Event Type: Medic Team s Patient Extraction Date: May 17, 2016 Location: Coyote Fire Note: This RLS is a preliminary report of an incident that occurred on the Coyote Fire on May 17, 2016. Based on a number of factors, the National Park Service will be conducting a Facilitated Learning Analysis (FLA) to delve into several additional opportunities to learn from this incident. The expanded FLA will be available in the coming weeks. NARRATIVE On the morning of the May 17, the Coyote Fire was officially transferred from its Type 2 Team to the incoming Type 3 Team. The incident s medics were assigned to A/D Division. Because it was the first day of the Type 3 transition in the middle of downsizing the incident s resources the incoming Type 3 Team had demobed the only available Short Haul Helicopter and the Rapid Extraction Module (REM) Team assigned to the fire. Due to this recent team transition, the lack of active fireline, and the fact that inclement weather was expected that afternoon, the incoming team was in a size-up mode for the day. The forecast predicted clear skies in the morning with low fire activity and a transition to afternoon storms with high winds and limited visibility. Modules Directed to Size-Up the Fireline During the Division breakout for A/D Division that morning, the Division Supervisor called for a slow roll of resources assigned to the Division until further orders could be ascertained from Operations. Two Wildland Fire Modules, A and B, were directed to size-up the constructed fireline to determine rehab needs for the long-term preservation of the forest. Module A decided to inspect the eastern portion of the canyon by dipping off of an established system trail into the black, which they would follow along the edge of the burn. Module B decided to inspect a fence line perimeter. The Medic Team two Sedona Fire Department Paramedics would stage in a nearby parking lot. They were prepared to respond to an incident occurring with either module. The Coyote Fire, burning in steep ground, on May 14. Agave Leaf Impales Squad Boss Calf At approximately 1415 hours, while the skies were still clear, Module A Squad Boss stepped onto an agave plant on the side of a steep pitch near the top of a canyon wall just above a rock formation. The agave leaf impaled his posterior left calf. Its tip broke off deep inside his calf muscle. Photo of an agave plant from Wikipedia. 1
The trail follows this ridgeline, whose maximum elevation is 7,916 feet. Photo shows the patient s location. The Medic Team decided they could make quicker access to the patient by traveling up a steep drainage approximately two miles to reach Module A s position in the canyon. Module A had an EMT-B assigned to the squad who quickly assessed the injury. The patient was in 6/10 pain at rest and a solid 8/10 upon any movement of the left foot. Therefore, the patient was deemed unable to ambulate by this EMT-B on scene, who encouraged Division resources to call the Medic Team up to ascertain whether or not they could provide further treatment to get the patient mobile and off the mountain. At 1430, the call came into the Medic Team to move toward Module A s position. Medic Team Determines Optimum Route into Patient s Location The Medic Team made radio contact with Module A to get a GPS location and determine the best access route to the patient. The Medic Team was informed that Module A had diverted off of the system trail approximately 6-7 miles down the trail. Judging by the topographic features on the map and pin placement via Avenza mapping software, the Medic Team decided they could make quicker access to the patient by traveling up a steep drainage approximately two miles to reach Module A s position in the canyon. This decision was made based on the expected inclement weather and darkness that would hinder rescue operations and also Certified Emergency Paramedic (CEP) Jonathan King s (Medic Team member) assessment of the time lag from taking the system trail, which he had hiked several days prior. 2
The decision was made to locally anesthetize the patient with lidocaine, splint the injury, and then assist the patient to get him down the mountain. While the Medic Team Certified Emergency Paramedics King and Mark Rippy was making access to the patient, several radio conversations occurred exploring a flight decision for the patient. Based on the EMT-B on-scene s assessment of the patient, the Medic Team believed that this was a minor injury that did not warrant a massive transfer of risk to a helicopter crew who would be landing in burned out canyon country on the top of canyon walls which had experienced intermittent 20-45+ mph wind gusts over the previous several days. Immediate Concern: Extricating Patient in Timely Fashion The Medic Team told Division A/D that: It will be hard work, but unless we are able to locate an extremely safe LZ, then we would rather put in the effort. After an approximately two-hour extremely arduous hike up the drainage, patient contact was made. The Medic Team determined that the agave plant had indeed penetrated deep into the patient s posterior calf. They believed that it likely was lodged somewhere along the Achilles tendon, inhibiting the movement of the patient s foot and causing extreme pain. They confirmed that in his current state, the patient was nonambulatory. The Medic Team s most immediate concern was extricating the patient in a timely fashion to avoid hypothermia and exposure to lightning and rain on top of the 8,000-foot, steep canyon wall. The closest safe LZ for a helicopter was located approximately 1.5 hours away on top of a burned-out ridge. However, within 15 minutes of the Medic Team making contact with the patient, heavy clouds moved in and socked the canyon in minimal visibility cloud cover. Three Options Discussed For Extricating Patient The Medic Team did not have the personnel nor equipment on scene to effect a quick rescue in the form of a Stokes basket and big wheel manned by a REM team, nor was there Short Haul rescue capability assigned to the fire. Therefore, the three options discussed by the Medic Team: 1. Treat the patient s pain with narcotics and shelter in place throughout the storm. 2. Treat the patient s pain with opiates and splinting, then attempt to hike him down the mountain along heavily exposed single-track trail systems. 3. Divert from protocol to locally anesthetize the patient s pain at the site with lidocaine and then splint the injury so he could semi-selfambulate down the mountain path without the risks of opiate use while hiking in steep and dangerous terrain. A Difficult Call Due to the lack of shelter in place resources and an expected three-day storm, the decision to shelter in place was ruled out. Due to the arduous, steep and rocky nature of the trail with 50+ foot fall exposures, the decision to give opiate pain medication to the patient and then attempt a hike out was also ruled out. Thus, the decision was made to locally anesthetize the patient with lidocaine, splint the injury, and then assist the patient to get him down the mountain. Because no cell service was available in the area, the Medic Team was unable to patch for orders at the base hospital. With a heavy storm rolling in, they were put in a time-crunched position to make a difficult call. 3
At approximately 2152 and seven more miles of arduous hiking all personnel had made the descent down the canyon to safety. Several local injections of lidocaine were administered by CEP Rippy which provided the patient with significant numbing and pain relief. This provided him the ability to move under his own power using minor assistance and his tool as a crutch. The crew splinted the injury and stepped off at approximately 1700 hours to begin the descent down the canyon. Finished Their Descent in the Dark During their approximate five-hour descent, the patient and other personnel on scene experienced rain, heavy winds, and cold temperatures. Several stops were made to re-administer lidocaine to help facilitate the patient s movement. Other resources in the A/D Division hiked up to meet the descending team and provide them with more lidocaine, headlamps, and snacks to help enable them to finish their descent in the dark. At approximately 2152 and seven more miles of arduous hiking all personnel had made the descent down the canyon to safety. Referred to Orthopedic Surgeon The patient was taken to a local ER located approximately 1.5 hours away. The attending physician there referred him to an orthopedic surgeon. Unwilling to operate on the patient s leg, the local orthopedic surgeon and the Incident Command Team made the decision to fly the patient home where he could seek out the best course of action for tending to his leg. The agave tip was indeed found to be lodged in the patient s Achilles tendon, which made the surgery to remove the tip a very high-risk endeavor. The patient is now doing well and is reported to have no further complications or long-term issues from this injury. LESSONS This Incident Prompts a New Three-Step Process for Contacting Local Medical Control The story of this successful medical extraction and the decisions and actions implemented by the two paramedics on this incident s Medic Team has prompted the Sedona Fire Department to develop a new three-step mechanism to further enhance a Medic Team s ability to contact Local Medical Control. Department officials explain that, as a general rule, Medic Teams must exhaust all methods of communication available to contact Local Medical Control prior to any deviation from protocol. 1. Upon arrival to an incident, Sedona Fire Department medical crews should tie-in with the Medical Unit Leader and establish a communications plan in the event a radio patch is necessary. The intent would be to relay to an individual with cellular coverage information to make a formal patch with the local Medical Center. 2. This is critical on incidents where there are known cell phone deficient areas within the incident. 3. Crews should also determine the availability of SatCom devices on the incident. 4
Fireline Medical Providers are far more effective as teams. Such teams are better prepared to deal with situations outside of standard treatment protocols and to ensure all of the potential downstream impacts are considered. Trust among the Medic Team should be built long before they are expected to make critical decisions in a difficult environment. While there is no weight restriction on medical gear, Fireline Medical Providers should be equipped to ensure that their total equipment fire shelter, line gear, food/water is 45 pounds or less. This is what they Pack Test at. This is therefore possible, it just means you need to invest in the gear. Don t build a plan to access or extract patients based solely on aircraft. In this medical incident, they could not fly. If the Medic Team had not been able to hike to the patient with their gear and drugs, the patient would not have been able to receive the appropriate care. Also, when faced with a long ground extraction, you need to be physically fit to do what needs to be done not just access the patient. Under the Circumstances Surrounding this Medical Extraction, The Decision to use Lidocaine Proved to be the Correct One The use of lidocaine to locally numb a patient s injury site is not something that is included in standing protocols (things we can do without asking our medical direction for permission). The treatment the Medic Team two Certified Emergency Paramedics provided on this incident was the same they would do if they were going to drill into the patient s bone when IV access is not possible. Therefore, the procedure was within their scope, but not necessarily for this purpose. Thus, there was a risk of negative consequence for engaging in these chosen actions. The Medic Team weighed this potential risk against the negative consequences that different alternatives posed to their patient. In this case, giving someone drugs like morphine or Versed may have impaired the patient s balance. Because the extraction route required their patient to walk on narrow trails on very steep terrain (transporting them by litter was not possible) it was determined that the consequence of a fall was too severe. This Medic Team weighed all options for getting their patient safely down the mountain. This incident is a prime example of the importance of such a Medic Team. In this case, these Medics determined that treating their patient with drugs that may have affected his balance was a poor risk management decision due to the narrow trail egress and very steep terrain immediately adjacent to this trail. The decisions and actions taken on this successful medical extraction underscores the importance for Medics to engage in dialogue with each other, the patient, and the patient s crew. This RLS was submitted by: The Sedona Fire Department; Jayson Coil; and this Incident s Paramedics Do you have a Rapid Lesson to share? Click this button: 5