Best Practices: Approach to the Residential Roof Rescue

Editor's Note: We have retooled the "Best Practices" column to address operational issues that may surface in particular incidents rather than focus on administrative issues as we have previously done. If you have an interesting EMS incident which you would like to submit for critique, evaluation or just to ask a question about a best practice related to direct patient care or incident management, send it along with a maximum of 3 questions or discussion points to Dr. Jaslow at jaslowd@einstein.edu. We can not guarantee that the case will be reviewed, but we will provide you feedback within about one month.

Case submissions should be succinct and contain pertinent dispatch, scene and patient care details. The preface to incident details should appear as it does in the original piece on Airway Management. Scan ECGs or convert to PDF when necessary. This column is not a "guess the diagnosis" or "prove the receiving ED wrong" forum. Therefore, discharge diagnoses or a solid ED working diagnosis should be present so that the readership can understand why this case has educational value to our nation's EMS professionals. Do not guess about the diagnosis! The ideal case for presentation will also contain one or more photos depicting scene conditions, patient pathophysiology, etc. The photo must be altered to prevent identification of the patient. Obviously, we assume that patient care was not compromised to obtain the photos and we hold authors responsible to this standard.

Case Presentation:
Date: 3/22/07
Agencies: Bryn Athyn Fire Company, Huntingdon Valley Fire Company
Location: Montgomery County, PA
Incident type: Penetrating trauma; technical rescue
Injuries sustained: Through and through puncture wound of left mid-foot by 4 inch roofing nail

Incident summary
Bryn Athyn and Huntingdon Valley Fire Company units were dispatched on a technical rescue assignment for what was initially described as a construction worker who was trapped on the roof of a house by a machine which had fallen on his leg. En route the information was updated by Montgomery County Emergency Dispatch Services to a worker who had unintentionally shot himself in the dorsal aspect of his left foot with a four inch roofing nail from a nail gun. The nail exited the plantar surface of his foot and implanted into the roof pinning the patient's foot to the plywood planking.

A cross-trained/dual role firefighter/EMS crew composed of an EMT-Basic with 30 years experience and an EMT-Paramedic with 15 years experience, both of whom are NFPA 1006 rescue technicians, responded to the incident and arrived quickly behind law enforcement units. Scene size up revealed an injured person and several other workers on the side "B" roof of a two story, ordinary construction, detached single family dwelling. The patient was awake and alert complaining only of pain in his foot, which was still encased in his work boots. Fellow workers had used a pry bar to disengage the patient's foot from the roof just prior to EMS arrival.

An immediate decision was made by the EMS crew to ascend to the roof to assess what medical and logistical concerns existed prior to arrival of the balance of the first alarm assignment. Initial access to the patient was made via a standard aluminum ground ladder found on the opposite side of the residence which was owned by the construction workers. The crew decided that their standard fire department work uniform and work boots would provide adequate protection in terms of PPE.

A SAM splint was applied to the patient's left lower leg to stabilize the foot, thereby reducing movement and lessening pain. Arriving fire officers worked with the crew to plan proper placement of the tower ladder bucket for extrication. Once the apparatus was positioned and outriggers secured, the boom was extended to the roof and the bucket was placed approximately five feet from the patient. Then a safety harness was placed on the patient and he was assisted into the bucket where he was secured for the ride to ground level. He was transferred to an awaiting ambulance litter and placed into the ambulance where an IV was established and morphine was administered for pain management. The patient was transported to the local Level II trauma center for definitive care and treatment. He was treated and released later that day.