Operational Rescue

Operational rescue , or as it is sometimes referred to, contingency or hasty rescue , is a multidisciplinary approach to rescue while operating within dynamic, often high-threat, and asset-depleted environments. This category often includes Special Operations Forces (SOF) personnel, tactical law enforcement personnel, and/or civilian specialized rescue elements (fire and rescue, disaster response, mountain rescue, USAR, counter-terror response, etc.), which are the first-line response to an unforeseen or outlier event that requires immediate rescue. Often this “immediate rescue” requirement is dictated by heightened threat and environmental variables that increase the risk of morbidity and mortality to not only the casualty but also the rescuer. These variables include but are not limited to enemy threat or gunfire, secondary collapse, toxic atmospheric conditions, weather, fire, and explosive devices.

Observations of training, review of mission After Action Reports (AARs), and ad hoc discussions with state and federal disaster response teams, federal law enforcement officers, and returning military units indicate that there exists a significant gap in terms of how first responders access and extract casualties in the tactical and technical environment. This work suggests that there is a requirement within the disaster and mass casualty response to develop foundational principles of rescue and to build appropriate tactics, techniques, and procedures (TTPs) for the evolving operational environment.

When we examine casualty management within an austere environment as a whole, it can be divided into four distinct categories: access , assess , stabilize, and extraction and evacuation . Operational rescue primarily focuses on the access and extraction and evacuation categories, although all are interdependent on one another.

Access issues may include gaining access to a casualty within an elevator shaft or a collapsed structure, or needing to breach into reinforced doors. Access is a real problem in terrorism-related events, both international and domestic. In fact, most active-shooter responses contain some type of access hurdle for responders to overcome. A prime example of this is the campus shooting at Virginia Tech on April 16, 2007. At this event, the shooter, Seung-Hui Cho, used locks and chains to prevent quick access by law enforcement. It should be noted that the Virginia Tech incident was the third in a series of school attacks within a 6-month period. Attacks at Platte Canyon High School and Nickel Mines Amish School occurred in the preceding months to the Virginia Tech incident. Each attack progressively increased in fortification, subsequently lengthening the “time-to-entry” of law enforcement.

Assessment requires a rapid systematic search for potentially preventable causes of death from which the casualty may be suffering. An example would be an uncontrolled arterial hemorrhage from an extremity that is amenable to a tourniquet or hemostatic agent.

Stabilize describes the required and appropriate treatment modalities based on the assessment. The term stabilize is dynamic. Stabilization will look different depending on the threat level within the rescue operational space. The goal of this phase will most likely not be to return to homeostasis but rather to keep the casualty alive through evacuation. If the casualty is outside of a direct-threat environment and minimal danger is present for the casualty and rescuer, care that is more thorough can be provided. For the casualty inside a collapsed structure, where a potential for secondary collapse exists, only limited, lifesaving techniques should be applied prior to extraction. What constitutes these “lifesaving techniques” has and will continue to be modified. As medical technology and capabilities increase, additional evidence-based skills may become part of the standard of tactical medical care.

Extrication or Evacuation describes the process of packaging and removing the casualty from the environment to transport or a secured casualty staging area. This could take the form of a high-angle rope rescue, confined-space movement, or removal from various vehicles to include armored wheeled and rotary or fixed winged aircraft.

Historical perspective

We define three distinct rescue categories. It is important to appreciate the differences between them to understand the rescue environment and how it might affect first-responder response.

Recreational rescue

Examples of recreational environments would be climbing, canyoneering, and mountaineering. By true definition, recreational does not qualify as a rescue category, although safe recreational climbing requires the expert to use safety techniques to mitigate accidents, which can be categorized as “preventative rescue” or “reactive rescue.” Rock climbing anchors are an example of equipment used for such a preventative purpose, and the use of these in recreation can easily translate into high-angle rescue techniques during an emergency response. In the recreational context, the climber is not responding to any kind of emergency, he or she is simply making his or her best attempt at preventing an emergency. He or she has time to engage in the analysis of the pathway, to weigh the pros and cons, reevaluate, and rig his or her best option. The climber also has evaluated and often specifically chosen his or her desired route. Some of these routes may also have predrilled, permanent fixed anchors available. Owing to the operational parameters listed, the safety-factor capability in this realm (although a rock face is demanding) is a luxury because of available time and lack of many variables that face disaster-response personnel (enemy fire, building collapse, flood, limited organic assets, etc.).

Situational Rescue

Situational rescue refers to a dedicated, organized element with the sole mission to respond to catastrophic events requiring rescue. This would include Fire Department Technical Rescue, Federal Emergency Management Agency (FEMA), Urban Search and Rescue (US&R), hazardous materials, and certain combat search and rescuer (CSAR) responses. These are groups of highly trained individuals with specific skill sets in various disciplines of rescue. Their gear typically has a high specificity and in many instances is prepackaged or cached in response vehicles, tractor trailers, aircraft cargo planes, or helicopters, ready for an immediate response. In many cases, the personnel are able to fill in within close proximity of the emergency or objective, and are not required to “pack-in” their equipment and supplies physically over great distances. In addition, once these personnel are activated, they function solely as a rescue element. This makes their posture reactive and specific to rescue. Their gear, “loadout,” and assets are rescue centric and mission specific.

Operational Rescue

This category describes personnel who are first responders to an unforeseen or outlier event that requires immediate action to save a life. Often these rescues would be conducted in extremis. As stated previously, for the rescuers involved, “Specialized Rescue” may not be their primary, secondary, or even tertiary role or responsibility in the mission. Rescuers must consider that a chaotic problem is unfolding in front of them, and they may be part of the problem. In addition, rescuers must recognize that they are rescuing within a complex environment with unknown hazards and constantly changing variables. ,

In the past, both Department of Defense (DoD) and civilian-response capabilities were constructed around the “Situational Rescue” paradigm. The need for operational-rescue techniques is becoming more evident as active-shooter incidents become more commonplace and involve the response of the entire public-safety response system. No discussion on active-shooter response would be complete without mentioning Columbine High School and the events that unfolded on April 20, 1999. This incident changed the way responders, particularly law enforcement, responded to these types of incidents. The theory of confining the perpetrator to the building and trying to negotiate to free hostages was no longer applicable for this type of violence.

Recall the outcry from parents and loved ones of the injured and deceased for answers on why it took so long for law enforcement and medical providers to reach those inside the building. The most notable example involved David Sanders, a teacher killed in the Columbine High School attack. At approximately 11:40 am , David Sanders was shot while encouraging students to evacuate the cafeteria and directing them through a stairway. Mr. Sanders, along with 50 other students and teachers, took refuge in Science Room 3. While in the science room, students and teachers administered first aid and made contact with 911 emergency-services operators. The first direct outside contact was delivered to David Sanders at 4:00 pm , 3.5 hours after the first 911 calls were made requesting help.

In all, it would be over 45 minutes before the first law enforcement officer would make entry. It would be even longer before the first medical personnel would make patient contact. The delay was so great, the last victim was removed from Columbine High School 4.5 hours after the attack started, and 3 hours after the perpetrators, Klebold and Harris, committed suicide.

Operational-rescue techniques are well suited for the active-shooter environment. First, active-shooter incidents are highly stressful for the responder. Studies have shown that humans do not become smarter when they are confronted with a highly stressful situation. As Lt. Col. Dave Grossman puts it, “we do not rise to the occasion, we sink to our training.” Not only do stress and/or self-preservation not help our intelligence and decision making, hormone-induced tachycardia also decreases our ability to perform fine and complex motor skills. For this reason, operational-rescue techniques are built around very simple equipment and very basic techniques. It is important that no operational-rescue procedure requires extreme dexterity or technical calculations.

Another reason established operational-rescue techniques are desirable in an active-shooter situation is due to the specialized equipment involved. Typical fire-rescue and rope-rescue equipment weighs in at nearly 60 lbs., for a typical equipment bag, and another 40 lbs. for two ropes. Using operational-rescue equipment and techniques, responders are able to decrease the weight of the equipment from roughly 100 lbs. to only 8 to 15 lbs. The hardware in operational rescue is aluminum (versus stainless steel for traditional rescue), and the rope is much thinner (7.5 to 9 mm vs. 12.5 mm). From the perspective of technique, a typical urban-rescue-team rope rescue would include using a two-rope system. One rope would be the mainline supporting the victim, the other rope is considered a safety rope, should the mainline system fail. With regard to operational rescue, only one rope is used to facilitate hasty setup. If a second rope is available during the execution of an operational rescue, it should be used to rescue additional civilians or personnel.

No discussion regarding operational rescue during an active-shooter response would be complete without mentioning the development of the Rescue Task Force (RTF) concept; this concept is born out of the Department of Homeland Security (DHS). In 2008 DHS stated, “The first officers to arrive on scene will not stop to help injured persons. Expect rescue teams comprised of additional officers and emergency medical personnel to follow the initial officers. These rescue teams will treat and remove any injured persons.”

In 2009, the Arlington Fire Department, under the direction of Dr. Reed Smith, was perhaps the first organization to develop RTF’s into what they are now. The RTF concept is that the initial on-scene officers will go directly to the threat. This direct-threat area is the area where active violence is taking place and/or a location where the threat has unrestricted movement. The direct-threat area could also be where a known hazard, such as improvised explosive devices (IED), could be located.

Once the threat is confined, barricaded, or eliminated, remaining officers will pair with teams of firefighters and emergency medical services (EMS) personnel to create an RTF. The RTF, under the protection of law enforcement, will enter the building, treating and extracting victims as quickly as practical. Treatment of victims should include the use of Tactical Emergency Casualty Care protocols.

In 2013 the U.S. Fire Administration published Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. The purpose of this document was to support planning and preparation for active-shooter and mass casualty incidents. One section of this document titled Maximizing Life references a joint effort between the American College of Surgeons and the Federal Bureau of Investigation to develop a concept to maximize the survivability in a mass-shooting event. The consensus paper (known as the Hartford Consensus) identified the simple act of hemorrhage control as core treatment to improve survival. In an effort to facilitate rapid treatment and extraction, the U.S. Fire Administration (USFA) references the THREAT acronym.

  • T —threat suppression (law enforcement direct to threat)

  • H —hemorrhage control (Tactical Emergency Casualty Care [TECC] protocol and tourniquet application)

  • RE r apid e xtrication to safety (through traditional or operational-rescue means)

  • A —assessment by medical providers (exterior triage and treatment)

  • T —transport to definitive care

Even though medical treatment is an important part of the RTF response, it is only one piece of the puzzle. The evacuation of the injured is equally important. The traditional methods used to move casualties are not at the core of operational rescue. One would not be able to use traditional patient packaging methods, such as the use of backboards and stretchers, in the direct-threat environment. Standard techniques would require the caregiver to be exposed for too long, and the techniques are too cumbersome for quick extraction. This is especially true when casualties must be removed from multistory buildings, where stairwells would be the most direct routes out of the building. The use of stretchers and backboards would simply be too difficult and too slow. However, operational-rescue techniques would be highly applicable should a gain in extraction time occur, or threats reemerge during the RTF’s deployment. Remember, operational-rescue techniques could be deployed when organic assets such as equipment, and personnel resources are at their minimum. In a multistory structure, teams should be prepared to use hasty rope systems to accomplish the emergency evacuation of victims and the RTF itself. This can be accomplished using a rope system and a very basic casualty extraction strap to conduct a basic stairwell evacuation, or as complicated as rigging a full rope-based lowering system. The size and complexity of the event will dictate the rescue system used. Personnel can easily carry a basic, lightweight, and capable rope system in a fanny pack, in addition to the medical equipment appropriate for TECC.

Another environment primed for operational rescue is the structural collapse. Structural collapse can occur through various means, including weather or other environmental emergencies, human-made causes, such as terrorism, fires, and even simple accidents, such as driving a vehicle through a house. When the topic of structural collapse comes up, many emergency personnel think of the FEMA US&R system. However, this great resource only responds when an incident is declared a federal disaster. Many structural collapse responses are staffed only by state and local responders, typically standard fire and EMS professionals, who are unlikely to have specialty training in advanced rescue techniques. Some departments do train specialty operators for search and rescue, but this is likely to be found only in larger metropolitan areas. Should a local jurisdiction have a rescue team, it may be ill-equipped for a structural collapse. Once again, we can look to the operational-rescue approach to make these local responders more effective in their response.

As an example, it may occur that to enter a collapsed building, a rescuer needs to place shoring material to keep collapsed walls, floors, and roofs stabilized. For the FEMA US&R team, this would involve deploying engineers and shoring teams along with thousands of dollars’ worth of equipment to make the building safe for entry. However, for the first responder, these resources are likely not readily available. They must rely on a more asymmetric approach, such as using debris from the collapse as shoring material to make an area safe, or using pipe found in the pile along with concrete block as a lever and fulcrum to lift an item off a victim. Known or unknown, this rescuer is using the concept of operational rescue to make a difference.

The most frequent user of operational-rescue techniques is the U.S. military. The Global War on Terror brought with it a battlefield that presented many types of hazards of rescue. This includes, but is not limited to, the following:

  • Remote mountainous terrain (including altitude problems)

  • Rivers

  • Deserts

  • Lack of infrastructure (drinking and sanitation wells)

  • Threat of improvised explosive devices

Many of the operational-rescue techniques used now were derived from AARs or interviews with military personnel. An example where ad hoc operational-rescue techniques were utilized is during the U.S. Consulate attack in Benghazi, Libya, on September 11, 2012. The attack moved from the U.S. Consulate to the CIA annex, and Americans were wounded and trapped on a rooftop. A small element of operators hastily created a rope-rescue system using “rope they had cut from gym equipment,” and they lowered the casualty. This operation was a prime example of operational rescue. The rescue occurred in a highly stressful environment, and was executed with few personnel and limited equipment. In addition, the equipment used was an improvised organic asset, or an asset that was found on the scene, versus carried to it.

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Aug 25, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on Operational Rescue
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