Hazardous Terrain

EMS Skills Rescue awareness Types of specialized teams Effective coordination with specialists Hazardous terrain litter evacuations

Hazardous Terrain Types High angle Low angle Flat terrain with obstructions

High Angle Surfaces inclined >40o Very smooth surfaces <40o Gorges Cliffs Buildings Very smooth surfaces <40o Require use of hands in climbing Ropes, aerial apparatus required for access, removal Errors can cause life-threatening injury, death

Low Angle Surfaces inclined <40o Accessed by walking, scrambling Difficulty can be affected by presence of: Water Ice Boulders Brush, down trees Ropes used to counteract gravity, act as hand lines Errors can result in falls, tumbles Presence of obstructions can result in serious injury

Flat Terrain with Obstructions Examples: Trails Paths Creek beds Difficulty may be increased by: Downed trees Rocks Slippery leaves Scree (rock debris) Patients can be moved by carrying Least hazardous form of rugged terrain Slips, falls can result in injury

Patient Access

High Angle Access/removal usually carried out by technical teams Additional resources needed to balance technical/medical aspects of rescue

High Angle Rescuer skills Knot tying Ascending, descending skills Rigging of hauling systems Packaging of patients for evacuation

High Angle Specialized Terms “Aided”—using means other than hands, feet, body “Anchor”—technique for securing rescuers to vertical face “Belay”—safeguarding climber by use of a rope secured to an anchor “Rappel”—descend by sliding down a fixed double rope

Low Angle Access/removal conducted by EMS personnel in many systems Still requires appropriate training/equipment

Low Angle Skills Assembly/use of harnesses Setting up hasty rope slides Rappelling, ascending by rope Patient packaging Rigging simple hauling systems

Patient Packaging

Stokes Basket Stretcher Standard litter for rough terrain evacuations Provides rigid frame for patient protection Easy to carry

Stokes Basket Stretcher Come in plastic and wire/tubular (military) styles Wire/tubular style will NOT accept long spine boards Plastic styles weaker, but provide better shielding to patients All require additional strapping, use of plastic litter shields

Stokes Basket Stretcher During high/low angle evacuations: Apply harness to patient Apply leg stirrups to patient Secure patient to litter Tie tail of one litter line to harness Use helmet, litter shield Give fluids Allow accessibility for assessment, management Ensure adequate padding Consider heating/cooling system use Provide gravity “tip line” to clear airway if necessary

Patient Removal

Flat Terrain When possible, walk patient out! Carrying over flat ground is strenuous under ideal conditions

Flat Terrain Two to three teams of 6 litter-bearers All approximately same height “Leapfrog” ahead to save time Webbing straps tied to stretcher frame and pulled across rescuer shoulders to free hand can lessen load Litter wheel may help on flat ground

Low/High Angle Anchors, personnel safety equipment, patient packaging, and hauling systems must be checked multiple times for safety Hauling systems may require multiple personnel to move weight of patient, basket, and ropes

Low/High Angle Fire department snorkels can be used for patient evacuation Stokes stretcher must be properly belayed to snorkel basket Aerial apparatus is NEVER used as a crane to move a litter

Helicopters Capabilities, policies vary widely Understand policies regarding: Loading and unloading practices Restrictions on carrying non-crew Use of winches for rescues Weight restrictions Restrictions on hovering rescues Use, practice of one-skids and toe-ins Use of short hauls and rappel rescues

Extended Care Issues

Protocols Long-term hydration Dislocation repositioning Wound cleaning/care Impaled object removal Non-pharmacologic pain management Pharmacologic pain management Assessment/care of head/spinal injuries Hypothermia/ hyperthermia management CPR termination Crush/compartment syndrome management

Environmental Considerations Weather/Temperature Extremes Risk of hypo/hyperthermia Difficulty in exposing patient for assessment Use of specialized packaging

Environmental Considerations Limited Patient Access Inaccessible parts of patient Cramped space Low lighting conditions

Environmental Considerations Difficulty Moving Equipment Identify minimum essential equipment Carry in backpack

Environmental Considerations Cumbersome PPE Restricted rescuer mobility Temporary removal of PPE to perform procedures

Environmental Considerations Patient Exposure Covering for thermal protection Hard protection from sharp objects, debris

Environmental Considerations ALS Skills Wires, tubing complicate extrication Limit to absolute necessities Oxygen may have to be given at slower flow rates to prolong cylinder life

Environmental Considerations Patient Monitoring Modification of procedures (palpated BP) Modification of equipment (compact pulse oximeters) Non-use of equipment (ECG monitors)

Environmental Considerations Improvisation Splinting using patient’s uninjured body parts Light-weight splints Downsized or improvised medical gear