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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. 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. Consequently, this is probably the most common position in which rescued firefighters would present.
Assessment of the ABCs (airway-breathing-circulation) can begin immediately, with the turnout gear still on. It is not an accurate assessment until the facepiece 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 Immediately Dangerous to Life or Health (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.
A cervical injury should be suspected; depending on the method used to rescue the firefighter – for example, the firefighter’s carry or inward ladder method – the spine may or may not be stabilized. So, as with other patients, this must be started simultaneously to the ABCs by holding the head on the sides, similar to the initial stabilization of a driver of a vehicle. 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) dependent on the severity of the patient’s injuries.
The head of a firefighter is protected by three items: a helmet, protective hood and facepiece. 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 (Photo 1). The head should now be stabilized with one hand on the mandible and another at the back of the head, similar to the initial hand position on a motorcycle helmet. This allows the hood to be pulled completely to the back (Photo 2). The mask straps are now exposed and can be either loosened or cut, and the mask pulled out of the way. The facepiece 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.
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, it should be cut, because it is thinner and can be tighter. The shoulder straps should also be cut, at the lower adjustable section (Photo 3), again to reduce patient movement. However, do not remove the SCBA yet. Instead, unfasten the turnout coat and cut the sleeve that is 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. 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 streetclothes 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. 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 is recommended the boots 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 and in the pelvis can be massive. 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. n