Confined space rescue operations present rescuers with difficult patient packaging and transfer scenarios. This is due to the internal configuration of confined space enclosures and portal opening size limitations. The removal of patients to a safe environment can become a grueling task especially when rescuers are hindered by the presence of  breathing apparatus, airlines, communications devices and rope rescue systems.

Patients that must be quickly accessed, stabilized, supplied with respiratory protection, and then maneuvered through various obstacles create great difficulty for rescuers. Many confined space scenarios will force the rescuers to move patients through narrow tight spaces where the rescuers upper body strength cannot be maximized. Training and planning for effective patient packaging and removal are essential elements of a successful confined space rescue.

This article will address confined space patient packaging alternatives and considerations, as well as the planning aspects of a patient removal task.

Learning Objectives

The student will:

1. List patient packaging devices that can be utilized for a confined space     rescue.

2. Discuss alternative methods for patient packaging and removal.

3. Identify and discuss patient removal planning considerations for a           confined space incident.

The safety of rescuers is the fundamental concern when operating at any confined space rescue event.  Atmospheric monitoring, ventilation, control of energy sources, maintaining competent communications systems, and implementation of an incident management system are all requirements of a confined space rescue operation. These requirements must mesh with the patient care aspects of the event.

Generally, confined space patient packaging is performed in a manner considered appropriate for the patients clinical condition. This will include the prevention of any glaring cervical spine movement if at all possible. Real world scenarios inside process vessels, sewers, or tanks cars may not always allow for the preferred patient packaging procedure.

The characteristics of the confined space such as the size of the access opening, internal configuration, and obstacles which the patient must be maneuvered around, will dictate the type of device used to package the patient. Atmospheric conditions and their effect on the patient will also dictate how quickly the patient must be removed, and how much time can be allowed for packaging.

Easily accessed patients that need rapid removal to a non-hazardous atmosphere in order to survive, can be attached to wristlets for rapid removal. In this situation the patients chances for survival are reduced unless they can be quickly moved to a safe environment. A low oxygen level, toxic condition, or highly flammable atmosphere may not allow for a proper, yet time consuming patient packaging scenario.

In other situations the rescue team may be able to quickly access the patient, supply breathing apparatus to the patient, and then more effectively package the patient for removal. Patients with obvious or suspected trauma due to falls or contact with other physical hazards need to receive effective cervical spine stabilization and proper packaging.

However, this should occur after the environment has been stabilized (ventilation supported by monitoring) and/or respiratory protection has been implemented.

Confined space patient packing devices must allow for the patient to be maneuvered through narrow access portals, around extremely tight corners, and through long narrow areas such as sewers or tunnels. The packaging device must allow the patient to be tightly wrapped in order  to lessen the profile of the patient while at the same time allowing  flexibility for movement of the patient around tight turns and through obstacles.

Rigid stretchers, (long backboards),  may allow for good patient stabilization, however, they are impractical for movement of patients in tight quarters.

The patient removal evolution in a confined space will require rescuers to navigate around piping, mechanical equipment, and through hatchways. . Commercially made devices such as a SKED device or Reeves Sleeves have proven to work well in these situations with some limitations.

When utilizing the SKED device it is usually beneficial to unfold the device and prepare it for use prior to taking it into the space. The device is difficult to unfold in an area with limited space.

As the patient is packaged in the SKED it is important to use a half board or full spinal immobilization board inside the SKED if it will be required to pivot the patient over an obstruction. If a spine board is not used, the patient will bare the full force of the pivoting action as the pivot point will normally occur on the patients back. The trade-off of using a full backboard with either of these devices is that flexibility and maneuverability in tight spaces will be lost.

The Reeves Sleeve can be used with a half backboard inside the device to supply spinal immobilization while at the same time allowing for flexibility in the pelvic area for maneuvering around corners and objects. Both of the devices are designed with smooth surfaces so that they will not be caught on protrusions. However, heavy use of the Reeves Sleeve device both in practical training and actual rescues has proven that the device will experience serious wear on the outside covering over an extended period of time

Many confined space situations will require rescuers to utilize a spinal immobilization device that can be attached to a retrieval line for lifting with a tripod and mechanical advantage system. The LSP Halfback device has proven to work well in this situation.

An alternative option is to use a non rated spinal immobilization device such as the KED board in conjunction with a full body harness or improvised rescue harness. Although not as clean a package as the commercially rated lifting device, it will work successfully.

Patient Removal Planning

Action plan development for a confined space rescue should include plans for patient packaging, removal, and final transfer to a transport unit. The level of patient packaging and removal difficulty will change depending on the complexity of the incident. A rescue of a worker down in a utility vault will require a simplified plan as compared to a maintenance employee trapped inside an elevated water storage tank that is located 100' above ground level.

Patient removal planning should include identifying and staging the needed packaging equipment. This  includes patient packaging devices as well as rope rescue gear. If the decision is made to access and supply respiratory protection to the patient, this must be a part of the plan including identifying the type of breathing apparatus and how to package it in with the patient.

Using supplied air breathing apparatus or egress bottles to supply respiratory protection to the patient usually allows for easily packaging the unit into the device with the patient. The use of SCBA for this purpose generally is difficult to attach, is too bulky and increases the profile of the patient. This will create difficulty moving through hatchways and other limited openings.

Once the patient is located the exact path for removal must be identified along with any obstacles that must be traversed. Situations that will not allow rescuers to maximize their upper body strength should be identified. These situations may require multiple entries for removal or extra personnel inside the space at the same time.