How to Assess and Treat Injured Firefighters

Literature on the topic of rapid intervention, like many other subjects, began as individual articles, grew into larger chapters and has now evolved into entire textbooks. It is such an important topic, in part, because the larger concept of overall incident safety has become much more of a priority than in the past. This area, again like any other, will continue to evolve. The purpose of this article is to start with the subject of rapid intervention and build on it, taking the discussion in a new direction.

Consider this scenario: At a residential house fire, where all departmental rules are followed and all of the firefighters act appropriately, a firefighter falls through a weakened area in the floor and radios for help using the LUNAR format. A rapid intervention team (RIT), already staged, enters the home and with the help of other firefighters successfully removes the injured colleague. The RIT members are successful because rapid intervention has been covered in numerous texts and training programs and the team has the proper training and equipment to complete the task. The injured firefighter is brought outside to a safe area. Rapid intervention is now complete, and all those involved in the rescue are accounted for and directed to the rehab area.

It is at this point, at the completion of a rescue, that a new area of discussion can be suggested. While the body of literature addressing how to remove a firefighter from a hot zone has grown exponentially, there seems to be a gap in the literature concerning the care of the injured firefighter once he's successfully removed from a building. This gap is the focus of this article—managing an injured firefighter after he's successfully rescued.

There are established practices for how to rescue an injured firefighter through a window, or down a ladder. However, once the firefighter is brought out of the house to a front lawn or street, and medical care is initiated, a new set of questions is raised. For example, how should he be positioned? Can he be immobilized while in full protective clothing and SCBA? Is it faster and/or safer to cut off his turnout gear and SCBA, or remove it in the normal fashion?

There are published procedures for the removal of a motorcycle helmet¹ or the pads and helmet of a football player, but no established practices exist concerning a firefighter. Yet, in comparison, football gear does not fully envelop the player and weighs less than 30 pounds, while a full firefighting ensemble does encapsulate the firefighter and can weigh up to 75 pounds (50 pounds turnout gear plus 25 pounds SCBA). Therefore, some type of rapid, systematic approach is needed for removing a full protective firefighting ensemble from the firefighter/patient to ensure any existing injuries are not aggravated and new ones aren't created.

Clearly, no two rescue scenarios will be the same. However, it's possible to create general categories, such as conscious versus unconscious, or ambulatory versus non-ambulatory. It is also possible to identify typical patterns, such as the firefighter who falls or becomes lost, calls for help but is still able to self-rescue. It is important to remember, though, that the specific injuries will always be different, depending on the events that led to the rescue.

In the context of the injured firefighter who has been rescued from a building, the firefighter will present in one of three general categories: 1) cardiac arrest, 2) breathing, but unconscious, or 3) conscious. Of course we could further create more detailed subcategories. For example, under category 1, he could be in respiratory arrest only, or under category 3, there could be varying levels of consciousness. Whatever the circumstances, as this patient is assessed and treated the integrity of the spine and the patency of the airway both need to be protected. Just as in the management of a football player or any helmeted and/or protected patient, a system is needed.

In order to explore this area more thoroughly, discussions were held with firefighters and paramedics. Practice scenarios were conducted in order to find the best method of beginning patient assessment and treatment, while removing the turnout gear and maintaining the integrity of the airway and spine. The scenarios were meant to begin with a rapid intervention setting and evolve from there.

The first point of discussion was the initial presentation of the patient, which would represent the conclusion of the rapid intervention process. It was found that a conscious and oriented firefighter, with minor injuries, could walk out of a building, alone or with assistance, and then assume a position of comfort while he doffed his gear or was assisted in doing so. This would be the firefighter who was able to self-rescue, or who received minimal assistance—perhaps one who had received soft tissue injuries or an extremity fracture.

The patient who is seriously injured or unconscious, or whose mental status is decreased, however, would be carried, dragged or lowered out of a building. In this scenario, it was noted that almost inevitably the rescuing firefighters would lay the patient supine but tilted to one side because of the air cylinder (Figure 1). Consequently, this is probably the most common position in which rescued firefighters would present, and would represent the starting point for their assessment.

Assessment of the ABCs can begin immediately, with the turnout gear still on. It is not an accurate assessment until the face piece is removed, but if the patient is breathing adequately this will be heard through the mask. Slow or shallow breathing may also be heard, depending on the actual rate and quality. However, one of the first actions, as soon as the patient is out of the IDLH atmosphere, is to disconnect the regulator from the mask. Assessing the ABCs of the conscious patient will clearly be easier, and further, he will be able to state the location of his pain or injuries.

Depending on the mechanism of injury, a cervical injury should be suspected; depending on the method used to rescue the firefighter—for example, the fireman's carry or inward ladder method²—the spine may or may not be stabilized. So, as with other patients, this must be started simultaneous to the ABCs by holding the head on the sides, similar to the initial stabilization of a driver of a vehicle (Figure 2). Removal of the turnouts should then be thought of in three steps: head and neck, upper body, and lower body, with the speed of each step and the method chosen (cutting vs. loosening) dependant on the severity of the patient's injuries.

Remember that the head of a firefighter is protected by three items: a helmet, protective hood and face piece. While the head is still being held from the sides, the helmet must be unstrapped and removed. Next, the front neck area of the hood should be cut straight down from the face opening to the bottom, and pulled to the sides (Figure 3). The head should now be stabilized with one hand on the mandible and another at the occiput, similar to the initial hand position on a motorcycle helmet. This allows the hood to be pulled completely to the back (Figure 4). The mask straps are now exposed and can be either loosened or cut, and the mask pulled out of the way. The face piece and hood are being held in place only by the provider's hands. Stabilization of the head is now transferred to the sides again, giving access to the back. With the hood and mask completely separated, all items are removed from the head and neck. Attention can be turned to the upper body.

At this point the patient is still supine, lying on the harness and cylinder, and a provider is maintaining cervical stabilization from the sides. Since the waist strap has an accessible buckle, it can be easily removed. Due to its thickness, don't bother trying to cut this strap. But if an upper-chest strap is in place (MSA SCBA has this strap, Scott does not) it should be cut, because it's thinner and can be tighter. The shoulder straps should also be cut, at the lower adjustable section (Figure 5), again to reduce patient movement. However, don't remove the SCBA yet. Instead, unfasten the turnout coat and cut the sleeve that's facing up, starting at the wrist and proceeding up the arm. Instead of continuing to the thicker or bulkier collar, turn near the armpit and continue cutting straight across the chest to the opening of the coat (Figure 6). Turn the patient so he is completely recumbent. While the patient is in this position, the SCBA may be completely removed, the coat pushed to the ground, and the suspenders and street clothes or uniform cut, so the back can be assessed and a backboard potentially placed against the back. The patient can now be laid flat and the uncut side of the coat pulled off (Figure 7). The head, neck, torso and arms should all be exposed now, and the patient should be correctly placed on a board. A cervical collar can now be applied. With the airway properly managed and the spine protected, the final section—the lower body—can be addressed.

At this point, the patient is supine on a backboard and wearing only turnout pants and boots. Because of their construction, and the body area they protect, it's recommended the boots simply be carefully pulled off in a normal fashion. However, the pants should be cut, due to the fact that the lower body has not yet been assessed and blood loss in the thighs (up to 2,000 ml) and in the pelvis can be massive.¹ Immediately after the turnout pants are cut, the patient's regular pant legs should be cut as well. Now completely exposed, the patient can be fully assessed and immobilized.

Bear in mind, no two rapid intervention scenarios will be the same, nor will the injuries of the firefighters. Further, the details of the scenario will play a large part in determining the speed and methods used in the removal of the turnout gear. Clearly, though, to better care for the firefighter who has been injured and successfully rescued, a system is needed. Just as procedures exist for the removal of equipment from the athlete or motorcycle rider, a procedure should also exist for the removal of a firefighter's protective ensemble.

References

1. NAEMT. Prehospital Trauma Life Support. St. Louis, MO: Mosby JEMS Elsevier, 2011.

2. Jakubowski G, Morton M. Rapid Intervention Teams. Stillwater, OK: Fire Protection Publications, 2001.

John G. Alexander, MS, NRP, is a retired fire captain and has been involved in the career and volunteer fire service for 33 years, including 26 years as a paramedic. He is currently a full-time faculty member at the Maryland Fire & Rescue Institute, University of Maryland.

Christopher T. Stephens, MD, MS, NREMT-P, FP-C, has a BS in biology from Loyola Marymount University, a MS in pharmacology from the University of Houston College of Pharmacy, and MD from the University of Texas, Medical Branch, School of Medicine. He is currently assistant professor of anesthesiology at the University of Maryland School of Medicine and attending trauma anesthesiologist for R Adams Cowley Shock Trauma Center in Baltimore, MD, as well as director of education, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, medical director for the Maryland Fire & Rescue Institute and an instructor for the Maryland State Police Aviation Command.