With almost 25 years of service with the Oklahoma City Fire Department (OKCFD), I have attended countless training classes that discussed entrapment incidents. The training always involved lockout/tagout procedures, de-energizing the equipment and extrication through disassembling of the equipment.
The training never discussed incidents where personnel were unable to take the equipment apart either due to the size of the equipment, location of entrapment or patient condition.
On March 11, 2021, all three of these situations came into play and presented our personnel with the extrication of a lifetime.
At 1:15 p.m., a 911 incident was received by OKC Fire Dispatch that started out like a regular rescue response for a person whose hand was caught in a belt at Oklahoma City industrial facility. The initial unit assigned was an advanced life support engine company and an EMSA ambulance.
After additional information was obtained, additional resources were assigned to the incident, including a technical rescue unit and a district chief.
Incident command (IC) was established on arrival. The first unit on scene conducted a visual patient assessment from the ground level. The patient, a worker at a steel recycling company, was standing with his right arm trapped in a steel discharge chute. The arm was pinned just distal of the shoulder joint.
After rapid scene assessment, IC requested additional resources which included a 95-foot platform ladder, an additional battalion chief, a safety chief, the EMS chief, the shift commander, a hazardous materials unit and the public information officer.
An ALS ambulance and field operations supervisor (FOS) from EMSA, the city’s EMS medical transport agency, were also on scene along with a representative from the Office of the Medical Director which serves the Oklahoma City metro area.
The 95-foot aerial platform was utilized to provide access to the patient and provide a safer work area. The platform was placed next to the discharge chute that was attached to the machinery because it provided the best access to the victim.
The first arriving battalion chief assumed incident command and assigned the OKCFD Safety Chief as the incident safety officer. Upon arrival of the EMS Chief, the incident commander established an EMS Group and Rescue Group.
The EMS group was led by the EMS chief and included the ALS engine, ALS transport ambulance and the FOS. The EMS group was initially able to gain access to the patient utilizing the 95-foot platform. The patient was being held in place by a coworker.
A fire paramedic ascended to perform a closer assessment of the patient. After patient contact was made, the fire paramedic took over stabilization of the patient from the coworker.
The patient was facing away from the fire paramedic. Vital signs were obtained utilizing a cardiac monitor and it was determined the patient was stable.
Vascular access was obtained in the patient’s left hand. Due to the air temperature of 53 degrees and wind speed of 14 mph, the patient’s jacket was left on him to provide warmth.
The Rescue Group included the 95-foot platform ladder apparatus and the technical rescue unit. The Rescue Group’s purpose was to obtain access to the patient, provide safety equipment and evaluate extrication.
In addition to the 95’ platform, two extension ladders were placed to assist in evaluation and access to the patient and equipment. To increase the safety of the patient, a Class 2 harness was placed on the patient.
After securing the patient, the Rescue Group worked with the EMS Group to develop a plan that was best for the patient.
After access to the patient was obtained, it was determined by an EMS Group paramedic, and verified by the Rescue Group, that the best outcome for the patient was to amputate the arm. The decision was made because the man’s arm was pulled into an area of the conveyor belt machinery that was approximately 1.5 to 2 inches wide located between the steel drum pulley and steel plate housing.
There was severe trauma to the arm, including open fractures, but no visible hemorrhage was noted because the arm was pulled into the smallest area of the machine, temporarily tamponading bleeding from the traumatized areas.
The conveyer belt had pulled the patient’s arm and chest up to the side of the conveyer belt housing. This limited the ability to place a Combat Application Tourniquet (CAT) on the victim.
Without being able to place a tourniquet, the concern was the development of severe hemorrhage if the equipment was taken apart. The decision was then made to request a trauma surgeon from the local Level 1 trauma hospital. The EMSA field operations supervisor contacted OU Health-University of Oklahoma Medical Center Emergency Department to request a surgeon.
A report of the situation was given to the hospital staff. Once the hospital staff was ready, the shift commander for the OCFD responded to the hospital to pick up the staff.
A trauma surgeon, physician’s assistant, and a registered nurse were brought to the scene with the necessary preplanned and packaged instruments and equipment to perform a field amputation.
The medical staff ascended in the 95-foot platform ladder to conduct an assessment. The surgeon confirmed the need to amputate the arm.
The surgeon was then placed in a safety harness and a tag line was attached to secure him in the event of a fall. The surgeon made the decision to work outside of the platform on the extension ladders for better access to the area to be amputated.
The initial plan to amputate the arm was to use a Gigli saw. However, due to the rotation of the arm, the brachial artery was rotated toward the machinery. The location of the artery also concerned the surgeon because he would have had to cut the artery before he could cut the bone, which would cause blood loss while completing the amputation.
The surgeon therefore requested a battery-operated oscillating bone saw from the hospital. While waiting for the additional equipment, the surgeon, dressed only in ED scrubs, was placed in a nearby vehicle to keep him warm.
Once the additional equipment arrived, the surgeon reascended and performed the amputation. The patient was freed from the equipment quickly and without incident, and a CAT tourniquet was rapidly applied.
The patient was then secured to a backboard and moved to the ground by rotating and lowering of the 95-foot platform.
The machinery was secured with a Lock Out, Tag Out (LOTO) tag to ensure there were no additional injuries from its use. LOTO is a safety procedure used in industry and research settings to ensure that dangerous or injurious machines are properly shut off and not able to be started up again prior to the completion of an investigation after an incident that causes injury to a worker, during maintenance or while repair work is underway.
Once on the ground, the patient was transported via EMSA ambulance, with the involved hospital team and EMSA paramedic attending to him, to the trauma center.
Lessons Learned & Recommendations for EMS Systems
- Prepare in advance for incidents of this nature and know how to make the notifications and requests for a field amputation team.
- Identify a system to provide the hospital and trauma surgeon with pictures or video of the entrapment.
- Have the trauma center add a battery-operated oscillating bone saw to their response equipment.
- Consider special personal protective equipment (PPE) and safety needs for surgical/hospital staff who will arrive and work on your scene.
With these types of incidents, pre-planning is the key. Since this incident, a cooperative effort involving the Oklahoma City Fire Department, EMSA, OU Medical Center, and the Office of the Medical Director for Metropolitan Oklahoma City area has identified what went well and where we can improve on these difficult incidents.
We were fortunate at this incident because the EMSA field operations supervisor who was on this scene was also on the last field amputation performed in Oklahoma City Metro Area and offered input on who to contact.
After the incident, we evaluated how to make the notifications of this nature in the future. On the day of the incident, a direct call to the emergency department of the Level 1 Trauma Center was sufficient in our system.
However, this is an area that other agencies need to evaluate and put in place prior to an incident in their area.
The second lesson learned was the importance of providing much needed information to the surgeon and hospital staff. Once the surgeon was able to evaluate the position of the arm, he determined that performing the amputation from the posterior side utilizing a different bone saw would be best for the patient.
This required a second trip to the hospital to retrieve additional equipment something that the hospital team learned could be alleviated by adding a battery-operated oscillating bone saw to their response kit.
Our EMS system has now identified multiple ways to provide still photographs and video clips of the entrapment to the trauma center. This allows the hospital staff to plan for the amputation before being transported to the scene.
Depending on the entrapment, specialized surgeons and assisting staff may be necessary to perform the amputation and bring specific equipment for the situation. Therefore, EMS systems should develop a transportation plan to get the surgical/hospital staff and all necessary equipment to the scene rapidly.
Time to assemble and deliver a specialized hospital team is important. We were fortunate because this incident scene was less than five miles from the hospital. With the hospital being a short drive from the scene, delivering the hospital staff to the scene was easy. However, our city covers approximately 621 square miles. Therefore, making multiple trips to the hospital is not feasible for all locations in Oklahoma City.
Depending on your city or service area, a plan needs to be established before the incident to bring all essential hospital staff and all necessary equipment to the scene on the first request and response. In rural areas transportation of hospital staff and equipment by helicopter should be considered.
The last issue which was identified was the need for PPE for the surgeon and assistants. Upon notification that a field amputation was needed, the hospital staff gathered equipment, assembled and left the hospital. Once the surgical team was on scene, they immediately ascended the 95-foot platform and began care of the patient.
The surgical team was wearing hospital scrubs. While this clothing is sufficient for them while working inside the hospital, it was not enough clothing for them while at the incident scene. The air temperature was 53 degrees Fahrenheit and a constant 14 mph wind made it cool for the hospital staff.
Another PPE consideration was head protection. While we could have provided a structural firefighting or rescue helmet to the hospital team, but these helmets are heavier than the staff may be accustomed to wearing and could lead to more stress on the surgeon and assisting team members.
Hospitals and their EMS agencies should therefore consider purchasing compact headgear, with chin straps, easily adjusted headbands and attachment points for lights (like the helmets worn by tactical physicians and medics), to be available to responding staff.
We have now procured disposable coveralls for responding hospital staff. This PPE will be carried on our technical rescue unit with a field amputation kit.
The best outcome for these incidents will come from meticulous preplanning and preparation. Training is also key to success at incidents of this nature. Our system is now planning training to involve all partners, starting from the field personnel and involving all hospital personnel that might be tasked with response to incidents of this nature in the future.