Size-Up

To select the best method for getting a patient to definitive care, the rescuer must make a realistic assessment of several factors. Scene safety is the initial priority. The necessary evaluation, called the size-up (Box 39-1), involves a (usually hasty) determination of whether the victim, rescuer, or both are immediately threatened by either the environment or the situation. Proper immobilization and patient packaging are always preferable, but sometimes the risk for aggravating existing injuries is outweighed by the immediate danger presented by the physical environment. In such a situation, the rescuer has little choice but to immediately move the patient to a place of safety before definitive care is provided or packaging is completed.

Evacuation options are limited by three rescuer-related variables: (1) the number of rescuers, (2) their levels of fitness, and (3) their technical abilities. Carrying a victim, even over level ground, is an arduous task. At an altitude where just walking requires great effort, carrying a victim may be impossible. The specific rescue situation or environment encountered may present challenges beyond the capability of the available rescuers. Complex rescue scenarios requiring specially trained personnel and special equipment are called technical rescues and often involve dangerous environments, such as severe terrain, crevasses, avalanche chutes, caves, or swift water. To avoid becoming victims themselves, rescuers must be realistic when evaluating their abilities to perform these types of rescues.

Drags and Carries

The most fundamental and expedient method of transporting an ill or injured person is by dragging or carrying him or her. Although these methods of transportation are far less than ideal and may not meet standard care criteria, the urgency of the situation may outweigh the risks involved. The process can be physically demanding, and rescuers can quickly become fatigued to the point of hazard. Therefore other options often should be considered before a victim is moved, especially a long distance. A drag or carry may be the best option when a person cannot move under his or her own power, injuries will not be aggravated by the transport, resources and time are limited, the need for immediate transport outweighs the desire to apply standard care criteria, the travel distance is short, or the terrain makes the use of multiple rescuers or bulky equipment impractical.

A blanket drag (Figure 39-1, A) can be performed on relatively smooth terrain by one or more rescuers rolling the victim onto a blanket, tarp, or even a large coat and pulling it along the ground. This simple technique is especially effective for rapidly moving a person with a spinal injury to safety, because the victim is pulled along the long axis of the body. In extreme circumstances, the fireman’s drag (Figure 39-1, B) can be used. In this type of drag, the rescuer places the bound wrists of the victim around his or her neck, shoulders, or both and crawls to safety.

FIGURE 39-1 A, Blanket drag. B, Fireman’s drag. Both techniques are intended to be used when expeditious transport over a short distance is required.

(From Auerbach PS: Medicine for the outdoors: The essential guide to emergency medical procedures and first aid, ed 5, New York, 2009, Mosby.)

A carry should be considered only after it is confirmed that the victim cannot assist rescuers or travel on his or her own. Beyond simply lifting a person over one’s shoulder in a fireman’s carry (Figure 39-2) or acting as a human crutch, a more efficient one-person carry can be accomplished by using equipment, such as webbing, backpacks, coils of rope, or commercial harnesses. Equipment-assisted carries are particularly effective when an injured climber or hiker must be evacuated across a short distance over rough terrain or when a person must be quickly removed from a hazardous environment. In the simplest equipment-assisted carry, 4.5 to 6 m (14.8 to 19.7 feet) of webbing is wrapped around the victim, who is then “worn” like a backpack by the rescuer (Figure 39-3).

FIGURE 39-2 Classic fireman’s carry: a single rescuer technique for short-distance transport only. The rescuer must use his or her legs for lifting.

(From Auerbach PS: Medicine for the outdoors: The essential guide to emergency medical procedures and first aid, ed 5, New York, 2009, Mosby.)

FIGURE 39-3 Web sling (tied into a loop) used to carry a victim. The rescuer must use his or her legs for lifting.

Similarly, a split coil of climbing rope or a backpack (also called a rucksack) can be fashioned into a seat in which the patient sits while carried by the rescuer. A single-rescuer split-coil carry (Figure 39-4) requires only equipment already carried by a climber or mountaineering group and works well for conscious patients without severe injuries. However, the patient’s legs hang close to the ground, especially during downhill carries and when the rescuer is shorter than the patient, and together the rescuer and patient can carry only one rucksack.

FIGURE 39-4 Single-rescuer split-coil carry. Note that the coil can be tied in front of the rescuer, and the wrists of the victim can be bound and wrapped around the rescuer’s neck for more stability.

A similar method, the rucksack carry, simply uses a rucksack as the slinging device (Figure 39-5). The rucksack is placed on the patient with the patient’s legs placed through the shoulder straps and over the waist straps if present. The rescuer then positions the patient on his back (generally with assistance), then the shoulder straps of the pack over his shoulders, and then stands. This method places a victim high relative to the rescuer’s center of gravity; stability of both patient and rescuer can be a factor. This method is particularly useful when used on a patient with a lower limb injury or other situation where he or she is conscious and able to sit up and hold onto the rescuer. It also allows both the rescuer and patient to carry rucksacks.

FIGURE 39-5 Backpack or rucksack carry.

Methods and/or devices that attach a patient in a sitting position to the back of a rescuer are sometimes referred to as Tragsitz (German for “carry seat”) methods and/or devices.¹³ Although original Tragsitz devices were made from canvas and specifically designed to carry a patient securely and comfortably, they can also be improvised, as in the split-coil and rucksack carries, or commercially produced using modern, stronger, and more robust fabrics (Figure 39-6).

FIGURE 39-6 Manufactured Tragsitz harness in use.

For carrying infants and small children, a papoose-style sling works well and can easily be constructed by the rescuer, who ties a rectangular piece of material around his or her waist and neck to form a pouch. The infant or child is then placed inside the pouch, which can be worn on the front or back of the rescuer’s body.

If two rescuers are available, additional and often superior options for carrying a patient are possible. One option consists of two rescuers forming a seat by joining their hands or arms together. The patient sits on the “platform” and holds on to the rescuers for support (Figure 39-7). It is difficult to cover a long distance or rough terrain when using this technique, and the patient must be conscious and able to sit up and hold on.

FIGURE 39-7 A, Four-hand seat used to carry a person. In this technique, the upper body is not supported. B, Alternative four-hand seat that helps support the victim’s back.

(From Auerbach PS: Medicine for the outdoors: The essential guide to emergency medical procedures and first aid, ed 5, New York, 2009, Mosby.)

A coil of climbing or rescue rope can be used to form a two-rescuer split-coil seat, with each rescuer slipping a side of the rope coil around his or her outside shoulder (Figure 39-8). The patient then sits on the “seat” formed by the rope. A similar approach involves using padded ski poles or stout limbs tied together and supported by backpacks worn by rescuers. The victim sits on the supported poles with his or her arms around the rescuers’ shoulders. If the poles are properly padded and securely attached to sturdy rescuers, this technique can be quite comfortable for both the rescuer and victim. This approach requires gentle terrain without narrow trails.

FIGURE 39-8 Two-rescuer split-coil seat.

Spine injuries generally prohibit the use of drags or carries because the victim cannot be properly immobilized, but drags or carries may be acceptable when immediate danger outweighs the risk for aggravating existing injuries. Drags are particularly useful for victims who are unconscious or incapacitated and unable to assist their rescuer (or rescuers) but may be uncomfortable for conscious victims. When a drag is used, padding should be placed beneath the victim, especially when long distances are involved. The high fatigue rates of rescuers makes carries less attractive options when long distances are involved.

Litter Improvisation

The simplest improvised litter is made from a heavy plastic tarpaulin, tent material, or large polyethylene bag (Figure 39-9). By wrapping the material around a rock, wadded sock, or glove and securing it with rope or twine, the rescuer can fashion handles in the corners and sides to facilitate carrying. The beauty of this device is its simplicity, but it can be fragile, so care must be taken not to exceed the capability of the materials used. As an additional precaution, all improvised litters should be tested with an uninjured person before being loaded with a victim. This type of nonrigid, “soft” litter can often be dragged over snow, mud, or flat terrain but should be generously padded, with extra clothing or blankets placed beneath the victim.

FIGURE 39-9 Improvised handled soft stretcher.

Three or four filled rucksacks (depending on the size and shape of the patient) can also be laid end-to-end—carrying/strap side up—to serve as an improvised litter. Lay the packs on the ground in a straight line with the tops of all the packs oriented in the same direction, and use the shoulder straps to tie them together. Open the waist straps wide and place the patient flat on his or her back (lifted flat by clothes, neck immobilized if necessary) on the packs before tightening the waist straps. The patient’s head should be placed at the end with the top of the packs. Moving the patient safely in this device takes a coordinated effort, one leader, and at least four rescuers. The full rucksacks offer support beyond that which is provided by only the packs and their straps, but their weight when full and added to the patient’s weight can be demanding on rescuers. When stopping to rest, rescuers must be sure not to allow the patient to roll over. This method works well for patients who require transport in a supine position, including those who are unconscious or have femur, pelvis, or spine injuries. It also provides superior stabilization in the body axis compared with most other improvised litter options, and it is unlikely to allow the patient to fall out even if a rescuer slips while carrying.

A coil of rope can be fashioned into a litter, called a rope litter or clove hitch stretcher, but a 46- to 61-m (150.9- to 200.1-foot) climbing or rescue rope is required (Figure 39-10). The rescuer constructs the litter by laying out 16 to 20 180-degree loops of rope in the middle of the length of rope (8 to 10 on each side of center) across an area the desired width of the finished litter (Figure 39-11). The running ends of the rope are used to tie a clove hitch around each of the loops (Figure 39-12), and then the unused portion of rope is passed through the loops and tied off to form a handhold around the peripheral edge of the resulting device (Figure 39-13). The litter can then be padded with clothing, sleeping pads, or similar material. Lateral stability can be added by tying skis or poles to the finished product. Because of its nonrigid construction, this litter offers virtually no back support, can be uncomfortable for patients, and is best suited for patients with injuries that do not require mechanical stabilization or immobilization. One advantage of this device is that items commonly carried on a wilderness or climbing trip are all that are needed to configure it. However, it can take 30 to 45 minutes to construct and can be difficult to get properly proportioned (length and width) unless rescuers are well practiced. Comfort for the victim is limited at best, and therefore the use of this litter is best suited for carries over a short distance. Although the idea of this device may seem initially attractive and relatively easy, in reality it takes quite a long time to construct, is easily tied wrong (taking even longer to re-tie), and is uncomfortable for most patients.

FIGURE 39-10 Tying an improvised rope (nonrigid) stretcher.

FIGURE 39-11 Laying out the rope for an improvised rope stretcher.

FIGURE 39-12 Tie clove hitches around each loop.

FIGURE 39-13 A to C, The unused portion of rope is passed through the loops and tied off to form a handhold around the peripheral edge of the resulting device.

A sturdy blanket or tarp can be used in combination with ski poles or stout tree branches. The blanket or tarp is stretched over the top of two poles, which are held about 1 m (3.3 feet) apart; tucked around the far pole; and folded back around the other pole. The remaining material lies over the first layer to complete the litter (Figure 39-14). The weight of the patient holds the blanket in place but the weight of the patient also tends to force the poles together and tightly wrap around the patient. This quickly gets uncomfortable for the patient and is best used only for short periods of time. A similar, and in some ways superior, device can be improvised by passing the poles through the sleeves of two heavy, zipped (closed) parkas.

FIGURE 39-14 Improvising a stretcher from two rigid poles and a blanket or tarp.

It may be necessary to transport victims with certain injuries (i.e., spine injuries; unstable pelvis, knee, or hip dislocations) on a more rigid litter. Ski poles, stout tree limbs, or pack frames can provide a rigid support framework for such a device. For example, three curved backpack frames can be lashed together to form a platform (Figure 39-15). Ski poles or sturdy branches then can be fastened to the frames for use as carrying handles, and the platform can be padded with ground pads, sleeping bags, or a similar material.

FIGURE 39-15 Pack frame litter. Note that the sapling poles on the litter can be attached to the rescuer’s pack frames to help support the victim’s weight.

Combining a rope litter with a rigid litter can provide more strength and versatility. The rescuer fashions this type of litter by first building a platform of poles or limbs, using a blanket as in a rigid litter, and placing the victim in a sleeping bag on the platform. The patient and platform are wrapped and secured with a length of rope. Because a mummy sleeping bag is used to encapsulate the victim, this device is sometimes called a mummy litter. Although this type of litter offers improved support, strength, and thermal protection, careful thought must be given to the physical and psychological effects such a restrictive enclosure may have on the victim (Figure 39-16).

FIGURE 39-16 Mummy litter.

(From Auerbach PS: Medicine for the outdoors: The essential guide to emergency medical procedures and first aid, ed 5, New York, 2009, Mosby.)

If long distances must be traveled or if pack animals are available, a litter may be constructed so that it can be dragged or slid along the ground like a sled. One such device is known as a sledge (Figure 39-17). This litter is fashioned out of two forked tree limbs, with one side of each fork broken off. The limbs form a pair of sled-like runners that are lashed together with cross members to form a patient platform. The sledge offers a solid platform for victim support and stabilization. If sufficient effort is put into fashioning a smooth, curved leading edge to the runners, a sledge can be dragged easily over smooth ground, mud, ice, or snow. Ropes also can be attached to the front of the platform for hauling and to the rear for use as a brake when traveling downhill.

FIGURE 39-17 A “sledge.”

A travois is a similar device that is less like a sled and more like a travel trailer (without wheels). A travois is a V-shaped platform constructed out of sturdy limbs or poles that are lashed together with cross members or connected with rope or netting. The open end of the V is dragged along the ground, with the apex lashed to a pack animal or pulled by rescuers. Although the travois can be dragged over rough terrain, the less smooth the ground, the more padding and support necessary for comfort and stabilization. A long pole can be passed through the middle of the platform and used for lifting and stabilization by rescuers when rough terrain is encountered.

When victims are transported in improvised litters, especially over rough terrain, they should be kept in a comfortable position, with injured limbs elevated to limit pressure and movement. To splint the chest wall and allow full expansion of the unaffected lung, victims with chest injuries generally should be positioned so that they are lying on the injured side during transport. For a person with a head injury, the head should be elevated slightly, and for persons with dyspnea, pulmonary edema, or myocardial infarction, the upper body should be elevated. Conversely, when the victim is in shock, the legs should be elevated and the knees slightly flexed. Whenever possible, unconscious patients with unprotected airways should be positioned so that they are lying on their side during transport to prevent aspiration.¹

Rescue Litters and Stretchers

The image most often associated with rescue immobilization and transportation devices in the United States is that of a traditional tubular steel and chicken wire–netted basket, which came to be known as the Stokes basket. Although this apparatus was and still is ubiquitous, many may recall the Thomas, Duff, Mariner, Brancard Piguillem, Perche Barnarde, Neil Robertson, MacInnes, and Bell stretchers for their evolutionary and robust designs. Today there are a variety of devices that meet the following two primary wilderness medical needs:

Desirable Characteristics of a Wilderness Stretcher

Peter Bell,⁴ rescue equipment historian and developer of Bell stretchers in the United Kingdom, has described several specific characteristics of a high-quality, useful rescue stretcher. Bell claims that a good stretcher should have the following characteristics:

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