Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 5 Special Considerations/ Operations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 10 Rescue Awareness and Operations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Role of the Paramedic Protective Equipment Safety Procedures Rescue Operations Surface Water Rescues Hazardous Atmosphere Rescues Highway Operations and Vehicle Rescues Hazardous Terrain Rescues

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction Rescue is the “act of delivering from danger or imprisonment” In EMS, rescue means extricating and/or disentangling the victims who will become your patients

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Role of the Paramedic

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Awareness training imparts knowledge about rescue operations to EMS personnel In any rescue situation, treatment begins at the site of the incident Paramedics should have the proper training and personal protective equipment (PPE) Role of the Paramedic

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Role of the Paramedic Paramedics should understand the hazards associated with various environments Recognize when it is safe and unsafe to access the patient © Jeff Forster

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Protective Equipment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Protective Equipment Rescuer Protection –Visible clothing –Adapt PPE –PPE may not completely prevent exposure to infectious disease © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rescuer’s Protective Equipment Helmets Eye protection Hearing protection Respiratory protection Gloves Flame protection Personal flotation devices Lighting Hazmat suits Wilderness protection

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Patient Protection Helmet Eye protection Hearing and respiratory protection Protective blankets Protective shielding

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Safety Procedures

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Safety Procedures Steps in curbing “heroics” and maintaining optimum safety include: – Rescue SOPs – Crew assignments – Preplanning © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rescue Operations

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rescue Operations Phase 1 –Arrival and size-up Phase 2 –Hazard control Phase 3 –Patient access Phase 4 –Medical treatment Phase 5 –Disentanglement Phase 6 –Patient Packaging Phase 7 –Removal/transport

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 1—Arrival and Size-Up Establish medical command Conduct a rapid scene size-up Be careful not to overestimate your capability to handle a rescue situation © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 2—Hazard Control On-scene hazards must be identified with speed and clarity Control as many of the hazards as possible Potential hazard

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 3—Patient Access Begin by formulating a plan Use appropriate safety equipment and procedures Formal briefing should be held for rescue personnel prior to effort © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 4—Medical Treatment Three responsibilities –Initiation of patient assessment and care as soon as possible –Maintenance of patient care procedures during disentanglement –Accompaniment of the patient during removal and transport © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 4—Medical Treatment Identify and care for existing problems Anticipate changing patient conditions and determine in advance the assistance and equipment needed Continually evaluate risks to both rescuers and the patient

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 5—Disentanglement Responsibilities –Personal and professional confidence in the technical expertise and gear –Readiness to provide prolonged patient care –Ability to call for and/or use special rescue resources © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 6 – Patient Packaging Consider means of egress Factor time based on the patient’s medical conditions Properly package the patient to prevent additional injury © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phase 7 – Removal/Transport Requires the coordinated effort of all personnel Coordinate decisions regarding transport early Ongoing assessment © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Surface Water Rescues

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Surface Water Rescues Water rescues may involve many kinds of water bodies –Pools, rivers, streams, lakes, canals, flooded gravel pits, or even the ocean Paramedics participating in water rescues are trained and equipped properly

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Surface Water Rescues Always wear a PFD whenever you are around water or ice Become familiar with safe aquatic practices

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Water Temperature Factors contributing to hypothermia –Incapacitation and an inability to self-rescue –Inability to follow simple directions –Inability to grasp a line or flotation device –Laryngospasm Heat Escape Lessening Position (HELP)

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Basic Rescue Techniques PPE –Include dry suits for ice rescue Water rescue model is reach– throw–row–go Become proficient with a water-throw bag

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Moving Water The most dangerous water rescues involve water that is moving Hydraulics of moving water –Variables, including water depth, velocity, obstructions to flow, changing tides, and more Four swift-water rescue scenarios

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Recirculating Currents May create a “drowning machine” Can look very tame Once caught, it is very difficult to escape

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Strainers Water flows through obstructions Currents force a patient up against a strainer Try and swim over, if possible

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Foot/Extremity Pins It is unsafe to walk in fast-moving water over knee depth –Danger of entrapping a foot or extremity To remove the foot or extremity, it must be extracted the same way it went in

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Dams/Hydroelectric Intakes Often found along rivers Height of the dam is no indication of the degree of hazard –Drowning machines Intakes become strainers

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Self-Rescue Techniques Use of PFD’s HELP technique to maintain warmth Other techniques

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Flat Water A large proportion of drowning or near-drowning incidents take place in flat or slow-moving water Alcohol is a factor in many instances

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Personal flotation devices Cold-protective response –Mammalian diving reflex Parasympathetic response occurs Location of submerged victims Rescue vs. body recovery Factors Affecting Survival

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Factors Affecting Survival In-Water spinal immobilization technique Occurs in phases –Phase 1 –Phase 2 –Phase 3

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazardous Atmosphere Rescues

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazardous Atmosphere Rescues One of the most serious threats of confined space rescue is an oxygen-deficient environment 60% of all fatalities are people attempting to rescue a victim

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Confined space –Any space with limited access/egress that is not designed for human occupancy or habitation Examples Hazardous Atmosphere Rescues

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazardous Atmosphere Rescues Entering confined spaces, such as silos, requires training, equipment, and experience © Michal Heron

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Confined-Space Hazards Oxygen-deficient atmospheres Toxic or explosive chemicals Engulfment Machinery entrapment Electricity Structural concerns

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Confined-Space Protection In the Workplace Employers must provide a training program for all employees who work in or around confined spaces Permit process Types of emergencies –Falls, medical emergencies (often hazmat related), oxygen deficiencies or asphyxia, explosions, and entrapment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cave-Ins and Structural Collapses Collapsed trenches or cave- ins can occur in almost any community –Most occur in trenches less than 12 feet deep and 6 feet wide © Michal Heron

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Reasons for Collapse Contractors disregard safety regulations The lip of one or both sides of the trench caves in The wall shears away or falls in entirely “Spoil pile” is placed too close to the edge of the trench Water seepage, ground vibrations, intersecting trenches, or previously disturbed soil

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rescue from Trenches A secondary collapse is likely Secure the scene, establish command, secure a perimeter, and immediately summon a team specializing in trench rescue Proper shoring must be in place

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Highway Operations and Vehicle Rescues

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Highway Operations and Vehicle Rescues Traffic flow is the largest single hazard associated with EMS highway operations Reducing traffic hazards –Staging –Positioning of apparatus –Emergency lighting –Redirection of traffic –High visibility

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Highway Operations and Vehicle Rescues Fire and fuel Alternative fuel systems Sharp objects Electric power Energy-absorbing bumpers Air bags Hazardous cargoes Rolling vehicles Unstable vehicles Other Non-Traffic Hazards

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Auto Anatomy Motor Vehicle Collisions (MVCs) present EMS with the most common access and extrication problems You must know some basic information about automobile construction or “anatomy” Considerations include: –Frame/construction –Firewall/engine-compartment components –Types of glass –Doors

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rescue Strategies Perform initial scene size-up Control hazards Assess the degree of entrapment Establish circles of operation Treatment, packaging, removal © Joshua Menzies

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rescue Skills Practice Practice and/or observe the various disentanglement or extrication skills commonly used Become familiar with the use of heavy hydraulic equipment © Joshua Menzies

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Rescue Equipment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hybrid Vehicles HEVs contain both an electric motor and an internal combustion motor The high-voltage component poses a particular risk for rescue personnel –Easiest way to control is turn off the vehicle and remove the key Both photos: © Ray Kemp/911 Imaging

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazardous Terrain Rescues

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hazardous Terrain Rescues Activities such as mountain climbing, rock climbing, cross-country skiing, snowboarding, and hiking have drawn more people into rugged areas You should know how to perform litter evacuations without causing additional injury to patients

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Types of Hazardous Terrain Steep slope or low-angle terrain –Can be accessed by walking or scrambling Vertical or high-angle terrain –Usually involves a cliff, gorge, side of a building, or terrain so steep that hands must be used when scaling it Flat terrain with obstructions –Trails, paths, or creek beds

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Patient Access in Hazardous Terrain High Angle Rescues –Must have extensive initial and ongoing training –Terms Aid Anchor Belay Rappel © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Patient Access in Hazardous Terrain Low-Angle Rescue –Rescue is considered a low- angle rescue up to 40° –Low-angle rescues involve less technical skill than high-angle rescues Initial and ongoing training is essential © Ken Kerr

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Patient Packaging The Stokes Basket –The standard litter for rough terrain evacuation –Most Stokes baskets are not equipped with adequate restraints Additional strapping necessary

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Utilization of the Stokes Apply a harness to the patient Apply leg stirrups Secure the patient to a litter Tie the tail of one litter line to the patient’s harness Use a helmet or litter shield Administer fluids

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Utilization of the Stokes Allow accessibility for taking BP, performing suction, and assessing distal perfusion Ensure adequate padding Consider use of a patient heating/cooling system Provide for an airway clearing system via a gravity “tip line”

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Patient Removal from Hazardous Terrain Flat, Rough Terrain –Have enough litter carriers 2-3 teams of six carriers –Devices exist to ease the difficulty of a litter carry Straps Litter wheels

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Patient Removal from Hazardous Terrain Low-Angle/High-Angle Evacuation –Require specialized knowledge and skills Evacuation is a team effort –Use of aerial apparatus such as tower-ladders or bucket trucks Utilizes Stokes basket Litter belay

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Use of Helicopters Helicopters can be useful in hazardous terrain rescues You must understand the capabilities of helicopters along with their advantages and disadvantages

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Use of Helicopters Boarding and de-boarding practices Restrictions on carrying non-crew members Use of cable winches for rescues Weight restrictions Restrictions on hovering rescues Use of short hauls or sling loads of equipment and/or personnel

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Practicing Evacuation Techniques Familiarize yourself with the specific equipment Practice the skills required for low- angle and high- angle rescues Be familiar with local resources © Craig Jackson/In the Dark Photography

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Extended Care Assessment Consider protocols addressing the following areas: –Long-term hydration management –Repositioning of dislocations –Cleansing and care of wounds –Removal of impaled objects

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Environmental issues –Weather/temperature extremes –Limited patient access –Difficulty transporting street equipment –Cumbersome PPE Extended Care Assessment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Extended Care Assessment Environmental issues (cont.) –Patient exposure –ALS care –Patient monitoring –Improvisation

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Role of the Paramedic Protective Equipment Safety Procedures Rescue Operations Surface Water Rescues Hazardous Atmosphere Rescues Highway Operations and Vehicle Rescues Hazardous Terrain Rescues