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FIREFIGHTER INJURIES FIGURE 6: Cutting across the chest will avoid extra shoulder layers, radio pockets, D-rings, and any flashlight or miscellaneous straps. FIGURE 7: With the patient on the backboard, the remainder of the coat is removed. 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) dependent on the severity of the patient's injuries. Remember that the head of a frefghter 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 48 JUNE 2013 | EMSWORLD.com 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 fat 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 fnal 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 frefghters. 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 frefghter 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 frefghter's protective ensemble. BIBLIOGRAPHY Jakubowski G, Morton M. Rapid Intervention Teams. Stillwater, OK: Fire Protection Publications, 2001. NAEMT. Prehospital Trauma Life Support. St. Louis, MO: Mosby JEMS Elsevier, 2011. John G. Alexander, MS, NRP, is a retired fre captain and has been involved in the career and volunteer fre 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, 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.