By KAREN OWENS
Scenario: At the station, you are completing dinner when you hear the announcement over the radio: “Dispatch from Broad Street Command, please upgrade this incident to a working fire. We have heavy smoke and fire from A/B corner with an unknown number of occupants still inside.”
From this initial dispatch information, you know that you are the first-in medic unit, and you prepare for your response to the incident. Although you are prepared to handle the potential patient care issues, you also begin preparing to conduct rehab at the incident. As you arrive on scene, you are contacted by Operations, who radios you: “Medic 1 from Operations, please place your unit at the corner of Broad and E. Main Street, and meet me face-to-face for your assignment.”
During your face-to-face, Operations advises that personnel are still searching for potential trapped occupants and that you should set up rehab until there is a known number of victims. You also prepare to treat victims suffering from burns, smoke inhalation, injuries from fallen debris, and other issues. You also consider the need to assist firefighters in rehab efforts (i.e. cooling off, rehydrating, and so on).
You then realize that you are not prepared for the next radio transmission: “Mayday, Mayday, Mayday—Truck 6 Firefighter Jones operating interior Division 1—I have been separated from my company and become trapped during a partial collapse in what I believe is the A/D corner. I currently have three-quarters of a tank of air supply left. I am requesting activation of a RIC [rapid intervention crew].”
Command: “Command to Firefighter Jones, I copy the Mayday and will send the RIC. Try to remain calm and conserve your air. Command to Dispatch, strike an additional alarm.”
Command: “RIC from Command, deploy immediately into the structure for a collapse trapping a firefighter.”
RIC: “RIC, understood. Deploying with a crew of three to Division 1 through side A for firefighter rescue. Command from RIC, we have rescued the firefighter and are removing him through the side A door. He appears to be conscious but severely burned; have the Medic Unit standing by.”
Command: “Command copies. Medic 1 from Command, report to side A of the structure for patient care.”
You gather your bag and quickly approach the front door just as the RIC is leaving the structure with the injured firefighter. As personnel put him on the ground, you notice the firefighter has lost his gloves and has visible burns on his hands, and his coat appears to have become undone. You cannot be sure if that occurred during the rescue or prior to the incident. Regardless, you recognize that this may lead to additional injuries.
THE GEAR
Patient burns require many considerations during treatment. When those burns occur to a firefighter dressed in full turnout gear, not only must you deal with the emotions of treating a fellow provider, but you must also deal with the issues that will arise from the personal protective equipment (PPE) that he is wearing.
Turnout gear provides a protective and heat-resistant barrier for a firefighter in an active fire environment. However, it is only designed to provide protection for certain temperatures for a certain time period. In some situations, turnout gear may be unable to tolerate certain conditions, leading to injuries to the firefighter wearing the gear.
Turnout gear is comprised of three protective layers, which follow:
- Outer shell—provides heat and flame resistance while also providing protection to the two inner layers.
- Moisture barrier—provides protection from moisture being absorbed through the gear while allowing perspiration to escape. It also allows for the release of body heat, decreasing the amount of heat buildup within the gear.
- Thermal layer—provides protection to the firefighter from transfer of thermal heat from the fire.
Although each turnout gear layer is important in providing protection during firefighting operations, it can drastically change your approach to patient care.
THE COOLING PROCESS
Training tells us that when an individual is suffering from a burn, the first thing you must do is stop the burning process1; this means limiting the size, depth, and severity of the injury by flushing the injury with water or, as taught to children in schools across the country, “Stop, Drop, and Roll.” Unfortunately, when the patient is a firefighter encapsulated in turnout gear, the cooling methods must change significantly. Because of the thermal layer’s design and composition, flushing a firefighter with water, physically patting him down, and compressing his gear may actually cause more significant burns. The air pockets, when functioning appropriately, do not effectively conduct heat, providing adequate protection during firefighting operations. However, when the air is compressed, either by force of water or compression of the air pockets, the thermal layer successfully conducts heat, leading to steam burns or thermal burns on the patient. Quickly remove the gear from the firefighter in a manner that will not cause you or the patient any additional injuries. Not only will this remove the heat source from the firefighter, but it will also allow you to better assess and treat injuries.
In the scenario, your patient is not able to stand to assist in turnout gear removal; this can make for an easier task. When a patient is unable to stand, you can cut off and remove the turnout gear with trauma shears. Remember, if not already completed, removing self-contained breathing apparatus (SCBA) is also necessary. If the firefighter can stand, remove the turnout gear carefully. The process is thorough, but each step limits the potential of injuries caused by the gear. Table 1 lists steps to remove turnout gear.
When removing turnout gear, also conduct a visual inspection. Look for damaged areas or gear that is on fire. Also consider where the firefighter was in the building and any potential hazardous materials that may be on the gear. Also, when coming off an ambulance, you may not have the essential equipment to assist in removal of the superheated gear. Patient care gloves will not provide sufficient protection from the heat radiating off the PPE. Always wear firefighter gloves when removing the turnout gear. If firefighter gloves are not available, use RIC members or other firefighters to assist in gear removal.
After removing the SCBA and turnout gear, you begin to assess the firefighter’s injuries. During your initial assessment, you realize that you know the patient. He is a rookie, just out of school, who also pulled some hours on your medic unit. Although this realization shakes you, you have to focus on treating him, regardless of the emotions.
ASSESSING THE INJURIES
After removing the turnout gear, your firefighter patient now becomes just like every other burn patient you encounter. You must reassess to ensure that the burning process has stopped and all areas are sufficiently cooled. The process of cooling thermal burns may change, depending on the substance that caused them. Treatment of thermal burns caused by a flame should follow a process of wetting down, smothering, and then removing the clothing.3 Treating thermal burns caused by a semisolid (i.e. grease, wax, tar, and so on) follows the process of cooling with water without removing the substance. (3) After ensuring that the burned areas are appropriately cooled, you can begin your assessment.
Overall, assessing your burn patient is done the same as for any other trauma patient. Start with your initial assessment (airway, breathing, circulation) and continue through with a hands-on assessment, looking for any injuries or issues. You still treat life threats as you come to them, but recognize that the burns may be the life threat you have to focus on.
Once you have found the patient’s injuries and have treated any life threats you can, focus on your assessment and treatment of the burns. When assessing burns, you must determine the severity of each burn. Burn severity is based on six factors, which follow:
- Agent or source of burn.
- Body region affected.
- Burn depth.
- Extent of the burn.
- Patient’s age.
- Patient’s medical history. (3)
The source of the burn is important to know because it can also lead to other issues that may arise during your response. Patients with chemical burns must be decontaminated (if they are not already). Patients with electrical burns may have internal injuries far more significant than external wounds. When considering the body region burned, you must again remember that any burn to the face or airway is a life threat. Those injuries will compromise the airway because of swelling and physical damage. You should also consider that burns to the hands and feet may limit mobility of the appendages. Other regions of concern include the genitalia, which can increase the chance of introduction of bacteria, and circumferential burns, which can compress the area, leading to decreased circulation. (3) Circumferential chest burns are also significant because they limit the patient’s ability to expand the chest for deep breaths.
When determining burn depth, three categories are considered: superficial, partial thickness, and full thickness. Characteristics of these depths are listed in Table 2.
You also need to determine the extent of the burn and the area of the body impacted by the injury. The “Rule of Nines” is the best method to determine the percentage of body surface area involved. It states that each major body area represents nine percent of the body. A great percentage of burned area means that the patient is at a more significant risk of infection and possible death. The patient’s age and other illnesses and injuries may also impact his ability to fight infection.
Your assessment of the injured firefighter determines that he has partial and full thickness burns on his hands and partial thickness burns on his chest. You classify him as a high-priority patient with critical burns and prepare to treat him as such. Your driver then asks what you need.
TREATING THE INJURIES
With burn classification and assessment complete, you must now focus on the treatment of the burns themselves. Since cooling is finished, remove any clothing that is still around the wound. Also remove any jewelry that is around the injury site. Swelling could easily prevent removal of rings and bracelets later. Remember that jewelry may also still be hot or warm to the touch, so remove it with caution.
Cover burns with a dry, sterile dressing, secured tightly to the injury. Because the burn has damaged the skin, a protective barrier between the underlying muscle and tissue preventing the introduction of bacteria into the body is essential. Using dry, sterile dressing is important because moist environments generate a larger bacterial environment. When dressing hand and toe burns, wrap each finger and toe separately.
As a basic life support provider, focus on airway management in addition to dressing wounds. Airway management includes high-concentration oxygen through a nonrebreather mask or bag valve mask; when possible, use humidified oxygen. If protocols allow, consider using a more advanced airway such as the supraglottic airway device when the situation presents. Many burn patients, especially those showing smoke inhalation or airway compromise, are likely to have carbon monoxide (CO) poisoning. High-flow/high-concentration oxygen is the treatment for CO exposure; patients with significant CO poisoning may require hyperbaric oxygen (HBO) treatment. As CO symptoms correlate very poorly with poisoning, field assessment of patients using a pulse CO-oximeter (an oximeter capable of measuring blood levels of CO) or an exhaled breath CO monitor can help determine if your patient requires transport to an HBO-capable facility.
ADVANCED LIFE SUPPORT (ALS) TREATMENT CONSIDERATIONS
ALS burn treatment includes additional considerations to assist the patient, which fall under the following categories.
<Airway management.Because of the high probability of airway swelling, consider early intubation. This ensures that even when swelling of the trachea occurs, the airway is open. If the airway has been compromised prior to the ALS provider’s arrival, consider a surgical airway. Remember that airway access is the highest priority during treatment of this or any patient.
<Fluid resuscitation. Because of the heat from the burn, there is a great need to support fluid replacement during treatment and transport. Establish at least one large bore IV (preferably two). Use lactated ringers, normal saline, or another crystalloid solution during initial resuscitation.4 If IV access is unobtainable because of the severity of injuries, then consider intraosseous (IO) access, and follow local protocols.
<Pain management.With IV access established, be aggressive with pain management. With the administration of any narcotic, remember to closely monitor your patient for any changes.
Cyanide.Cyanide (CN) is a poisonous gas released during incomplete combustion of virtually any occupied structure. Survival of victims pulled from structure fires in cardiopulmonary arrest who receive a cyanide antidote are dramatic—in some studies, exceeding 50 percent. As there is no rapid and reliable field or hospital test for CN exposure, administer a CN antidote to patients (including firefighters) pulled from a structure with known fire smoke exposure in an enclosed space and showing evidence of airway compromise and significant hemodynamic instability (cardiac or respiratory arrest or unconsciousness with profound hypotension).
Conventional CN antidote kits have included three drugs given in sequence: amyl nitrite, sodium nitrite, and sodium thiosulfate. The first two agents work by inducing a chemical change in the blood (methemoglobinemia) that limits oxygen-carrying capacity. In the presence of CO, as often seen in smoke inhalation, this additional oxygen debt can be catastrophic. A newer antidote, hydroxocobalamin does not rob the body of oxygen but binds with CN to form vitamin B12, a harmless by-product excreted in the urine. Fire victims’ health drastically improves with use of hydroxocobalamin.
PATIENT TRANSPORT
Once the patient is packaged, transport becomes the priority. Transport burn patients to the local burn center as per local protocols. When transport time is delayed or made even longer, consider air transport.
While transporting the patient, remember to monitor vitals, airway, and interventions. Ensure that IV access is maintained, pain is successfully managed, and no additional problems arise prior to arrival at the receiving medical facility.
You have finally transferred care of the firefighter over to the local burn center. You have cleaned your truck and, on the way back to your station, you visit the first-due’s firehouse and inform the rookie’s crew that the doctor said the rookie was stable. You see the visible relief on their faces.
When an individual suffers burns, your treatment of his injuries is based on the assessment, the same as with any injury. Burns can be significant, but the focus is still on life threats. A burn pre-sents issues with airway, breathing, or circulation; those issues become priority during treatment. Once those issues are treated and stabilized, treatment can extend to other areas of the patient.
Calls can be complicated when the patient you are treating is a member of the emergency services field. On completion of any call involving fellow providers, remember to consider the need for critical incident stress debriefings to assist in dealing with the emotions associated with the situation. Ensuring a thorough assessment and appropriate care of the injuries is important in ensuring the call’s overall success.
ENDNOTES
1. American Academy of Orthopaedic Surgeons. Outdoor emergency care book, 4th Edition, 2005. Jones and Bartlett: Massachusetts.
2. Brown, P.L. Doffing superheated turnout gear. emberly.fireengineering.com, June 16, 2008.
3. Limmer, D. and O’Keefe, M.F. Emergency Care, 10th Edition, 2005. Prentice Hall: New Jersey.
4. Caroline, N. Emergency Care in the Streets: Trauma Medical, vol. 2, 2007. Jones and Bartlett: Sudbury: MA.
Enter 114 at fireeng.hotims.com
KAREN OWENS is the emergency operations assistant manager for the Virginia Office of EMS, where she has been employed since 2001. She oversees the emergency operations training programs including MCI management, terrorism awareness, and vehicle rescue. Owens has a BA in psychology and an MA in public safety leadership. She is a Virginia certified firefighter and has been a Virginia EMT-B instructor since 2002.
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