BY THOMAS F. KENNEY
On June 30, 2008, at 1822 hours, the Hyannis (MA) Fire Department received a 911 call reporting a woman with her arm trapped in a machine at a commercial laundry service at 95 Airport Road. The initial response dispatched was a paramedic ambulance and the heavy rescue company. The ambulance was on the road already, as it was returning from a previous run, and arrived at the address within two minutes. Senior Firefighter/EMT Barry Pina established command and started a size-up. When we arrived on-scene, we encountered a 36-year-old female employee with her left arm extending deep into a folding machine, where it was trapped. She was conscious, alert, and in obvious pain. Laundry coworkers were trying to assist the trapped woman and to free her.
Pina ordered all nonfire personnel to leave the area and radioed his initial report to fire alarm and the incoming heavy rescue. His initial efforts at getting control of the scene were complicated because only one of the dozen or so employees present spoke English. An interpreter was used to communicate with the patient and other employees. In addition, the prompt arrival of the police took the crowd-control problem away from the firefighters.
OPERATIONS
Pina and his crew assessed the patient and made sure the machine was locked out. The patient was initially in a standing position with her arm extended overhead into the machine. You could not see her hand and most of her arm; the face of the machine obscured them. A counter, just higher than the patient’s waist, extended out about 18 inches and ran the entire length of the front of the machine. The patient was lifted onto the counter and placed in a reclining position (photo 1). The responding paramedic assumed a position on the counter behind the patient and was able to comfort her and secure her in his lap for the duration of the operation.
 (1) Photos by Barnstable Police Patrolman Owen Needham. |
The interpreter described how the accident happened and explained that the “emergency stop” had been activated to shut off the machine.
On arrival, the heavy rescue company began to evaluate the entrapment situation. Chief Harold Brunelle, now on-site, took command. Members verified that electrical power to the machine had been shut down with both emergency stop switches and the breakers in the building service panel. Medical and extrication functions continued in unison.
MEDICAL SITUATION
The patient, now in the reclined position on the counter, remained alert and was exhibiting signs of hypovolemia, including diaphoresis and tachycardia. We could see her forearm if we looked up under the face of the machine. It was evident that her hand had passed, palm up, between two steel rollers that ran the length of the machine. The rollers, about eight inches in diameter, had her pinned at about the level of her wrist; there was a clearance of about 3⁄8 inch between the rollers. Her hand, clenched into a fist as a result of compression by the rollers, was barely visible when we looked down from the top of the machine. Machine components, which included fabric conveyors and keepers as well as a piece of channel iron that ran the length of the top of the machine, obscured the view. A deep avulsion, caused by the steel edge of the face of the machine as she was pulled in by the rollers, was present between her elbow and bicep.
Initial therapy included administering high-flow oxygen, bleeding control, dressing the open wound, initiating two large-bore intravenous lines with pressure infusers, and monitoring both her ECG and pulse oximetry. Command requested a med-flight helicopter, and the paramedic established radio contact with Cape Cod Hospital for medical control. A pain management plan was initiated using morphine sulfate intravenously at a starting dose of four milligrams.
EXTRICATION PLAN
The first steps included getting a view of the hand and rollers from the top down. Then a firefighter on top of the machine encountered numerous fabric conveyor bands that ran over the roller system. After ensuring that cutting them would not result in any unwanted movement, he cut the bands with crash scissors and unscrewed the aluminum keeper strip for the bands. The keepers were attached to a piece of two-inch channel iron, which ran over the rollers.
This channel also housed control cables and a previously unseen compressed air supply. Our initial lockout/tagout efforts were directed at electrical power sources and unwanted movement; we now had to initiate an immediate “all stop” until the air supply valve could be located and locked out. After once again determining that no unwanted movement would result, we cut the cables and air lines with cable cutters and removed the channel iron with a hydraulic cutter. We were then able to see the patient’s hand at the point where it came through the rollers (photo 2). The hand was cyanotic, was cool to the touch, and had no evident capillary refill. The sensory function was still intact, and there was no evidence of open wounds.
 (2) |
Morphine sulfate therapy and fluid resuscitation were ongoing to help manage the patient’s pain. We used pneumatic tools to disassemble the end of the machine closest to the patient. Fortunately, this was the nonpowered end of the machine. The gears, motors, and chain-drive mechanism were at the opposite end. With the relocation of some circuitry, we were able to see the main axle bolt and slack adjusters. Loosening the slack adjusters gave us some roller movement, but a channel iron edge partially blocked the main axle bolt.
The degree of compression on the patient’s forearm caused the muscles and tendons to retract; the hand formed a contorted/contracted fist. The size of the fist necessitated about a two-inch space between the rollers for the hand to clear.
With the slack adjusters loosened, we now had about a half inch of space. We inserted small air-lifting bags on either side of the hand between the rollers and inflated them to get the clearance we needed. With the adz end of a halligan bar inserted between the rollers and pulled sideways, we had enough of a gap to slide in the air bags. Once we positioned the air bags, we slowly inflated them to see the action on the rollers. The result wasn’t satisfactory; in fact, because the surface contact was small, the roller started to turn and would have pulled in the patient’s arm more deeply.
We then set wedges between the face of the machine and the top roller to prevent the roller from turning. We placed a larger air bag further in between the rollers (photo 3). With the fork of the halligan, we pried and reshaped the channel iron so we could get the impact socket on the axle bolt. Once the axle bolt was spun out, we slowly inflated the air bags. The wedges kept the roller from turning, and the bags lifted the rollers beyond the height we needed.
 (3) |
We slid the patient’s hand and arm out and immobilized them in a padded trauma box splint. We then packaged the patient and placed her in the ambulance for a less than one-mile ride to the airport. She was flown to Boston Medical Center and underwent nine hours of surgery, including five open reductions of fractures, pin and rod placement, and vascular repair. She underwent occupational therapy and was discharged five days post-accident. The continuing therapy most likely will result in little or no deficit to the hand.
LESSONS LEARNED/REINFORCED
- It is imperative that you identify all sources of power and that you follow lockout, tagout, and blankout procedures. Consider the many types of power used in machinery, and continuously reassess your extrication plan to prevent unwanted movement.
- Size matters. In this case, because the shape of the object to be lifted was round and the support was also round, a larger air bag was the right choice. It was able to “pillow” around both of the rollers and had enough surface area to make the lift.
- Anticipate patient changes during the rescue. Closely monitor vital signs, and treat for the potential of hypovolemia with fluid replacement. Pain management during the operation is an invaluable tool as well. It helps promote patient comfort and stability and allows rescuers to concentrate on the task at hand. This patient received 16 milligrams of morphine sulfate during the 42-minute procedure. Pressure infusers are also necessary. This patient could not be placed supine; therefore, in this case of sudden hypotension, our only option was to replace volume.
- Have a rescue plan B. In this case, adding wedges to pin the top roller still while the air bags lifted was a quick solution. And if you are using plan B, you had better be thinking about plan C. Plan C should include the possibility that a field amputation may be necessary if the patient’s vital signs are deteriorating; loss of life may be a consequence if extrication cannot be completed any other way. Request a Hospital Emergency Response Team of whatever field surgical intervention may be available in your area to stand by in case a field amputation or other advanced care may become necessary. This is a standard protocol for “man in machine” calls for many departments.
THOMAS F. KENNEY is a lieutenant with the Hyannis (MA) Fire Department, with which he has served 27 years. He is a rescue team manager and SCT instructor with DHS FEMA and Massachusetts USAR Task Force 1. Kenney is an FDIC HOT instructor and a partner in Heavy Rescue Incorporated, a fire service training company.
