URBAN SEARCH AND RESCUE

DISASTER MEDICINE 0733-8627/96 $0.00 + .20

URBAN SEARCH AND RESCUE

Joseph A. Barbera, MD, and Anthony Macintyre, MD

Collapsed structure and heavy rescue events are increasing markedly in frequency, both nationally and internationally. The causes of the collapses are myriad, ranging from natural hazards such as earthquakes (Northridge, Califor- nia), to spontaneous collapse (Seoul, South Korea mall collapse), terrorism (Okla- homa City bombing), and technology (gas explosion, New York City). They also include events such as train derailments and collisions with passengers trapped in the heavy debris requiring extrication that exceeds the typical auto extrication method (New York City subway accident). As our infrastructure ages, as we continue erecting large structures in areas of seismic, hurricane, and other natural hazard risks, and as powerful weapons such as bombs become more available to terrorists, a continued increase in the frequency of collapsed structure calamities is expected.

With the increasing sophistication of emergency management, emergency medical services (EMS), emergency medicine, and medical, technical and rescue equipment, the potential capacity for immediate and effective response to this type of incident is enormous. At the same time, the improvements in telecommu- nications and news reporting have increased the ability of the press to immediately cover these events and the aftermath.20 This media capability has both raised the public's expectation of a rapid and capable r e ~ p o n s e ~ ~ , ~ ~ and improved their ability to monitor the effectiveness of emergency actions, particularly because all incidents involving prolonged entrapments generate an intense media coverage. As a result of these many factors, there has been a rapid evolution in search-and-rescue response capabilities in recent years.

In the period immediately following a catastrophic collapsed-structure event (earthquake, major bombing, spontaneous failure, and other mechanisms), many trapped victims will be rescued by uninjured bystanders and surviving local emergency responder~?~, 48 The remaining trapped survivors are usually deeply entombed and beyond the ability of unspecialized responders to locate or reach them. Although this remaining number of victims is small in relation to the

From the Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

VOLUME 14 * NUMBER 2 * MAY 1996 399

400 BARBERA & MACINTYRE

total number of victims, their discovery, extrication, and survival has been demonstrated to be vitally important to the affected community for many rea- sons:

Each life is valued. Although Americans tend to discourse on the cost- effectiveness of lifesaving intervention during budget negotiations and planning sessions, this is never discussed during the time when the intervention is needed.32 At that time, our societal (and political) values dictate that everything possible must be done to save lives.35 This phenomenon has been observed in every recent US event. Moving from response to recovery after a disaster occurs is delayed until there is reasonable certainty that no trapped survivors remain. Until that time, the overwhelming attention and resources are centered on search and rescue. This phenomenon has highlighted one of the most difficult aspects of collapsed structure search and rescue, that of concluding that no more survivors remain amid the dense, unstable debris. It is difficult, if not impossible, to move family members from the scene to safer and more controlled circumstances as long as uncertainty about their trapped loved ones remains unresolved. The survival of extricated victims is important to the victim and the victim's family. In a larger sense, it is also important to the local and national psyche as the impacted community attempts to cope with the impact of the event. This was best demonstrated by the euphoria46 surrounding the finding and rescue of a live freeway victim 90 hours after the Loma Prieta, California, earthquake (1989)49, s2 and the subsequent dismay as his condition deteriorated to death.

Urban search and rescue (US&R) has evolved rapidly over the past decade to meet these vital needs? US&R is the science of locating, reaching, medically treating, and safely extricating deeply entombed survivors of collapsed structures. It is a multidisciplinary specialty that includes search (canine and technical), heavy rescue, medical services, hazardous materials experts, structural engineers, communications specialists, management, and other disciplines.

Many trauma events occur on a regular basis with "light entrapments," including motor vehicle accidents. These are very important rescue opportunities, but they are short-lived, within the capabilities of any competent fire/ rescue service, and the medical issues are those covered by everyday EMS, particularly in regards to trauma care and the"Go1den Hour" ~0ncept.I~ The term urban search and rescue, on the other hand, refers to the capability of responding to a heavy structural collapse (reinforced concrete or steel-frame structures, tunnels, and so forth) with the potential for prolonged entrapment and major difficulty in locating, reaching, and extricating entombed victims.

Often, the victims of this type of entrapment have been found to be critically injured with unusual medical problems such as crush injuries and airway dust impaction. The process of extrication can markedly accelerate the pathologic processes in these entities and may cause rapid deterioration and death in a seemingly stable patient who has survived for days of entrapment. Many of these medical problems are amenable to immediate aggressive intervention by properly equipped and trained medical

HISTORY (UNITED STATES)

The experience with organized, specialized US&R in the United States before the 1990s was rather limited. This is in contrast to Europe, where the

URBAN SEARCH AND RESCUE 401

World War I1 ordeal involving aerial bombardments of civilian city populations provided a large experiential and a resultant impetus to develop search and rescue. Since that time, experience in widespread collapse with large-scale entrapments has been gained primarily through major earthquakes.

In the United States during the early 1980s, isolated collapsed-structure events, minor earthquakes, and the threat of a major earthquake prompted the development of local collapsed-structure response capabilities, particularly in California and East Coast metropolitan areas, such as New York City and Fairfax County, Virginia. The first well-known attempt to develop a fully integrated, multidisciplinary task force for collapsed-structure response in the United States was by the Office of US Foreign Disaster Assistance (OFDA). These initial efforts were prompted by the earthquake response experience of OFDA-sponsored responders to earthquakes in Mexico City (1985)53 and El Salvador (1986).55 Further organizational efforts were induced after the difficult response experience gained in the massive Armenian earthquake (1988).15, 38 The first well- integrated and fully equipped US team deployment for an earthquake response occurred in July 1990, when a Disaster Assistance Response Team (DART) was deployed by OFDA to Luzon Province, Philippines, for a catastrophic earthq~ake.'~, 72 The task force consisted of rescue specialists (Fairfax County, Virginia, and Metro-Dade County, Florida, Fire and Rescue services), emergency physicians, and paramedics (Special Medical Response Team, Penn~ylvania~~), canine search personnel, structural engineering specialist, hazardous materials and logistics, communications specialists, and management personnel. Experi- ence gained from this deployment was integrated into the early development of the response model for the US national response system.

The Armenian earthquake demonstrated to the US response community the value of having an organized response capability." It was obvious that the European teams were well ahead of the United States in this effort. With the predictions of a major earthquake in West Coast seismic zones,", 54, 75 coupled with the increasing awareness of the potential for a catastrophic earthquake in the New Madrid (Missouri) the urgency to develop a national response capability began to emerge.2z, 56 The temporally related events of Hurricane Hugo's destruction of Charleston, South Carolina (September 1989), and Loma Prieta Earthquake's impact on the Oakland/San Francisco area (October 1989) demonstrated the importance of moving rapidly with this development effort. No federal entity, however, was charged with the specific responsibility of developing a domestic US&R program on a national scale. OFDA, as a part of the Agency for International Development, is prohibited from developing capabilities for response within the United States or its territories.

The initial federal efforts to develop a national US&R capability were directed by default to the US military. From the Plan for Federal Response to a Catastrophic Earthquake (1987)23 through the Federal Response Plan (1991),24 the Emergency Support Function for US&R was assigned to the Department of Defense (DoD). Although the DoD had the logistical capabilities to support heavy urban rescue response and the manpower to provide for light search and rescue, DoD had no capabilities for the specialized technology, skills, and experience required by heavy urban rescue. The DoD plan was to provide light search and rescue (soldiers to remove rubble by hand and with earth-moving equipment) and support civilian heavy rescue even though none existed. At that time, the Federal Emergency Management Agency (FEMA) was a disaster recovery organization with no mandate for operational development or control of response resources. When Hurricane Hugo and Loma Prieta Earth- quake focused attention on the national deficiency in heavy rescue preparedness,


FEMA received a congressional and presidential mandate to develop and imple- ment an operational US&R capability on a national scale. Beginning in 1990, FEMA assembled recognized experts from across the country in the various US&R disciplines.20, 3o Using the OFDA model as a prototype, The National Urban Search and Rescue System was developed, consisting of a disaster response management structure and 25 US&R task forces from across the United state^.^^,^^ The first deployments were for Hurricane Iniki, and the US&R System has been used extensively since then for earthquakes (Northridge), hurricane responses, and the Oklahoma City bombing. The Federal Response Plan has been amended to reassign the primary responsibility for urban search and rescue to FEMA.

TASK FORCE DESCRIPTION

The National US&R Task Force System is designed to promote the development of the advanced capabilities required for heavy urban rescue and to provide those capabilities wherever needed via a national mutual aid system.', 25 Each 56-person task force has a local or state agency as its primary sponsoring organization and is designed to be primarily a US&R resource for its own jurisdiction. For federal deployment, they must each meet the extensively docu- mented standards and operational principles defined by the national FEMA provides partial funding for the task forces and assumes all costs when a task force is deployed on a federal assignment. The task forces are designed to function under the worst-case scenario: a massive event that has destroyed the impacted area's emergency response, utilities, and infrastructure.

Teams are self-sufficient, including food, water, shelter, power, communications, and search-and-rescue equipment. They require only local transportation and basic fuel (gasoline for tools and generators). The FEMA program has become the most advanced system in terms of US&R development, exercise, and response field testing, so it' is presented as the model system for the United States today.

SCIENTIFIC BASIS

The federal heavy-rescue capability was developed after extensive research illustrated many important issues and requirement^.^^, 58 Interestingly, much of the critical information came from the medical and public health literature. Medical and emergency response reviews of multiple collapsed structure events provide a repetitive picture that evolves from almost all collapsed-structure events.I9, 31, 71, 76 The initial event causes chaos, with an often prolonged time interval before adequate local organized responders arrive ~n- scene .~~ Most of the trapped victims will be lightly entangled and rescued by uninjured bystanders and first responders.', 12, 63 Li ght-rescue skills, effective first aid, and basic trauma life-support techniques are essential for reducing morbidity and mortality in this pop~la t ion .~~ Scoop and run and "Golden Hour" trauma management strategy is the accepted prehospital approach to these patients. In a widespread or overwhelming multicasualty event, effective triage, initial treatment, and expedient transport are the disaster medical issues that must be addressed in the planning, training, and execution phases of emergency management.3 In a heavy structural collapse, a high probability exists that a percentage of trapped victims will be deeply entombed and beyond the rapid discovery and extrication


capabilities of first responders and even most well-equipped, modern US fire and rescue services. Specialized techniques and equipment are required.62

Reviews of earthquake response and rescue demonstrate a recurring concept: the incidence of live extrications begins to drop off dramatically following the initial 24 hours. This phenomenon has been labeled the ”Golden 24 Hours”60 or “Golden Day,” analogous in concept and urgency to the ”Golden in trauma management. Review of the emergency response literature also demon- strates the danger inherent in heavy structural collapse response. This was most vivid following the Mexico City Earthquake (1985), with one source noting that after the first postearthquake day, deaths among potential rescuers approxi- mated the number of live victims rescued.8 To safely and effectively intervene to decrease morbidity and mortality after a structural collapse, rapid response by sophisticated search and rescue resources must be instituted. It was this basis that led to the evolution of the current search and rescue program in the United States.

Other factors have also greatly influenced the development in US&R. Recent advancement in management theory and practice by emergency managers and the fire/rescue service, particularly with the incident command system,% has promoted the ability of many essential disciplines to work effectively together on very dangerous and complex situations, such as collapsed-structure incidents. The evolution of prehospital medical especially with confined space43 and technical rescue expertise, provided an insight into the medical capabilities available to US&R teams. Technologic advancement has allowed the explosive increase in available tools, including search equipment (remote cameras, fiberoptic scopes, acoustic listening devices); rescue capabilities for cutting, lifting, and other essentials for penetrating reinforced concrete and steel rubble; hazardous materials detection gear; medical monitoring and intervention equipment that is portable and rugged; and prehospital patient immobilization and extrication equipment.

FEMAURBANSEARCHANDRESCUETASKFORCE

US&R is distinguished from other emergency rescue entities by its unique capability to overcome the impediments caused by steel, reinforced concrete, and other heavy construction to locate victims and effect rescue. The structure of each 56 member FEMA US&R Task Force is noted in Figure 1 and is organized according to the principles of the incident command The capabilities and complete description of the multidisciplinary units have been described extensively during the development processz5 and are reviewed briefly here.

The search component consists of both canine and technical search elements. The dogs are trained extensively to work under the supervision of skilled canine handlers to climb through debris and identify a victim’s location y air scent.26

specialists are experienced in search strategy and equipped with ulthasensitive seismic, acoustic, and other detection devices, including fiberoptic scopes and remote cameras. With these combined resources, victims may be located despite a thick layer of heavy debris. The sear& ham may also assist the rescuers in gaining proximity to the victim during the excavation process, without getting close enough to injure them with the dangerous cutting and drilling tools.

The rescue component uses structural engineering knowledge and compact, powerful, yet portable cutting and drilling devices to penetrate the dense rubble of steel and reinforced-concrete collapses. Their capabilities include jacks and

They are often able to distinguish live from dead victims. The te t hnjcal search


Search Rescue team team

manager manager (2) (2)

I I Rescue squad

Officer and 5 specialists

Canine search

specialist (2)

Task force Incident leader support

Medical Technical team team

manager manager (2) (2)

I Medical Structures

specialists specialist (2) (2)

Rescue squad Technical

specialist Officer and El r l 5 specialists

Rescue Squad Officer and 5 specialists

Heavy equipment and rigging

specialist (2)

information specialist

Communications specialist

specialist

Figure 1. FEMA Urban Search and Rescue task force, which has 56 positions and operates 24 hours a day. (Modified from Federal Emergency Management Agency: Urban Search and Rescue Response Operational System Description and Mission Operational Proce- dures. Washington, DC, FEMA, 1992.)


airbags for lifting, shoring devices, rope rescue equipment, and myriad other capabilities to reach and extricate the victim. This process often involves cutting debris, tunneling, shoring, rappelling, and other specialized techniques?' Equip- ment has been selected to allow work within confined spaces without generating carbon monoxide and other toxic fumes.

The medical team consists of emergency physicians and paramedics with the equipment and training to provide sophisticated emergency and prehospital medical care to task force personnel and victims?6 Because the FEMA mandate during development was to prepare for the worst-case scenario (local medical system completely compromised9), the medical cache was expanded to provide an almost complete emergency department capability. Because trapped victims may vary from neonates in a hospital nursery, as occurred in the Mexico City earthquake, to the elderly nursing home population, the cache includes an extensive range of medical equipment sizes and medication dosages.

Technical specialists with expertise in hazardous materials recognition and protection, structural engineering, heavy rigging (to coordinate efforts with crane operators), communications, logistics, technical information, and management complement this coordinated capability to detect, reach, extricate, and medically treat victims trapped beyond the proficiency of most local fire and rescue units.

Because time is critical for victim survival, the task forces are designed to mobilize and become fully operational as early as possible, with the maximum departure time being 6 hours after initial activation. Each task force is equipped and staffed to run two-shift, continuous 24-hour search and rescue operations and to be self-sufficient in terms of personnel, supplies, and equipment for the initial 72-hour response period. Members are recruited based on their expertise, a willingness to undergo extensive training, and a commitment to meeting the short-notice mobilization.

On incident, the task force has multiple, well-described assignmentsz8, 29 in order to complete its mission. These tasks include meeting with the local emergency managers and obtaining an assignment, performing reconnaissance to locate the buildings with the greatest probability for rescue opportunities, insti- tuting search procedures in the structures, effecting rescue and treatment of victims as they are identified, and providing vital information to emergency managers as it is developed. These important data include the presence of hazardous materials or other health threats, the list of structures that have been "cleared" by the US&R resources after thorough search has determined that no live entrapments remain, the structural integrity of essential buildings (such as hospitals and communications centers), and other information uncovered by the highly trained US&R personnel. The medical component of the task force must be managed carefully so that the many risky activities of task force personnel have close medical coverage for rescuers and immediate medical care available for any victims reached by rescuers.

URBANSEARCHANDRESCUEMEDICALISSUES

In the victim population with prolonged entrapment, the likelihood of serious injury is high,6I even though the majority of "Golden Hour" injuries will be fatal to the victim being reached and e~tricated.4~ The remaining injuries commonly encountered in the urban collapsed-structure environment, including crush injury and airway compromise, may be physiologically complex but are not as dependent on immediate operating room availability for the survival of


the critically injured patient. The "scoop and run" approach common to the everyday trauma victim may be precluded in heavy rescue by a number of factors. These include the inherent delay in the arrival of the heavy-rescue resources to the disaster site, the excavation time it may take to reach a victim, the often prolonged extrication period after the patient has been accessed, the possibility that the event has disrupted roads and other rapid transportation means, or that nearby health care facilities have been overwhelmed or compro- m i ~ e d . ~ The medical team must therefore be prepared for potentially prolonged field management of critically injured patients.

The unusual range of medical problems encountered in collapsed-structure victims and the impediments inherent in confined-space medical care compel the medical personnel to be equipped with specialized equipment and training.

Building collapse generates dense clouds of suspended dust particles, so much so that dust asphyxiation has been the sole cause of death in some cases.76 Trapped survivors have a high incidence of airway injury from dust impaction and toxic inhalation, which may be worsened by the rescue process that un- avoidably re-suspends large amounts of particulate matter in the air.% Once the victim is reached, protection of the airway from further insult is vitally important, as is the ability to intervene with sophisticated airway control (humidi- fied oxygen, intubation, positive end-expiratory pressure support) in the uncon- scious or airway-compromised patient. Because the lack of room in a confined space may make traditional laryngoscopic intubation impractical, training and equipment include capabilities for lighted-stylet int~bation:~ digital intubation," and needle or surgical (cricothyroidotomy) airway control.

The high likelihood of dehydration, blunt trauma, lacerations with blood loss, and crush injury with massive third-spacing may require rapid fluid resuscitation. The medical team must have the ability to establish reliable and adequate intravascular access even in a partially accessible patient. Being equipped to attain large-bore vascular accessso by Seldinger venous cut-down, central venous approach, and intraosseous infusion devices allows a capability beyond traditional intravenous catheter placement for victims who may have only a small part of their body accessed by the rescuers. Adapting fluid administration by evacuating all air from the intravenous administration set-up and using a pressure infuser ensures the flow of fluid even in a tight space where gravity flow is not possible.

Severe crush injury and crush syndrome are common in victims of collapsed-structure e n t r a ~ m e n t . ~ ~ Because the compressed body area is isolated from the central circulation, the victim may remain stable throughout a prolonged entrapment. When the compressing force is removed and vascular flow is restored, third-spacing of fluids, creation of toxic oxygen metabolites, and diffusion of potassium, metabolic acids, prcl taglandins, and other injurious products may cause rapid deterioration and death. Early fluid administration is essential to prevent shock and acute renal failurelo and close monitoring is important to recognize and treat hypovolemia and metabolic abnormalities that may lead to cardiac arrest.*, Cardiac monitorinq and portable pulse oximetry are important adjuncts in monitoring these critically injured prehospital cases, particularly in the dangerous period immediately following release of the crushed tissue. Although controlled experience is difficult to capture in this unusual injury, the Israelis have demonstrated that early fluid resuscitation beginning during or immediately following extrication will prevent renal failure, even in the severely crushed ~at ient .6~

Blunt trauma, skeletal fractures, closed head, and spinal cord injuries are similar in type to those found in the usual prehospital (EMS) setting. Impedi-


ments may be encountered, however, that are not typically experienced in the prehospital care of these injuries. The confining space may make evaluation and stabilization difficult. Moving the patient past obstructions and through a potentially tight egress route may require specialized immobilization of fractures and sophisticated pain management. Extrication from destroyed structures may require lifting or lowering the patient, causing difficulty with close medical monitoring and urgent interventions. Even after reaching the patient, the process of freeing entanglements and then extricating the victim often takes hours, requiring preparation to provide prolonged care during extrication and egress through debris. In addition, contaminated lacerations and open fractures may have been untreated for prolonged periods, making wound careI6 and early administration of antibiotics2’ perhaps important to prevent infection and promote limb survival. Entrapments necessitating controlled amputation may be encountered,” although the interdisciplinary approach combining medical and rescue expertise improves the likelihood of an intact extrication.”

Experience has shown that the often lengthy extrication procedure may be expedited by medical intervention. By providing effective immobilization and by maximizing pain control with modalities such as morphine sulfate, nitrous oxide, ketamine, benzodiazepines, and regional blocks, the patient may be more expeditiously removed from the rubble. The medical team may also use ana- tomic and physiologic knowledge to advise the rescuers on how to safely approach and extricate a trapped victim’s body part?

Multiple additional medical problems may be encountered in the collapsed- structure calamity: hazardous material exposure, hypothermia, other environ- mental dangers, exacerbation of psychiatric illness, and many other difficulties. The medical team must also be prepared to address these nontrauma entities in the confined space.

Because of the severity of these many pathologic entities and the possibility of the patient deteriorating during the extrication processG (Picture caption, The New York Times, December 13, 1988), the medical team is designed to begin evaluating and treating victims as soon as they are reached and the surrounding space is stabilized. They are to continue the process until the patient is fully extricated and transferred to a follow-on medical resource.

The evaluation of a partially accessible patient and the provision of medical care within a confined space requires additional equipment and expertise beyond the usual EMS and emergency medical experience. Safety is of paramount importance.

Medical personnel must be fully equipped with personal protective equipment, including hard hat, goggles, particulate respirator, coveralls, steel-toed boots, and leather gloves. Universal precautions extend beyond the usual protection, because the potential exists for a patient bleeding, vomiting, or otherwise contaminating a tight, confined space occupied by rescuers. Using barrier material such as Mylar space blankets will help isolate the patients body fluids and assist the patient in maintaining body temperature.

A coordinated, team approach is required when providing medical care in a very confining space. The care providers at the patient’s side must convey their findings clearly to other team members so that medical needs may be anticipated and equipment may be prepared. Using extended cardiac-monitoring cables and long extension tubing for oxygen and intravenous fluid keeps medical equipment from cluttering an already physically constraining area and allows monitoring of cardiac rhythm and remaining oxygen and intravenous fluids by other personnel. Specialized immobilization equipment such as the flexible Sked (Skedco, Portland, OR) backboard and half-backboard devices allow greater


flexibility in moving the victim. Using ropes, patients may be maneuvered through tight spaces by having rescuers on the “outside“ doing the pulling, allowing a controlled movement without risking back or other injuries in the confined-space care providers. These many adaptations require extensive training and preparation.

In addition to the care of victims, the medical team’s primary responsibility in collapsed structure response includes providing medical coverage for all response team members, including both prevention and intervention measures. By the nature of its mission, the heavy rescue task force operates in a dangerous and potentially unstable environment. Severe earthquakes are commonly fol- lowed by frequent, unpredictable aftershocks for many days following the initial event. Partially collapsed structures may shift with aftershocks or with the excavation and rescue efforts, causing rescuer injury. Sharp debris, heavy rubble, trip hazards, slippery surfaces, lack of light, and other factors contribute to the injury potential. Hazardous materials exposure is also a very real possibility. Personnel operate under extreme stress and fatigue while living in a very austere environment for a prolonged response period.69 The medical team must therefore monitor personnel for adequate rest, hydration, caloric intake, hygiene, and other health maintenance factors. Intervention must be made as indicated, both with affected individuals and through a systems approach to the rescue effort.6 Personnel must also be evaluated continuously for early signs of excessive stresss7 and this problem must be addressed as it is identified. Because each search and rescue task force must be completely self-sufficient, the medical team must additionally be prepared to treat minor injuries and routine illnesses incurred by task force personnel. Response experience has demonstrated that the personnel health maintenance and medical care aspect of medical team activities is very time and effort consuming, yet it is a vital component of task force activity.’* In the FEMA US&R Task Force, basic veterinary care for the canines is also a responsibility of the medical team.

RESEARCH/FUTURE DEVELOPMENT

The field of US&R has advanced rapidly in the United States over the past decade, with its effectiveness demonstrated particularly after the Northridge Earthquake and the Oklahoma City bombing. The medical aspects of the field have developed with a similar rapidity and are becoming an accepted area of expertise even within regular EMS systems such as New York City EMS. The development of extensive educational programs through the FEMA process’ has aided this process.

The FEMA medical team concept is currently undergoing a comprehensive review and update, incorporating procedures, equipment, and training that have been developed through response experience, training exercises, application of research findings, and garnering pertinent findings from other medical fields, such as military medicine, wilderness medicine, and medical support for tacti- cal teams.

It is expected that these sources, along with developing methods to capture the experience of US&R medical teams systematically in future deployments, will provide an avenue for further development of confined space medical care. Bench and clinical research in unusual injuries such as crush syndrome and airway dust impaction will provide clearer clinical pathways for treatment of these difficult entities.

The evolving application of public health and preventive medicine to the


US&R response will continue to improve the ability to counter the high risks inherent in prolonged responses to collapsed-structure incidents. Current efforts to better understand the factors that exacerbate the psychological impact on responders during extended incidents such as collapsed-structure events will allow a more effective mitigation of these problems and a more sensitive method for identifying rescuers who are experiencing extreme psychological effects. This is a distinct need that is not filled by Critical Incident Stress Debriefing or Defusing, which focuses on the involved individuals rather than the system factors. The development of a consistent postincident survey (in progress) will help identify subtle physical and psychological effects of collapsed structure rescue on responders.

SUMMARY

Addressing the wide-ranging medical aspects of US&R response requires a thorough familiarity with medical care and preventive health, a working knowledge of EMS procedures including immobilization and extrication technique, and an understanding of emergency management and effective integration into a disaster-response structure.

References

1. Allen R Fire in the city. Emergency 2432-33, 1989 2. Allister C: Cardiac arrest after crush injury. BMJ 287531-532, 1983 3. Angus DC, Barbera JA, Kvetan V Modern medical response to disasters. In Carlson

RW, Gehab MA (eds): Principles & Practice of Medical Intensive Care. Philadelphia, WB Saunders, 1993, 25-47

4. Barbera JA: Medical treatment at collapse rescues. Fire Engineering Dec:27, 1990 5. Barbera JA, Cadoux CG: Search, rescue and evacuation. In Kvetan V (ed): Disaster

management. Crit Care Clin 7:321-337, 1991 6. Barbera JA, DeAtley C, Macintyre AG, et al: Medical aspects of urban search and

rescue. Fire Engineering 148:88-92, 1995 7. Barbera JA, Lozano M: Urban search and rescue medical teams: FEMA task force

system. Prehospital Disaster Medicine 8349-355, 1993 8. Bay Area Regional Earthquake Preparedness Project: Management of emergency re-

sponse: Search and rescue. San Francisco, Networks Earthquake Preparedness News, 1986

9. Bendel MA, Ritter J: Hospitals can barely keep up in postquake chaos. USA Today Jan 18:ZA. 1994

10. Better OS, Stein JH: Early management of shock and prophylaxis of acute renal failure

11. Blakeslee S: Scientists see new perils afkr California tremblors. The New York Times

12. Brand S: Learning from the earthquake. Whole Earth Review 68:2-15, 1990 13. Bywaters EGL 50 years on the crush syndrome. BMJ 301:1412-1415, 1990 14. Castillo CJ: Philippines earthquake: International disaster with an international re-

15. Castillo CJ: Small successes are just as sweet: U.S. SAR team saves lives in Armenia.

16. Cohen J, Bonfiglio M, Campbell CJ: Orthopedic pathophysiology in diagnosis and

17. Cowley RA: The resuscitation and stabilization of major multiple trauma patients in a

in traumatic rhabdomyolysis. N Engl J Med 322825829, 1990

July 13:A1, D10, 1992

sponse. Fire Engineering Dec:20-28, 1990

Rescue Magazine 24144,1989

treatment. New York, Churchill Livingstone, 1990, pp 205-206

trauma center environment. Clinical Medicine 83:14-22, 1976


18. DeAtley C, Macintyre AG, Perks DH, et al: The response of Virginia Task Force: I. A medical perspective. Fire Engineering 148:92-96, 1995

19. De Bruycker M, Greco D, Annino I, et al: The 1980 earthquake in southern Italy: Rescue of trapped victims and mortality. Bull World Health Organ 61:1021-1025, 1983

20. Downey R: The rescue company: Urban search and rescue. Fire Engineering 143:14- 15, 1990

21. Epps CH Jr (ed): Complications in orthopedic surgery, ed 2. Philadelphia, JB Lippin-

22. Federal Emergency Management Agency: An assessment of the consequences and preparations for a catastrophic California earthquake. Washington, DC, FEMA, 1980

23, Federal Emergency Management Agency: Plan for federal response to a catastrophic earthquake. Washington, DC, FEMA April 15, 1987

24. Federal Emergency Management Agency: The federal response plan: For public law 93-288, as amended. Washington, DC, U.S. Government Printing Office, 1992,

25. Federal Emergency Management Agency: Urban search and rescue response system: A component of the Federal Response Plan under Emergency Support Function 9. Washington, DC, FEMA, U.S. Government Printing Office, 523-835/40339, 1991

26. Federal Emergency Management Agency: Canine criteria and canine search team evaluation: Urban search and rescue response system: a component of the Federal Response Plan Under Emergency Support Function 9. Washington, DC, FEMA, U.S. Government Printing Office, 523-835/40339,1991

27. Federal Emergency Management Agency: Urban search and rescue program: Notice of solicitation for award. Federal Register 5623708-23709, 1991

28. Federal Emergency Management Agency: Urban search and rescue response system operational system description and mission operational procedures. Washington, DC, FEMA, July 1992

29. Federal Emergency Management Agency: Urban search and rescue response system task force orientation student manual. Washington, DC, FEMA, July 1992

30. Federal Emergency Management Agency: Summary of proceedings: Urban search and rescue workshop sponsored by the Federal Emergency Management Agency, Washington, DC, January 29-February 2, 1990

31. Glass RI, Urrutia JJ, Sibony S, et al: Earthquake injuries related to housing in a Guatemalan village. Science 197638443, 1977

32. Goldsmith M F Armenian earthquake elicits aid from all, strengthens American-Soviet ties. JAMA 261:341-342, 1989

33. Headquarters, Forces command. CINCFOR Catastrophic earthquake response plan (urban search and rescue). Forces Command Domestic Emergency Planning System (DEPS), vol V. Fort McPhearson, GA, Forces Command Apr 5, 1991

34. Hingston RA, Hingston L Respiratory injuries in earthquakes in Latin America in the 1970s: A personal experience in Peru (1970), Nicaragua (1972-3) and Guatemala (1976). Disaster Medicine L425-426, 1983

35. Hutcheson R A nation joins in sorrow: Clinton consoles mourners. Fort Worth Star- Telegram Apr 24:A1, Al l , 1995

36. Irwin RL The Incident Command System. In Auf der Heide E (ed): Disaster Response: Principles and Practice. St. Louis, Mosby, 1989, pp 133-163

37. Jones NP, Krimgold F, Noji EK, et al: Considerations in the epidemiology of earthquake injuries. Earthquake Spectra 6:507-527, 1990

38. Keesecker WL, Caulfield-Vasconez K S The international search and rescue component of the U.S. government’s foreign disaster relief response. washington, DC, Agency for International Development/Office of U.S. Foreign Disaster Assistance, 1989

39. Keller B: Soviet press calls the rescue effort bungled and inept. New York Times, Dec 13, 1988, pp Al, A8, 1988

40. Klain M, Ricci E, Safar P, et al: Disaster reanimatology potentials: A structured interview study in Armenia. Prehospital Disaster Medicine 4135-152, 1989

41. Klain M, Ricci E, Safar P, et al: Disaster reanimatology potentials: A structured interview study in Armenia. Prehospital Disaster Medicine 413.5152, 1989

cott, 1986, pp 186-187

625-688/ 60582


42. Krimgold F: Could Washington survive a quake. The Washington Post March 25:C3, 1990

43. Kunkle RF: Medical care of entrapped patients in confined spaces. Proceedings of the International Workshop on Earthquake Injury: Epidemiology for Mitigation and Response, July 10-12, 1989. Baltimore MD, The Johns Hopkins University, 1989, pp

44. Kunkle RF: Special medical response team. Prehospital Disaster Medicine 1:54-55,1986 45. Lovitt JT, Price R: At [Northridge Meadows] apartments, horror stories. USA Today

46. Lubrano A: California: New life and hope, survivor stuns doctors. New York Daily

47. Mahoney LE, Reutershan TF: Catastrophic disasters and the design of disaster medical

48. Manning Do: San Francisco/Bay Area earthquake (Loma Prieta 10-17-89), report by

49. Marcano T, Lubrano A: Man found alive: Miracle by the bay. New York Daily News

50. Mateer JR, Thompson BM, Aprahamian C, et al: Rapid fluid resuscitation with central

51. McGroarty M: Rescue from collapsed buildings. Rescue 2:24-31, 1989 52. McQueen I: The quake of ’89. Emergency 24:30-33, 57, 1989 53. Michaels M: Catastrophic quake in Mexico: Disaster spurs worldwide emergency

response. Firehouse (Dec:53-58, 1985 54. Michaels M: Frisco anticipating the ”big one.” Firehouse Dec:58, 1985 55. Milnes R A moment’s notice: Metro-Dade coordinates El Salvador rescue. Firehouse

(Feb:50-52, 73, 1987 56. Minetree I11 JL: An assessment of urban search and rescue in the United States.

[position paper]. The National Institute for Urban Search and Rescue, June, 1989 57. Mitchell J T Assessing and managing the psychological impact of terrorism, civil

disorder, disasters, and mass casualties. Emergency Care Quarterly 251-58, 1986 58. Moede J D Medical aspects of urban heavy rescue. Prehospital Disaster Medicine

59. Navarro RA: Disaster dispatch. Emergency 24:31, 1989 60. Noji E K Medical care for earthquake victims. UNDRO News July/August; 6-7, 18,

1990 61. Noji E K Natural disasters. In Kvetan V (ed): Disaster management. Crit Care Clin

7271-292, 1991 62. Noji EK The medical consequences of earthquakes: Coordinating the medical and

rescue response. Disaster Management 4:32-40, 1991 63. Noji EK, Kelen GD, Armenian HK, et al: The 1988 earthquake in Armenia: A case

study. AM Emerg Med 19:891-897, 1990 64. Reeder L: Disaster preparedness: Unreadiness in Armenia, uncovering the deeper

disaster. Rescue Magazine 236-40, 1989 65. Reeder L The big one hits the midwest: Translating awareness into readiness. Rescue

minutes after being unearthed (Picture ca 2 n-AP). The Hartford Courant Jan

4:3845, 1991 66. Rescuers on Thursday [56 hours after Kobe eart quake] . . . the boy died just 10

21:A16, 1995 67. Ron D, Taitelman U, Michaelson M, et al: Prevention of acute renal failure in traumatic

rhabdomyolysis. Arch Intern Med 144277-280, 1984 68. Seldinger SL: Catheter replacement of the needle in percutaneous arteriography: A

new technique. Acta Radio1 39:36%376, 1953 69. Shields T: A somber welcome home: Montgomery rescue team [Maryland] recalls the

pain, exhaustion of Oklahoma City. The Washington Post Apr 30:B1, B7, 1995 70. Stewart RD: Tactile orotracheal intubation. Ann Emerg Med 13:175-178, 1984 71. Stratton JW: Earthquakes. In Gregg MB (ed): The public health consequences of

disasters 1989. Atlanta, GA, US Dept of Health and Human Services, Centers for Disease Control, 1989, 13-24

338-344

Jan 18:3A, 1994

News 69:5, 1989

care systems. Ann Emerg Med 16:1085-1091, 1987

the Los Angeles City Fire Department Nov 227, 1989

69:5, 1989

venous catheters. Ann Emerg Med 12149, 1983

6341-345, 1991


72. Tamillow M. U.S. rescue team assists Philippine earthquake victims. Fire Chief (Nov:44-47, 1990

73. Thompson KG, Sullivan A On-site amputation [Oklahoma City]. Fire Engineering 14897,1995

74. Vollmer TP, Stewart RD, Paris PM, et al: Use of a lighted stylet for guided orotracheal intubation in the prehospital setting. Ann Emerg Med 14:324-328, 1985

75. Ward PL, Page RA: The Loma Prieta Earthquake of October 17,1989: What happened . . . what is expected . . . what can be done. U.S. Geologic Survey [revised second printing] Jan:l-16, 1990

76. Yong C, et a 1 editors. The great Tangshan earthquake, 1976: An anatomy of a disaster. New York, Pergamon Press, 1988

Address reprint requests to Joseph A. Barbera, MD

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Washington, DC 20037

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