Improvised Litters and Carries

Scene Size-Up

To select the best method for bringing a patient to definitive care, the rescuer must make a realistic assessment of several factors:

Scene safety is the initial priority.
The necessary evaluation, called the scene size-up ( Box 57.1 ), involves a (usually hasty) determination of whether the patient, rescuer, or both are immediately threatened by the environment or situation.
Box 57.1

Scene Size-Up Factors
- What are the scope and magnitude of the overall situation?
- Are there immediate life-threatening hazards?
- What is the location, and how many patients are there?
- What is the patient's condition? Is the patient able to assist rescuers?
  - No injury (able to walk unassisted)
  - Slight injury (able to walk unassisted)
  - Slight injury (assistance required to walk)
  - Major injury (requires considerable attention and assistance)
  - Deceased
- Is there a need for technical rescue?
- Is the scene readily accessible?
- What rescue resources (including rescuers and equipment) are available?
- How far must the patient (or patients) be transported?
- Are ground or air transport assets available?
Proper immobilization and patient packaging are always preferable, but sometimes the risk for aggravating existing injuries is outweighed by immediate danger presented by the physical environment. In such a situation, the rescuer may choose to immediately move the patient to a place of safety before definitive care is provided or packaging is completed.
Evacuation options are limited by three variables:
- Number of rescuers
- Fitness of rescuers
- Technical ability of rescuers
Carrying a patient, even over level ground, is an arduous task. At an altitude where walking requires great effort, carrying a patient may be impossible.
Complex rescue scenarios requiring specially trained personnel and special equipment are called technical rescues and often involve dangerous environments, such as severe terrain, crevasses, avalanche chutes, caves, or swift water. To avoid becoming patients themselves, rescuers must realistically evaluate their abilities to perform these types of rescues.
When a patient is transported on an improvised litter, especially over rough terrain, they should be kept in a comfortable position, with injured limbs elevated to limit pressure and movement.
To splint the chest wall and allow full expansion of the unaffected lung, a patient with a chest injury generally should be positioned so that he or she is lying on the injured side (injured side “down”) during transport.
For a patient with a head injury, the head should be elevated slightly; and for a patient with dyspnea, pulmonary edema, or myocardial infarction, the upper body should be elevated. However, any patient positioning is superseded by the ability of rescuers to safely carry the victim without exhausting themselves.
Whenever possible, an unconscious patient with an unprotected airway should be positioned lying on his or her side (“rescue position”) during transport to prevent aspiration.
When time permits, practice constructing the improvised litter first and then use it to carry an uninjured person, to “work out the kinks.”

Drags and Carries

A drag or carry may be the best option when (1) a patient cannot move under his or her own power, (2) injuries will not be aggravated by the transport, (3) resources and time are limited, (4) the need for immediate transport outweighs the desire to apply standard care criteria, (5) travel distance is short, and (6) the terrain makes use of multiple rescuers or bulky equipment impractical. Spine injuries generally prohibit using drags or carries because the patient cannot be properly immobilized. Drags are particularly useful for patients who are unconscious or incapacitated and unable to assist their rescuer (or rescuers), but may be uncomfortable for conscious patients. When a drag is used, padding should be placed beneath the patient, especially when long distances are involved. The high fatigue rate of rescuers makes carries a less attractive option when long distances are involved.

Blanket Drag ( Fig. 57.1A )

1.
This can be performed on relatively smooth terrain by one or more rescuers rolling the patient onto a blanket, tarp, or large coat and then pulling it along the ground.
2.
This simple technique is especially effective for rapidly moving a patient with a spinal injury to safety because the patient is pulled along the long axis of the body.

FIGURE 57.1, A, Blanket drag. B, Fireman's drag. Both techniques are intended to be used when expeditious transport over a short distance is required.

Fireman's Drag (see Fig. 57.1B )

1.
In an extreme circumstance, the “fireman's drag” can be used.
2.
In this method, the rescuer places the bound wrists of the patient around his or her neck, shoulders, or both, and crawls to safety.

Fireman's Carry ( Fig. 57.2 )

Classic carry, but difficult for an untrained or smaller (than the patient) rescuer

FIGURE 57.2, Classic Fireman's Carry: A Single-Rescuer Technique for Short-Distance Transport Only.

Three-Person Wheelbarrow Carry ( Fig. 57.3 )

This system is extremely efficient and can be used for prolonged periods on relatively rough terrain. The patient places his or her arms over the shoulders of two rescuers standing side-by-side. The patient's legs are then placed over a third rescuer's shoulders. This system efficiently equalizes the weight of the patient.

FIGURE 57.3, Three-Person Wheelbarrow Carry.

Two-Hand Seat

1.
Two carriers stand side by side. Each carrier grasps the other carrier's wrists with opposite hands (e.g., right to left).
2.
The patient sits on the rescuers’ joined forearms.
3.
The carriers each maintain one free hand to place behind the back of the patient for support (support hands can be joined).
4.
This system places great stress on the carriers’ forearms and wrists.

Four-Hand Seat ( Fig. 57.4 )

1.
Two carriers stand side-by-side. Each carrier grasps his or her own right forearm with the left hand, palms facing down.
2.
Each carrier then grasps the forearm of the other with his or her free hand to form a square “forearm” seat.
3.
The patient must support his/herself with a hand around the rescuer's back.

FIGURE 57.4, A, Four-hand seat used to carry a patient. In this technique, the upper body is not supported. B, Alternative four-hand seat that helps support the patient's back.

Ski Pole or Ice Axe Carry ( Fig. 57.5 )

1.
Two carriers with backpacks stand side by side with four ski poles or joined ice axe shafts resting between them and the base of the pack straps.
2.
The ski poles or ice axe shafts can be joined with cable ties, adhesive tape, duct tape, wire, or cord.
3.
Because the rescuers must walk side-by-side, this technique requires wide-open, gentle terrain.
4.
The patient sits on the padded poles or shaft with his or her arms over the carriers’ shoulders.

Split-Coil Seat (“Tragsitz”) ( Fig. 57.6 )

1.
The split-coil seat transport uses a coiled climbing rope to join the rescuer and patient together in a piggyback fashion ( Fig. 57.7 ).
2.
The patient must be able to support himself or herself to avoid falling back, or must be tied in.

FIGURE 57.6, Single-Rescuer Split-Coil Carry.

Commercial Tragsitz Harness ( Fig. 57.8 )

A few commercial harnesses allow a lone rescuer and single patient to be raised or lowered together by a technical rescue system.

Two-Rescuer Split-Coil Seat ( Fig. 57.9 )

1.
The two-rescuer split-coil seat is essentially the same as the split-coil Tragsitz transport, except that two rescuers split the coil over their shoulders.
2.
The patient sits on the low point of the rope between the rescuers ( Fig. 57.10 ). Each rescuer maintains a free hand to help support the patient.

FIGURE 57.9, Two-rescuer split-coil seat.

Backpack Carry

1.
A large backpack is modified by cutting leg holes in the base. The patient sits in the backpack as if it were a baby carrier.
2.
Some large internal frame packs incorporate a sleeping bag compartment in the lower portion of the pack that includes a compression panel. With this style of pack, the patient can sit on the suspended panel and place his or her legs through the unzipped lower section without damaging the pack; or the patient can sit on the internal sleeping bag compression panel without the need to cut holes.

Nylon Webbing Carry ( Fig. 57.11 )

1.
Nylon webbing can be used to attach the patient to the rescuer like a backpack.
2.
At least 4.6 to 6.1 m (15 to 20 ft) of nylon webbing is needed to construct this transport.
3.
The center of the webbing is placed behind the patient and brought forward under the armpits. The webbing is then crossed and brought over the rescuer's shoulders, then down around the patient's thighs.
4.
The webbing is finally brought forward and tied around the rescuer's waist. Additional padding is necessary for this system, especially around the posterior thighs of the patient.

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