Curriculum Update: Ambulance Operations and Rescue Operations

1
Curriculum Update Ambulance Operations and
Rescue Operations

• March
• 2005

2
Objectives

• Upon successful completion of this module, the
  EMS provider should be able to
• define the role of the EMS provider in rescue
  operations
• discuss the various hazards involved in a variety
  of rescue situations
• participate in case review studies
• successfully complete the quiz with a score of
  80 or better

3
Rescue Situations

• Use of protective gear
• what are your departments current criteria for
  required equipment on a rescue call?
• Appropriate training
• do you know your departments personnel resource
  for various rescue situations?
• who are your experts?
• Safe rescue practices
• your departments standard operating procedures
  need to be followed
• the incidence of vehicular collisions needs to be
  reduced
• parking loading ambulances need
• to be thoughtfully
• safely accomplished

4
Safe Vehicle Operation

• Factors in safe driving
• use of escorts when appropriate
• planning for adverse environmental conditions
• appropriate use of lights sirens
• safely proceeding through
• intersections
• parking safely at the emergency
• site
• recognizing due regard
• for all others

5
Safety Equipment Supplies for Responders - they
only work if you use them

• Body substance isolation equipment
• Head protection
• Eye protection
• Hearing protection
• Respiratory protection
• Flame/flash protection
• Water rescue equipment (ie PFD)

• Gloves
• Boots
• Coveralls
• Turnout coat/pants
• Specialty equipment
• Lighting
• Hazmat suits or SCBA

6
Safety Equipment for Patients

• At many rescue situations we need to protect the
  patient during the rescue procedure
• head protection
• eye protection
• hearing respiratory protection
• protective blankets
• protective shielding

7
Role of the Paramedic in Rescue Operations

• Definition
• Rescue according to Webster - the act of delivery
  from danger or imprisonment
• Stranded or traumatized
• humans need rescue
• No patient - no rescue
• Rescue is a patient driven event

8
Phases of a Rescue Operation

• Arrival size-up - starts with dispatchs call
• Hazard control - your safety is number one
• Patient access - formulate a plan, stabilize
  physical location
• Medical treatment - can start at the time of 1st
  contact made with the patient
• Disentanglement - usually the most technical
  time-consuming portion of the rescue
• Patient packaging - do no further harm
• Removal/transport - reassessment as indicated

9
Role of the Paramedic

• Rescue uses
• medical skills
• mechanical skills
• Correct amount of each
• must be applied at the
• appropriate time

10
Role of the Paramedic

• Access and assess for treatment needs
• Treatment must begin at the site
• Release patient from entrapment or imprisonment
• Continuous medical care and reassessment of
  patient condition interventions provided
  throughout incident

11
Role of the Paramedic

• There is no army in the world that does not train
  and deploy medical people into combat
• Medical and mechanical skills balanced to ensure
  that patients receive
• effective treatment and
• timely extraction

12
Role of the Paramedic

• Well coordinated effort between medical care and
  specialized rescue efforts should be considered
  for every call answered
• Rescue effort must be driven by the patients
  medical and physical needs

13
Cold Water Drowning

• Cold protective response
• Increases chances of cold water survival
• Documented saves from cold immersion have
• been recorded up to 45 minutes
• Colder water seems to increase chances
• of survival - mammalian diving reflex
• (face in cold water triggers parasympathetic
  nervous system response, pulse B/P drop
  patient vasoconstricts blood vessels shunting
  blood from skin to more vital organs)
• Keeping the head above water during the
• cooling process extends chance of survival

14
Cold Water Drowning

• Survivability profile affected by
• age
• posture
• lung volume
• water temperature (water causes heat loss 25
• times faster than air)
• Factors contributing to a poor outcome
• incapacitation inability to self-rescue
• inability to follow simple directions
• inability to grasp line or flotation device
• laryngospasm (spasm of larynx?suffocation)

15
Cold Water Drowning

• You are never cold and dead - only warm and dead
• Hypothermic patients
• should be presumed
• salvageable
• A patient must be
  
• re-warmed before an
• accurate assessment
  
• can be made

16
Treatment for Cold Water Emergencies

• Routine trauma care protect C-spine
• 100 O2 support as soon as possible
• If normothermic, treat dysrhythmias per protocol
• If hypothermic extremities can be flexed, you
  may attempt IV ETT drugs repeated at maximum
  time interval
• If extremities cannot be flexed, no IV no ETT.
  Limit defibrillation attempts to 3 shocks,
  continue basic CPR during transport

17
Recirculating Currents Creating Drowning
Machines

• Recirculating currents is created by water moving
  over a uniform obstruction to flow (ie large
  rock)
• Most commonly found on "low head" dams
• Commonly found on many rivers

• Innocuous in appearance
• Victims are caught in the recirculating flow of
  the current that moves against the rivers
  natural flow
• Escape very difficult
• Same hydraulic can be created by many other
  obstructions
• Hazardous rescue - requires training experience

18
Moving Water Hazards

• Strainers
• Created by moving water flowing through
  obstructions in floods or riverbeds
• trees
• grating/ wire mesh
• Current may move victim into the strainer
• force of water against the victim makes
• escape difficult
• Hazardous rescue

19
Moving Water Hazards

• Foot/Extremity Entrapment
• Unsafe to walk in fast moving water over knee
  depth
• Limb may become entrapped in obstacle
• Weight/force of water may knock you below surface
  of water
• Limb must be extracted same way it went in
• Water currents make this extraction difficult
• Rescue needs to be below surface of the water
  which increases the danger level of this type of
  rescue

20
Moving Water Hazards

• Dams, hydroelectric intakes
• Height of dam no indication of the degree of
• hazard
• Intakes can act
• as strainers
• Most dams create
• recirculating currents
• Hazardous rescue
• Low head dams create drowning
• machines

21
Surface Water Rescue

• Moving water
• Hydraulics of moving
• water change with many
• variables
• Water depth
• Velocity
• Obstructions to flow
• Changing tides for areas
• influenced by tides

22
Water Rescue Methods

• Shore based rescue is attempted first
• Talk/guide the victim into self-rescue
• Reach, throw, row, go
• (go is a last resort)
• Either boat based or
• go techniques
• require specialized
• training

23
Water Rescue

• Reach-Throw-Row-Go
• Reach - long pole or
• rescue device
• Throw - flotation
  device or water- throw bag
• Row - using boat
• Go - only as last
  resort

24
Water Rescue

• Even with shore based rescue techniques
• PFD must be worn
• Use a pole or long rescue
  device to reach for the
  patient
• Throw a floatation
  
• device
• Become proficient
• with a water throw bag
• Begin spinal immobilization in the water
• Ventilation support should be started as soon as
  possible even starting in the water

25
Water Rescue

• Self rescue in flat or moving water if needed
• Cover your mouth and nose during entry
• Protect your head and keep face out of the
  water
• If flat water, assume the HELP position
• heat escaping lessening position
• fetal tuck position
• In moving water do not attempt to stand up,
  steer with your feet as you float on your back
• Float on back with feet pointed downstream and
  head pointed towards the nearest shore at 45
• degree angle

26
Water Rescue

• Factors determining - rescue or recovery
• Number and age of victims
• Number of trained and equipped rescuers
• Environmental conditions present and
• expected
• Length of submersion
• of victims
• Known trauma to
• victims
• Temperature and
• speed of water

27
Confined Spaces

• Defined as a space with limited access/ egress
  and not designed for human occupancy or
  habitation
• Oxygen deficiency is a potentially fatal threat
  in a confined space
• environment
• 60 of all fatalities are of
• people attempting to
• rescue the victim

28
Examples of Confined Spaces

• Tanks
• Vessels
• Grain bins and silos
• Wells and cisterns
• Storage tanks
• Manholes, pumping stations
• Drainage culverts
• Underground vaults
• Pits
• Mine or cave shafts

29
Hazards Associated with Confined spaces

• Oxygen deficient atmospheres
• Oxygen deficient atmospheres are not a visible
  problem
• Rescuers often presume an atmosphere is safe
• Be aware that increased oxygen content, even from
  a gust of wind, can give atmospheric monitoring
  meters a false reading
• Atmosphere monitored for oxygen concentration,
  hydrogen sulfide levels, explosive limits,
  flammable atmosphere, toxic contaminants

30
Confined Space Hazards

• Toxicity of chemicals may displace oxygen in the
  red blood cells
• Explosion is a hazard in some environments
• Chemicals commonly found
• Hydrogen sulfide (H2S)
• Carbon dioxide (CO2)
• Carbon monoxide (CO)
• Low/high oxygen concentrations (FiO2)
• Methane (CH4)
• Ammonia (H3)
• Nitrogen dioxide (NO2)

31
Confined Space Hazards

• Engulfment
• Grain, coal, sand or substances
• can bury a person who falls
• into the space
• Dusts can also create a highly explosive hazard
• Machinery entrapment
• Spaces often have auger/screws
• which can entrap body parts

32
Confined Space Hazards

• Electricity
• Confined spaces often use motors and materials
  management equipment that is powered by
  electricity
• All power to the site needs to be cut off
• Stored energy should be dissipated
• The space needs to be ventilated
• for the hazard of oxygen
• deficiency or explosive
• dust particles

33
Cave-Ins Structural Collapse

• Trench/cave in facts
• Most trench collapses occur in trenches less than
  12' deep and 6' wide
• Weight of soils - 1 cubic foot 100 pounds
• 2 feet of soil on the chest or back 700-1000
  pounds

34
Reasons for Trench Collapse

• Safety guidelines ignored out of negligence or in
  efforts to cut costs
• Improper shoring or lack of use of a trench box
  for excavations deeper than 5'
• Lip of one or both sides of trench caves in
• Wall shears away and falls in
• Spoil pile (dirt removed from the hole) placed
  too close to the edge causing collapse
• Water seepage, ground vibrations, intersecting
  trenches, or previously disturbed soil weakens
  the structure

35
Trench Rescue

• Initial response
• If collapse has occurred causing burial,
  secondary collapse is likely to occur
• Secure the scene, establish command, and secure a
  perimeter
• Call for a team specializing in trench rescue
• Do not allow entry into the trench or cave in
  area
• Safe access is allowed only when proper shoring
  is in place

36
Trench Rescue

• Patient assessment begins and includes whatever
  can be reasonably and safely performed
• Body temperature can fall while patient is
  entrapped
• Consider
• supplemental oxygen if safe to administer in the
  environment
• warmed fluid therapy - hotpack over IV insertion
  site (to prevent dehydration and to maintain the
  body temperature)
• anticipate compression injuries to chest
  extremities

37
Highway Operations

• Hazards in highway operations
• Traffic flow is the largest hazard associated
  with EMS highway operations
• Rescue response may be to both limited
  unlimited access highways
• Risk to apparatus and rescuers of being struck
• Traffic back-up impedes flow to and from
• scene for emergency response vehicles
• Studies show that drivers
• tired, drunk, or drugged
• drive into emergency lights
• EMS must work closely
• with law enforcement to
• maintain a safe environment

38
Highway Operations

• Traffic hazard reduction techniques
• Stage unnecessary apparatus away from scene
• Place apparatus in position to protect scene
• Use only essential
  warning lights - too much
• increases confusion
• Use traffic cones/flares
  to redirect traffic - allow
• flares to burn out
• All rescuers should
  be in high visibility
  clothing

39
Highway Operations

• Other scene hazards
• Energy absorbing bumpers may become loaded
  spring out causing trauma to rescuers
• Air bags/ supplemental restraint systems(SRS) may
  deploy during rescue attempts
• Alternate fuel systems especially with
  high-pressure tanks
• Fuel fire hazards
• Downed power lines
• Hazardous cargoes
• Rolling vehicles
• Unstable vehicles

40
Auto Anatomy

• Unibody (most commonly found on modern vehicles)
  maintains integrity when roof posts, floor,
  firewall, truck support, windshield remain
  intact
• Roof and roof support posts - lettered from front
  to back starting at roof support at windshield -
  A, B, "C, "D" posts
• Fire wall engine compartment - can collapse
  onto patients feet battery can pose fire
  hazard.
• Operate electric seats windows
• before disconnecting battery

41
Safety versus Tempered Glass

• Safety glass - usually found in windshields 3
  layers of infused materials. Stays intact when
  shattered or broken. Can produce glass dust
  long shards of glass
• Tempered glass - high tensile strength. Does not
  stay intact when shattered or broken. Breaks
  into multiple small pieces

42
Air Bag Systems or SRS

• Potential to release stored energy
• Deactivation should be made prior to
  disentanglement
• Deactivation information can be obtained from
  auto manufacturer
• Power removal
• Power dissipation
• Note many newer model vehicles are equipped with
  side impact air bags

43
Hazardous Terrain Terms

• Low angle terrain
• High angle terrain
• Belay
• Rappel
• Scrambling
• Hasty rope slide

44
Hazardous Terrain

• Low angle or steep slope terrain
• can be walked on without use of hands
• footing may be difficult
• difficult to carry litter even with multiple help
• rope used to counteract gravity during litter
  carry
• consequence of error likely to be a fall or
  tumble
• High angle or vertical terrain
• a cliff, building side, or terrain so steep hands
  are used for balance when scaling it
• total dependence on rope or aerial apparatus
• consequence of error likely to be fatal

45
Hazardous Terrain Rescue Techniques

• Rescue Techniques
• belay
• procedure for sliding down a fixed double rope
  using anchors, harnesses, other gear
• rappelling
• descending by sliding down a fixed double rope
  using the correct harness other gear
• scrambling
• to gain access by scrambling

46
Patient Movement

• Non-technical/ non-rope evacuation is usually
  faster. The patient is usually walked out.
• Flat rough terrain - obstructions may be rocks,
• creeks, scree (loose stones or rocky debris)
• Litter carrying procedures - best if carriers of
  same height
• Leapfrogging - saves time
• by leapfrogging ahead
• Adequate number
  of bearers necessary
• Load lifting straps used to
  
• assist with carry

47
Patient Movement

• Low angle/ high angle evacuation
• Anchors need to be secured
• Rope lowering systems in place
• Rope hauling systems in place
• Specialized knowledge and skill required for use
• Ropes should never be used if there is any
  question regarding their safety!!!
• Do no further harm!!!

48
Patient Movement

• Use of aerial apparatus
• Tower-ladder or bucket trucks
• how do you attach
• secure litter to bucket?
• Aerial ladders
• ladder nor aerial apparatus
• should not be used as a
• crane to move the litter

49
Aeromedical Transportation

• Considered when
• time of transport by ground to an appropriate
  facility poses a threat to patients survival
  recovery
• extrication rescue or weather/traffic
  conditions would delay patients access to
  advanced life support
• Region X members may contact a helicopter service
  directly
• Notify medical control that a helicopter service
  has been contacted give brief patient condition

50
Aeromedical Transport

• Scene EMS to inform aeromedical crew who they
  have been in contact with for medical control
• Aeromedical crew will be contacting same medical
  control to announce
• We are transporting a age, gender, to
  destination. We are assuming Medical Control of
  this patient.
• If there is any delay in helicopter arrival to
  the scene, you must think back to considering
  alternate ground transportation

51
Crush Injury

• May cause
• compartment syndrome
• or
• crush syndrome
• Compartment syndrome defined
• increased pressure within a closed space that
  leads to microvascular compromise ultimately to
  cell death due to oxygen starvation
• Crush syndrome defined
• a reperfusion injury as a result of traumatic
  rhabdomyolysis (skeletal muscle breakdown with
  release of toxins)

52
Compartment Syndrome

• Compartment syndrome may be secondary to
  entrapment or any crushing mechanism
• there is increased pressure in the muscle
  compartment enclosed by fascia (tissue)
• increasing pressure restricts
• blood flow causing
• ischemic damage to muscle,
• nerves, blood vessels
• tissue necrosis nerve
• injury can occur

53
Compartment Syndrome

• Most common causes
• tight cast, tight dressing
• trauma, burns
• high pressure injections
• iatrogenic (caused by medical procedure)
• Most commonly the syndrome is seen 48 hours after
  injury (ie not in the field)
• Diagnosis difficult in patient with altered level
  of consciousness (non-verbal would delay
  complaints that would start investigation)
• Necrosis after 6 hours of ischemia

54
Compartment Syndrome

• Clinical features
• severe pain at rest not responding to elevation
  or pain medication
• swelling, hard shiny skin
• pain on passive stretching
• more advanced, later stages
• sensory deficit
• muscle weakness
• paleness of skin

55
Compartment Syndrome

• Field treatment
• as the syndrome rarely occurs within first 4
  hours of injury, will rarely be seen in the field
• field care focused on care of underlying injury
• splint immobilize suspected fractures
• use traction as needed for suspected femur
  fractures
• cold packs over injured tissue
• elevation of affected extremity single most
  important action to be taken in the field
• reduces edema
• increases venous return
• lowers compartment pressure
• helps prevent ischemia

56
Compartment Syndrome

• Treatment goals in the hospital
• a surgeon must decompress all compartments at
  risk
• skin, fat, and fascia widely decompressed
• includes debridement of necrotic tissue
• amputation if necessary
• secondary closure later

57
Crush Syndrome

• Compressive forces crush a body part and cause
  prolonged hypoxia
• Prolonged compression defined as 4 hours or
  greater of compression
• The patient may appear stable while the
  compressive forces are in place
• If the compressive force is removed the part may
  be reperfused releasing toxins into blood
• Vascular volume is lost into the tissue
• Most commonly seen after disasters where people
  have been entrapped for hours

58
Crush Syndrome

• Destruction of skeletal muscle cells leads to
  release of myoglobin (a cell protein), potassium,
  lactic acid, uric acid, other toxins
• When entrapment pressure is released, toxins can
  then enter the bloodstream
• The patient develops metabolic acidosis
• Materials released are also toxic to the kidneys
  heart - the patient often develops fatal
  dysrhythmias kidney failure
• Deterioration and death is usually rapid

59
Crush Syndrome

• Most immediate problems at the scene will be
  hypovolemia shock shortly after extrication
  occurs
• Field treatment
• high index of suspicion especially if entrapment
  has been greater than 4 hours
• rapid transport
• adequate fluid resuscitation (fluid boluses)
• monitor EKG
• splint injuries, loosely cover with dressings

60
Pain Control

• Non-pharmacological management
• distraction
• splinting, elevation, ice packs
• Pharmacological agents (if B/P 100 mm/Hg)
• morphine 2 mg slow IVP
• may repeat 2mg as needed every 3 minutes to max
  of 10 mg
• Continuously monitor respiratory status, pulse
  oximetry, vital signs
• If B/P drops, are you sure its not another
  injury or situation causing the drop and not the
  morphine?

61
Morphine

• Opioid, narcotic analgesic
• Used to reduce pain anxiety
• Dose 2 mg slow IVP may repeat in 2 mg
  increments every 3 minutes as needed up to 10 mg
  maximum
• Side effects hypotension (vasodilitation
  effect) respiratory depression (support
  depressed respirations with BVM reverse effects
  with narcan)

62
Narcan

• Narcotic antagonist
• Used mainly to reverse the respiratory depression
  associated with narcotic use
• Dose 2 mg IVP can be repeated 2 mg every 5
  minutes to maximum of 10 mg
• Onset peak
• Duration 20-120 minutes
• Side effects rare but can see hypertension,
  nausea vomiting
• Observe closely for effects wearing off

63
Case Study 1

• Your victim is a 29 year-old male who is
  entrapped up to the mid-chest in a cave-in while
  working in a roadside ditch that was 8 feet deep
  and 4 feet wide

64
Case Study 1

• What are the safety issues that need to be
  addressed?
• What resources (personnel equipment) need to be
  mobilized to the site?
• What treatment can be started while the patient
  is still entrapped what would be added after
  extrication?
• What complications need to be watched for and how
  would you deal with them? (hint think crush
  syndrome)

65
Case Study 2

• You have a 54 year-old male who was the foreman
  on a demolition job of a multi- story apartment
  building which has collapsed causing entrapment.

66
Case Study 2

• What are the safety issues that need to be
  addressed?
• What resources (personnel equipment) need to be
  mobilized to the site?
• What interventions can be started while the
  patient is still entrapped?
• What are all the interventions that need to be
  considered necessary during the call?
• What complications need to be considered when
  extrication is accomplished and how would they be
  handled?

67
Case Study 3

• You have a 17 year-old non-English speaking male
  with his arm entrapped in a grinding machine up
  to the elbow
• What are the safety issues that need to be
  addressed?
• What resources (personnel equipment) need to be
  mobilized to the site?
• What care/interventions need to be considered for
  caring for the anticipated wounds?

68
Case Study 3

• Upon extrication, this is the wound you must
  attend to
• Is the patient a candidate
• for aeromedical transport?
• What interventions could be
• considered for pain control -
• non-pharmacological
• and pharmacological
• measures?

69
Acknowledgement

• NIEMSCA contribution for packet by
• Marlene Eisenhut Blacklaw, RN Education
  Coordinator
• Kathy Wexelberg, RN EMS Coordinator
• Additions made by
• Sharon Hopkins, RN, BSN EMS Educator

70
Rescue Operations
Questions ??