Extraordinary Extricaton

     Attack One is dispatched for a report of a person injured in a fall. As they respond, the crew is notified of a potential trap situation from a building collapse, and the dispatcher upgrades the response to include extrication equipment. It is a beautiful day, warm and sunny, and the area of town is one that has large decks which occasionally collapse. There has been discussion in the past about the potential for an incident where patients are down under a wooden deck behind a home in this area.

     But as Attack One pulls up to the house, a frantic person is looking down below the front door. To the crew's surprise, there is a man lying at the bottom of about a 15-foot drop through a broken and dangling cement front porch. He is in a partial sitting position, unresponsive and partially covered by a large chunk of the cement pad he fell through. His wife says he "just walked out the front door, and the cement gave way." She says he was originally groaning, but then became unresponsive.

     The man is in a pit measuring approximately 8 feet by 7 feet. The cement slab that was his front porch broke into pieces, and portions of it are dangling down, barely attached to the house. The front wall, farthest from the house, also broke up, and some large segments fell onto the legs of the victim. His head is obviously injured. He does appear to be breathing.

     The crew quickly locates some strapping material and a ladder, but cannot safely enter the cement-lined pit. The concrete sections hanging from the wall could fall at any time, and there is no way to safely shield anyone who's in the hole. As the extrication crews arrive and quickly build rigging to hold the concrete pieces in place, the paramedics prepare the small amount of equipment that could accompany them into the pit. The crew agrees to carry down the airway kit, a bag-valve mask, a short board and cervical collar, a pulse oximeter, a blood pressure cuff and bandaging material for the patient's legs, to which the extent of damage cannot yet be determined. All other equipment will be ready topside following the extrication.

     Using a unique approach that strings the rope stabilizers through the front door of the house to the back porch, where they can be anchored, the extrication crews quickly place webbing material onto the dangling sections of concrete. The remaining part of the front wall is stabilized to prevent further collapse onto the victim. At this point, a ladder can be dropped into the pit, and the crew can descend to the victim. They find him unresponsive but breathing. The pulse oximeter shows a heart rate of 60 and perfusion of the fingers with a pulse oximeter reading of 92%, and the crew counts a respiratory rate of about 32. The victim has a large head gash, but no depressed skull is noted. Bleeding is controlled, but the man's pupils are small, and response is sluggish. No obvious chest or abdominal wounds are visible. The lower legs are trapped under an almost vertical section of the front wall measuring about 4 feet by 6 feet. One foot can be accessed, so the patient's shoe and sock are removed, and the pulse oximeter placed on the toe. No pulse reading can be obtained.

     The victim is trapped under the largest section of the wall, plus some smaller segments. The extrication crew will need to lift these out of the hole before the victim can be removed. Preparing the lifting elements will take several minutes, so the medics have a short time to stabilize the victim's airway and prepare for a short-board immobilization. The cervical collar is placed. The victim's torso is partially upright, with his back against the concrete wall, providing an excellent position from which to perform an upright endotracheal or nasotracheal intubation. With some facial trauma evident, the crew thinks that endotracheal intubation from the victim's front will be less traumatic than attempting it through the nose. Capturing his airway at this point will protect it during the lifting process and reduce the risk of aspiration during the lift and subsequent immobilization in a supine position.

     The Attack One medics are skilled at upright intubation, which they often perform on victims trapped in automobiles. This victim can only be approached from the front, so the blade is slid into the man's mouth, and the tube and stylet passed alongside. The second crew member provides enough cricoid pressure and stabilization to allow the tube to pass on the first attempt, and the patient is then bagged. Chest wall movement is symmetrical, and no air is felt in the stomach as the ventilation is performed. There is too much noise from the extrication activity for any attempt at auscultating airway sounds, so the medics use the feel of chest movement as their basic evidence of good tube placement. With the airway in place, the short board is prepared with packaging straps.

     The victim is noted to have adequate peripheral veins, but it would not be worthwhile to attempt line placement in the hole. The topside crew is informed that large intravenous catheters will be appropriate once the victim is lifted to them, and several liters of fluids are prepared in pressure infusers. The extrication crew does a remarkably timely job of preparing for the lift, and the wall segment is safely raised off the victim and out of the pit. The man has severe trauma to both legs, and the pulse oximeter gets no readings on either foot. The Attack One crew straps the victim onto a short board, and he is placed in the lift and raised to the waiting crew above. There, supplemental oxygen is provided, he's immobilized on a long board, two intravenous lines are placed and fluid pressure infused, and then he is prepared for an air transport to the trauma center.

     Shortly after the extrication is completed and the crew leaves the hole, one large segment of the concrete slab breaks loose and crashes into the pit below.

Hospital Course
     The patient had critical head, abdominal and leg injuries. The trauma team collaborated for stabilization and then an intense rehabilitation period, and the patient had a great outcome.

Organization and Scene Management
     This incident involved an unexpected and intense extrication of a critical patient. The man had fallen into a deep void that unknowingly existed under his front porch. The concrete slab failed, and a portion of the supporting wall was pulled in on top of him. Large pieces of concrete dangled over the victim. Once those dangers could be partially stabilized, the small area at the bottom of the pit would allow a very small number of rescuers with minimal amounts of equipment. All rescuers needed to operate in full protective wear, in a noisy rescue environment. And the patient had critical injuries and would need to be lifted out of the hole.

     As with all extrications, there is a balance that must be maintained between the priorities of medical care and extrication. It is a critical role for Incident Command to moderate both functions, so that both timely extrication and lifesaving stabilization and treatment can occur. When the patient is critical, time management is very important. Each of the provider groups-medical and extrication-must carefully select and then carry out their critical functions.

     In this incident, the extrication crew needed to stabilize the area over the victim, prepare a lift system and provide access to the victim without harming the rescuers or the patient at the bottom of the hole. The medical care providers needed to access the victim with a small number of tools, stabilize the airway in an unconventional position and not initiate procedures that would ultimately make moving the patient more difficult. Another medical care team was also working in the front of the house, preparing to receive the patient topside and provide needed interventions and rapid transport.

     Command was established, and the crews made great decisions in prioritizing care. Safety concerns were recognized as a priority, and when the major hazards were addressed, access to the patient and emergency medical care were initiated.

Critical Decisions
     What other clues from the scene or patient presentation could have helped diagnosis in this case? The mechanism was apparent, and the wife provided the necessary history. All physical injuries could be identified through the mechanism of injury and limited physical assessment possible.

     Was this the only treatment path? The best management path is rapid assessment, appropriate packaging and stabilization for removal from the confined space. Certain interventions were delayed because they could not be safely performed in the available space and the patient had to be lifted by himself (i.e., no rescuer could walk or ride along with him to carry IV fluids or hold an oxygen cylinder). Airway management was done with the patient still upright and the tube stabilized for the lift. A simple bag-valve mask allowed the crew to support ventilation.

     What communications are critical for the patient? The most critical communication was that carried out between the extrication crew and the medical crew in the confined space. It allowed each to do their work safely, in the shortest time possible. Additionally, the topside crew needed to prepare for the interventions that could not be performed in the space, and for rapid transport.

     Would different equipment or medication have helped? Not in this case.

Medical Decision-making
     A severely head-injured patient is a potential crisis, and airway compromise will worsen both immediate and long-term damage. As demonstrated by this patient encounter, the airway can be managed while the victim is still trapped, especially if the victim is upright. Two typical trauma interventions were selectively avoided in the initial resuscitation to minimize the difficulty of lifting the patient out of the hole: Oxygen administration is beneficial but not immediately lifesaving, and the pulse oximeter confirmed that the upper body was adequately oxygenated. A bottle would make care more difficult in the small space, and especially during the lift, so it was left above. Similarly, establishing an IV line and administering fluids would have been difficult in the space and during the lift, so this was also left as a priority for the topside crew.

     The pulse oximeter, on the other hand, is an excellent and compact tool. It provides great information related to the status of a trauma patient, with the pulse rate and perfusion of the distal portion of the extremity. It is one tool that should be part of every trauma assessment.

     Airway management by endotracheal or nasotracheal intubation with the patient upright is a necessary skill for prehospital providers. It is a great skill to practice during monthly training and in the procedures lab.