By David Cone
Photos Courtesy Old Lyme Fire Department and Old Saybrook Fire Department

At 0026 HRS on the morning of Aug. 23, 2009, the Old Lyme (Conn.) Fire Department (OLFD) and Old Lyme EMS were dispatched for a tractor-trailer that had struck a sedan, rolled over and crashed through a wooden sound barrier on Interstate 95. Connecticut State Police were already on scene and had requested a second ambulance and the state air medical service.

The OLFD chief arrived on scene at 0035 HRS to find four passengers in the sedan with apparently minor injuries and a tractor-trailer lying on its left side. The trailer was still on the highway but the cab was off the road, having penetrated a heavy-wood sound barrier lining the highway.

The chief established incident command and placed a mutual-aid call for an engine and rescue truck from the Old Saybrook Fire Department, along with a request for a third ambulance.

With the arrival of OLFD’s engine at 0042 HRS and heavy rescue at 0043 HRS, a deputy chief and captain were assigned to manage the extrication of the tractor-trailer driver, who had not yet been located in the wreckage of the cab, while another captain was assigned to supervise the assessment and management of the four patients in the sedan. A third captain was assigned to assess the load in the trailer. A paramedic from the regional hospital-based service arrived at 0045 HRS, and the first two ambulances arrived at 0046 HRS and 0047 HRS.

The Old Saybrook companies arrived on scene at 0100 HRS and were assigned to cut an access “door” through the intact portion of the wooden sound barrier just east of the truck to allow for easier movement of personnel and equipment between the highway and the cab.

The four patients in the sedan were assessed, found to have no substantial injuries and transported to a nearby emergency department; all were subsequently released. The driver of the tractor-trailer was found heavily entangled in the cab, awake and alert. Access to the patient was extremely limited, making a detailed clinical assessment impossible.

The truck’s fuel tanks were intact, with no spill, and the trailer contained no hazards. Precautionary 1 ¾" handlines were stretched to protect the scene, though there was no smoke or fire at any time.

At 0109 HRS, a heavy wrecker was requested from a commercial towing firm in case the tractor-trailer needed to be moved or lifted. A 44-ton wrecker arrived on scene at 0128 HRS.

Due to a heavy mist with low ceiling and a temperature of 82 degrees F, the state air medical service was unavailable. Recognizing the likelihood of several additional hours of extrication, the regional physician response team was requested at 0129 HRS, and the EMS physician arrived on scene at 0156 HRS.

By about 0130 HRS, the firefighters working to extricate the driver were becoming fatigued; some were exhibiting signs of heat exhaustion. One was transported to a local hospital for evaluation, and six others were treated by EMS on scene. A strict work rotation of 10 minutes was implemented, eliminating any further issues with heat exhaustion. One additional firefighter was transported to the emergency department for stitches to an ear laceration that occurred later in the extrication.

A third heavy rescue was requested from the Essex (Conn.) Fire Department at 0135 HRS, and a fourth from the Flanders (Conn.) Fire Department at 0151 HRS.

Extrication efforts continued, with a total of 10 hydraulic lines working off the various apparatus for cutters, spreaders and rams. The cab was essentially dismantled from around the patient, allowing the paramedic and physician better access to the victim. No substantial bleeding was noted, though lower extremity fractures were suspected due to the degree of entanglement and visible deformity. Supplemental oxygen was not used due to the lack of respiratory problems, and the potentially hazardous environment. An intravenous line was placed fairly early in the extrication, but the patient pulled it out. It was replaced at about 0245 HRS when the patient’s mental status began to deteriorate, and intravenous fluids were infused.

The saddle tank was removed intact from the right side of the cab, allowing crews to work up through the floor of the cab to help disentangle the patient by removing parts of the seat base and flooring. The patient’s right leg was freed from the wreckage at about 0250 HRS, and an obvious femur deformity was noted.

Additional manpower from the Lyme (Conn.) Fire Department and the Old Saybrook Fire Department was requested at 0300 HRS to provide relief for working crews. At about this time, it was determined that the driver’s left leg was pinned between the seat and the driver-side door, which was on the ground. Attempts to spread the space between the seat and floor had been unsuccessful, so it was decided to lift the entire cab, then push the door downward toward the ground, away from the seat.

The wrecker crew rigged their dual lift for a straight vertical hoist, and lifted the entire cab 8 to 12 inches, allowing the driver-side door to be pushed downward, back toward the ground, freeing the patient’s left leg. He was rotated to a supine position while being removed from the cab, and placed on a long spine board that was then placed in a Stokes basket for removal up the slope, through the “door” in the sound wall, and out to the highway.

Extrication was completed at 0342 HRS—more than 3 hours after the initial dispatch.
The patient was moved to the ambulance. Due to continued deterioration in mental status, the patient was intubated by the paramedic using rapid-sequence techniques with etomidate and succinylcholine. The second and third liters of IV fluid completed infusion early in transport, and the fourth and fifth liters of IV fluids were initiated during transport.

At 0504 HRS, the last fire units cleared the scene, leaving the Connecticut State Police in charge to continue their investigation.

Lessons Learned
1. Call for additional manpower early when rescuer fatigue is likely.
2. Call for non-traditional resources (such as heavy-duty wreckers, cranes, etc.) as soon as their need is anticipated. Having agreements in place in advance with companies or agencies that can provide these resources can be very helpful.
3. Use the incident command system for all responses. It allows a large incident to be managed effectively by breaking it into smaller, more manageable assignments.
4. Ensure that all personnel are wearing all necessary personal protective equipment during extrication and rescue activities, even in adverse weather conditions.

David Cone, MD, is an associate professor of emergency medicine and EMS Section Chief in the Department of Emergency Medicine at Yale University in New Haven, Conn. An active EMS provider since 1984, he is also a 10-year veteran firefighter with the North Madison (Conn.) Volunteer Fire Company, and chief of the New Haven SHARP Team, the only state-certified physician response team in the state. He has also served as Medical Team Manager of two urban search and rescue task forces (Pa. and Conn.). He is the immediate past president of the National Association of EMS Physicians, and editor-in-chief of the journal Academic Emergency Medicine.

Chief David Jewett with the Old Lyme Fire Department and Brad Fowler, EMT-P, of Middlesex Hospital assisted in the preparation of this report.

Responding Departments
Old Lyme Fire Department
Old Lyme EMS
Old Saybrook Fire Department
Old Saybrook EMS
Essex Fire Department
Essex EMS
Flanders Fire Department
Westbrook EMS
Middlesex Hospital Medic
New Haven SHARP Team
Lyme Fire Department
Valley Shore Communications

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