An Urban Search and Rescue (US&R) team is a specialized group of individuals with appropriate equipment, skills, and training that may be called into action during the disaster response phase. A US&R team or task force (TF) plays a crucial role in any situation where victims are trapped under debris or in confined areas. The US&R team’s tasks and duties are localization of victims, victim extrication, and provision of initial medical treatment to victims during extrication operations. In many cases, both human-made and natural disasters involve collapsing buildings and entrapped casualties. These disasters include tsunamis, hurricanes, earthquakes, explosions, terrorist attacks, typhoons, avalanches, and mudslides, as well as confined spaces including mines, caves, wells, and trenches. US&R operations may be conducted over short or extended timelines, depending on the type of incident and the specific situation. One extreme example of extended operations is the mudslide in Oregon in March 2014 that killed more than 40 people and required more than a month of operations by US&R teams.
It is essential for any disaster responder to have a basic understanding of the role of US&R in an overall incident response where there may be trapped or confined victims because, during disaster medicine operations, significant overlap in geography and roles may occur between routine disaster response and the US&R TF operations. Disaster medicine physicians, paramedics, and other medical providers may be asked to provide medical support for specific US&R missions or may provide patient care to the victims rescued by US&R personnel, although such responders should not be put in harm’s way without proper training and equipment. In addition, first responders and firefighters may be asked to provide additional workforce for search operations, for victims in widespread disasters such as tornados or hurricanes.
Search and rescue operations have been part of disaster response since ancient times. The first existing literature regarding this topic is perhaps contained in a piece written by Pliny the Younger, where he described how his uncle, Pliny the Elder, died ( AD 79) during the Vesuvius eruption while he was attempting to rescue his friends from that ongoing disaster. A more recent example would be after the Haiti Earthquake of 2010 or New Zealand Urban Search and Rescue (NZUSAR). NZUSAR was originally established as a Coast Guard organization in the 1890s, in response to multiple failed ship-rescue operations. In the United States, the first specific US&R teams were founded and developed in the 1980s, by the Fairfax County Fire & Rescue Department and the Metro-Dade County Fire Department. The tasks of the teams were to respond to disasters (most often hurricanes) by providing heavy rescue and search capability and medical care and to communicate a damage assessment while doing so. In addition, they provided support in the research of search and rescue operations, attempting to improve the field as a whole. Under an agreement with the Office of Foreign Disaster Assistance (OFDA) of the U.S. State Department, these US&R responders have been deployed to respond in several international disasters, including earthquakes (1985 Mexico City, 1986 El Salvador, and 1988 Armenia) and hurricanes (1988 Jamaica and 1989 Eastern Caribbean). In 1988 the very well-known Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) codified the role of all agencies of the Federal Government in provision of assistance to state and local governments during and following a disaster. The Stafford Act also established a formal search and rescue component to federal disaster response, and, in 1989, the Federal Emergency Management Agency (FEMA) formally created the National US&R Response System to satisfy provisions of the Stafford Act. Twenty-five US&R teams from 19 states were created within this system. In 1991 the US&R teams were incorporated as part of the Federal Response Plan (FRP). US&R is now incorporated in the National Response Framework (NRF), an update to the FRP, in the Emergency Support Function (ESF) #9 ( Box 52-1 ). At present, 28 teams are sponsored by FEMA and the Department of Homeland Security (DHS). Multiple other nonfederal US&R teams sponsored by state and municipal authorities provide primarily local response. (In Oklahoma, e.g., the state sponsors an equivalent US&R team [OK-TF1] that is equipped, trained, and staffed to federal standards and has responded both in-state and to contiguous states for multiple disasters.)
|ESF 3||Public works and engineering|
|ESF 5||Emergency management|
|ESF 6||Mass care, housing, and human services|
|ESF 7||Resource support|
|ESF 8||Public health and medical services|
|ESF 9||Urban search and rescue|
|ESF 10||Oil and hazardous materials response|
|ESF 11||Agriculture and natural resources|
|ESF 13||Public safety and security|
|ESF 14||Long-term community recovery and mitigation|
|ESF 15||External affairs|
Urban Search and Rescue Task Force Composition and Deployment
As stated previously, there are 28 FEMA-sponsored US&R teams in the United States ( Table 52-1 ), and additional US&R teams have been sponsored by states and large municipalities, such as Oklahoma’s US&R TF1. The TF teams are geographically distributed across the United States in a manner to best assure that a FEMA-sponsored TF team could be on the site of a disaster after only a few hours from when it is initially called for. In accordance with the overall federal direction of disaster response, the primary mission objectives of a US&R TF in the response phase are to save lives, protect property and the environment, stabilize the incident, and provide for basic human needs. Specifically, when called upon, US&R teams locate, extricate, and give immediate medical care to casualties found under collapsed buildings and in other confined spaces. Their activities are required in response to multiple kinds of disasters, such as earthquakes, hurricanes, tornados, and floods, among others. Their activities are noted among the most challenging and dangerous in disaster response. US&R teams are also trained in trench rescue; however, most trench rescues are local events involving limited numbers of casualties. Therefore federal teams are rarely involved.
|No. of US&R TFs||State|
In a disaster, FEMA will typically deploy the three closest TFs to the event, supplementing any state and municipal US&R teams that may also be deployed at the disaster. Each TF consists of at least 62 active members and each is given 6 hours to assemble, deploying members at their departure point when activated. US&R members include firefighters, health care professionals, hazardous-material specialists, rescue specialists, structural engineers, and canine search teams. Many US&R organizations have multiple teams to ensure full staffing. For example, Oklahoma TF1 US&R has red, blue, and white teams, with response duties on a daily rotation. Each team and each member is equipped and trained to be self-sufficient for the first 72 hours. US&R TFs have six components, as follows:
“Search”—locating casualties and victims in the collapsed buildings or destroyed structures—this component consists of canine search teams and technical teams with fiber-optic cameras (eyes), electronic listening devices (ears), potential ground-penetrating radar, and even “sniffers” for electronic odor detection.
“Rescue”—removing entrapped victims or victims in a confined space—the rescue group has equipment to stabilize structures, ensure the safety of rescuers and victims, and extricate victims from surrounding damaged structures.
“Technical”—providing technical support for the TF—this component is provided by the medical director and the structural engineers who monitor for the possibility of noxious substances and other health threats, as well as structural instability and recommend mitigation and response strategies.
“Logistical”—providing logistical support for the group—the logistics group provides and repairs all of the specialized equipment needed, as well as the supplies for the accommodations, food, and water for the TF members.
“Medical”—providing medical treatment for victims before, during, and after rescue at the disaster site—medical teams are typically composed of two TF physicians and four Medical Specialists. The TF medical equipment carried includes medications, fluids, devices to allow intubation and ventilation, defibrillators, burn and amputation sets, and emergency surgical and suture kits. During the operation, the medical section is also responsible for the well-being and medical care of the other TF team members.
“Command”—providing overall leadership and direction, as well as supporting communications—the command group is responsible for overall decision making within the Incident Command System (ICS) framework. The communications section of the TF is managed by the command group and is responsible for communications with local emergency medical service(s) (EMS) providers, hospitals, fire, and police. They may also be able to set up satellite access and wide-area wireless network systems.
Search and Rescue Operations
Injuries and fatalities are a major and persistent threat during search and rescue operations, as rescuers are operating in a hazardous environment and are at the same risk of sustaining injuries as the disaster victims are. Therefore it is important that every TF member receives sufficient, proper training and education regarding current and possible hazards, wears appropriate personal protection equipment (PPE), and always enters and works in a building or a confined space with a partner or supervised by another member (the “two person rule”). Appropriate PPE may include a mask or respirator, helmet, glass, gloves, clothing protecting against chemical and fires, and safety shoes, among other equipment. The accountability for team members is also essential during search and rescue operations. All team members must check in and out of response areas. Typically, team members are issued multiple ID cards, and the team leader uses another ID card to check the team member in and out of the specific response area and to identify the partner paired with the team member. The S&R TF command group and physicians in the team have the general responsibility to ensure that each team member has appropriate PPE, adequate hydration, and sufficient rest to perform his or her duties properly.
When first arriving on a disaster scene, the TF command group will evaluate the situation including safety considerations, environmental assessments, weather updates, and tasks assigned by the ICS, and then decide on the tactical plan and assign tasks for the work site. The search and rescue operations are subdivided into the following five phases:
Assessment of the disaster area
Removal of all surface victims as quickly and safely as possible
Search and rescue of victims from accessible void spaces
Selected debris removal to locate and rescue victims
General debris removal to render the scene safe for further operations.
The assessment phase involves survey of the operational area to identify and evaluate the buildings involved and to consider their configuration and structural features (occupancy and void locations). During this first step, responders consider the size of the area involved in the operations, the possible hazards to victims and rescuers, the best access and escape routes, and the type of materials and equipment the TF needs to pursue the operations. The assessment phase also may involve structural engineers who provide building reconnaissance and evaluations, including structural triage, assessment, and marking of both safe ingress and clearly dangerous areas. The assessment phase often includes the rapid reconnaissance of the area and localization of victims, which begin with verbally calling out to locate awake and alert victims. When nonambulatory casualties are located, the rescuer can safely remove light debris and free minimally entrapped casualties. When multiple casualties are found, triage may or may not be needed. If the casualties are in close proximity and outnumber the medical providers, triage of the casualties will likely be necessary. However, when the extrication process is slow because of heavy structural damage or large amounts of overburden, triage may not be needed because the casualties are evacuated one by one. As casualties are evaluated and extricated, the medical provider plans for further treatment and subsequent medical evacuation.
After the rapid operations to locate and extricate easily found victims conclude, the team then begins a more detailed and systematic research to check every building and area where victims may be trapped. For casualties who are not easily found, dogs, cameras, or other more sophisticated devices are often employed to explore any space that could be created during the collapse. Dogs can be very useful to identify unconscious victims and can fit in much smaller spaces than humans can. Humans may also use acoustic and seismic listening devices, fiber-optic equipment, or thermal imaging to identify victims. For these casualties, access and extrication are determined by the mechanism of rescuer access and the machinery required for evacuation of each specific casualty. Access to and extrication of victims can require hours of work to build a retrieval system and ensure safety for both victims and rescuers during the operations.
During the search phase, it is frequently suggested to interrupt the research activities for a while and periodically call out and listen for possible answers or noises coming from entrapped victims.
The medical care of entangled and/or entrapped victims has had several developments over the years. It is known that casualties under debris can be found alive, having survived the event after days, but rarely after weeks. In some situations, the rescue and medical support for entrapped people can even take months. An extreme example is the Copiapò Mining Accident in 2010, when 33 miners remained trapped for 69 days and remained in a void space of 540 square feet, at around 2300 feet (700 m), underground about 3 miles (5 km) from the mine’s entrance.
The physician must be prepared and trained to treat casualties in different types of incidents with different types of injuries, often while the victims are still entrapped. Each casualty must be assessed and treated based on the unique circumstances to which he or she has been exposed. For the entrapped victim, the physician must carefully consider the risks and potential benefits of every maneuver or medical care provided, determine the value of all equipment needed (transport to the patient’s side may be convoluted and dangerous), and consider how to improvise equipment on scene. The physician must consider that everything that the provider accomplishes (i.e., orotracheal intubation) must be managed for the entire duration of the rescue operation, including transportation out of the immediate disaster area. This medical care should not delay the extrication, unless there is a life-threatening condition that requires immediate action.
The first step is the initial medical care to evaluate the victim’s level of consciousness and assure integrity of airway and breathing. If there is airway and/or breathing compromise, it is necessary to obtain a definitive airway. Depending on how the victims are trapped and what kind of access there is to the victims, the rescuer may need to use unusual airway techniques, such as blind nasal intubation, digital intubation, or cricothyrotomy in suboptimal conditions. As per usual trauma protocols, the cervical spine must be stabilized and the back immobilized during extrication, as soon as possible. Next, the medical providers should assess for potential major hemorrhage and look for burns, hypovolemia, dehydration, and thermoregulatory problems. If patient access and circumstances permit, intravenous access should be obtained to provide fluid replacement and, if necessary, to start the administration of medications. Analgesics are indicated both for pain relief and to ease the extrication operation. If attempts to obtain IV access are unsuccessful, intraosseous vascular (IO) access may be considered; IO access is a reliable bridging method to gain vascular access in patients under resuscitation with difficult peripheral veins. Moreover, IO access is more efficacious with a higher success rate on first attempt and a lower procedure time compared with central venous catheterization (CVC) and without other complications such as infection, bleeding, or pneumothorax.
It is fundamental to consider the amount of time required to extricate victims. Buried victims can develop acute crush syndrome, dehydration, hypoglycemia, and hypothermia or hyperthermia. To avoid worsening these conditions and the initial injuries, rapid extrication is essential. It is also crucial, of course, to treat any ongoing external bleeding. Although tourniquets can be appropriate for field management of rapid exsanguination, the rescuer must realize that the victim sought by US&R may require hours of extrication time and limb ischemia from a tourniquet may impair limb salvage. Tourniquets should be used only as a last resort when all other methods of controlling external bleeding have failed.
The US&R medical teams must check status and vital signs frequently during the extrication. Even with a conscious patient, the risk of medical deterioration is high, so ongoing reassessment of the victim’s condition is crucial. , In case of development of respiratory problems, it is essential to provide prompt and aggressive treatment. The patient should be kept dry, with eye protection as needed, and warm.
Victims can be exposed to several different conditions: heat or cold, burns, chemical or electrical burns, poisoning. If possible, any wet clothing should be removed, and assurance provided that the patient’s body temperature is being maintained within the normal range, with warm and dry skin, to prevent subsequent hypothermia.
Confined Space Medicine
Confined spaces with potentially life-threatening gases or lack of oxygen present perhaps the most dangerous environments for rescuers. Data regarding confined space rescue show that up 60% of the fatalities occurring during the process of disaster response in this very dangerous environment actually are rescuer fatalities. It is important to consider that confined spaces can increase the risk of explosions caused by inflammable gas and also increase the inhaled concentration of other agents. For example, silos or pits containing animal slurries can release hydrogen sulfide, which has flammable and explosive features, and is highly toxic, affecting the nervous system and able to cause unconsciousness rapidly after exposure. The practice of medicine in these confined spaces is always demanding and stressful, and it requires close attention. Therefore, the rescuers must always check and size up the scene carefully to provide safety, assess the situation, and arrange for precautions. Confined spaces are prone to extreme conditions in terms of temperature and humidity, and it is important to evaluate the casualty’s circulation and perfusion. Even though the general approach to the patient is the same as any other emergency, the limited space, environmental conditions, and time to extricate and recover the victim make operations in confined spaces very challenging.
Crush Injury and Crush Syndrome
Crush injury and crush syndrome are typical medical conditions that US&R medical teams find frequently during the rescue of trapped victims. Second only to direct trauma impact, crush syndrome is the second most frequent cause of death after mass disasters. It often appears in victims trapped under the rubble of a building collapse.
Crush injury is defined as compression of extremities or other parts of the body that causes muscle swelling and/or neurologic disturbances in the affected areas of the body, usually the extremities. Crush syndrome is the systemic manifestation of breakdown of muscle cells caused by the compression, provoking the releasing of cell components (creatine kinase, lactic acid, myoglobin, and potassium) into the extracellular fluid. This causes hypovolemia, hyperkalemia, metabolic acidosis, renal hypoperfusion, and ischemia resulting in acute renal failure (ARF).
The likelihood of developing acute crush syndrome is directly related to the compression time (at least 1 hour, generally after 4 to 6 hours). Therefore victims should be extricated as quickly as possible. However, extrication must be performed carefully to try to avoid a complication often called “smiling death” or “the grateful dead syndrome,” because the casualty may smile when freed only to die shortly thereafter. This complication occurs because the trapped victim may have had severe extremity compression, which does not allow extremity perfusion. During this period of limited or absent perfusion, dangerous electrolyte disturbances and toxic metabolites can accumulate in the tissues, only to suddenly distribute centrally when the trapped person is freed. This abrupt release of potassium and other intracellular electrolytes can induce malignant cardiac dysrhythmias soon after the extrication.
These complications are potentially manageable or preventable with aggressive therapy consisting of adequate IV fluid hydration given during the extrication operations.
After a long extrication time, it is necessary to evaluate the hydration status, urine output, and urine pH (better pH greater than 6.5) and check electrolytic abnormalities. The administration of a large amount of intravenous crystalloid is crucial to dilute the myoglobin and preserve the renal perfusion. If the patient has decreased urine output, the first therapy should be an appropriate fluid challenge. After hydration is assured, the medical provider may consider mannitol and the use of furosemide. To promote urine alkalization and prevent myoglobin precipitation with intratubular cast formation it is often suggested to give bicarbonate, which also acts to reduce hyperkalemia. If the patient develops renal failure, hemodialysis may be needed.
During the extrication of these patients, it is appropriate to identify in advance a hemodialysis facility that can accommodate the patient once freed. If possible, the transportation should be minimal: the duration of the sustained crush injury and time until appropriate in-hospital treatment of the patient with crush injury increase morbidity and mortality. The medical provider must evaluate the risks and benefits of any long-distance transportation of the patient with crush syndrome.
When the compression involves the thorax, by direct chest pressure from debris, traumatic asphyxia (also called Perthes syndrome), can occur. Traumatic asphyxia can be caused by any compression of the thorax or upper abdomen. The patient has limited chest excursion, which limits both oxygen intake and carbon dioxide exhalation. The direct pressure increases intrathoracic pressure and decreases the cardiac pump function. This syndrome is associated with subconjunctival hemorrhage, craniocervical cyanosis, petechiae, and neurologic symptoms.