The 140-member company protects a population of 70,000 in an 80-square-mile first-due area, answering over 7,000 calls a year from two stations. Apparatus includes six engines, one heavy rescue, two trucks, one air unit, two brush trucks, three advanced life support (ALS) ambulances and two paramedic chase cars.
Upon arrival, Snyder and EMS Assistant Chief John Blake quickly assessed the scene and determined that aviation was required due to severe trauma to the lower extremities of the belted passenger. Approximately seven feet of guardrail had penetrated the passenger compartment of the vehicle at the passenger door, coming to rest in the area of the steering column. The patient’s legs were pinned from the knees down between the door skin, guardrail and steering column. In addition, one ankle was pinned under one end of the guardrail. It was determined that additional resources were needed to complete the extrication.
Within minutes of the aviation request, Blake called for the Shock Trauma “Go-Team.” Based at the University of Maryland Shock Trauma Center, the Go-Team is comprised of trauma surgeons, nurse anesthetists and support staff. This team can perform a wide variety of hospital-based skills that are outside the protocols of field-based paramedics, such as amputations, sedation, and whole blood or other blood product transfusions. The Go-Team was requested for two reasons. First, due to the position of the patient’s leg versus the position of the guardrail, it was virtually impossible to determine whether the foot or leg was impaled on the guardrail and would need a field amputation. Second, in the position the patient was found, any movement of the vehicle or guardrail would cause excruciating pain in his lower extremities. The Go-Team could sedate him to complete the extrication.
Harford County Emergency Operations/Communications advised command that the Maryland State Police Med-Evac would arrive in about 10 minutes and the Go-Team in 20 to 30 minutes. Snyder then directed personnel to immediately remove the roof. This gave EMS personnel better access to the patient and gave firefighters a better view of what they had to work with. Firefighters were assigned the following tasks:
2. Remove the passenger door, which was situated on top of the patient.
3. Staff a charged hoseline.
4. Remove the remaining guardrail and a street sign that was blocking rescue workers from getting to the passenger side of the car.
5. Roll the dash forward.
At this point, the extrication efforts became difficult. Firefighters pushing, pulling or lifting in one direction caused the opposite reaction at other end. Because the guardrail had penetrated the fire wall, pushing the dash forward caused the guardrail to be pressed down on the patient, causing extreme pain. The rescuers tried to lift the guardrail from numerous positions, but this only caused the dash to roll forward toward the patient’s feet. Firefighters then attempted to use a high- pressure air saw to remove small pieces of the door to get better access to the patient’s lower legs, but this was time consuming.
Upon arrival of the Go-Team, a decision was reached among all involved to chemically sedate the patient, then determine the next step once some of the vehicle could be removed from around his lower extremities. Again, due to the positions of the patient’s leg and the guardrail, it was impossible to determine whether his foot or leg was impaled. After enough of the door was removed with a high-pressure air saw, firefighters began to lift the guardrail at the same time they pushed the dash forward. This required the simultaneous use of four hydraulic rescue tools.
At the same time, firefighters stabilized the floorboard of the car and the back end of the guardrail to eliminate the seesaw effect. Just under 90 minutes into the incident, firefighters pushed the dash away from the patient’s leg and foot. It was then determined that his foot and leg had not become impaled, as feared, so there was no need for further medical or rescue intervention. The patient was moved to the ambulance for transport to a landing site under the care of a trauma physician.
This call points to the importance of multi-jurisdictional cooperation. Such relationships help emergency incidents such as this one flow smoothly and provide for maximum patient benefits. Units on the scene included Bel Air Paramedic 391, Rescue 351 and Engine 313; Harford County Sheriff’s Office; Maryland State Police Med-Evacs 1 and 8; University of Maryland Shock Trauma “Go-Team”; Baltimore County Fire Department Medical Director Dr. Andy Pollack, a member of the Go-Team; and Lisa Chervon of Maryland Institute for Emergency Medical System Services (MIEMSS). Bel Air Engine 311 and Air Unit 361 were special called.
“Without this total team effort,” Blake said, “the outcome of this patient probably would have not been as positive. The rescue effort displayed today showed how positive and effective Maryland EMS is, from the level of the first responders in the fire service (EMTs and paramedics), to the Maryland State Police Aviation Division, to MIEMSS and the University of Maryland Shock Trauma Center.”
As with any emergency incident, lessons were learned:
2. Crews utilized a large amount of oxygen during this call. Fortunately, they carry a significant amount of portable cylinders and that was not an issue. However, if this incident had lasted any longer, they would have had to call for additional oxygen. Bel Air is purchasing items that will let it utilize its on-board oxygen bottle remotely, for just this type of situation.
3. Expect the unexpected. Prior to arrival, the company was told that a simple “door-pop” would free this patient. This could have created an improper mind-set about an easy operation or caused an inappropriate downgrading of the running assignment.
4. Call for mutual aid if any special equipment may be needed. Another option for this extrication was to use a plasma cutter or other metal slicing tool for a more “gentle” cut of the guardrail, but Bel Air’s rescue did not carry such a tool at the time. Although it was not needed, it would have taken a mutual aid company 15 minutes to get the tool to the scene once requested.
5. Learn what your specialized local emergency, surgical teams can do. The Go-Team is based out of one the best trauma hospitals (University of Maryland) in the world. The members know how the body will react in various situations, such as this incident. Integrate such teams into your response plans.
6. Continue to train with mutual aid resources. Once the Go-Team arrived, its members worked seamlessly with fire-rescue personnel. This occurred because the fire-rescue personnel continually take courses and attend drills offered by these agencies and exchange information on how the fire department operates.
Richard H. Gardiner is a 15-year member of the Bel Air Volunteer Fire Company in Harford County, MD. He currently serves as the department’s chief spokesperson and public information officer.
