Hazardous Terrain

1. Hazardous Terrain

2. EMS Skills • Rescue awareness • Types of specialized teams • Effective coordination with specialists • Hazardous terrain litter evacuations

3. Hazardous Terrain Types • High angle • Low angle • Flat terrain with obstructions

4. Surfaces inclined >40o Gorges Cliffs Buildings Very smooth surfaces <40o Require use of hands in climbing Ropes, aerial apparatus required for access, removal Errors can cause life-threatening injury, death High Angle

5. Surfaces inclined <40o Accessed by walking, scrambling Difficulty can be affected by presence of: Water Ice Boulders Brush, down trees Ropes used to counteract gravity, act as hand lines Errors can result in falls, tumbles Presence of obstructions can result in serious injury Low Angle

6. Examples: Trails Paths Creek beds Difficulty may be increased by: Downed trees Rocks Slippery leaves Scree (rock debris) Patients can be moved by carrying Least hazardous form of rugged terrain Slips, falls can result in injury Flat Terrain with Obstructions

7. Patient Access

8. High Angle • Access/removal usually carried out by technical teams • Additional resources needed to balance technical/medical aspects of rescue

9. High Angle • Rescuer skills • Knot tying • Ascending, descending skills • Rigging of hauling systems • Packaging of patients for evacuation

10. High Angle • Specialized Terms • “Aided”—using means other than hands, feet, body • “Anchor”—technique for securing rescuers to vertical face • “Belay”—safeguarding climber by use of a rope secured to an anchor • “Rappel”—descend by sliding down a fixed double rope

11. Low Angle • Access/removal conducted by EMS personnel in many systems • Still requires appropriate training/equipment

12. Low Angle • Skills • Assembly/use of harnesses • Setting up hasty rope slides • Rappelling, ascending by rope • Patient packaging • Rigging simple hauling systems

13. Patient Packaging

14. Stokes Basket Stretcher • Standard litter for rough terrain evacuations • Provides rigid frame for patient protection • Easy to carry

15. Stokes Basket Stretcher • Come in plastic and wire/tubular (military) styles • Wire/tubular style will NOT accept long spine boards • Plastic styles weaker, but provide better shielding to patients • All require additional strapping, use of plastic litter shields

16. Apply harness to patient Apply leg stirrups to patient Secure patient to litter Tie tail of one litter line to harness Use helmet, litter shield Give fluids Allow accessibility for assessment, management Ensure adequate padding Consider heating/cooling system use Provide gravity “tip line” to clear airway if necessary Stokes Basket Stretcher During high/low angle evacuations:

17. Patient Removal

18. Flat Terrain • When possible, walk patient out! • Carrying over flat ground is strenuous under ideal conditions

19. Flat Terrain • Two to three teams of 6 litter-bearers • All approximately same height • “Leapfrog” ahead to save time • Webbing straps tied to stretcher frame and pulled across rescuer shoulders to free hand can lessen load • Litter wheel may help on flat ground

20. Low/High Angle • Anchors, personnel safety equipment, patient packaging, and hauling systems must be checked multiple times for safety • Hauling systems may require multiple personnel to move weight of patient, basket, and ropes

21. Low/High Angle • Fire department snorkels can be used for patient evacuation • Stokes stretcher must be properly belayed to snorkel basket • Aerial apparatus is NEVER used as a crane to move a litter

22. Helicopters • Capabilities, policies vary widely • Understand policies regarding: • Loading and unloading practices • Restrictions on carrying non-crew • Use of winches for rescues • Weight restrictions • Restrictions on hovering rescues • Use, practice of one-skids and toe-ins • Use of short hauls and rappel rescues

23. Extended Care Issues

24. Long-term hydration Dislocation repositioning Wound cleaning/care Impaled object removal Non-pharmacologic pain management Pharmacologic pain management Assessment/care of head/spinal injuries Hypothermia/ hyperthermia management CPR termination Crush/compartment syndrome management Protocols

25. Environmental Considerations • Weather/Temperature Extremes • Risk of hypo/hyperthermia • Difficulty in exposing patient for assessment • Use of specialized packaging

26. Environmental Considerations • Limited Patient Access • Inaccessible parts of patient • Cramped space • Low lighting conditions

27. Environmental Considerations • Difficulty Moving Equipment • Identify minimum essential equipment • Carry in backpack

28. Environmental Considerations • Cumbersome PPE • Restricted rescuer mobility • Temporary removal of PPE to perform procedures

29. Environmental Considerations • Patient Exposure • Covering for thermal protection • Hard protection from sharp objects, debris

30. Environmental Considerations • ALS Skills • Wires, tubing complicate extrication • Limit to absolute necessities • Oxygen may have to be given at slower flow rates to prolong cylinder life

31. Environmental Considerations • Patient Monitoring • Modification of procedures (palpated BP) • Modification of equipment (compact pulse oximeters) • Non-use of equipment (ECG monitors)

32. Environmental Considerations • Improvisation • Splinting using patient’s uninjured body parts • Light-weight splints • Downsized or improvised medical gear