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Cold Stress and "Don’t Drop That Patient!"

Importance of Cold Stress:
Effects on Patient Handling

Andrea Zaferes

A rescuer without any core temperature loss might have such cold hands, because of improper gloves, that they are unable to effectively hold a tether line or save themselves from an entanglement.

Rescuers who simply feel cold, regardless of core temperature loss, are more likely to shortcut standards, use poor judgement, and rush. An inner voice continually tells them, "I am cold, I want to get out of here, I want to get back in the warm vehicle; why am I here? When is this going to end? Can’t we do this any faster? Why are they taking so long?"

Simply feeling cold adds stress and task loading to the rescuers’ job.

A drop in skin temperature results in the release of the hormone epinephrine, which is part of the fight or flight mechanism. That release adds to the epinephrine release already caused by the rescue incident itself, and can lead to fear, panic, mental disorganization, and loss of judgement.

The effects of cold and feeling cold can result in physical, mental, and even emotional stress well before medically-defined hypothermia (3 degree core temperature loss) occurs. We operationally define cold stress as the direct or indirect effects of heat loss not defined by a specific core temperature loss.

Think About Patient Handling!

The following information is true for all drownings that occur in water less than 92 degrees. We lose heat at the same rate in 80 degree water as we do in 42 degree air.

Replay in your mind fire calls and ambulance runs you have worked on or observed. How many times per call were patients dropped? Hopefully, none. How many times were patients yanked up by their arms, banged, and dragged across frozen ground? Again, the answer should be none.

Now, think of water emergency calls you observed or participated in, and photographs or videos of actual water calls. From the time the patient was removed from the water or ice and placed in the ambulance:

Our observations show that victims pulled out of the water are dropped, yanked, dragged, or banged at least three times before being secured in an ambulance.
A person who experienced a water-related accident is just as much a patient as any victim of a medical or land-based emergency, so treat them as such!
Ice Rescue

Understand that simple jostling, let alone being dropping, is enough to put a hypothermic heart into cardiac arrest. Immersion hypothermia victims must be handled extra-gently. They cannot afford to be dropped!

There are several reasons why victims of water rescues are dropped:

Has your team learned and then practiced effective procedures for gently extricating a slippery, helpless, extra-heavy (due to wet clothes) person out of an ice hole? Have team members practiced working, moving, and handling patients while wearing stiff neoprene gloves and exposure suits, which are probably one-size-fits-few? Surface ice rescue technicians must be physically fit enough to crawl hundreds of feet while periodically crashing through the ice. They must be competent swimmers and comfortable in the water. They must be capable of keeping the victim afloat and transporting the victim to shore. If not, then chances are that the victim will either not be reached in time, or will be mishandled.

Is there a practiced plan for transporting the victim back to shore? Some teams are taught the old, and less than safe method of securing the victim to the rescuer with a part of the tether line, to either use the rescuer as a sled for the victim or to drag the victim across the ice and water. Sure, before ice transport devices were readily available, that was an accepted method. Now it is not the best standard of care available. Both the rescuer and victim will suffer a beating on the ice if no transport device is used. Imagine a rescuer’s spine or head hitting a block of ice as tenders pull him to shore. What if the weight of the victim was on him?

Is there a practiced SOG for transporting patients from the water line to the ambulance in high snow, ice, and steep embankment situations? Is proper ice rescue equipment available, and are team members competent using it?

The more "no" answers to these questions, the more likely the victim will be dropped, yanked, dragged, and banged.

Close your eyes for a moment, and imagine that in front of you is an ancient Ming vase made of the thinnest, most fragile material imaginable. Its value is $2,000,000. You are responsible for it. You have to pick it up and carry it across the room. Imagine yourself doing that. How are you holding it? How are you moving? One wrong movement and it shatters. Now imagine that Ming vase at the water’s edge of a slippery, icy, snowy embankment. You have to transport the now wet, cold vase to the ambulance. Imagine how carefully you will wrap it, how carefully and slowly you will move.

Remember this vase next time you are on a water rescue site. Isn’t a life worth at least that much?

The thermal recovery stabilizer (TRS) is a highly effective tool for transporting and re-warming hypothermic and immersion hypothermic patients. Walt Hendrick, president of Lifeguard Systems, originally brought the TRS to the U.S. from England where it was used for hypothermia on the north sea oil platforms. Hendrick found a manufacturer, Marsars, to build a similar model in the U.S., making it affordable for U.S. teams. With the initial appearance of a big orange sleeping bag, the stabilizer retains the patient’s metabolized heat allowing the body to re-warm itself.

Tip Thermal recovery stabilizer is an excellent transport device to insulate the patient from conductive heat loss to backboards, the ground, air, and other heat losses. If you allow a patient to shiver, the patient’s oxygen consumption will increase by 50%, which could be more than the heart can handle.

Exposure Protection and Patient Handling

Latex EMS gloves and sneakers do not cut it in the cold!

Before you loose 1 degree of core temperature, your hands could be so vasoconstricted they have little blood in them. What do you think this loss does to manual dexterity and your ability to walk with a heavy load? What do you think happens when you try to help a rescuer, or try to pick up a slippery, freezing patient, while your hands and feet are frozen?

Tip Duty crew EMS personnel belong back in the rig where they can stay warm.

Duty crew EMS should not be allowed to stand outside watching the rescue. If they need to bring the transport device to the shore-line, they should wear warm gloves over their latex gloves. The patient should be handled with warm, strong hands with full strength, sensation, and dexterity.

Standing Around EMS and everyone on the scene should wear proper boots, and cleats if necessary, to protect their feet from freezing and slipping. How well can anyone perform with a sneaker full of snow? What happens to the patient when an EMT slips and falls? Wear proper hats, not ball caps. Wear coats and whatever else it takes to stay warm when outside. This advice may sound like common sense, but unfortunately, far too many actual ice rescues demonstrate it. Carry the appropriate PPE in your car if you respond directly to the scene.

BLS personnel have to be very concerned about proper handling, but what about ALS personnel? Think about what ALS personnel can do to the patient by administering cold IV fluid in addition to dry, cold oxygen. To increase the chances of a successful drowning or hypothermic victim save or resuscitation, each person must be properly trained and prepared, from the first responder to the hospital emergency department.

An excellent source of valuable information on ice rescue and patient handling: see Surface Ice Rescue & Patient Management by Andrea Zaferes and Walt Hendrick, Pennwell Publishing. For information on ice rescue training and patient management, contact Lifeguard Systems.


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