High Side Patient Removal

Side-resting vehicles can create many unique challenges, including stabilization issues, high-side glass, low-side dash displacements, and unusual patient positioning. If not mitigated appropriately, serious issues can result with the spinal immobilization and treatment of patients who are found belted in the high-side seat. Typically patients are found in that position either because they do not have the strength to release themselves or they have been injured to the extent they are unable to. In either case, responders will have to support their bodyweight during disentanglement tactics and transfer to a long spinal board. Assigning several members to support the patient early in the incident may be difficult because of lack of staffing, need to complete other tasks, or lack of accessibility.

In addition to high-side belted patients, the same techniques can be applied to several other situations. If the vehicle was initially involved in a frontal collision, the patient may be hanging from a lower extremity entrapment by the dash. Other similar cases may involve an extremity entrapped in the steering hub or the seatback holding the patient. When completing seat flips where the floor pan, seat, and bravo post are pivoted together toward the undercarriage of the vehicle, the patient is strapped into the seat and an intact seat belt can provide additional support. The last thing you want to do is prematurely cut a seat belt or its attachment points or relieve a secondary entrapment and allow the patient to fall.


Initially treat the incident as any other vehicle collision. Take the necessary steps to establish incident command, survey the scene carefully, call resources as necessary, control hazards, and stabilize the vehicle in the position found. Just like any other collision, once responders determine a patient is entrapped in a side-resting vehicle, they must determine the best tactics to mitigate the situation. These tactics should not only provide an effective path of egress in a proficient manner but also must ensure the safety of the patients and responders.

Typically a roof removal, partial roof removal, and/or roof flap will be sufficient. The first and most obvious consideration in determining the ability to complete a ridge cut for a partial roof removal or flap vs. full roof removal is the outward signs of construction features, such as sunroofs, luggage racks, and hardtop convertible, that complicate the tactic. The presence of these features does not necessarily rule the tactics out. The components should be evaluated to determine the ability to make the ridge cut from one point to another. In this case, unless a full removal provides needed space, a partial roof removal may be more advantageous to help support the long spine board during patient removal.

Follow these steps if the patient is determined to be belted in the high-side seat or unsupported with a secondary entrapment:

  •  Initiate and provide emergency medical care.
  •  Displace the interior trim and headliner to evaluate for possible hazards and determine the width of the side roof rails. This step also helps to determine the presence of any additional construction features that may cause difficulty.
  •  If readily available, use a hydraulic cutter to make a roof rail cut behind the bravo post and on the front just below the bottom edge of the high-side seat. The cutter should be able to make the cut in the thicker and larger material easier than other tools, especially if the collision has damaged the structural components. However, if the hydraulic tools require time to set up and a reciprocating saw or chisel is readily available, responders can begin the tactic with one of these tools. Ensure that other personnel continue to set up the hydraulic tools in case they are needed.
  •  When completing a partial or complete roof removal, the post closest to the patient should be severed last. By leaving that post until last, responders do not have to commit as quickly to holding the roof in position for fear of it falling down on the patient or interior responder. This area will also contain the seat belt attachment. Responders should avoid the attachment point of the seat belt with any of the necessary cuts to complete the selected roof tactic. If the seat belt is integrated into the seatback then this will not be a concern, but the patient should still be supported during transfer to the long spinal board. If the attachment point is integrated into the door frame on a track system, then avoid the door frame. When space between the door frame and posts has not resulted from the collision, a ridgeline cut may be necessary. In the more common location on the bravo post, simply ensure the cut location is closer to the roofline than the attachment point.
  •  Throughout the tactic, place hard protection between the patient and interior rescuer and the cut locations. Maintain an appropriate level of soft protection over the patient and interior responder during the operation.
  •  After completion of the tactic, harden the egress by covering the remaining sharp edges and clearing the hot zone as much as possible to decrease slip and trip hazards during patient removal.
  •  Secure a piece of webbing around the torso of the patient and use a responder to maintain tension on the undercarriage side of the vehicle. The vehicle will act as a friction device and allow the responder to easily hold the weight. If the seat belt is holding the patient in position, this step may not be necessary until the roof tactic is complete. However, if the patient is not supported, this should be done as early as possible.
  •  The disentanglement supervisor should transfer control to the interior responder for patient removal. Once responders are in supportive positions with hands on the patient, the seat belt can be severed at the shoulder and waist. In a coordinated effort with the responder holding tension on the webbing, move the patient to the long spinal board. With a partial roof removal and the cut location just below the bottom of the high-side seat, use the roof itself to help support the board during patient transfer.


Responders attempting to support a patient in an elevated position are typically inefficient and ineffective, especially considering the limited space and poor ergonomics. Responders should use simple techniques like webbing and cut locations to assist in the process. These techniques will ultimately limit the potential for responder injury and increase patient safety and treatment.

Special thanks to Lowcountry Fire and EMS Weekend.

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