Extrication has traditionally been a linear process: rescuers free the patient, then hand them over to EMS to start care. Sometimes that handoff comes five minutes after the crash. Sometimes it comes 55 minutes later, and everything that happened to the patient's physiology in between went unmanaged.
In our recent Prodigy EMS webinar, paramedic and EMS physician Dr. Jeremy Cushman makes the case for a different model, one where medical care and technical rescue happen at the same time, with the patient at the center of both. He calls it medically directed rescue, and he's been refining it over a career that includes a three-and-a-half-hour effort to free a man pinned beneath a 20-ton crane.
"In the 30-ish years that I've been doing this, no two rescues are the same," Cushman says. That's why the class offers a framework instead of a protocol. Here are a few of the teaching points.
One rescuer, eyes on the patient, the whole time
Cushman's first requirement at any entrapment is a single dedicated rescuer whose only job is face-to-face contact with the victim. At the crane incident, that was a firefighter who lay prone on the ground next to the patient for the entire rescue. Cardiac monitors, blood pressure cuffs, and sat probes are often impractical or unreliable in a wreck, and they tend to tell you what already happened. Mental status, respiratory effort, and skin color changes are earlier and more sensitive indicators, and they let the team decide in real time whether to speed up the extrication or slow it down. The one piece of technology that earns an exception is capnography, which Cushman uses whenever the patient has to be covered and he can't see their face.
Inconvenienced or crushed? The answer changes everything
One of the most practical parts of the class is Cushman's way of sorting entrapments: is the patient impaled, inconvenienced, or crushed? A patient who is merely stuck, whether by pain or anatomy, may need little more than good analgesia and some careful manipulation to come out 20 minutes sooner. A patient who is truly crushed needs aggressive resuscitation before the load comes off, and the class walks through what that looks like: balanced crystalloids over normal saline, warmed and delivered at a real rate, with the amount of muscle mass involved driving how worried you should be.
Assume they'll crash the moment you move them
Cushman is blunt about this one. "As soon as you move, we have to assume that anybody that is trapped in stuff, that they are going to lose consciousness." He shares a recent call where a patient hoisted from a tractor went apneic mid-lift, exactly as the team had planned for. The team's job is to be ready: airway assigned, stretcher staged, and above all a way to get the patient horizontal immediately. Decompensation should never surprise anyone on scene.
The rescue crew shouldn't carry the patient out
After the cutting is done, the extrication crew's adrenaline drains fast. Cushman has watched rescuers become physically incapable of doing anything more once the victim is free, which is why a separate crew should be assigned to move the patient from the point of removal to the ambulance, and why the evacuation route needs to be planned before anyone comes out. As he puts it, "Don't have these conversations for the first time at the wreck."
Earn the CE credit
The full class digs into much more, including tool selection around impalements, thermal protection in extreme cold, facilitated extrication with sedation, and how medical and rescue leaders share the go/no-go decision at a complex scene. The mission on both sides is the same. "We all want the patient going home to their family."
Watch the recording, pass the post-test, and earn one hour of CAPCE-accredited CE. Take the class on Prodigy EMS today.
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