Tactical Medical Mining Rescue − Guideline-based Tactical Emergency Medicine for Mine Rescue Teams and Rescue Organizations in Remote Areas

In mining and remote areas of resource industry, there has been a development towards lacking emergency medical first aid response, that creates a potential disadvantage for patients after work accidents and other medical emergencies compared to standard population. This is due to structural changes in mine rescue brigade coverage caused by transformation from formerly few major resource companies towards many small companies with a broad spectrum of company scopes in resource industry. This raises the question how a professional emergency medical coverage can be provided, taking into account lacking medical professionals in small resource companies combined with long rescue times. Facing this problem, new concepts of emergency medicine are necessary for these particular environments. Aiming on the closure of this gap, a team of the mine rescue brigade from the Research and Training Mine Reiche Zeche (Forschungs- und Lehrbergwerk (FLB) Reiche Zeche) of the TU Bergakademie Freiberg in Freiberg/Germany and its cooperating emergency department of the Freiberg District Hospital developed a totally new rescue concept using elements from tactical medicine and advanced emergency medicine combined with a specifically designed compact equipment and a highly standardized teaching curriculum.

Case example 1

At 10:16 in the morning, a serious accident occurs in a fault zone at a depth of 800 m and 19 km from the shaft: During securing work, a fresh shotcrete shell comes loose from the ridge when the reinforcement mesh is placed on the anchor in the carriage. The shotcrete shell hits the mine worker on the drill rig arm in the head area (Figure 1).

The man is pulled to the ground by the falling concrete mass and, in addition to a head laceration, suffers a deep lacerated wound to his thigh that is bleeding profusely. When the mine rescue team arrives, the casualty states severe pain in the area of the head and thigh. The wounds are provisionally covered with compresses and bandages, then the severely injured person is placed on the rescue stretcher. In doing so, vomiting of stomach contents occurs. After that, the injured man, who is now pale and covered with cold sweat, is transferred to the rescue stretcher when he becomes unconscious due to the traumatic brain injury. Furthermore, the already perfused wound dressing slips during the rescue measures causing a renewed increase in the previously unstopped bleeding. In recovery position, the unconscious man is transported in the emergency vehicle of the mine rescue team towards of the shaft. The arrival of the notified public rescue service in the mine is delayed due to safety-related briefings and various uncertainties and concerns on the part of the public emergency service regarding self-protection. At 11:10 a.m., 54 min after the alert, the life-threateningly injured patient is handed over to the public emergency service above ground. The casualty is now in hypovolaemic shock because of blood loss from the thigh and in acute oxygen deprivation by reason of aspiration of stomach contents into the lungs and insufficient spontaneous breathing. After a long course of intensive care therapy, he is finally discharged from hospital, permanently unable to work.

This fictitious scenario, with a seriously injured person in an underground mine, is intended to illustrate the medical challenges that the mine rescue service would face in such an emergency, the logistical problems that the civilian rescue service faces in the event of an accident in the mine and how this gap in medical care can affect the patient’s medical outcome. In this context, there is a systemic health care disadvantage for workers insured by the employers mutual insurance association because of their work in remote environments with inadequately adapted emergency medical coverage.

Can we do better?
Yes, we can. Case example 2 describes how adequate care of the casualty by the mine rescue team might look like after completion of a two-day − now guideline-based − standardized training curriculum based on the fundamentals of tactical medicine and with available specific advanced but compact emergency equipment.

Case example 2

After the arrival of the mine rescue team, the heavily bleeding thigh wound is quickly treated with easy-to-use and specific clot-activating dressings until the bleeding stops. To relieve the pain, the miners administer a strong and fast-acting painkiller to the casualty, which is applied through the nose. This enables comfortable positioning on the rescue stretcher with subsequent transport of the patient. After vomiting and loss of consciousness, the vomit is suctioned from the throat, the patient’s airway is secured with a specific laryngeal mask and the mask is connected to the Oxylator FR 300 B for ventilator support. Using a cannula inserted into the sternum, the miners apply volume replacement fluid to stabilize the circulation and a drug to stabilize blood clotting. After less than 15 min, the casualty is ready for transport in the mine rescue team’s vehicle under continuous pulseoxymetric monitoring. When the patient is handed over to the public emergency medical services, they find a stabilized patient that has been adequately and professionally treated according to the standards of emergency medical first aid and can be transferred to the next hospital without further measures, with a stable circulation, spontaneously breathing with respirator support and with a good oxygen supply (Figure 2).

Concept development

Due to various structural developments in mining as well as organizational and medical peculiarities in underground emergency rescue, it was urgently necessary to develop new concepts to ensure sufficient emergency care and to adapt the corresponding guidelines for the German mine rescue system. The restructuring of the mining industry from large companies to many small operations with an extended spectrum also inevitably entails a reorganization of the mine rescue system. Highly staffed mine rescue units with attached medical rescue personnel, as they are still known from the former large-scale operations, are hardly kept available today. This problem is aggravated by significantly longer rescue times underground compared to the civilian sector and thus a regular violation of the nationally accepted rescue times, which are 8 to 17 min depending on the respective state rescue service law. In the case of inadequate initial emergency care in the context of lay rescue, the delayed contact of the casualty with the public rescue service represents a serious risk to the patient and increases the risk of medical complications and a poorer medical treatment outcome.

In addition, public emergency rescue is not readily applicable to mining operations. The unsuitable equipment of the rescue service for hazardous areas and long transport distances, the lack of suitable means of communication, the lack of long-term respiratory protective devices as well as regulations of the professional associations for self-protection in hazardous areas enable emergency rescue underground by fire departments and public rescue services only to a very limited extent and on a voluntary basis. These facts are in enormous contradiction to the expected injury severity. Thus, the previously required level of qualification of company first aiders is no longer sufficient to guarantee adequate first aid for injured persons in the context of lay rescue.

Driven by the aim of closing this gap in medical care, a team of the mine rescue brigade from the Research and Training Mine ­Reiche Zeche of the TU Bergakademie Freiberg and the Central Emergency Department of the Freiberg District Hospital have developed a standardized training curriculum for mine rescue teams for emergency rescue underground and in hard-to-reach areas above ground. This course, which is unique for underground hazard conditions as well as for lay rescue, was awarded the Hans Werner Feder Prize at the annual conference of the German Society for Interdisciplinary Emergency and Acute Medicine in 2021. After initial skepticism within the relevant medical societies and also in the field of neighboring aid organizations with similar problems, it now faces major response.

Course organisation, legal framework and certification

After extensive legal examination and appropriate statements, including involvement of the respective administrative bodies of the mining industry, it was finally achieved to firmly implement the validated course concept in the ongoing training of mine rescue teams in Germany. Since 2022, training according to “Tactical-Medical-Mining-Rescue” (TMR^®) has been part of the guidelines of the German Committee for Mine Rescue, with the aim of improving the level of competence and qualification of mine rescue teams and ensuring adequate medical emergency care until the arrival of public medical emergency services. Further, the guidelines for the organization, equipment and deployment of mine rescue teams now call for “validated, extended training in first aid designed for underground and mine-specific conditions” if medical care measures cannot be provided immediately by an emergency physician. In this context, the TU Bergakademie Freiberg acts as the training and certification body for TMR^® and ensures the ongoing validation of the course and the appropriate didactic teaching of advanced emergency medical skills to medical laypersons, as well as the maintenance of the quality level of the training (info@tmr-kurs.com). In addition to the basic training and TMR^® certification through the TU Bergakademie Freiberg, it is optional to be certified as a TMR^® instructor after successful completion of a corresponding second level training course containing, e. g., specific elements of medical didactics. Repeated condensed courses are required every two years to maintain the level of competency. The extended emergency rescue by laymen is carried out on the legal basis of the entrepreneurial duty to ensure first aid in accordance with the General Federal Mining Ordinance (ABBergV) according to § 11 para. no. 4, the duty to provide first aid within the scope of emergency competence pursuant to the Criminal Code (§ 34 StGB) and the lack of underground competence and accessibility by the public rescue service (fire and disaster control laws of the federal states in Germany). Of course, once medical professionals are available, the emergency medical authority of the mine rescue team ends.

Course content, validation and emergency medicine competencies

For the development of the course concept, the operational spectrum of the past years in mining rescue was evaluated, which predominantly records traumatologic emergencies and thus clearly differs from the operational spectrum of the public emergency services. A large part of those workers involved in accidents are seriously injured, some with life-threatening injury patterns. This caused the necessity to focus the training content on the treatment of severely injured patients as well. A training curriculum, didactically adapted to laypersons, sequentially teaches the practical skills of a specially developed condensed emergency medical treatment algorithm. The modified c-AVPU-ABCDE algorithm is shown in figure 3. The algorithm includes assessment of an acute life threatening situation, resuscitation, hemostasis, stabilization of cardiovascular and respiratory function, pain management, reduction and splinting of fractures, body temperature preservation, transport positioning with fixed equipment, and options for drag and vertical rescue, including invasive ventilation. Within a maximum treatment time of 15 min, a patient can thus receive complete preclinical emergency care and be ready for transportation within the framework of the skills learned.

During the development of the treatment algorithm together with specific and extremely compact equipment, the demand for a high level of user safety as well as patient safety from the viewpoint of lay rescue was paramount. The aim is to provide a modern and rapid emergency rescue, taking into account the essence of current emergency medical guidelines, with a view to the best possible treatment outcome for the patient. For this purpose, established schemes from emergency rescue and tactical medicine were modified and used to create a separate logical chain of therapy that enables medical laypersons to safely handle and treat the patient without extensive prior medical knowledge on the basis of simple diagnostic results and clearly defined therapeutic measures. Hence, the specific practical skills to be applied in a step-by-step decisional tree, are taught in a realistic operational environment directly in the mine as part of a training course of 16 teaching units and are tested in realistic accident scenarios with simulated patients according to the Peyton scheme. At the end of the training, the course participants undergo a final examination at seven skills stations, which is conducted as an “Objective Structured Practical Examination” (OSPE). This ultimately demonstrates the acquired skills competence level and documents the course quality. In order to validate the course content and classify it in relation to the level of care of the public rescue service, randomly selected public rescue service personnel with different levels of training completed the identical OSPE examination. For this purpose, only the specific practical skills were tested while maintaining the working environment and equipment of the public rescue service. Within the clearly defined skills set of the TMR^®-instructed mine rescue men, the final scores were statistically equal to professional paramedics of public emergency rescue services. Compared to the paramedic basic level subgroup, the mine rescue team achieved even better test results. In order to evaluate the quality of the acquired skills after several months, the identical participants of the mine rescue team were subjected to a new OSPE examination after a six-month exercise-free interval. This showed that the acquired medical skills could be applied sufficiently and without statistically demonstrable loss of competence even after six months. The comparison of the test results of the mine rescue teams with the reference group public rescue service and the subgroup basic level paramedics is shown in figure 4.

Equipment configuration

During the development of the medical equipment, the specific underground environment was taken into account and the equipment was adapted according to the difficult operating conditions with wetness, dirt, narrowness, limited visibility conditions, potentially non-breathable atmosphere as well as long escape routes and special transport requirements. Compared to the regular rescue service, this resulted in a much more compact emergency backpack, which nevertheless covers the entire spectrum of operations in terms of the skills taught. In functional, removable pockets, the equipment is stowed in a logical sequence according to the treatment blocks (Figure 5).

When selecting the equipment, it was focused on easy and safe handling with a steep learning curve. The use of an exercise-intensive − and in the case of circulatory centralization often (even under ideal conditions) difficult to apply − peripheral venous access, e. g., was avoided. Instead, for the administration of drugs and fluids an access (E.Z.-I.O. T.A.L.O.N., Teleflex) to the bony vascular system was used, which can be easily inserted at the sternum after short practice on the phantom. To minimize stress and forego the teaching of profound differential therapeutic expertise, the use of drug dosage calculations was omitted. Instead, the available drug dosage forms were selected from the point of view that a complete ampoule is always drawn up and administered for the care of adults. For airway protection, a Laryngeal Mask Airway Supreme (Teleflex) is used, which can be easily inserted by the user into the lower pharyngeal region with a final fit on the larynx and which fulfills the insertion and sealing properties required for the special operating conditions. For ventilation, the Oxylator FR 300B (Panomed) is used, a pressure-controlled semi-automatic and self-contained ventilator, the mine rescue teams are already familiar with. With the aid of a specially developed patient card, the mine rescue team can quickly and clearly document the detected injury pattern and the administered therapy, and hand over the patient to the public rescue service in a structured manner (Figure 6).

Quality control

In order to control and maintain the quality level of the TMR^® courses conducted in the individual companies, the respective examination results are always statistically evaluated and compared with the initial validation results. So far, the results of all participants, who successfully completed the course, were statistically without any difference compared to the study participants in the course validation (Figure 7).

So far, practical utilization of the training content in real life-threatening accidents in mining has not yet been reported. However, the demonstrated skill development of the course graduates clearly shows the potential to close the gap of lacking professional emergency medical care in mining and remote areas of resource industry The TMR^® concept has already been presented at several national and international conferences, such as the Annual Meetings of the Mine Rescue Teams, the Plant Fire Brigades Association and the German Social Accident Insurance Institution for the Raw Materials and Chemical Industry (BG RCI), Society for Mining, Metallurgy and Exploration Annual Conference and International Mines Rescue Body Conference.

University curriculum

In order to sensitize future mining engineers to a high value of responsibility with regards to health and occupational safety − already during their university education, the teaching of emergency medical and physiological backgrounds of the TMR^® concept has been introduced as fixed part of the curriculum at the TU Bergakademie Freiberg from the winter semester 2022/23. This offering expands and supplements previous content on personnel safety such as the modules “Safety and Rescue Works in the Extractive Industries” and “Student Mine and Gas Safety Brigade”, which have already been offered for several years.

The four-part block lecture “Industrial Safety and Emergency Medicine for Engineering Professions” with a duration of two hours per semester week is currently offered in the Studium Generale and in the diploma course “Geotechnical Engineering, Mining and Geo-Energy Systems”. Furthermore, they are firmly integrated into the (planned) diploma courses “Geoengineering” and “Mining”, which will be introduced from the winter semester 2023/24.

The purpose of this lecture is to awaken the basic understanding of the necessity of a pre-emptive emergency medical secured work environment at an early stage, in order to provide the necessary information to the future responsible persons and decision makers, so that they can make necessary organizational decisions in their later area of responsibility with regards to staff safety and health. In addition to the positive evaluation results to date, the high demand by students and also employees reflects the relevance of the topic and shows the interest of future engineers in aspects of necessary emergency medical protection for personnel in their area of responsibility.