Medical Aspects of Urban Search and Rescue
BY JOSEPH A. BARBERA, M.D., FACEP; CRAIG DeATLEY, PA-C, EMT-P; ANTHONY G. MACINTYRE, M.D.; and DEWEY H. PERKS, EMT-P
The Oklahoma City bombing triggered the largest organized federal urban search and rescue effort in U.S. history. While small scale in terms of the size of the typical federally declared disaster site (the area was measured in city blocks), the medical aspects of this response illustrate the many common medical issues that arise in acute disaster events.
Victims of this type of structure-collapse entrapment often have been found to be critically injured with unusual medical problems such as crush injuries and airway dust impaction.1,2 If extrication is not properly performed, it can markedly accelerate the pathologic processes in these entities and may cause rapid deterioration and death in a seemingly stable patient who had survived days of entrapment. These medical problems very often respond to immediate aggressive intervention by properly equipped and trained medical personnel.3,4,5
The FEMA Urban Search and Rescue System has developed the ability to provide this crucial intervention, which is an integral part of each task force in the system. The medical team is comprised of two emergency medicine physicians and four experienced paramedics. They are trained and equipped to begin patient evaluation as soon as the victim is reached and to provide confined-space critical-care medicine throughout the extrication process. More importantly, they are trained to provide medical care to the members of their task force throughout the hazardous USAR deployment.
Specialized technical medical equipment caches to accomplish the multiple roles of the medical management team include the following:
Portable pulse oximeters and cardiac monitors to evaluate and monitor the patient.
Lighted intubation stylets for confined-space intubation of the patient in respiratory distress and portable, automatic oxygen-powered respirators to ventilate the intubated patient.
Intravenous starter kits that use the Seldinger technique (wire guides and over-the-wire dilators) so that the cannulation (tube insertion) of a small peripheral vein (in the hand of a partially accessible patient, for example) may be converted to a large-bore IV that can provide large volumes of critically needed intravenous fluids if required to treat dehydration or crush syndrome.
Sophisticated extrication devices, such as the Sked Stretcher®, a flexible, thin polymer material that can be easily transported into the confined space and slid under the patient. When it is “wrapped” around the sides of the victim, it becomes rigid in the head-to-toe plane and so acts as an excellent spinal immobilizer (allowing carrying, sliding, and rope-rescue lifting and lowering as needed). Additionally, wrapping it around the sides of the victim provides significant protection to a patient in the very vulnerable supine position.
Other extrication devices, such as the Halfback® used to provide cervical and thoracic immobilization in a situation where the patient must be flexed at the waist to effect removal through a tight egress route.
Medical team personnel undergo a rigorous four-day training course that covers the basics of confined-space medical care using a lecture and discussion format. A series of skill stations and patient-care scenarios follow; specialized equipment and training are used to solve medical problems likely to be encountered in building-collapse situations. Darkness, noise, simulated electrical and other hazards–as well as uncooperative victims–provide a challenging and stimulating but safe educational experience. The course ends with a full-scale exercise in heavy rubble in which the medical and extrication equipment are used. The students must “put it together.” This experience has been shown to stimulate the student to pursue further training experience. The course also reinforces the need for continuous practice in using the highly specialized equipment and techniques needed to save lives and promote team health and safety.
OKLAHOMA CITY RESPONSE
When the bomb in Oklahoma City was detonated, a preplanned local EMS response of police, fire, and EMS personnel occurred. In addition, a large number of local medical personnel (M.D.s, RNs, techs) spontaneously responded to the scene. The first IST medical personnel were deployed the day following the explosion.
By the time the first federal USAR personnel began to arrive 12 hours after the explosion, the local authorities had established good perimeter control and had secured the site, overcoming many of the usual site-control obstacles. One of the more surprising challenges for them was the difficulty they encountered in clearing the initial medical responders from the Alfred P. Murrah Federal Building. It appeared to professional rescuers that the physicians, nurses, and other non-EMS medical workers had vested themselves so emotionally in the event that law enforcement personnel had to coerce them to evacuate the very unstable and dangerous site even after all known live victims had been extricated. The FEMA USAR Task Forces were used over the ensuing two weeks to search the dense rubble, recover bodies, and ensure that there were no deeply entrapped survivors.
Search and rescue teams encountered a very hazardous situation, with most of the slabs, concrete beams, and support columns fractured by the blast effect. Also, large amounts of sharp rubble (rebar, glass, broken office equipment), nonhorizontal slabs, and unsecured hanging debris were some of the hazards that threatened to cause multicasualty trauma situations throughout the two-week rescue and body-recovery effort. Consequently, the USAR medical teams were prepared to provide trauma care at all times that such activity was underway. Two Oklahoma City EMS units also were stationed at the perimeter of the Murrah Building site throughout the rescue effort to provide support and transport.
The outpouring of support from the local population was overwhelmingly positive and an essential component to the rescue organization effort. At the same time, however, this disaster again demonstrated vividly that uncontrolled delivery of donations to the disaster site may have deleterious consequences.
Food donations. A clear example of this was the food donations. Foodstuffs such as prepared pizzas and hot box lunches from a fast-food Mexican restaurant were being delivered at such a rate that food was piling up all around the rescue site. There were few hand-washing stations during the first 24 hours, so rescue personnel were exiting the debris covered with dirt and partaking of food that had been lying out in an uncontrolled atmosphere for undetermined periods of time. The consequences were very predictable: One of the first-arriving task forces had a vomiting/diarrhea illness (of almost certain foodborne origin) that affected nearly one-third of the task force to some degree; three task force members needed intravenous hydration and IV antiemetics to control their illness.
Portable bathrooms had been placed at the site early, but the importance of ordering hand-washing stations to accompany them was among the important lessons learned in Oklahoma City.
Other food and beverage issues arose. Among them was a hospitable local business`s donation (and setting up) of free beer on tap for off-duty FEMA USAR personnel. Although a generous gesture, this form of heartland generosity was quickly stopped to avoid compounding the fatigue generated by the rescue work. Local authorities were very responsive to all these issues, and appropriate monitoring and control of food and beverages by the Health Department was accomplished expeditiously.
Decon. Local rescue authorities became concerned early in the incident about the infection potential of dead bodies, body vapors, and decomposing human tissue. Prior to the arrival of IST medical personnel, Oklahoma City Fire/EMS had set up decon stations and were fully decontaminating their exiting workers with a weak Lysol® solution. While the decon setup and procedures were very well done, the need for this effort-intensive and potentially hazardous activity was never clearly established. Unfortunately, the hazards inherent in decontamination were manifested when a staffing shortage for the decon stations arose during one of the early night shifts. While local EMS haz-mat personnel were being relieved by Air Force workers, decon solutions were inadvertently switched or combined, creating a caustic solution that penetrated the turnout gear on several Oklahoma City firefighters, causing chemical burns. The decontamination procedure was immediately revised, and only appropriately trained personnel were assigned to this duty station thereafter. No other problems occurred.
Other decontamination procedures, such as washing down the sites from which bodies or body tissue had been removed, may at first seem to be a harmless activity. However, the slipping hazard created by wet surfaces and the psychological risks to rescuers below the site who may be subject to dripping fluids also must be considered before instituting this questionably useful practice.
Additional issues. Multiple other medical issues, including the following, were encountered by task force medical teams and IST medical personnel.
A rescue team member of one USAR task force developed chills and flu-type symptoms on the military aircraft en route to Oklahoma City. The following day, he experienced rigors, a fever greater than 106ºF, severe headaches, and myalgias. It appeared to the task force emergency physician and the local emergency department physician that he had influenza. This presented the possibility of potentially infecting the entire 56-member task force during the close-quarters exposure on the military aircraft. Administering amantadine as a prophylactic medication for influenza was considered, but its antihistamine side-effects would have necessitated demobilizing the task force. There was also the concern that, since influenza is highly contagious, it could be passed on to other FEMA and local community rescuers. It was known at the same time, however, that a viral illness that caused similar symptoms but defervesced within 24 hours had been occurring in the area of the task force`s home base. After carefully considering all the issues, it was decided that the task force would be isolated as much as possible and would complete its current work shift but would be demobilized the following day if the index patient continued with a clinical course so consistent with influenza. Fortunately, he improved rapidly and recovered completely over the following day; the diagnosis of influenza was eliminated. The task force was able to complete its tour of duty in Oklahoma City, but the psychological effects of the threatened demobilization were significant.
Nurses, apparently sponsored by the Red Cross, were canvassing the rescue site attempting to administer tetanus toxoid to anyone who had not received a tetanus booster during the past two years. This is not only useless for people with up-to-date immunizations (within five to 10 years), but it is also potentially dangerous since frequent tetanus boosters are associated with an increased likelihood of developing a significant local reaction (redness, severe pain, and swelling). This type of response at the injection site in the upper arm essentially could demobilize a task force member from rescue site activities for several days. Through direct intervention (explaining to the nurses that they were not to offer the booster to any FEMA USAR personnel since they were all up-to-date as part of their deployment preparation) and education of task force personnel by their respective medical teams, unnecessary immunizations were avoided. Later in the response, other injection teams attempting to administer Vitamin B12 to rescue personnel circulated.
The psychological stress encountered during this response was typical of that of an overwhelming prolonged incident. Initially, it was dealt with through the USAR Task Force`s use of frequent briefings that stressed the normalcy of a stress reaction and education related to the symptoms and manifestation of stress. This information was reemphasized throughout the response. Task force personnel were continually monitored for behavioral changes indicative of critical incident stress (CIS). If discovered, formal and informal solutions were sought. During this incident, Oklahoma City public and local response workers (the fire department and EMS, veterinary and medical communities, Salvation Army, Red Cross, and spontaneous volunteers) helped tremendously to defuse this stress through their overwhelmingly generous support and frequent expressions of thanks. This kindness helped combat one of the primary causes of stress in a prolonged incident: that of action-oriented personnel having to deal with an incident that is “bigger than they are” and in which the sense of control and, therefore, effectiveness is very elusive. Also, volunteers trained in critical incident stress debriefing (CISD) were available for task force personnel at both bivouac areas.
Families of responders also experienced the typical stress of this type of response. Sources for this stress include the sense of danger for the responders, the sudden deployment that leaves spouse and family members with extra jobs and responsibilities, and the inherently poor information flow from the scene. Stress was often exacerbated by occurrences such as that in which a task force member strained his back and experienced enough pain so that he was evacuated to a local hospital on a backboard. The media inundated the hospital even before the ambulance arrived (they had been monitoring the radio frequencies of the rescuers and so had learned of the injury). Word of a “severe injury” had spread via news reports to the task force`s home jurisdiction prior to the task force leader`s ability to call home, identify the injured party, and explain the minimal nature of the injury. This caused consternation and needless anxiety, and it unnecessarily increased the stress impact on all of the family members of that task force.
Fatigue was an important consideration as the response progressed. Twelve-hour on-site periods translated into longer “on-duty” periods as equipment and supplies were moved to and from the base of operations. The many activities at the bivouac sites competed with the need for sleep and rest. This plus the extreme physical exertion of removing almost all the debris from the Murrah Building by hand resulted in some task forces` being “stood down” by their task force leaders (on the advice of their medical team personnel) prior to completion of some 12-hour work shifts, out of fear that fatigue could potentially compromise their health and safety. This decision was very appropriate and demonstrated the professionalism, maturity, and discipline of the task force system.
The Murrah Building had been constructed in the mid-`70s, raising the possibility that a significant amount of asbestos might be contained in the structure. The impact of the blast had fractured fire doors and had destroyed the heating systems and air ducts, all potential sources of asbestos. IST and task force medical personnel prompted task force personnel to use fiber-filtering respirators whenever they were in the structure while the issue of asbestos was being researched. Despite significant effort by the local fire officials, the EMS medical director, and IST medical personnel, it was difficult to ascertain with any degree of certainty the actual asbestos risk in the building.
Other workplace hazards were noted during the response. All of these issues were addressed by IST personnel by working with the local EMS medical director and through the county and state public health authorities (through a route consistent with the incident command system operating at the disaster). To ensure adequate control of workplace hazards, a request for assistance was made by local authorities to the Centers for Disease Control (CDC) in Atlanta. CDC and NIOSH (National Institute for Occupational Safety and Health) personnel responded quickly and were briefed on the rescue situation and the active medical and public health issues for rescuers. They were given a guided tour of the rescue site, the command posts, and the bases of operation for the task force personnel (at the Myriad Convention Center and the Southwestern Bell Telephone Building). The CDC and NIOSH personnel were able to access reliable information to determine the asbestos risks (which turned out to be negligible). Their early availability and expertise proved to be a very valuable asset in helping to minimize other workplace risks for rescue personnel (see sidebar on page 90).
Other dangers were recognized and effectively addressed by the Oklahoma City fire and EMS personnel, including covering trip hazards such as the communications and electrical wires that had been lying on the floor in the garage/command post adjoining the Murrah Building.
Due to the generosity of the local population, “tent marts” sprang up all around the rescue site and at both sites where task force personnel were bunked. While dispensing free over-the-counter medications, tobacco products, and clothing items was very well intentioned, it created several potential problems for task force personnel: With this type of drug dispensation, medical teams lose control of task force personnel assessment and monitoring of health problems, since task force personnel have access to another source of pharmaceuticals. Potential adverse reactions may occur between task force personnel`s baseline medications and those self-dispensed. Some of the free medications were poorly marked as to their contents (“foot powder,” etc.) and expiration dates. Task force personnel could potentially dose themselves with an antihistamine or other sedating over-the-counter medicine that would compromise safe operation at heights and with power equipment.
Again, the IST was able to intervene through the local public health and EMS authorities and limit this unusual health hazard. The Oklahoma volunteers were very understanding when we explained the rationale for limiting their largess in terms of the free beer, medications, and donated food.
Another significant role for the IST medical officer was monitoring task force medical teams and ensuring adequate dissemination of medical information to them. Twice-daily briefings, attended by one member of each task force medical team, were established to effectively acquire and disseminate information.
Due to the nature of the blast and the resultant collapse, no long-term entrapped survivors were found in the rubble (the final live victim was extricated by local personnel approximately 12 hours after the blast, shortly before the first task force arrived on scene).
Injuries among USAR workers were very few and relatively minor. They included a concussion from falling debris and other minor closed head injuries, several lacerations, eye foreign bodies, back and other strain injuries, contusions and finger tip crush injuries, along with other minor trauma. Falling debris and other hazards caused enough “near misses” throughout the response period to both prompt medical preparedness to remain high and to contribute to the high stress load carried by local and federal response personnel.
Additionally, significant medical problems unrelated to trauma occurred, including one task force member`s developing severe pneumonia; he had to return home early.
The professionalism of the Oklahoma City EMS, local and state public health officials, and the FEMA USAR medical teams enhanced the effectiveness of the role of the FEMA IST medical officer in addressing medical aspects of urban search and rescue. n
1. Noji, E.K. “Natural disasters.” In: Kvetan, V. (sted). Disaster Management. Critical Care Clinics 1991; 7:271-292.
2. Klain, M., Ricci, E., Safar, P., et al. “Disaster reanimatology potentials: A structured interview study in Armenia.” Prehospital and Disaster Medicine 1989; 4:135-152.
3. Moede, J.D. “Medical aspects of urban heavy rescue.” Prehospital and Disaster Medicine 1991; 6:341-345.
4. Barbera, J.A., Cadoux, C.G. “Search, rescue and evacuation.” In: Kvetan, V. (ed). Disaster Management. Critical Care Clinics 1991; 7:321-337.
5. Barbera, J.A., Lozano, M. “Urban search and rescue medical teams: FEMA task force system.” Prehospital and Disaster Medicine 1993; 8:349-355.
Crews queue up at the decon station. Decon stations must be staffed with personnel appropriately trained in decon procedures. (Photo courtesy of California OES Fire & Rescue.)
CENTERS FOR DISEASE CONTROL AND PREVENTION RECOMMENDATIONS
CDC Assessment: Oklahoma City Site Visit 4/24/95
The Centers for Disease Control (CDC) was asked on Day Five to visit the Alfred P. Murrah Federal Building and immediate environs to advise on biological and chemical hazards, appropriate use of personal protective equipment, and related safety issues. The site visit was made on Day Six.
1. On-site personnel have established excellent procedures for all aspects of health and safety.
2. The personal protective equipment/clothing used during rescue operations are certainly adequate for the minimal biohazardous risk associated with this operation.
3. Given the nature of disaster rescue operations, general sanitation is good. We are recommending that all personnel wash their hands before entering canteen food service areas. Portable handwashing stations may need to be provided at several locations.
1. There are no known biohazards that pose a public health concern or individual concerns to rescue workers.
2. Bodies in this collapsed building do not pose specific infectious disease risk to rescue workers. Bodies will begin to decompose, and in that process any infectious diseases that may have been in the living person will also decompose. Although the decomposition process will begin to smell bad, no infectious agents are associated with that process.
3. Rescue personnel who handle bodies (or body parts) are wearing disposable Tyvek® jumpsuits, rubber gloves, respirators, and hard hats. Disposable covers may be worn over boots.
4. Rescue personnel involved with activities like rubble removal are wearing firefighters` bunker gear or military fatigues. Both groups are wearing hard hats, respirators, boots, and leather work gloves.
5. Personnel who have been involved with rescue operations have been out-processing through decon stations. Respirator cartridges and gloves are discarded; boots are sprayed with Lysol® (l:50 dilution with water), and appropriate uniform parts are also decontaminated.
There have been staffing difficulties at the decon stations; these difficulties are being addressed, and control will remain with the Oklahoma City Fire Department.
We recommend that control “chutes” or other measures be instituted to ensure that all exiting personnel be properly processed.
1. Dogs are being used in rescue operations. These operations require the dogs to move in very dusty/dirty areas, and they may have occasional contact with bodies.
2. Showers have been established for shampooing the dogs after their tours of duty. This is appropriate and adequate for the dogs and for humans they may contact later.
The main concern was the presence of asbestos in the building prior to the explosion and therefore what level of respiratory protection was needed to protect against asbestos exposure. Since it was not known how much asbestos was present, rescue workers were using half-face, air-purifying respirators with HEPA filters.
Conversations, on April 24, with Steve Allen, of the State Department of Labor, and Bob Porter, with General Services Administration (GSA), revealed that very little asbestos-containing materials (ACM) remained in the building. Remaining asbestos included floor tiles and small amounts of insulation around pipe elbows in the basement. This amount of ACM is deemed to pose little or no risk to worker health. Therefore, air-purifying HEPA respirators are not required. However, dust respirators are recommended for general dust exposure inside the building. Disposable dust respirators (paper masks) are acceptable.
Furthermore, Tyvek® suits are not needed to protect workers from asbestos nor is decontamination of clothes for asbestos required.
It was observed that numerous gas-powered generators and tools were in use around the disaster site. Gas-powered equipment poses a serious hazard from exposure to carbon monoxide (CO), particularly in enclosed or semienclosed spaces. It is recommended that CO be monitored in areas where gas-powered equipment is being operated.
Centers for Disease Control and Prevention Hazard Assessment Team April 24, 1995
(signed) Jonathan Y. Richmond, Ph.D. Director , Office of Health and Safety
Charles S. McCammon, Ph.D., CIH Director, NIOSH Denver Field Office
Steven A. Lee, CIH Denver Field Office
Ronald C. Burger Emergency Response Coordinator Emergency Response Coordination Group
Rescuers pause for a brief moment of silence as yet another victim is removed from the Murrah Building. Body handlers wore disposable Tyvek® jumpsuits and other suitable protective clothing. This was more than enough protection: Infectious diseases decompose as the body decomposes.
JOSEPH A. BARBERA, M.D., FACEP, is an assistant professor of emergency medicine at The George Washington University and director of disaster medicine programs for the Ronald Reagan Institute of Emergency Medicine. He was the medical working group leader during the development of the FEMA Urban Search and Rescue Response System. Dr. Barbera is a member of Virginia Task Force-1. He responded to Oklahoma as the initial medical support officer for the FEMA Incident Support Team, the group that helped manage the FEMA USAR resources and their integration into the local response effort.
CRAIG DeATLEY, PA-C, EMT-P, is director of the EMS program (B.S. degree) at The George Washington University and associate professor of emergency medicine. He is an EMS captain, a flight paramedic, and the assistant medical director for the Fairfax County Police Helicopter Division. He responded to Oklahoma City as a member of VA-1`s medical team.
ANTHONY G. MACINTYRE, M.D., is chief resident in emergency at The George Washington University. Prior to medical school, he was a practicing EMT. He responded to Oklahoma City as a member of VA-1`s medical team.
DEWEY H. PERKS, EMT-P, is a captain and 23-year veteran of the Fairfax County (VA) Fire and Rescue Department. He was instrumental in the development and organization of the medical team and medical cache of VA-1. He responded to Oklahoma City as a member of VA-1`s medical team.