Rescue of patients from environments and circumstances that pose uniquely high levels of risk or that require the use of specialized techniques and equipment fall into a special category of medical operations. Although the average EMS physician, or prehospital provider, will not routinely encounter these circumstances, operational medical effectiveness requires some basic knowledge of these rescue types, their hazards, and specific medical challenges.
Deﬁne technical rescue and the major types of technical rescue.
Describe principles of medical support of general and speciﬁc types of technical rescue.
Describe a practical approach to medical support of general and speciﬁc types of technical rescue.
Discuss EMS physician–specific responsibilities.
The NFPA standard 1670 defines rescue as “those activities directed at locating endangered persons at an emergency incident, removing those persons from danger, treating the injured, and providing for transport to an appropriate health care facility” and technical rescue as “the application of special knowledge, skills, and equipment to safely resolve unique and/or complex rescue situations.”1 Although the technical aspects of the rescue described here may be beyond the ability and training of most EMS physicians, the medical aspects of the rescue, and the safety concerns for the rescuers, make this an essential area of awareness for EMS physicians and medical directors. In contrast to rescue, recovery operations (retrieval of property or victims’ remains) are nonemergency operations and should only be carried out in situations where risk assessment is favorable and operational planning has been completed in a thorough and deliberate manner with all alternatives considered.
In addition to being aware of the capabilities of the agencies operating in the EMS system, EMS physicians should also consider their community and the special features that may call for technical rescue operations. The existence of a mine or caves, open water or rivers, mountainous features, open wells, tall buildings, or other potentially challenging features should be considered. Partnering with municipal agencies, such as the department of public works, department of water, waste management, city planning, and emergency management can aid the medical director and other EMS system leaders engage in the necessary needs assessment.
A needs assessment is used to identify the level of response that should be expected of the system and at an agency level (Box 71-1). The first step is to perform a hazard analysis and risk assessment in order to determine the potential needs of the community. The next step is to consider the resources and capabilities of each agency and of the system as a whole. It is possible that a community or system may have identifiable hazards that require technical rescue capability that the system cannot support because of a lack of resources. This should lead to active pursuit of grants, training, or mutual aid agreements with agencies/systems that have the resources available. When considering the development of capabilities to provide a particular technical rescue operation, it is also important to consider the hazard that it is meant to mitigate. In some cases, the risk of rescue attempts may outweigh the potential for rescue. Confined space rescue in some environments may not be worth the risk when the likelihood of survival of the victim is low and the risks to rescuers are high, thus presenting an unfavorable risk/benefit analysis. The final consideration, after accounting for the other three, is to determine the operational level that is most appropriate. Not every agency should be expected to provide the maximum level of response to every hazard they may encounter; however, it may be appropriate to provide one of the three operational levels for every potential rescue operation that the agency may face during their duties.
Box 71-1 Needs Assessment
Hazard analysis/risk assessment
System/agency resources and capabilities analysis
Hazard-based risk/benefit analysis
Operational level analysis
There are three levels of operationally definable levels provider in the technical rescue environment: awareness, operations, technician (Box 71-2). Agencies providing rescue services should have written standard operating procedures (SOPs) to address any and all rescue operations to be performed by members of the agency. In addition, these SOPs should address the scope of the agency and the providers at the various levels. Awareness level providers are providers who have been deemed to have the minimum level of skill and capacity to respond to a technical rescue. Operations level providers are trained to the level required to identify hazards and intervene through the use of equipment and limited techniques. Technician level providers are capable of providing advanced techniques and are expected to also be able to coordinate and supervise a technical rescue operations.
Box 71-2 Operational Levels
Many times, the first on-scene provider(s) may be trained and equipped to the awareness level and should not attempt to initiate technical rescue. EMS physicians who arrive in this capacity should first perform a scene size-up, establish or communicate with command, and then assist in denying entry of less than operations and technician level providers. During this period there should be some attempt to contact victims and perform nonentry rescue procedures. Setting up safety zones should be initiated in order to limit hazards and everyone on-scene should be made aware of lockout (method for keeping equipment from being set in motion and endangering workers)1 and tagout (method of tagging, labeling, or otherwise marking an isolation device during hazard abatement operations to prevent accidental removal of the device)1 procedures. The incident commander should be made aware of the potential resource and rescue needs so that these resources and personnel can be requested. EMS physicians on rescue scenes should work with command and the safety officer to ensure highest level of possible provider and victim safety, including proper PPE for rescuers and victims, air supply/ventilation, and proper medical monitoring/rehab. Knowledge of the technical rescue teams and special operations assets in the community/system is essential.
Personnel require specialized training, equipment, and knowledge to be considered proﬁcient in the various types of technical rescue. Training levels correspond with the operational levels: awareness, operations, technician. It is important to note that in many cases, at the technician level a provider is considered technically proﬁcient in skills but still requiring direction. On the other hand, a provider considered to be a technical specialist is technically proﬁcient in skills and also does not require direction and is able to practice independently because they have obtained a level of special expertise in a particular area and are effectively a subject matter expert. As with all other complex skill sets, technician training and status does not necessarily confer proﬁciency in technical rescue. This requires practice/frequency of operation and continued study and application (NFPA 1670 4.1.5).1
OPERATIONAL MEDICINE IN TECHNICAL RESCUE
Medical personnel, including EMS physicians, need to be trained to the operations level or higher if they are to be expected to enter the “hot zone” to perform patient assessment, initiate advanced medical care, and assist with planning of patient extrication. In order for an EMS physician to become a medical expert within a technical rescue operation, they will have to receive the same training as other providers and must spend time training with the full team. In order for the physician to be of the most benefit to the team, they must also be accessible (occupational health, trust issues on scenes), personally train and train with the medical component of the team (to ensure proﬁciency and trust), and prepare to provide continuous medical surveillance of team members.
Size-up and incident management planning occur on the scene of the incident, take into account the specifics of the incident, result in an incident action plan, and are ultimately a function of the command structure. Preplanning is a multifaceted, multidisciplinary function of leadership within agencies and the system as a whole. The preplan for the system should include training events, development of a medical cache, acquisition and maintenance of special operations and safety equipment, and any and all PPE needed for potential operations. The level of preplanning should include medical oversight and involvement of the EMS physician for the development and delivery of medical education/training for medical and nonmedical team members, recognition of the need for medical care by all team members (eg, CPR and first aid), and occupational health for team members (acute and long term). Each known hazard/site within the community should also have a site-specific preplan that includes all operations components (including medical).
The planning and implementation phase of the incident begins at the time of the first call and continues through size-up and all the way through until rehab and after action. Initial components of the action plan include gathering important intelligence about the situation (ie, hazards, potential/known victims, potential for rescue/survival, immediately available resources, delay for specialized technical rescue resources if needed). The EMS physician’s roles include participation in planning medical and safety aspects of incident response, advising command regarding medical aspects that will have a bearing on rescue/extrication efforts, and coordinating/facilitating patient care and comfort during the rescue. Some direct responsibilities of the physician may include acute care of victims, clinical medical record-keeping, acute care for team members (human and canine), coordination with area EMS/transport agencies (ground and air) and deﬁnitive medical care entities (hospitals), and emergency management agencies as necessary. The EMS physician should be appropriately prepared to coordinate and/or participate in the transfer of care of patients (victims and/or team members as applicable) to deﬁnitive care entities and ensure/provide rehab2,3 for team members during and after the operations are complete.
The same nine components of rehab detailed in Chapter 65 apply for rehab in technical rescue operations.4 In addition to compiling and reviewing medical records and rehab charts, the EMS physician should follow up on any occupational injuries/illness of team members and prepare a summary for the hot-wash and/or after action report. A detailed review of the medical aspects of the operation should be conducted and adjustments should be made to medical caches, protocols, and policies based on the outcomes. Medical supplies should be restocked and equipment restored and maintained to ensure readiness for the next event.
TYPES OF TECHNICAL RESCUE
NFPA 1670 lists 12 types of technical rescue (Box 71-3).1 In all cases of involvement with technical rescue the proper operation-specific PPE and safety equipment should be used and personnel engaging in the operation should be well trained and qualified and be in appropriate physical and mental health prior to participation.
Box 71-3 Technical Rescue
Structural collapse search and rescue
Confined space search and rescue
Vehicle search and rescue
Water search and rescue
Wilderness search and rescue
Trench and excavation search and rescue
Machinery search and rescue
Cave search and rescue
Mine and tunnel search and rescue
Helicopter search and rescue
Animal technical rescue
Rope rescue scenes are typically those in which the patient is located in an inaccessible location, such as down a steep embankment or on the outside of a structure. High-angle rescue refers to rescue operations in which the rope supporting the weight of the rescuer is being used over a surface that is at greater than a 45° pitch/slope (Figure 71-1). Low-angle rescue is when the rope is still required and holds the weight of the rescuer, but the slope of the ground or working surface is less than 45°. Both high and low angle rope rescue operations are potentially dangerous. Medical personnel participating in a rope rescue need to be trained to the operations level or higher and be prepared to be lowered or transported/supported by ropes to perform patient assessment, initiate advanced medical care, and assist with planning of patient extrication. Safety concerns include issues related to high-angle dangers (falls, edge safety, risk of head injury) and any other hazard that makes a rope operation appropriate. Annual training and verification of proficiency is important in all tasks and skills defined by the NFPA under Chapter 5 of the NFPA 1670 standard.1 Box 71-4 lists some of the unique requirements called for by the standard. Due to the demands of the work, rescuers require significant personal fitness and technical proficiency. This type of rescue is very technical and requires study and practice with rope work, knot tying, and complete mastery of the mechanical advantage systems, rope rescue systems, fall protection system, edge protection, harnesses, and all other rope hardware and software. In order to ensure patient care needs can be met, it may be necessary to plan on a modular equipment/supply load out so that the rescuer(s) can deliver care without the burden of having to take significant amounts of unnecessary equipment to the patient.