By Dan Hunt
Lord Baden-Powell penned the Boy Scout motto, “Be prepared,” in 1907. Just as we should “expect fire on every run,” we should also be prepared for the eventuality that we may need to rescue a bariatric fire victim.
In 2004, Morgan Spurlock produced the investigative film, Super Size Me, inspired by the spread of obesity in America. Today, more than one in three adults (36.5 percent) are considered obese by the Centers for Disease Control and Prevention and the National Institutes of Health.1 Despite this, we are often caught off guard when faced with extricating fire victims much larger than ourselves. When working on drags, we commonly train with a 165- or 185-pound mannequin or a firefighter (and we typically choose the smallest person to drag). Given the prevalence of obesity in America, we should consider that one in three potential fire victims will be obese. In 2016, U.S. fire departments responded to an estimated 352,500 residential structure fires. These fires caused 2,735 deaths; 10,750 civilian injuries; and $5.6 billion in direct damages. A civilian dies in a residential fire every three hours and 12 minutes; on average, seven people die in U.S. residential fires per day.2
When we train with average-sized victims, we build an expectation in our minds that victims found in fires will be similar in size. Our introductory firefighter training provides basic structural fire rescue skills including searches, lifts, drags, and carries. Along with the basics, we typically incorporate webbing used to create “drag handles” on a victim. We learn how clothing can melt to the body or become brittle when exposed to high-heat conditions. We discuss how burned skin becomes slick and slippery and, under the worst circumstances, may separate from the body when a limb is pulled on or dragged. Considering the effects of the fire environment on the human body has allowed us to improve and refine rescue procedures.
(1a) The main harness is green and drag loops are orange. (Photos by author.) (1b) A continuous loop is made from each piece of webbing using a water knot that should be pre-tied prior to emergency response. To apply the green webbing, cross one side of the loop over the other to make a figure 8. (1c) The “X” of the figure 8 is placed over the groin of the victim. (1d) Next, slide the loops over the legs, extending each leg loop toward the shoulders and twisted. The twist is at the rib cage and prevents the victim from slipping out of the harness from the left or right. (1e) Next, slide the arms through each loop so that the loops rest on each shoulder. (1f) Attach a carabiner front and back to create positive contact closure of the harness. The red piece of webbing shows how to incorporate a girth hitch to extend the harness for very large victims. (1g) The orange loop of webbing is laced through the shoulder loops to create drag handles.
Unfortunately, very little time is devoted to discussing scenarios where a rescuer encounters a victim that is beyond his capability to extricate because of size and weight. Rapid intervention team (RIT) training may be the exception to this. It is widely accepted that up to 12 firefighters may be needed to rescue a single down or trapped firefighter, depending on the circumstances. The bulky gear on top of the firefighter’s weight makes multiple rescuers a necessity. We need to begin to look at the extrication of the bariatric victim in the same way as we look at RIT.
(2) The finished package with two additional grab loops added on the upper thighs using webbing loops and girth hitches. Four firefighters will be able to move a very large victim even if the victim has no clothing.
Typically, during training, a candidate practicing drags and structural fire extraction will begin to struggle with a victim larger than the typical 185- to 200-pound mannequin. A two-firefighter team will have difficulty rescuing a victim more than 250 pounds. If your department is involved in emergency medical services (EMS), you have probably interacted with a patient that necessitated multiple crews to remove him. In extreme situations, openings may have needed widening or rope systems may have been used to control descending stairs. Now imagine that same patient being found during a vent-enter-isolate-search operation under low-visibility, high-heat conditions with the fire still not contained. Could you extricate that patient with your search partner or team? Consider the effect of adding a weight vest to your 185-pound training mannequin; it probably would not be an extreme increase, but could you perform your normal extraction drills? For most of us, the answer is no. We need a plan to incorporate additional personnel, specialized packaging, and mechanical advantage for rescue of a bariatric fire victim.
The Bariatric Victim Package
Webbing has been widely used for many years to help create grab points on a victim to facilitate smoother movements and better leverage. Multiple techniques from simple girth hitches to full body harnesses with grab handles are taught. Commercial slings are available, as are a variety of homegrown custom riggings.
Most firefighters would be able to move a 200-pound victim using grab handles on the victim’s upper back and shoulders. Through training, we know that two firefighters can combine their efforts and efficiently move a victim weighing more than 200 pounds using grab handles. As the weight of the victim approaches 300 pounds, two firefighters would likely struggle to move a victim much beyond 10 feet.
Moving a victim more than 300 pounds can be facilitated by adding two additional firefighters with grab handles at the victim’s hips. Being able to quickly recognize the need for additional resources and being well-practiced in efficient application are time critical. You can create a bariatric victim package by first applying a full-body webbing harness that encompasses a sling seat for the pelvis. Create this by sliding loops up the legs to the groin area, then sliding the arms through two more loops that form grab handles (or anchors) at the shoulders. Apply carabiners to the webbing at chest level and the back of the sling to create positive closure in the front and rear. In some cases, you may need two smaller pieces of webbing across the front and back if the girth of the victim’s chest and back prevents you from closing the arm loops with carabiners (photo 1).
To add two firefighters at the hips for horizontal movement assistance, apply two girth hitches at the waist belt area and around the upper thighs with the handles facing outward (photo 2). With adequate practice, you can perform this packaging technique quickly and efficiently in low- to no-visibility smoke situations. For some victims, a 30-foot continuous loop of webbing may not be enough to encompass the patient from pelvis to shoulders. In these situations, consider joining two loops. Additionally, each firefighter should carry two carabiners with their webbing.
Once you have packaged the victim for removal, conduct an extrication assessment. Initially, you should have a good idea about your ability to move the patient by the effort it took to rig the webbing. If you realize the weight of the victim is beyond your team’s capabilities, call for additional firefighters to supplement your crew.
Extrication
If you find a victim who overwhelms your crew’s capabilities and command does not have adequate resources, you may have to create a defensible space until resources become available. You may have to breach a wall to move to a more defendable area, or you may need a handline that you can place between the search team/victim and the fire. In resource-limited situations, you may need to relocate an exterior line and operate it through a window to cool a space until resources are available to complete extrication. In a worst-case scenario where breaching complications exist, you may need to pass an attack line into the area in which the search crew and the victim have found temporary refuge to protect them while you mitigate the problems affecting their removal.
Make exterior wall breaches a standard part of your bariatric extrication play, if the building construction allows. We have developed and practiced techniques for creating a nonexistent opening in the sides of structures for access and removal of trapped firefighters. We may need to apply these skills to remove bariatric victims.
Window cut-downs, especially on the second division, will help with ease of extrication. It is preferable to remove bariatric victims as closely to where they are found as possible. Often, you will not be able to lift them above the windowsill. You can cut down the sill to the floor in the same manner as you would during RIT operations. Use two ground ladders, a tower platform, or a rigged high point to remove the bariatric victim from upper floors or divisions.
(3) A crude mechanical advantage created from rope, a carabiner, and a halligan bar. Wedge a knot between the forks. Drive the pike end of the bar into the floor so that the forks face away from the victim. Run the rope down and through the carabiner, back up and around the pike in the floor, and back down past the victim. As you pull the rope, you reduce the weight and pull the victim toward the bar. You can reset the bar farther away and repeat the process.
Initial packaging, including full body rigging with positive front and rear closures, will provide a high point for vertical lowering. The need for high-point lowering is the reason to package with a full-body harness instead of a shoulder and chest rig. Having to repackage the victim for lowering can waste precious time, especially if conditions are deteriorating.
Mechanical advantage can help facilitate horizontal movement to the point of exit. A crude rig using a halligan bar and personal rope (photo 3) or a prerigged and bagged 2:1 or 3:1 brought in with the extrication team provides mechanical advantage. A wall breach along with the application of an apparatus-mounted winch may be the most effective means of removal at ground level. This is feasible only if the resource is available and can be positioned at the point of extrication. Develop and practice various packaging skills along with horizontal and vertical movement tactics to ensure your ability to mount an aggressive response to difficult locations and situations.
Hard Decisions
Failure should never be an option, and we adopt this mindset when human lives are at stake. Being proactive allows us to develop and test a plan of action before an emergency arises. In our business, we know that we can do everything right, to the best of our abilities, and still have poor outcomes. There may be times where conditions are beyond our control and we simply cannot make a grab.
The techniques discussed in this article should allow us a good starting point to optimize our success. These tactics are in no way all inclusive, but they recognize the reality that there are individuals in our communities whose size will create challenges during rescue. Be prepared, expect fire, and anticipate a victim beyond your initial capabilities. Have a plan in place to expedite removal of a viable victim whose size and weight create a worsening situation.
References
1. Ogden CL, Carroll MD, Fryar CD, Flegal KM. “Prevalence of obesity among adults and youth: 2011 – 2014.” Centers for Disease Control and Prevention: NCHS Data Brief. 2015; 219. Available on line: www.cdc.gov/nchs/data/databriefs/db219.pdf.
2. Haynes H. “Fire Loss in the United States during 2016.” Quincy, MA: National Fire Protection Association. September 2017.
Dan Hunt is a 17-year veteran of the fire service and a firefighter/EMT with the Westridge Fire Department in Erie County, Pennsylvania. He has Pennsylvania certifications as a level II instructor and level I officer. Hunt is a local-level suppression instructor attached to the State Fire Academy through Butler County Community College and Bucks County Community College. He also teaches at County Fire School Weekends in Northwest Pennsylvania.
