James Yates / Paramedic / St John Ambulance / Christchurch, New Zealand
James Yates is a specialist Urban Search and Rescue and Chemical, Biological, Radiological, and Nuclear Paramedic with one of the Hazardous Area Response Teams in the UK, currently working out in Zealand. In this article, he gives Adventure Medic an overview of his work.
Urban Search and Rescue
Urban search and rescue (USAR) conjures up images of rescue teams in brightly covered overalls crawling over rubble piles amongst scenes of devastation and mass casualties.
Worldwide, highly publicised disasters such as the terrorist attacks on the World Trade Centre, the tsunami in Japan and the earthquakes in New Zealand have helped to increase the profile of USAR teams and the awareness of what they do.
However, images of rugged looking personnel lifting victims proudly from the debris may be appealing to the media, but they hide the fact that urban search and rescue remains one of the most challenging and hazardous of the disaster response activities. Over time though, the ability to safely locate and extricate victims of these disasters has improved, with highly trained, multi-disciplinary rescue teams, equipped with the latest technology and equipment.
An equally advanced medical team, integrated into the rescue team, has also become vital not only to reduce morbidity and mortality in the victims of such events, but also to attend to the medical needs of the rescue team themselves.
Medical staff require specific USAR training to allow them to operate safely in the hazardous conditions but also to develop an appreciation of what can be achieved by the rescue teams and the timescales involved in effecting a rescue.
They also need to be highly adaptable in their approach to patient assessment and management in order to provide high levels of care in an extremely demanding setting. Altered techniques for standard procedures may be required, pathologies particular to USAR may be encountered and the dark, dusty and noisy environment will hamper the work of even the best trained medic.
Communication and the Environment
Medicine though is not the only factor that needs to be considered in order to provide an effective medical response.
Prior to entering the collapse, many other important decisions need to be made, for example, the method of communication with other team members. Depending on the type of structure and the distances involved, many standard VHF radios used by the emergency services will have limited use. Specific two-way communication equipment is available, utilising a long reinforced wire, but this has the drawback of being a bulky piece of equipment to drag into the incident and its range is limited by the length of wire available.
As the environment will typically be dark or certainly dull, a light source will be vital. In a protracted incident, portable lighting units may be brought into the situation powered by external generators, but in the initial response it is likely that the only light available will be from a personal head torch. Light sticks can also be used for several functions such as marking a route or to identify equipment.
Another important concern is air quality, as when a structure collapses large quantities of dust, insulating fibres and other debris are distributed into the air. Therefore dust masks should be worn by all rescuers to provide protection from these substances. Unfortunately they cannot be relied upon indefinitely as large concrete dust particles and significant quantities of exhaled water vapour from the heavily breathing rescuer will quickly clog the filters demanding a change. Additional masks will also be required for victims of the incident during treatment and extrication.
Portable air monitoring equipment may also be necessary to detect a build up of dangerous gases, such as methane or hydrogen sulphide, or a reduction in the oxygen concentration of the inspired air. Gas monitoring is particularly important when working below ground level where gases denser than air can sink and settle.
Medical Equipment
Finally, a decision is required regarding the content of the medical kit. This is usually of no concern during a prehospital event, when popping back to your vehicle presents no problems, but in USAR access may be via a narrow breech, crawling through a passage or being lowered down a shaft. Excessive kit is not an option but neither is leaving the patient to return outside for forgotten items, so prioritisation of appropriate items is essential.
Standard equipment is often not suitable for use in this environment due to its fragility, weight and bulk. Specialist items may be utilised during patient assessment and management, but often the medic will have to rely on manual techniques and clinical judgement alone. An appreciation of the patient care interventions that may be necessary, or can successfully be carried out, will probably dictate to some extent what assessment tools will be carried. Arguably, the assessment kit could be reduced down to a sphygmomanometer, blood glucose monitor and a stethoscope.
Patient Assessment
As well as using limited technical equipment, the medic can be faced with some unusual patient presentations which demand an adaptive approach to patient evaluation.
Imagine a patient who is trapped behind a pile of debris and only their arm is accessible. Can the entire patient realistically be assessed? Probably not, but an estimation of their gross physiology is possible. A simple squeeze of the hand and receiving a squeeze in return will tell us their level of consciousness as a start. The skin colour can be inspected for signs of cyanosis to indicate their respiratory status, a palpable radial pulse estimates blood pressure and this combined with the heart rate and skin texture gives an idea of the patient’s cardiovascular status.
It is a crude and basic assessment, but adapting to what is presented is the key challenge to successful USAR medicine. Sometimes even physical contact with the patient will be a luxury and assessment may have take place via a camera or remote microphone lowered through a void which is too small for human access. Once again, the thoroughness of an assessment is mainly limited by the medics’ imagination.
Patient Management
When patient assessment has been completed the management phase can begin, and this too may not be as straight forward as expected. The dark, cramped conditions may demand adapted techniques to standard interventions or the use of alternative procedures altogether.
Interventions such as gaining vascular access normally present only limited difficulties, but finding a vein using the light from a headtorch when the patient is shocked, cold and dirty may prove very challenging. The availability of intraosseous equipment in this situation can prove to be essential, as identifying the landmarks for IO access can be much simpler and the likelihood of successful vascular access far higher.
If endotracheal intubation is required and there is not enough room to proceed past the patient, then face-to-face intubation using the pickaxe method may be necessary. If the vocal chords cannot be visualised using this technique then digital intubation may be attempted. Here, the index finger and middle finger of the left hand are slid over the surface of the tongue until the epiglottis is palpated. The ET tube, held in the right hand, is then passed between the fingers and guided into the trachea. It may sound bizarre, but if this is the only way to secure the patient’s airway then it can be a life-saving procedure.
Specialist equipment may also assist in the effective care of the patient. Many will present with significant bleeding and there are numerous options available. Tourniquets have had a resurgence in prehospital care and are proven to decrease mortality in the setting of uncontrollable bleeding from a limb. Haemostatic agents, whether in powder form or impregnated into gauze, can assist with stopping major bleeding from the torso where placement of a tourniquet is impossible.
Pelvic splints are also available which will stabilise a fractured pelvis during the inevitably bumpy extrication, though improvisation with a blanket wrap is also possible. Malleable splints made with a thin layer of metal surrounded by foam are extremely versatile and can be used to stabilise ankle, leg, wrist and forearm fractures as well as acting as an improvised cervical collar. These fit very well into the category of “adaptable equipment” and as such have proved to be very popular in USAR.
Alongside standard traumatic injuries which are dealt with on a daily basis in emergency care, there are some less common presentations which may be encountered in a USAR incident. Crush syndrome is the most significant cause of morbidity and mortality in patients after successful rescue from entrapments and, as such, the medic needs to be familiar with its treatment and be very aggressive with the management of these patients. Prolonged entrapments also increase the likelihood of compartment syndrome, dehydration and hypothermia.
Rescuing the Rescuers
Injuries are not just isolated to victims of these disasters however, and rescuers may also present to the medic with unique demands. Though limiting the time using breaching equipment is strictly enforced, hand-arm vibration syndrome is a risk for rescue workers and, as many of the power tools in use at an incident are hydraulic in nature, high pressure injection injuries may occur. These can appear innocuous, with only a small surface puncture wound, but there may be significant sub-dermal damage and the development of severe pain.
Rescue workers are also a multi-disciplinary group and the medic may find themselves dressing the wounds of the rescue dogs as well as their human counterparts.
The Final Word
The final word on USAR operations needs to be one of realism. In a major incident with large numbers of casualties, not all patients will be treated in the optimal fashion and not all will be salvageable. Difficult decisions will need to be made both with regard to patient care and resuscitation decisions. If a patient is trapped and deteriorating, with the chance of rapid extrication slim, and numerous other patients awaiting your attention, what would you do?
The medic is also not immune to damage and crawling around in the dirt, breathing dusty air and working in hot, cramped spaces can lead to dehydration, heat exhaustion or contraction of infectious diseases. The psychological aspect of this work should also not be underestimated. Extended periods of time may be spent with a patient, in close quarters, during a significant and extraordinarily frightening episode in their lives.
The medic may also be scared and in extreme danger but is still expected to provide advanced care in some of the most difficult situations imaginable, with limited equipment and on their own.
Urban search and rescue is therefore a unique and dangerous environment in which a medic can choose to work. The multitude of challenges that may be faced demand physical, professional and psychological resilience along with an adaptable and inventive approach to patient care. But to overcome all the adversity to be that rugged rescuer pulling a victim from the rubble and smiling for the cameras makes it all worthwhile.
