You probably all remember that one piece of equipment that you weren’t confident with in the first years of your career. In my case, it was a mechanical winch, known as a Tirfor. This was because we rarely (if ever) trained with it. Maybe once a year, we would get it out and I felt like every time I touched it, I had to relearn its use. When we did train with it, we probably used it to about 20% of its potential; not solid grounding for its effective operational use. Thinking back, this unfamiliarity and lack of confidence with the Tirfor meant I would often prefer to leave it on the truck, rather than wanting to use it. My early memories of the Tirfor reminds me of today’s approach to the hydraulic ram that many rescuers have.
The hydraulic ram, in my experience, is the least mentioned when it comes to discussions regarding rescue tools. The focus is primarily on cutters, followed closely by spreaders. Even the hydraulic pump (or more recently battery technology) gets more attention during training sessions. This is universal, no matter where I am in the world. So why is this the case especially when we consider the importance of hydraulic rams in many rescue situations?
Well, my theory is quite simple and is based on what I perceive to be ‘reduced confidence in its use’. Most rescuers I talk to, have a lack of familiarity with the ram as their training experience goes no further than dashboard relocation (dash roll). This is further exacerbated by many rescuers’ preference to relocate a dash using a dash lift which may preclude the use of a ram altogether. (Although the ram may be inserted to prevent movement of the structure when the relief cuts are made.) This very often means that the ram becomes the last tool to be used and when it is picked up, it is rarely used to anywhere near its full potential.
Where are the ram videos?
There is no doubt that using a tool safely, effectively, competently and confidently requires some hours of training; time to hone skills and develop techniques in a controlled environment. This is something that rescuers generally do in all areas of their work to great effect with positive results. However, this is where the inability to effectively train with the hydraulic ram may lead to the lack of confidence explained above. In addition to this, the internet is full of instructional videos, discussion on all manner of tools and techniques, but ram applications are severely lacking; another sign that from an industry point of view, it is not a focus area.
Ever thought of cross ramming?
Aside from performing a dashboard roll, another key use of the ram is cross ramming. Cross ramming is performed inside the vehicle (horizontally or vertically) and is effective when a patient is trapped as a result of a massive intrusion into the passenger cell of the vehicle, following a collision. The aim of cross ramming is to move the construction of the vehicle back towards its original manufactured position (or at least as close to). This allows us to:
- Remove physical entrapment
- Gain better medical access to the patient
- More easily apply the well-known techniques, as the vehicle is now ‘car shaped’ once again
Cross ramming is a difficult technical skill for a number of reasons:
- Operators have to be inside the vehicle, they are essentially working in a confined space.
- Positioning the bottom of the ram can be difficult and a solid base is needed.
- Knowledge of vehicle construction is vital in order to perform the technique effectively.
- Wooden cribbing can be used to spread the load, but this is an inexact science and it often wastes time (the cribbing moves).
From a medical perspective, it is very often the case that cross ramming is required in order to remove a physical entrapment e.g. a patients arm may be trapped between the B-post and seat following a side impact. When this is the case, rescuers must understand the following principle:
Initial placement of the ram head is vital
Unlike a dashboard roll where we make relief cuts, cross ramming rarely (if ever) allows us to make relief cuts in order to remove strength. It is therefore imperative to remember that once the cross ramming has commenced, any slippage of the ram head will likely result in the construction ‘springing back’ and re-trapping the patient (as well as possibly worsening their injury). So, the initial placement of the ram head is vital; you only get one chance to position the ram. Therefore operators must be able to identify the ideal initial ram head placement and should also consider:
- Selecting a point of strength for the base which is stronger than the area to be moved. This ensures the hydraulic forces travel in the desired direction.
- Positioning the ram head to ensure maximum contact with the construction and negate slippage.
- Positioning the ram head to create maximum space once the ram is extended.
Cross ramming requires good communication between rescuer and medic, especially where the operation is being carried out very close to the patient. In addition, communication between tool operators and incident commander is also vital. And the decision of initial placement must be carefully considered based on experience and acute awareness of vehicle construction. From a safety point of view, it is imperative that ram operators DO NOT position the ram head with their hands as there is the very real possibility of injury. Always decide on the desired position of the ram head, mark the area and allow the ram to extend without guiding the ram head with your hand.
Vehicle for training
Now that we are aware of the finer points of cross ramming, let’s return to the subject of training. We can immediately see that although it is easy (in most places) to obtain an old vehicle for training purposes, for many it is very difficult (or impossible) to obtain vehicles with the damage that will provide a useful basis for practising cross ramming. For those who can obtain such vehicles, they will likely be old (or very old) and will not respond in the same way that a new vehicle will due to its aged construction. This automatically disadvantages many rescuers when it comes to furthering their skills, their competence and their confidence with the hydraulic ram. It, therefore, remains that the best place for rescuers to learn about the skills required for cross ramming will be at a live extrication. This is far from ideal; We all know that a real incident is NOT the place to learn.
Human nature dictates that confidence in a subject promotes discussion; the more we know about something, the more we talk, discuss and challenge the norm. A lack of confidence, awareness and understanding leads to reticence and limits development. The extrication world is full of great information when it comes to spreading and cutting, but lacking massively when it comes to information on the safe and effective use of hydraulic rams. We tend to train with rams in a one dimensional way and default to a dashboard roll, when in reality the ram can be (and is) used for far more applications, which are complex and require a high degree of training and preplanning. This, in turn, breeds confidence and although training for cross ramming is difficult, we must endeavour to find a way to practice such a vital skill by obtaining appropriate vehicles. Twenty-five years on, I am now confident with the Tirfor; once my ‘nemesis’, now I can use it in my sleep.
For more information, go to www.holmatro.com