Depending on the type of system in which you work or volunteer, you either have turnout gear of your own, walk by it on a regular basis, or periodically work next to firefighters in turnout gear on calls. How much do you really know about turnout gear? If you were presented with a firefighter who had been injured, and was still in a full protective ensemble, or maybe a hazmat or proximity suit, would you know how to remove this gear rapidly, yet safely?
In 2011, the Federal Emergency Management Agency (FEMA) reported that between 2006 and 2008, an estimated 81,070 firefighter injuries occurred annually. Of this number, nearly 40,000 occurred on the fireground and 4,880 occurred while responding/returning from an incident. The majority of fire-related firefighter injuries (87%) occur in structure fires. In addition, on average, structure fires have more injuries per fire than non-structure fires.2
The National Fire Protection Association (NFPA) estimates that 65,880 firefighter injuries occurred in the line of duty in 2013. An estimated 29,760 (45.2%) of all firefighter injuries occurred during fireground operations. An estimated 11,800 occurred during other on-duty activities, while 12,535 occurred at non-fire emergency incidents. Strain, sprain and muscular pain were the leading types of injury received during fireground operations (55.3%), followed by wound, cut, bleeding and bruise (13.8%).1
These two sets of data, especially the number of injuries that occur on the fireground, demonstrate that in the vast majority of firefighter injuries, the firefighter will probably still be wearing turnout gear, and quite possibly a self-contained breathing apparatus (SCBA).
Considering the NFPA reported that the most common injuries are traumatic and musculoskeletal, an injured firefighter will probably be able to remove their gear. However, in 2013, I authored an article with Christopher Stephens, MD, where we observed that “in the context of the injured firefighter who has been rescued from a building, the firefighter will present in one of three general categories: cardiac arrest; breathing, but unconscious; or conscious.”3
Clearly, the most common presentation would be a conscious firefighter with minor injuries who may remove their own gear. For a firefighter who is unconscious and potentially with more severe injuries, you will need to remove the protective ensemble without causing injury, or aggravating an existing injury. Subsequently, if there is any chance you would respond to a firefighter who has been injured, you should be familiar with the design and construction of turnout gear, and adaptive or emergent procedures for removing it.
A firefighter’s protective ensemble includes a helmet, hood, coat, pants, boots and SCBA, all of which are regulated by NFPA standards. Figure 1 lists pertinent NFPA standards.
Different firefighting operations require specific types of protective equipment—structural, aircraft, wildland and, of course, hazmat. It’s absolutely necessary that all components being worn must be similar or compatible. Protection from one hazard may not provide protection from another.
A protective ensemble is designed to cover every part of a firefighter’s body during any type of movement, while also preventing heat from being transferred from a fire to the body. Because turnout gear is designed to prevent heat from entering the body, a problem is that it also prevents heat from leaving the body. Normally, the body sweats to expel excess heat and regulate body temperature. Turnout gear may prevent cooling by trapping excess heat and moisture next to the body, causing an increase in core temperature and a consequent increase in respiratory and heart rate.
Turnout coats and pants are comprised of three distinct layers: an inner thermal liner, a middle moisture barrier and an outer flame-resistant shell. The innermost thermal liner is considered the most important component because it has the greatest impact on protection from heat. In fact, the thermal liner and moisture barrier together represent about 75% of the thermal protection. Thermal liners, typically made from Kevlar and Nomex, are designed to trap air between layers of material. Both are copyrighted materials created by DuPont in the 1960s.
The middle moisture barrier, made of the DuPont product Nomex with a polytetrafluoroethylene (PTFE) film, is designed to protect the wearer against water, chemicals and biological agents. This middle layer represents the most delicate of the three protective components. It’s important that all turnout gear receive an individual inspection after each use, and an advanced inspection yearly or when routine inspections indicate a problem, as specified in NFPA 1851, Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting.
The first line of defense, the outer shell, is also constructed of Nomex and Kevlar. It aids in thermal protection, accounting for the remaining 25%. It protects the wearer and inner layers against flame, water, cuts and abrasions. Outer shells of turnout coats and pants may also use ripstop construction (Figure 2), a special reinforcing technique that makes material resistant to tearing and ripping. During weaving, thick reinforcement threads are interwoven at regular intervals—generally 0.2 to 0.3 inches—in a crosshatch pattern. Thin and lightweight ripstop fabrics may have a three-dimensional structure because the thicker threads are interwoven in thinner cloth. A similar effect may be achieved by weaving two or three fine yarns together at smaller intervals. Besides firefighting protective clothing, ripstop construction is also used in items such as sails, hot air balloons and parachutes.
A relatively new addition to the design of turnout coats is the drag rescue device (DRD), designed to help firefighters rescue an injured or unconscious colleague. The DRD is meant to assist in pulling or dragging an incapacitated firefighter along a flat surface, especially a floor. It’s not designed to raise or lower a person vertically.
The DRD isn’t unique to the fire service; it may be adapted to other professions or types of clothing where needed. But in general, a drag rescue device for use with a structural firefighting turnout coat consists of a loop of ribbon-shaped material that includes left and right sides, with the portions joined to each other at a drag end of the loop, which is then configured to pass through an opening at the base of the neck of the coat, and held closed with Velcro. It’s this piece that’s accessed and grabbed by a rescuer, allowing him to pull the incapacitated firefighter to safety. A DRD may be manufactured from materials such as nylon, Kevlar, Nomex or other materials; it may be made from a single loop of material and permanently attached to a coat or it may be an entirely separate piece, which is slid between the coat layers.
In May 2015, a firefighter in Matthews, NC, fell through an attic floor. He was rescued but unconscious when removed from the house.4 It was believed he may have slipped on a rafter or possibly had a seizure. This is a real-world example of a firefighter successfully rescued from inside a building, unconscious, and the nature of the injury or illness wasn’t clear.
In a scenario like this, an injured firefighter may be rescued from inside a structure fire because of several factors: the proliferation of literature concerning rapid intervention procedures and teams; the subsequent availability of training in these procedures; and the development of rapid intervention bags now carried on some fire apparatus (Figure 3).
This firefighter, after being rescued, would have needed medical care initiated immediately, while still dressed in full turnout gear, and would depend on you to remove his gear without causing or aggravating injuries. This is why you should have a good understanding of turnout gear, how to begin assessment through it and how to remove it.
After a successful rapid intervention operation has been completed and a firefighter is outside the building, basic assessment of airway and breathing may be initiated because breathing may be heard through the SCBA face piece. Obviously, the protective ensemble must be removed. Additionally, depending on whether the firefighter was injured or became ill, cervical stabilization should be started. Some goals of rapid intervention are to locate, get air to and remove an injured firefighter. Generally, cervical stabilization may not be addressed during the removal of the firefighter. The typical extremity, cradle and blanket carry are examples. Thus, once the firefighter is outside, this would probably be the first opportunity to manually stabilize the head.
As you approach the head of a firefighter, you will see three items in order: the helmet, protective hood and face piece. The helmet should be snug on the patient’s head, with earflaps down and chinstrap fastened. The only concern in a rapid removal would be the chinstrap, which could be either cut or simply unfastened. After the helmet is removed, a provider would look at the hood, which could simple be pulled off. However, if trauma is truly a concern, the front of the hood may be cut and removed while stabilizing the patient’s head.3 Under the hood is the face piece, which covers the face and is held in place by straps. Like the helmet, the straps may be either cut or unfastened. At that point, the firefighter patient’s head, face and neck are now completely exposed, allowing a complete ABC assessment and the beginning of airway management.
As you move to the torso, the SCBA and turnout coat could be simply unfastened and removed, but the challenge is to remove them with a minimum of patient movement. A provider’s first instinct might be to start pulling straps and unfastening buckles, but with a better understanding of the design and construction, a firefighter patient’s ensemble may systematically be rapidly removed. SCBA harness straps may be unfastened or cut. If there’s a chest strap, it’s normally thin and accessible. If shears are close by, it may be easier to cut. The waist strap is thicker, but also very accessible. It normally has a very basic buckle, and is probably easier to unfasten normally. The shoulder straps may not be removed without moving the patient’s arms, so it may be faster to cut them. This would need to be done at the lower, adjustable section because it’s much thinner. The upper section includes padding, hoses and the integrated PASS device. The SCBA may now be pulled away or left behind the firefighter, supporting him while the turnout coat is addressed.
There are multiple methods of fastening turnout coats, including Velcro, zippers and snaps. Thus, the front of a turnout coat should be unfastened in the normal manner. Removing the turnout coat quickly and with a minimum of patient movement could be the most challenging step in this process. The coat could simply be pulled off, but this causes quite a bit of patient movement. Because of trapped heat, an injured firefighter will probably have a layer of sweat between his skin and the turnout coat, making sliding or pulling more difficult. To avoid excessive movement, there are methods in which a turnout coat may be partially cut to facilitate removal. If the firefighter is supine or still lying on the SCBA, one method is to start at the wrist and cut up the sleeve, turning into the torso around the armpit. This avoids any padding, pockets or clips (Figure 4).
If the SCBA has been removed and the firefighter is on his side, another method is to cut straight up the back. Again, there are no pockets, clips or other impediments. As stated earlier, turnout gear is meant to resist rips and tears. Adding to the problem: a typical engine or squad doesn’t carry a wide variety or cutting implements. The choices would generally be bolt cutters, seat belt cutters or trauma shears. Bolt cutters are impractical, and seat belt cutters may bunch up the material and become stuck. The coat in Figure 4 was cut with standard trauma shears. If done in two motions—cutting the outer shell, and then cutting the thermal liner and moisture barrier—this method may work well. Obviously, it’s slower than cutting street clothes, but it may be done fairly quickly. Remember that after cutting the outer shell, one will probably see the exposed DRD, which is normally between 1–5 cm wide and 1–4 mm thick, and may simply be cut when seen. After using one of these methods of cutting, the turnout coat may be pulled off with a minimum of patient movement, accomplishing the goal. With the turnout coat gone, the suspenders may be easily cut or just released, and any regular clothes or uniforms may then be easily cut as with any other patient. It should be noted that aside from trauma shears or seat belt cutters, commercially available tools are being developed specifically for cutting through turnout gear.
Unlike a coat, it may be more difficult to find a rapid pathway for cutting turnout pants (Figure 5). There are generally knee pads in front and pockets on the side.
Additionally, attempting to cut turnout boots may be exceedingly slow and difficult. Because of this, and the fact that unlike the arms, pants may be pulled straight off, the recommendation is that turnout boots may be pulled off, and pants simply may be unfastened, and then pulled off. The firefighting protective ensemble is now completely removed.
The rescue of an injured colleague—and probably a good friend—is an emotionally charged event. A common initial response could be to remove everything as quickly as possible. Keep in mind that we have accepted practices for the removal of motorcycle equipment and football gear. There are also procedures for removing a patient from a vehicle or swimming pool. These all exist to protect a patient from further injury. We now have established practices for removing a firefighter from a window, or down a ladder. Why then do the procedures stop? Once a firefighter is rescued from a hot zone, he deserves the same level of consideration a football player, motorcycle rider or any other patient receives. We should not be in such a hurry that we don’t care how we remove a protective ensemble. The injured firefighter deserves a system, or a procedure, that may be practiced by others and reduce the chance of further injury during a rescue.
John G. Alexander, MS, NRP, is a retired fire captain and has been involved in the career and volunteer fire service for 33 years, including 26 years as a paramedic. He is currently a full-time faculty member at the Maryland Fire & Rescue Institute, University of Maryland.