Rescue Awareness and Operations

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Rescue Awareness and Operations
Chapter 50
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Rescue

• Defined as the act of delivery from danger or
  imprisonment
• A patient-driven event (no patient no rescue)
• Requires specialized medical and mechanical
  skills, with the right amount of each being
  applied at the appropriate time

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Appropriate Training for Rescue Operations

• Rescue
• Requires training and expertise so that medical
  and mechanical skills are carefully balanced to
  ensure that patients obtain effective treatment
  and timely extrication
• Success of a rescue is dependent on a coordinated
  effort that allows for
• Patient access and assessment for treatment needs
• Treatment to begin at the site
• Release from entrapment or imprisonment
• Medical care to continue throughout the incident

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Role of the Paramedic in Rescue Operations

• Systems operations approach
• Most rescue operations in the United States are
  provided using this approach
• Extrication activities are performed by fire
  service personnel, specialized units, or both
• Patient care activities are the responsibility of
  the EMS provider

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Role of Paramedic in Rescue Ops

• A second type of system provides rescue services
  by fire, EMS, or law-enforcement agencies that
  have cross-trained personnel
• Roles and responsibilities for rescue and patient
  care are shared in this system

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Role of Paramedic in Rescue Ops

• Primary role of the paramedic in rescue
  operations
• Have proper training and appropriate personal
  protective equipment (PPE) to allow access and
  the provision of treatment at the site and
  continuing throughout the incident

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Role of Paramedic in Rescue Ops

• As first responders to many incidents
• Understand hazards associated with various
  environments
• Know when gaining access or attempting rescue is
  safe/unsafe
• Have skills to effect a rescue when safe and
  necessary
• Understand the rescue process and when certain
  techniques are indicated or contraindicated
• Be skilled in patient packaging techniques to
  allow for safe extrication and medical care

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Role of Paramedic in Rescue Ops

• Safety
• Important because of the potential for associated
  risks that may involve
• Hazardous materials
• Inclement weather
• Temperature extremes
• Fire
• Electrical hazards
• Toxic gases
• Unstable structures
• Heavy equipment
• Road hazards
• Sharp edges and fragments

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Role of Paramedic in Rescue Ops

• Initial scene assessment for hazards, personal
  protective measures, and constant monitoring
  throughout the operation is essential
• Safety priorities
• Personal safety
• Safety of the crew
• Safety of bystanders
• Rescue of the trapped and injured

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Role of Paramedic in Rescue Ops

• The crew is the support team for the rescuer
• Crew safety is essential to ensure an effective
  operation and provide mutual support for each
  member of the team
• Operating with disregard for the safety of fellow
  team members increases risk of injuries and
  complications of the operation
• Uninvolved people must be evacuated and kept
  clear of hazards
• Bystanders or untrained helpers only increase the
  risk of additional injuries and complications of
  the rescue operation

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Role of Paramedic in Rescue Ops

• Rescue of the trapped or injured is the last
  priority
• These people are already trapped or injured
• Carrying out the first three priorities safely
  maximizes the chance for a successful rescue

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Phases of a Rescue Operation

• Seven phases of a rescue operation
• Arrival and scene size-up
• Hazard control
• Gaining access to the patient
• Medical treatment
• Disentanglement
• Patient packaging
• Transportation

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Arrival and Scene Size-Up

• Requires the paramedic to determine what is
  needed at a particular emergency event
• Quickly gathering facts about the situation
• Analyzing the problems
• Determining the appropriate response

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Size-Up

• A continuous evaluation of the emergency scene
  that begins when the call is received
• Be constantly alert to situations that may change
  the needs of a particular incident
• Establish command and conduct a scene assessment
• Determine the number of patients and triage as
  necessary
• Determine if situation is a search, rescue, or
  body recovery

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Size-Up

• Risk versus benefit analysis
• Request additional resources
• ICS used as a command/control mechanism
• Make a realistic time estimate in accessing and
  evacuating

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Assessment Phase

• Response
• En route, gather as much information about the
  situation as possible including
• Exact location
• Type of occupancy (e.g., manufacturing,
  mercantile, residence)
• Number of victims
• Type of situation
• Hazards

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Assessment Phase

• Other factors
• Description of the scene
• Time of day may dictate scene requirements
• Resources that may be needed to handle an
  emergency event

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Hazard Control

• Identify and control as many hazards as possible
• Manage, reduce, and minimize the risks from the
  uncontrollable hazards
• Make the scene as safe as possible
• Ensure all personnel are in PPE appropriate for
  the situation

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Gaining Access to the Patient

• Critical component in patient's eventual outcome
• Trauma patient may require
• Rapid assessment
• Stabilization
• Extrication
• Rapid transportation
• Extrication tools and equipment

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Gaining Access to the Patient

• Paramedics
• Have primary responsibility for patient care
• Serve an important role as observers for
  potentially hazardous procedures

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Extrication Tools and Equipment
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Medical Treatment

• Provide medical treatment appropriate for the
  situation
• Spinal immobilization
• Airway management and ventilation
• Oxygen administration
• IV fluid therapy
• If a rapidly fatal or potentially fatal condition
  is recognized, load and go
• A physical examination should be performed after
  the initial assessment is complete and
  life-threatening conditions have been stabilized

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Disentanglement

• Involves making a pathway through the wreckage of
  an accident and removing wreckage from patients
  (release from physical entrapment)
• Methods must be driven by patients needs
• Perform a risk vs. benefit analysis that
  considers personal safety
• Assess the need for specialized equipment and
  techniques
• Be aware of available resources and how to
  mobilize them

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Patient Packaging

• Packaging refers to physical stabilization and
  preparation for transport
• May require special rescue capabilities (e.g.,
  moving patients over hazardous terrain, lifting
  patients by hoist to a helicopter)
• Coordination of activities and patient care
  responsibilities offer greatest chance of
  successful outcome
• Coordination of the removal phase
• Paramedic responsibilities

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Transportation

• Have a wheeled stretcher, basket stretcher, or
  long spine board available
• Consider equipment needs and personnel for moving
  the patient
• Transport vehicle should be appropriately warmed
  or cooled for patient comfort
• During transport, continue patient care and
  advise medical direction of patient status

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Rescuer Personal Protective Equipment

• EMS providers involved in rescue and other rescue
  personnel should have access to the following
  PPE
• Impact-resistant protective helmet with ear
  protection and chin strap
• Safety goggles with an elastic strap and vents to
  prevent fogging
• Lightweight turnout coat that is puncture
  resistant
• Slip-resistant, waterproof gloves
• Boots with steel insoles and steel toe protection
• Self-contained breathing apparatus (SCBA)

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In-line SABA
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Rescuer PPE

• The same PPE is not appropriate in all situations
• PPE must be appropriate for/to the situation
  encountered
• PPE may not prevent exposure to infectious
  disease but it does minimize risk
• PPE for specific rescue situations
• Personal protection from blood-borne pathogens

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Surface Water Rescue

• People are drawn to moving water for recreation
• Many people (including rescuers) underestimate
  the power and hazards of water
• The hydraulics of moving water is affected by
• Depth and velocity of water
• Obstructions to flow

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HELP and HUDDLE

• When floating in cold water alone, conserve body
  heat by using the HELP body position
• When floating in cold water with other people,
  HUDDLE together

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Obstructions to Flow

• Water that moves over a uniform obstruction can
  create recirculating currents (drowning
  machines)
• Can trap victims and make escape difficult
• Recirculating currents are commonly found in
  rivers and on low head dams
• Height of the dam is no indication of the degree
  of hazard
• Force of the moving water is very deceptive
• Hazardous rescue
• Trapped victims often succumb to fatigue,
  hypothermia, and drowning

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Obstructions to Flow

• Strainers are obstructions (e.g., trees, grating
  wire/mesh) that allow current to flow through,
  yet can trap objects such as boats or people
• The force of the water against the victim makes
  escape difficult
• The rescuer must cautiously approach strainers to
  avoid their own entrapment

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Obstructions to Flow

• Low-head dams range in height from 6 inches to 10
  feet and can create dangerous hydraulics

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Foot/Extremity Pin

• It is unsafe to walk in fast moving water over
  knee depth
• Extremity may become trapped in a strainer
• Victim is dragged under the surface of the water
• If a foot or extremity pin occurs, body part must
  be extricated from entrapment in the same way it
  went in

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Flat Water

• About 3900 deaths occur each year in flat
  (static) water (lakes, ponds, and marsh) from
  drowning
• Factors that contribute to these deaths include
• Alcohol or other drug use
• Cool water temperature that leads to hypothermia
• Personal flotation devices (PFDs) routinely worn
  and fastened properly when on or around the water
  can save lives by decreasing the likelihood of
  drowning

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Water Temperature

• Immersion in water that has a temperature less
  than 98º F (32 º C) can cause hypothermia
• A person cannot maintain body heat in water below
  92 º F (33 º C)
• Water causes heat loss 25 times faster than
  exposure to air at the same temperature
• The colder the water, the faster the rate of heat
  loss
• A person who experiences a 15-to 20-minute
  immersion in 35 º F (1.6 º C) water will likely
  die from hypothermia and drowning

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Water Temperature

• Sudden immersion in cold water may trigger
  laryngospasm that can lead to
• Aspiration
• Severe hypoxia
• Unconsciousness
• Hypothermic patients rapidly lose the ability for
  self rescue

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Water Temperature

• Water temperature varies widely with seasons and
  run off
• Even on warm days water temperature can be very
  low
• PFDs lessen heat loss and energy required for
  flotation
• If sudden immersion occurs, a single victim
  should assume HELP position
• If multiple people are in the water, huddle to
  decrease heat loss

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Cold Protective Response

• Mammalian diving reflex
• Increases the chance of a victims survival in
  cold water
• Protective physiological response
• Face immersion in cold water causes
  parasympathetic stimulation
• Heart rate decreases/bradycardia
• Peripheral vasoconstriction shunts blood to the
  core
• Hypotension

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Cold Protective Response

• Effectiveness of this response is affected by
• Victims age
• Posture in the water
• Lung volume
• Temperature of the water
• Hypothermic patients should be presumed
  salvageable
• A victim is never cold and dead only warm and
  dead
• Patient must be rewarmed in a hospital before an
  accurate assessment can be made

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Rescue vs. Body Recovery

• Besides water temperature, other factors that
  affect a patients clinical outcome after a
  submersion incident include
• Length of time of submersion
• Known or suspected trauma
• Environmental conditions
• Age and physical condition
• Time until rescue or removal has been achieved

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Rescue vs. Body Recovery

• Resuscitation should be initiated by rescuers at
  the scene unless there is obvious physical
  evidence of death
• Putrefaction
• Dependent lividity
• Rigor mortis

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In-Water Spinal Immobilization

• Requires special training
• Only rescuers trained in water rescue should
  enter the water
• Procedure

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Overview of Rescue Techniques

• Never underestimate the power of moving water
• The water rescue model is reach-throw-row-go

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Rescue Techniques

• Self-rescue techniques if fallen into flat or
  moving water
• Cover mouth/nose during entry
• Protect your head and keep face out of the water
• If in flat water, assume the HELP position
• If in moving water, do not attempt to stand up
• Float on back with feet downstream and head
  pointed toward the nearest shore at a 45-degree
  angle

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Hazardous Atmospheres

• Oxygen-deficient environments may occur in
  confined spaces
• A confined space is one with limited access or
  egress not designed for human occupancy or
  habitation
• Examples of confined spaces
• Grain bins and silos
• Wells and cisterns
• Storage tanks
• Manholes and pumping stations
• Drainage culverts
• Underground vaults
• Trenches and cave-ins

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Hazards Associatedwith Confined Spaces

• Oxygen-deficient atmospheres
• Chemical/toxic exposure/explosion
• Engulfment
• Machinery entrapment
• Electricity
• Structural concerns

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Emergencies in Confined Spaces

• OSHA requires a permit process before workers may
  enter a confined space
• Non-permitted sites are likely locations for
  emergencies
• Types of emergencies that can occur in confined
  spaces
• Safe entry for rescuers

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Rescue From Trenches/Cave-Ins

• Most trench collapses occur in trenches less than
  12 feet deep and 6 feet wide
• Federal law requires either shoring or a trench
  box for evacuations that are 5 feet or deeper
• Factors that contribute to collapse
• Lips on one or both sides of the trench that cave
  in
• Walls that shear away and cave in
• Excavated dirt piled too close to the edge,
  causing collapse
• The presence of intersecting trenches
• Ground vibrations
• Water seepage

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Rescue From Trenches/Cave-Ins

• When arriving at the scene where a collapse has
  occurred causing burial, be aware that a second
  collapse is likely to occur and do not approach
  the lip
• Rescue attempts by EMS personnel should not be
  made unless trench is less than waist deep

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Confined Space Entry Permit
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Highway Operations

• Traffic flow is the largest hazard in EMS highway
  operations
• Factors associated with highway hazards
• Emergency responses to limited and unlimited
  access highways
• Emergency vehicle crashes
• Back-up of traffic that impedes flow to and from
  the scene
• Techniques to reduce traffic hazards

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Fuel/Fire Hazards

• Gasoline spills are a common fire hazard
• Decrease risk that flammable liquids will ignite
  by
• Turning off the vehicle ignition switch
• Forbidding smoking
• Avoiding use of flares near the spill
• Vehicle fires

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Electrical Power

• Only utility workers and trained rescuers should
  secure downed electrical wires
• Vehicles in contact with downed wires
• If patient contact is necessary, use
  nonconductive equipment
• No equipment will provide absolute safety from
  electrical injury

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Unstable Vehicles

• Must be stabilized before gaining access
• Standard methods
• Supporting vehicle with wooden cribbing, wheel
  chocks, air bags
• Securing vehicle with ropes and cables
• Chaining vehicle to poles, trees, other vehicles
  and structures

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Equipment Used to Stabilize Vehicles
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Vehicle Stabilization
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Vehicle Stabilization
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Vehicle Stabilization
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Vehicle Stabilization
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Vehicle Stabilization
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Vehicle Stabilization
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Airbags/Supplemental Restraint Systems (SRS)

• Types of airbags
• Incident with fire
• Incident with a deployed airbag
• Incident with an undeployed airbag

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Hazardous Cargoes

• Most hazardous substances transported in the
  United States travel by road
• Be suspicious of crashes involving commercial
  vehicles
• Methods that can be used to identify carriers of
  hazardous cargoes
• UN numbers
• Placards

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Auto Anatomy

• Roof and roof support posts (A, B, C, and D
  posts)
• Fire wall
• Engine compartment and power train
• Undercarriage and unibody vs. frame construction
• Safety glass vs. tempered glass
• Doors
• Rescue strategies

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Anatomy of a Car
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Extrication Techniques
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Extrication Techniques
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Extrication Techniques
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Extrication Techniques
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Hazardous Terrain

• Low-angle (steep slope)
• Refers to terrain that is capable of being walked
  on without the use of hands
• Secure footing may be difficult
• Difficult to carry a litter even with multiple
  rescuers
• Low-angle rescue
• Rope used to counteract gravity during litter
  carry
• Consequence of error likely to be a fall and
  tumble

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Hazardous Terrain

• High-angle (vertical)
• Refers to cliff, building side or terrain so
  steep hands must be used for balance when scaling
  it (slopes greater than 40 º)
• Total dependence on rope or aerial apparatus for
  litter movement
• Consequence of error likely to be fatal
• Rappelling by trained personnel to retrieve
  victims is required in high-angle rescue

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Flat Terrain

• May have various obstructions that can make
  rescue difficult
• Examples include level land with large rocks,
  loose soil, and waterbeds or creeks
• Additional manpower and resources may be needed
  to safely extricate a victim and ensure safe
  litter movement

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Low-angle Rescue

• Rope is secured at top of slope litter is
  attached to rope and rescuers hold litter and
  walk up or down slope

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High-angle Rescue
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Patient Packaging Using Litters

• Basket stretcher standard for rough terrain
  evacuation
• Rigid frame provides protection for the victim
• Relatively easy to carry with adequate personnel
• Patients immobilized on a long backboard and
  secured in the basket
• Alternative spinal immobilization devices (e.g.,
  vest-type devices) can be used with the basket
  stretcher

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Litter Carry Over Terrain
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Helicopter Use in Hazardous Terrain Rescue

• Helicopters can be used for patient transport and
  for rescue operations
• When used for rescue, the mission, crew, and
  capabilities of the helicopter team (civilian and
  military) are specific for rescue techniques vs.
  providing medical care and transport
• Rescue helicopter team has specialized knowledge
  and skills required to hover or land in tight
  places and to transport people and equipment

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Assessment Procedures During Rescue

• Environmental issues affecting assessment
• Weather and temperature extremes
• Access to patient may be limited
• Equipment limitations
• Patient may be entrapped for an extended period
• Rescuer PPE essential but cumbersome

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Assessment Procedures During Rescue

• Specific assessment/management considerations
• Exposure of patients
• ALS skills
• Patient monitoring
• Improvisation
• Pain control