Best Practices: Approach to the Residential Roof Rescue
Editor's Note: We have retooled the "Best Practices" column to address operational issues that may surface in particular incidents rather than focus on administrative issues as we have previously done. If you have an interesting EMS incident which you would like to submit for critique, evaluation or just to ask a question about a best practice related to direct patient care or incident management, send it along with a maximum of 3 questions or discussion points to Dr. Jaslow at jaslowd@einstein.edu. We can not guarantee that the case will be reviewed, but we will provide you feedback within about one month.
Case submissions should be succinct and contain pertinent dispatch, scene and patient care details. The preface to incident details should appear as it does in the original piece on Airway Management. Scan ECGs or convert to PDF when necessary. This column is not a "guess the diagnosis" or "prove the receiving ED wrong" forum. Therefore, discharge diagnoses or a solid ED working diagnosis should be present so that the readership can understand why this case has educational value to our nation's EMS professionals. Do not guess about the diagnosis! The ideal case for presentation will also contain one or more photos depicting scene conditions, patient pathophysiology, etc. The photo must be altered to prevent identification of the patient. Obviously, we assume that patient care was not compromised to obtain the photos and we hold authors responsible to this standard.
Case Presentation:
Date: 3/22/07
Agencies: Bryn Athyn Fire Company, Huntingdon Valley Fire Company
Location: Montgomery County, PA
Incident type: Penetrating trauma; technical rescue
Injuries sustained: Through and through puncture wound of left mid-foot by 4 inch roofing nail
Incident summary
Bryn Athyn and Huntingdon Valley Fire Company units were dispatched on a technical rescue assignment for what was initially described as a construction worker who was trapped on the roof of a house by a machine which had fallen on his leg. En route the information was updated by Montgomery County Emergency Dispatch Services to a worker who had unintentionally shot himself in the dorsal aspect of his left foot with a four inch roofing nail from a nail gun. The nail exited the plantar surface of his foot and implanted into the roof pinning the patient's foot to the plywood planking.
A cross-trained/dual role firefighter/EMS crew composed of an EMT-Basic with 30 years experience and an EMT-Paramedic with 15 years experience, both of whom are NFPA 1006 rescue technicians, responded to the incident and arrived quickly behind law enforcement units. Scene size up revealed an injured person and several other workers on the side "B" roof of a two story, ordinary construction, detached single family dwelling. The patient was awake and alert complaining only of pain in his foot, which was still encased in his work boots. Fellow workers had used a pry bar to disengage the patient's foot from the roof just prior to EMS arrival.
An immediate decision was made by the EMS crew to ascend to the roof to assess what medical and logistical concerns existed prior to arrival of the balance of the first alarm assignment. Initial access to the patient was made via a standard aluminum ground ladder found on the opposite side of the residence which was owned by the construction workers. The crew decided that their standard fire department work uniform and work boots would provide adequate protection in terms of PPE.
A SAM splint was applied to the patient's left lower leg to stabilize the foot, thereby reducing movement and lessening pain. Arriving fire officers worked with the crew to plan proper placement of the tower ladder bucket for extrication. Once the apparatus was positioned and outriggers secured, the boom was extended to the roof and the bucket was placed approximately five feet from the patient. Then a safety harness was placed on the patient and he was assisted into the bucket where he was secured for the ride to ground level. He was transferred to an awaiting ambulance litter and placed into the ambulance where an IV was established and morphine was administered for pain management. The patient was transported to the local Level II trauma center for definitive care and treatment. He was treated and released later that day.
Discussion Points
1. Strategy and tactics for execution of a residential roof rescue
Residential roof rescue incidents are relatively straightforward from the fire-rescue standpoint. There are two clear cut objectives: 1) extricate the patient as rapidly as possible 2) perform this rescue safely to prevent injury to emergency responders as well as further morbidity to the patient. A successful strategy to achieve the objectives invariably involves using either ground ladders or aerial devices or both to access and eventually extract the patient. This strategy is implemented through three tactical phases: 1) patient access and initial evaluation 2) deployment of essential equipment and personnel to the roof and/or positioning of aerial apparatus to perform the rescue and 3) the actual immobilization and/or extraction phase in which the patient is brought down to the ground from a height.
Residential rescue may not appear complicated, but it is by definition a technical rescue. Thus, to the degree possible, its performance is guided by the NFPA 1670 standard. Although there is no subsection in this standard for roof rescue, these incidents most closely resemble rope and high/low angle rescue events. The 1670 standard is particularly valuable because it stresses safety, use of ICS, and performance of rescue skills only by properly trained personnel. These points are discussed in the General Requirements section at the beginning of the standard.
Typically, these incidents require a relatively small amount of rescue equipment especially if a tower ladder or snorkel is available which precludes the need for complex rope evolutions. Emergency responder access to the patient is usually made via the same pathway as the patient, typically a ground ladder which is still in position. A ropes/rigging system is necessary if a rescue basket must be lowered to the ground or lowered down an aerial ladder main. A rescue basket is recommended when the patient requires immobilization or he is unable to stand or sit upright. The patient, and in certain circumstances the rescuers, should be secured to the aerial device or a fixed point which will not fail by a harness or webbing prior to being moved to the aerial device or prior to engaging in any activity which could lead to a fall from the roof. The patient is then assisted or carried to the bucket or he is placed into a rescue basket which is secured to the aerial device or lowered via the aerial device to the ground.
EMS personnel should anticipate a period of at least 30 minutes until the typical roof rescue is complete as measured from the time of dispatch. However, this time hack assumes a two story residence, good weather, adequate access for fire apparatus positioning, rapid response by emergency services and a stable patient who does not require resuscitation. If one or more of these conditions are not met, the rescue will likely require more time to complete.
2. Appropriate PPE for a technical rescue incident
NFPA 1670 instructs the Incident Commander and the Safety Officer to jointly decide what elements of the personal protective equipment (PPE) ensemble are necessary at a technical rescue and when they must be worn. The same concept is echoed in several NFPA standards on health and safety and incident management (1500 series). However, it is difficult to make blanket recommendations in a national standard concerning which components of the PPE ensemble are required for every technical rescue incident considering the many factors which are involved in making such a decision.
Non-fire related residential roof rescues will rarely involve risks of direct blunt or penetrating injury to emergency responders during the rescue provided that they do not fall off the roof or from a ladder. Furthermore, a fall off the roof of a dwelling is very likely to produce potentially serious orthopedic, head and internal injuries. There is no evidence to date that such injury patterns will be less severe or avoided altogether because standard firefighting or technical rescue PPE is worn. However, it is quite possible that bulky PPE may cause the emergency responder to have limited mobility and increase the risk of loss of balance while on a roof. Similarly, rubber firefighting boots are probably not the best choice for standing on a sloped roof when compared to standard emergency services work boots or fire-resistant leather boots.
We believe that the standard work uniform with modifications for weather and environmental conditions provides adequate protection for emergency responders engaged in a residential roof rescue. Why is there typically a lack of uniformity of PPE at an incident scene? Common reasons may include volunteers who do not wear standard work uniforms routinely and who may respond directly to the scene or station from work or pleasure, lack of a policy concerning PPE use at a technical rescue, no choice other than firefighting PPE and an incorrect assumption that firefighting PPE offers a greater degree of protection regardless of incident type. Emergency response agencies are encouraged to create SOPs and educate their personnel concerning this issue.
3. Emergency medical care at a residential roof rescue
Medical complications which produce the need for a residential roof rescue can be divided into trauma and non-trauma. Traumatic injuries are largely the result of construction mishaps among "professional" and amateur (homeowner) laborers. Such injuries include head injuries from striking fixed objects, falls onto or off of the roof, and penetrating injuries from saws, nail guns, other power tools and punctures to the plantar aspect of the foot. Non-traumatic conditions can be divided into those which are precipitated by exertion, such as acute coronary syndrome, and non-exertional conditions such as hypoglycemia, seizures, respiratory distress, allergic reactions to insect bites/stings, etc.
From an acuity standpoint, few medical emergencies that occur on a roof which require 911 activation can be characterized as minor, since the patient would be expected to self-extricate if that were the case. Consequently, EMS personnel must quickly evaluate the patient and decide whether or not he requires emergency medical treatment on the roof prior to evacuation. Such care can be both difficult and dangerous to administer due to slip and fall hazards created by the pitch of the roof and/or foul weather conditions. While history-taking can be easily accomplished either at the patient's side or from the ground provided that the patient is able to communicate, it is rarely necessary to perform a hands-on physical exam to make a decision about what immediate treatment is indicated. Heart rate, respiratory rate and respiratory effort combined with level of consciousness and degree of distress should predict patient acuity.
A best practice philosophy which promotes responder safety as the number one priority dictates that medical therapeutics which are neither life or limb-saving be kept to the minimum necessary to expedite the rescue process. Diagnostic tests should be limited to the few rapid studies which may confirm the severity of illness and/or predict the need for IV access or resuscitation prior to extrication. Such point-of-care testing may include pulse oximetry, blood glucose testing and 12-lead ECG.
If there is a delay in rescue, the latter test should be performed for any patient with cardiac symptoms in order to determine whether ST-segment elevation MI (STEMI) exists, which would prompt the placement of IV access, an "all hands" philosophy to complete the rescue process and a notification to the closest hospital with cardiac catheterization lab capabilities. This action may be the single most important contributor to saving a life. Otherwise, this procedure can be accomplished in the ambulance.
Dr. Jaslow is the Chief of the Division of EMS and Disaster Medicine and the Director of the EMS Special Operations and Disaster Medicine Fellowship program within the Department of Emergency Medicine at Albert Einstein Medical Center in Philadelphia. He is the Assistant Chief and EMS Medical Director for Bryn Athyn Fire Company, Medical Director of the Bucks County Technical Rescue Task Force and Medical Director of Pennsylvania Task Force-1 Urban Search and Rescue. Dr. Jaslow serves on the editorial advisory board for Advanced Rescue Technology and as the Medical Editorial Consultant for EMS Magazine. Kevin Gordon and Jeff Tarman are career personnel at Bryn Athyn Fire Company. Eric Maier is a member of Bryn Athyn Fire Company and he is a Lieutenant at its neighbor and automatic aid department, Huntingdon Valley Fire Company. Eric is a certified fire investigator who serves as the career Fire Marshal for Lower Moreland Township.
