also be
  assessed.