Case study: Rescuing a pinned, suspended industrial worker
An unstable pile of sharp steel sheets pinning a worker's leg raised questions of field amputation and rescuer safety; here's how we handled it
By Mike Montgomery
On Sept. 25, 2015 at 7:57 a.m. a 911 call came into Union County, Ohio. The caller reported that "a worker is trapped; we have equipment to get him out but need a medic." The first units dispatched arrived a few minutes later and reported a collapse at an electrical substation.
The worker was pinned and the first medic to arrive requested permission to perform an emergency field amputation from local medical control. Mutual aid was dispatched as well as a medical helicopter.
The substation routes electrical power out of state to major urban centers in the Midwest. It has step-down transformers that reduce voltage from 765,000 volts to 138,000 volts, or lower, for local power consumption. These units are constructed of steel and copper on a steel platform base supported by a thick, poured-concrete pad.
The heart of the unit is a 15-foot-high core comprised of hundreds of pieces of plated steel sheeting wrapped in fiberglass and encased in cardboard. The sheets are treated with an oil before being assembled. The core weighs 40,000 pounds, according to the contractors on scene.
On the day of the incident, contractors were given permission to disassemble the transformer; the power was de-energized. The workers were using an aerial work platform and telehandler to maneuver material around the site. A telehandler resembles a forklift, but performs as a crane and can lift 10,000 pounds up to 50 feet via a retractable boom.
The transformer unit was torn down and only the wrapped core remained standing. A worker was cutting the cardboard to allow a telehandler to puncture the fiberglass wrap to free the steel sheeting of the core, allowing for disassembly.
The victim had just initiated the cut to the cardboard when the fiberglass wrap unexpectedly failed resulting in a catastrophic failure of the core. The victim attempted to leap from the platform, but several tons of material pinned his left lower leg and threw him over the side.
The victim was left trapped in an inverted position with only his head and shoulders resting on the concrete below. Large piles of the steel sheeting were draped over the worker creating a void space supported by the steel platform, and forming an open area roughly 4 feet high by 3 feet wide.
When emergency responders first arrived, coworkers had attempted to use the telehandler and heavy webbing to support and stabilize the load.
First on scene
Initial rescue crew actions focused on scene assessment. A telehandler was set up on compacted gravel with stabilizing feet set. One of the feet had been placed on a concrete lid resulting in its failure and the load beginning to list.
Located behind the victim was a 15-foot-high block wall designed to shield the transformers from each other. The telehandler boom was oriented that if it fell, it would strike the wall causing further collapse.
Crews established a collapse hot zone marked by yellow scene tape and stabilized the telehandler foot with 4x4 cribbing in a box tower resting on solid ground to prevent further movement.
A second telehandler was positioned to support the first by placing its forks under those of the unit carrying the load. Simultaneously, the patient was assessed and found to be stable, but in significant pain. His trapped limb was fractured above the left ankle and rotated 180 degrees laterally.
Steel sheeting obstructed the majority of his lower limb, but the tissue was warm to the touch proximal to the fracture. The weight of the steel and patient positioning stopped any bleeding.
Command requested heavy earth-moving equipment and cranes be sent to the scene.
No field amputation
At 8:30 a.m., a Medflight helicopter landed on scene and a meeting was held at the command post. The primary-care paramedic reported that a field amputation at this point was not necessary, but the patient would almost certainly require an above the knee amputation and suffer massive blood loss.
Incident commanders shifted from immediate lifesaving intervention to salvaging the patient's limb to improve the outcome and quality of life after the incident. Command formed a medical and a rescue sector and established a scene safety officer.
The primary-care paramedic led the medical efforts by monitoring the patient, providing care and addressing his pain.
The rescue sector ran all activities involving patient extrication. It also would determine if the load became unstable and if the medical sector should act to remove the patient.
With the help of the HEMS crew, the patient was monitored for changes in neuro status, blood pressure, pulse, respiration rate and quality, end tidal capnography, perfusion and bleeding. The first medic on scene initiated a 20-gauge IV well to administer 100 mcg of Fentanyl.
Oxygen was initially supplied by non-rebreather mask; this was switched to a cannula to conserve a limited oxygen supply.
A focused physical exam showed no significant injuries other than what was initially discovered. The patient was awake and alert reporting no loss of consciousness.
Shoring the load
Pads were placed under the patient's shoulders to relieve the strain on the trapped limb. However, this increased his pain as the tension on the fracture was released; the patient requested to be placed back in his original position of relative comfort.
Because the patient remained hemodynamically stable with an intact airway, he was placed in his original position so as long as no deterioration in his status was observed. Additional pain medication was given as needed and tolerated.
The rescue sector shored and shielded the void space to protect the victim and workers. A big problem was that the individual steel sheets were not yet secured and still capable of sliding off the pile.
To mitigate this, a wood pallet was placed over the void to redirect falling debris. Then cribbing was used to shore the aerial platform railing that the steel sheeting was draped over.
Workers then used a loader and clamshell digger to remove material. This process was meticulous and slow.
The rescue sector leader examined each piece of the pile prior to removal to ensure what direction it would move. The clamshell digger would grab a sheet of steel, direct it off the pile in a controlled manner and the loader cleared it away.
By 9:15 a.m. a trauma surgical team from the Ohio State Medical Center4 was deployed to the site. The trauma team consists of a board-certified surgeon, a resident, specialized equipment and has the ability to carry and administer blood products, according to Dr. David Evans, the trauma medical director.
This decision was influenced by the time a surgical team would need to deploy and the time needed to extricate the victim with available resources. There was no reliable way to know if the equipment needed to free the patient would be available for many hours to come.
The situation was further complicated by the very real risk of uncontrolled bleeding. Surgical intervention and blood products were justified.
A crane was on scene and in operation at 9:55 a.m. Heavy webbing was slung under a stack of steel sheeting to lift it off the pile.
After this lift, the surgical team arrived at 10:15 a.m., and the physician met with the medical sector and requested a sodium bicarb infusion.
A second crane arrived at 10:20 a.m., and was placed opposite of the first to work in tandem. One crane lifted while the other provided traction to pull the steel sheeting out and away from the victim. The load was split into two bundles and removed.
During this operation it was not safe for any rescue workers to remain in the hot zone. A tourniquet was applied to the trapped limb just above the knee to control bleeding once the pressure to his leg was released.
The patient was extricated at 10:38 a.m., after just over 2.5 hours of being trapped. The patient was packaged with full spinal immobilization, tourniquet in place and transferred to the surgical team before being flown to The Ohio State Medical Center in Columbus, Ohio for treatment.
"Heavy, sharp, water." That is how the lead rescue tech described the pile.
Steel sheeting behaves like a ream of 8.5- x 11-inch paper. Confined, it has weight and stability, and can even stand on end. Released from its wrapping, the stack comes apart and each sheet becomes loose and floppy.
When on an angle the sheets tend to respond to gravity by sliding from higher to lower elevation, much like a liquid. Attempts to support the pile from beneath enhances the pile's tendency to slide and continue to move outward from the lower end.
Further, being coated in an oily substance only added to this effect. In this scenario, the sheeting was also sharp and posed a cut hazard.
Upon arrival and size up, it quickly became clear that the material trapping the victim was going to behave like the paper described above. A heavy, elevated steel platform supported the high end of the pile with material tapering across the victim to ground level.
The terrain was flat concrete and gravel. The lower coefficient of friction added to the tendency to slide. The best option for patient extrication was to remove material from above and control the movement of material.
A second steel core was in the immediate vicinity and posed a safety risk if it was impacted by heavy equipment. Its weight kept it stable as long as its wrapping remained intact.
Risks like this are mitigated with careful coordination of movement and effective communication.
The victim survived surgery and lost his left leg just above the ankle. This below-the-knee amputation will provide more tissue for a better prosthetic fit and improve his quality of life.
4 lessons learned
1. Keep calm and reassess
In a stressful, fluid situation, take steps to slow down, gather input and make informed, evidence-based decisions. Slowing down can make a bad situation better.
Multiple agencies as well as civilian contractors were together in one space at one time with heavy equipment. Everyone must be on the same page.
Open communication was encouraged during the planning session and reassessment stages. Closed communication during operations was essential for safety.
Know your people, and know your own limitations. Good communication skills are a must for intra-agency and inter-agency to ensure all sides of a complex operation are on the same page.
3. Tap human capital
This incident required individuals with multiple and specific skills to bring about a positive outcome. The ability to delegate essential tasks to subject-matter experts can make or break a large incident.
For example, rescuers were confronted with unfamiliar materials and machinery and used people on scene who work with them every day. The contractors were an invaluable resource in this incident.
4. Appoint a safety officer
Having a dedicated safety officer helped evaluate and mitigate risk.
About the Author
Mike Montgomery is a 12-year firefighter/paramedic for the Marysville (Ohio) Fire Division. Montgomery has experience as a former flight nurse with Air Evac Lifeteam, U.S. Army Nurse Corps and U.S. Navy as a hospital corpsman. He is also an emergency department RN for Memorial Health in Marysville. He holds two degrees: an associate of science in nursing from Excelsior College and bachelor of arts from Ohio State University.