Confined space medicine (CSM) may be defined as the emerging body of knowledge concerned with the rescue and treatment of victims in collapsed structures or similar urban search and rescue (US&R) environments, with limited access and egress, and unfavorable environmental conditions. It has also been defined as “the unique body of knowledge concerned with the medical needs of the trapped individual” [1]. Confined spaces may be collapsed buildings, roadways, or other structures, or may be structures such as grain silos, utility tunnels, underground power vaults, caves, and other locations that are “confined” in terms of limited ingress, egress, and ventilation even when intact and used as intended. Confined space simulators have become common training settings for US&R teams and other rescue services, including fire departments, that may be called upon to provide this type of technical rescue (Figure 41.1). Live training exercises on demolished buildings provide an additional level of realism, but also involve additional hazards (Figure 41.2).

The goal of CSM is to provide sophisticated medicine in an austere environment, despite limited space, personnel, and equipment. Unlike the “conventional” trauma environment, where “scoop and run” is the general approach, prolonged interactions between victims and rescuers “in the rubble” are to be expected, and it is often necessary to bring EMS, emergency medicine, and critical care capabilities to the patient, rather than bring only EMS and then transport the patient to emergency medicine and critical care. The potential lack of adequate medical back-up, due to compromise of the local medical system in larger events, may place further demands on US&R medical personnel, who may have to continue caring for victims after rescue.

Urban search and rescue medical personnel can decrease morbidity and mortality through prompt assessment and stabilization of the victim, and can expedite extrication. For example, providing adequate pain control can decrease the apparent urgency of the extrication as viewed by rescue personnel, and improve patient cooperation. A careful examination of the patient in the rubble might also, for example, allow for extrication without a backboard, simplifying the mechanical process of patient removal from the confined space.

Specific components of CSM practice include the following [2].

• Gather patient data as early as possible. This can include getting information from bystanders, family, or coworkers before contact is even made with the patient. Once the patient has been located, a relatively sophisticated assessment can be made by simple voice communication, before physical contact is possible [3].
  
• Monitor the effect of the rescue efforts on the patient(s). Ensuring that atmospheric testing is completed before spaces are entered will contribute to rescuer safety as well as victim safety. Medical personnel should also watch for carbon monoxide (CO) production (from gas-powered tools or nearby vehicles) or dust created by rescuers, and should provide victims with dust masks, or oxygen by face mask if needed.
  
• Preposition equipment that is likely to be needed, to save time once the patient is reached. This may include the preplanning of strategies to deliver the necessary equipment by means of rope systems or other techniques.
  
• Begin physical assessment as soon as any physical contact is possible. A small amount of exposed skin or simple voice contact can allow for basic assessment of perfusion and overall neurological function. Victim report of injuries can allow for planning of care once access has been gained, including bringing the necessary equipment, medications, etc. into the rubble.
  
• Initiate stabilization. After taking universal precautions and ensuring victim and rescuer safety to the greatest extent possible, the rescuer should protect the victim from further harm by providing a dust mask, face shield, helmet, etc. as needed. The standard ABCDE approach to trauma care may need to be modified somewhat, but still provides a useful general format for identifying and stabilizing clinical problems as they are found. Unlike the conventional EMS setting, where a number of interventions such as IV access and supplemental oxygen are often provided in a “precautionary” manner, such interventions should only be applied if clinically indicated, due to issues of space, equipment and line tangles, and time.
  
• Provide anatomical and physiological advice to the rest of the rescue team regarding moving the patient.
  
• Reevaluate the patient after each significant move, particularly if advanced airway management (e.g. intubation) has been performed.
  
• Prepare the patient for hand-off to local EMS personnel, if available.

Rescuer safety

The Occupational Safety & Health Administration (OSHA), US Department of Labor, defines confined spaces as follows.

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