Accessing the Void

• By Marc Barrera
• Feb 01, 2009

Confined space rescue demands speed, expertise, and guts. For a successful rescue to take place, many factors must come together. A rescue team's efforts can be all for naught without the important contributions of specially trained medical team personnel who are prepared to administer emergency care in dangerous and unpredictable environments.

In recognition of this, the Federal Emergency Management Administration has issued Urban Search and Rescue training guidance for medical teams' care in confined spaces. This article outlines that guidance, which should be expanded upon in a formal training situation.

The first step is to recognize the differences between traditional emergency medical care and confined space medicine. The key determining factor is the hazardous environment. Confined space medical personnel must consider not only the safety of the victim, but also their own safety and that of their team. Confined space rescue settings can include mines, caves, tunnels, collapsed buildings, manholes and sewers, utility tunnels and crawl spaces, collapsed elevated roadways, and other man-made structures. Medical personnel must not only stabilize the victim, but also the immediate environment, mitigating hazardous exposures and protecting against roof collapse and the possibility of asphyxiation from poor ventilation.

Apparel

Before responding to a call, medical team personnel must ensure they are properly equipped for their own safety. The number one rule is that rescuers' safety must come first. All rescuers must maintain proper immunizations, including vaccination for hepatitis B. The following personal protective equipment is essential:

• Respiratory Protection: This should include cartridge-type respiratory masks with asbestos filtration--at least until asbestos and other toxic dusts have been ruled out from the scene. An SCBA may also be necessary in the event of toxic atmospheres.
• Hearing Protection: Numerous rescue tools may be in operation during rescue efforts creating noise levels that may result in hearing loss.
• Safety glasses or faceshield: The operation of the aforementioned rescue tools can create large amounts of fine dust that can result in corneal abrasions or deposits of foreign bodies.
• Helmet with cap lamp or helmet light: This is vital for head protection and visibility.
• Gloves: Latex gloves should be worn under the rescuer-type leather gloves. Leather gloves protect the rescuers' hands from sharp objects or abrasions; however, they also soak up blood and body fluids, providing no barrier to such exposure.
• Appropriate footwear: Steel toe and shank boots are preferred. Because of leather's previously mentioned propensity for soaking up fluids, also consider using shoe covers.
• Impermeable coveralls: Coveralls made from Tyvec or similar materials provide added protection from blood and body fluids.

Medical Team

An effective confined space medical team is one with clearly defined roles for its members. This is one organizational method of these different roles' functions (several functions may be covered by one person):

• Provider(s): The "point person" having "hands-on" contact with the victim, this person performs patient evaluation and treatment, and must be able to think and act "out loud." The ideal choice of provider for each situation varies based on multiple parameters: physical characteristics, the size of the space compared to the size of personnel, along with the strength needed to move the patient, etc.; technical needs, physician procedures and assessments versus medics' immobilization and extrication skills; personal, consider each team member's level of fatigue, heat sensitivity, etc.
• Anticipator: This person listens to the evaluation/treatment and communicates the anticipated needs of the Provider(s). This individual ensures equipment and supplies are delivered and prepped to prevent "dead time."
• Medical Control MD: A physician who provides orders if the Provider(s) are Medical Team Specialists. This role can be combined with the role of the Anticipator.
• Recorder/Safety Officer: Vitally important, this person records "timed" assessments, interventions, repeated vital signs, and patient re-assessments. This person also: ensures atmosphere monitoring reading if indicated; ensures the recheck of "roof" and other safety precautions; monitors the Providers' length of time "in the hole" and need for rotation, etc.; tracks amount of oxygen in tanks; records the type and number of feet of rope into a space; and ensures the number of Providers in and out of the space are equal.
• Equipment/Supply Officer: Charged with obtaining needed equipment and supplies, this person prepares and preassembles them for immediate use by providers and monitors their expenditure.

Scene Assessment

In an ideal situation, medical personnel will have access to a patient's medical history. In an emergency response setting that is filled with many unknown factors, this is not always possible. Still, acquiring any patient data can be extremely helpful. Bystanders, co-workers, and family are ideal sources of information on items such as the victim's age, personal medical history, and more. There are a group of common collapse-structure injuries that are commonly faced in everyday EMS and emergency department care facilities: fractures/lacerations, multiple trauma, closed-head injury, hypothermia, and dehydration. Less-common injuries or medical considerations present at a confined space rescue can include crush injury and syndrome, dust impaction in the airway, hazmat exposure, prolonged untreated trauma, and pain control in a pre-hospital setting.

The function of the structure is just as important in assessing possible hazards present, which can include chemical, electrical, propane and fuel oil, sewers, etc. The type of structure is also a good predictive indicator of the types of injuries sustained. Wood structures mainly present laceration and puncture injuries, while adobe and brick structures predominantly present dust impaction airway injuries.

Stabilizing the Scene

Each scene is different, presenting its own unique set of challenges. However, when dealing with a collapsed structure, most scenarios will present one, or many, of the following outcomes:

• Pancake collapse: Floors fall one on top of another, creating void spaces near appliances, heating and air conditioning units, or other supporting structures. Victims can be found in these small void spaces next to whatever object is supporting the ceiling or between the floor joists of the floor above. This type of collapse can be supported with standard box cribbing and, once cribbed, is rather stable.
• "Lean-to" floor collapse: A floor collapses but is supported by one wall, forming a void along the supporting wall. This void can be stabilized with raker shoring or box cribbing; however, failure of the supporting wall can result in the total collapse of the void space.
• V collapse: The center of the floor collapses but is supported along walls, creating void space there. Stabilization and hazards are similar to that for a lean-to collapse: raker shoring or box cribbing for stabilization. Failure of supporting walls can result in the collapse of the void space.
• Cantilever collapse: Formed when one end of the floor is hanging free because of one or more wall failures; the other end is still attached to walls. This scenario presents a high-hazard risk of secondary collapse and requires extensive cribbing and shoring.

Due to their unpredictable nature, collapsed structures can also present undefined patterns. Cribbing wedges should ideally be made from rough-cut oak and should never exceed two times the width of their base unless they are also adequately shored. Shoring materials, used for bracing the structure, can come in many forms, usually consisting of wooden posts or structural steel.

Victim Evaluation

Patient evaluation begins as soon as voice contact is made with a victim. The general patient approach includes:

• Protect the patient from further harm (dust mask, faceshield, ear plugs, further shoring of the roof, C-collar, etc.).
• Remove all jewelry, constrictive/wet clothing, etc.
• Administer standard BTLS/PHTLS care--airway, breathing, circulation, disability, exposure (use tactile evaluation), secondary survey (includes constant re-evaluation and close monitoring).

Accessing the void containing a victim presents its own challenges. Access may require entry from any angle. Lateral access may involve access through a supporting wall or a collapsed floor section. Vertical access may involve access from above the void through the roof or from below the void through the floor.

If crawling is necessary to reach the victim, crawl on elbows and push with your toes. In tight spaces, usually, if your head and chest fit, the rest of your body will. Equipment may be pulled from behind by a rope or cord. It may be necessary to back out, roll over, and re-enter to perform a given function, such as trying to start an IV while lying supine due to the tight space. Determine if the route is large enough to accommodate the patient and the immobilization equipment (a tape measure is a necessary tool for this). If the route needs to be enlarged, ensure that rescue personnel provide additional shoring and stabilization. For patient and rescuer protection, cover and pad all sharp objects, such as cut-off rebar.

Medical response team personnel must expedite extrication by stabilizing the patient's vital signs, immobilizing fractures, administering pain control, reassuring the patient to improve cooperation, providing anatomic/physiologic advice for moving the patient, and preparing the patient for hand-off to appropriate accepting personnel. Re-evaluate the patient after any significant extrication move.

Atmospheric monitoring is equally important for the victim and rescue personnel. Common problems in confined spaces include decreased oxygen concentration due to consumption by rescuers working strenuously in small areas; high carbon dioxide concentrations generated by victim and rescuers; carbon monoxide created by rescue vehicles, generators, or mechanical equipment; the presence of natural gas from a rupture in gas lines; or hazardous materials present in the building that were released during the structure's collapse. Monitoring must include all new void areas that are penetrated and must be conducted prior to canine or human rescuers being permitted to enter and search. All unusual odors and/or liquids should be evaluated by hazmat specialists. Dead bodies produce a very foul odor. Use of charcoal impregnated masks or Noxema under the nose will help with the unpleasant odors.

Documentation and Practice

Equally important to a victim's chance of survival is a smooth hand-off to waiting medical personnel. Key to that transfer is information. Medical response team personnel must fill out as completely as possible all pertinent patient information on their Patient Care form and Patient Referral form. This must include the victim's medical history, physical findings, details of entrapment, interventions performed, and the patient's course.

In order to be most effective and compensate for unknowns, learn safe operation in confined spaces. Hone efficiency to eliminate "down time." Anticipate the next intervention and its requirements so necessary medicine and equipment are prepped and ready. And, most important, communicate profusely with colleagues so all is done before being needed. This will help everyone develop a comfort level in confined space and an efficient personnel methodology. It will also expose the subtle but important limitations of personnel, equipment, and situations.

This article originally appeared in the February 2009 issue of Occupational Health & Safety.