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Patient Packaging in Confined Spaces: Getting It Right When the Walls Close In
- Empact Staff
- 6 days ago
- 5 min read
In this month's issue of First Due, we're tackling one of the most physically demanding and technically challenging aspects of confined space rescue: patient packaging. You've sized up the space, controlled the atmosphere, and made entry—now you've got a patient who needs to come out. The packaging decisions you make in the next few minutes will directly impact patient outcome, extraction efficiency, and the safety of your entire team. Unlike packaging on open terrain, confined spaces force you to work within physical constraints that limit your options and test your adaptability. This article will walk you through device selection, the realities of packaging in restricted environments, and the critical relationship between your packaging plan and your extraction plan.
As always, these articles are designed to provide an introduction to the material or a refresher of knowledge you already have and don't replace real-life training. If you're interested in learning more about rope rescue, we've listed our upcoming rescue courses after the article, so make sure you take a look at those before you go!
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The Confined Space Patient Packaging Problem
Here's the reality of confined space patient packaging: everything you know about packaging still applies, but the environment actively works against you.
You're dealing with limited working space around the patient, restricted movement for rescuers, awkward patient positioning, and access points that dictate how—and in what orientation—that patient is coming out. Add in potential atmospheric hazards requiring SCBA or SABA, communication challenges, and the physical fatigue of working in a cramped environment, and you've got a task that demands both technical proficiency and adaptability.
The most common mistake? Committing to a packaging device before fully understanding the extraction pathway. Your packaging and extraction plans aren't separate considerations—they're two halves of the same decision.
Device Selection: Matching the Tool to the Task
Selecting the right packaging device in a confined space requires you to answer several questions simultaneously:
What is the patient's condition?
Spinal immobilization, medical emergency, traumatic injury, or conscious and ambulatory with assistance? Patient condition drives your immobilization requirements. A conscious patient with a lower extremity injury has very different packaging needs than an unconscious patient with an unknown mechanism of injury.
What is the geometry of the space?
Vertical entry and exit? Horizontal crawl? Multiple direction changes? The shape of the space—and particularly the access point—will often eliminate certain device options entirely. A full-length backboard isn't going through a standard 24-inch manhole, and a Stokes basket won't navigate a 90-degree turn in a utility tunnel.
What is the extraction method?
Will the patient be hauled vertically? Passed along horizontally by rescuers? A combination of both? Your packaging must be compatible with your rigging and hauling system.
Common packaging devices and their confined space applications:
Flexible Stretchers (SKED, Ferno Traverse, etc.) The workhorse of confined space packaging. Their flexibility allows them to navigate tight spaces and bends while still providing patient security. Most can be rigged for vertical hauling with proper attachments. When space is truly restrictive, flexible stretchers are often your only viable option.
Half-Back/Short Board Devices (KED, XP1, etc.) Ideal for patients requiring spinal immobilization who must be moved through tight vertical access points. These devices secure the torso, head, and neck while leaving the lower body free for maneuvering through restrictions. Once clear of the confined space, the patient can be transferred to a more comprehensive device.
Vertical Lift Devices (LSP Half-Back, Yates Spec Pak, etc.) Purpose-built for vertical extraction through limited-diameter openings. These streamlined devices keep the patient's profile narrow during the lift.
Full-Length Devices (Backboards, Stokes Baskets) Generally limited to larger confined spaces with generous access points—think large tanks or vaults with oversized hatches. When you can use them, they provide excellent immobilization and integrate easily with standard hauling systems. But don't force them into spaces where they don't fit.
The Packaging Process
Once you've selected your device, the packaging process in a confined space follows the same clinical priorities as any other environment—but execution looks different.
1. Access and Initial Assessment
Before you touch a packaging device, complete your patient assessment. In the confined space environment, it's tempting to rush toward extraction—fight that urge. A missed injury or incomplete assessment will complicate care once the patient is out of the space.
2. Create Working Space
Move any debris, tools, or obstructions that limit your access to the patient. In a confined space, even six inches of additional working room can dramatically improve your ability to package effectively.
3. Position the Device
Getting the device under, around, or onto the patient in a confined space often requires creative problem-solving. Flexible stretchers can be rolled or folded to slide beneath a patient. Short spine devices may need to be applied with the patient in a non-traditional position, then the patient moved into alignment. Work with your space, not against it.
4. Secure the Patient Systematically
Follow your device's securement sequence, but be prepared to adapt. In extremely tight spaces, you may only be able to access one side of the patient at a time. Communicate clearly with your team members about what's secured and what still needs attention before any movement.
5. Prepare for Extraction
Before the patient moves an inch toward that exit point, confirm your rigging attachments are correct, your haul system is ready, and everyone understands the plan. The transition from packaging to extraction is a high-risk moment—don't rush it.
Vertical vs. Horizontal Considerations
The orientation of your extraction significantly impacts packaging requirements.
Vertical Extraction
When hauling a patient vertically through a manhole or hatch, your primary concerns are:
Patient security against sliding within the device during the lift
Narrow profile to clear the opening
Proper attachment points rated for the load
Head protection during the lift (helmets or padding)
Airway management positioning—monitor for compromise during vertical lifts
Vertical extractions place significant strain on packaging device attachments. Inspect your equipment regularly and understand its rated capacity.
Horizontal Extraction
Horizontal moves through tunnels, pipes, or crawlways present different challenges:
Smooth outer surface to prevent snagging on obstructions
Low profile to clear overhead restrictions
Ability to navigate bends or direction changes
Rescuer positioning for pushing or pulling the packaged patient
In long horizontal extractions, patient monitoring becomes more difficult. Establish check-in protocols at regular intervals.
Integration with Your Team
Patient packaging in confined spaces is not a solo operation. Clear communication with your team—both inside and outside the space—is essential.
Before you begin packaging, confirm:
Your backup team knows what device you're using and what rigging they need to prepare
The extraction pathway is clear and your hauling system is ready
Everyone understands the sequence of events from packaging completion through patient delivery
Talk through the plan before you start. Adjusting your approach mid-packaging while wearing SCBA in a 36-inch diameter pipe is not the time to discover a miscommunication.
Training Implications
Patient packaging in confined spaces requires hands-on repetition across multiple space configurations. Reading about device selection is valuable, but nothing replaces the experience of actually wrestling a SKED around an unconscious patient in a 30-inch manhole while wearing full PPE.
Seek out training opportunities that provide realistic confined space environments with varying geometries, multiple device options to compare, and the chance to work through complete packaging-to-extraction evolutions. The skills you build will directly translate to better patient outcomes on real incidents.
The Bottom Line
Patient packaging in confined spaces rewards preparation and adaptability. Know your devices, understand the space, visualize the complete extraction pathway, and communicate relentlessly with your team. The skills you build through realistic training will directly translate to better patient outcomes when it counts.
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