Techniques for Patient Rigging, Packaging & Transport

Issue 5 and Volume 3.

Rescuers have located their patient at the bottom of a deep rock crevice, but they’ve had some difficulty accessing him; they first walked, then down-climbed, and finally crawled into the space. This scenario sounds like a complex rescue situation, but actually it was a mock rescue that took place out in the Joshua Tree National Park.

As the scenario played out, the rescue team chose to package the patient in a Sked and set up a rope system to extract the patient from the space. Once the patient was brought up onto a small open area above the crevice, he was to be lowered 80 feet down a vertical rock face. As the patient was packaged for the extraction, part of the team rigged a lowering system to perform the second half of the rescue. The team had decided to use a Stokes basket for the second lower with a litter attendant.

It all sounded good, but as the slope quickly became less vertical, the litter attendant found himself in an awkward position. There were other challenges, as well as a couple valuable lessons to be learned, all of which I’ll reveal at the end of this article.

Rope rescue can be tricky when terrain changes, which is why training on rescue techniques and tools is so important. In this month’s column I’ll discuss the following questions:

  • Should you use vertical or horizontal rigging for the basket?
  • Should you use a Stokes basket or other type of patient movement device?
  • Do you need a litter attendant?
  • How will the litter attendant be attached to the system?
  • Does your department have a standard way to rig litter attendants or do you rig them differently each time?
  • How will you secure the patient to the basket?
  • How should you protect the patient?
  • How will you attach the main and belay lines?

Vertical or Horizontal?

For areas that are narrow or have many obstructions, it may be best to choose a vertical configuration. Stokes baskets can be rigged for vertical or horizontal situations. The patient will tolerate traveling in a horizontal head-up position most often, but the terrain and departure and landing areas will ultimately determine the best position for them.

A small 4:1 pulley system (a “set of fours”) built with two double-sheave 1 mini-prusik-minding pulleys and 30 feet of 9-mm accessory cord is a great tool to carry, because it will allow you to change the orientation of your basket as needed. There’s a myth about litter spiders that you can easily lengthen them. Actually, they’re pretty darn hard to adjust once weighted. The set of fours allows you to take the weight off one end and disconnect the foot spider so you can re-rig it vertically.

Type of Litter

Stokes baskets are the tool of choice for patient transport when you’re not operating in a confined space or an area that requires negotiating tight turns. Because the Stokes basket has a solid railing to grab, many rescuers can assist with movement over uneven terrain. But Stokes baskets don’t bend around corners; I’ve seen more than one wedged into a narrow opening. So when confronted with small openings and tight corners, use a patient-packaging device that will allow for some bending and movement, such as a Sked, an LSP Halfback, a Yates Spec Pak, a PMI Chrysalis roll stretcher or a Rescue Ease Wrap Evac. All of these litters are rated and designed to be rigged for vertical raises and lowers. Read the manufacturers’ instructions to find out how to rig each one, but don’t go overboard—if the patient will only be dragged horizontally, they probably don’t need a complicated harness system. Webbing straps might do the job. Also consider using a skateboard stiff plastic sheets or a half Sked.

Litter Attendants

This isn’t as much of an issue on lowering systems, but on raising systems I like to avoid hauling any more weight than necessary. Often in training, we place an attendant on the litter because it’s a great photo op and we want to give everyone some time and experience managing a litter over an edge. In actuality, a litter attendant usually isn’t needed; a simple tag line will do the job.

Litter attendants perform two main jobs: They keep the litter from getting hung up on obstructions and they attach the main and belay lines to the litter.

If a patient has a minor injury, is alert and oriented, and not flipping out over the upcoming “ride,” do you need a litter attendant? Probably not. If they need reassurance, should someone rappel down alongside them? Will that be to your advantage? Maybe. But most of the time litter attendants help keep the basket moving by physically pushing it away from windows, signs, ledges and other obstructions. In situations where you’re unable to set up a system from above or rig a high-directional pulley, it can be difficult to coordinate getting the litter over the edge and getting the attendant onto the system.

Important: If you don’t use a litter attendant, you should attach a tag line to the litter to help it avoid obstructions. Tag lines need only pull the load enough to clear the obstruction (a few inches), so you don’t need to rig a mechanical advantage (MA) system. What is needed is distance. The further the tag line tender is from the base, the better. The ideal distance is twice the vertical dro, so for an 80′ vertical drop, the tender should stand back 160 feet.

When attaching the main and belay lines to the litter, litter attendants must keep the distance between the litter spider and the main litter attachment point as short as possible. I like to use a steel ring because it reduces the number of carabiners needed to make all the connections if you use a direct tie-in. (Note: You can purchase a 25,000-lb. ring for less than $10.) Carabiners add length and have the potential for side-loading and being left unlocked. Screw links, unless closed with a wrench and left closed, also have the potential of being left unlocked.

The hurdle rescuers must overcome involves quickly doing a direct tie-in to the steel ring. Initially, this is a challenge to students, but after several attempts and some good tips, they quickly overcome the hurdle. I’ve found that a long-tail bowline works well, as you can easily re-adjust it if the length achieved is not appropriate for the situation. Once the evolution is over, you can also untie a bowline easier than other knots. If you don’t need the long tails, you can back up the knot with a double overhand bend or a Yosemite finish.

If the situation calls for a litter attendant, remember they must be able to position themselves in relation to the top litter rail and use their feet to help the litter avoid obstructions and prevent it from dragging on rocks and structures.

Litter attendants must also be able to easily travel up and down in order to reposition themselves, because oftentimes the position you start in is not the position you must be in once the litter is over the edge and weighted. (Note: There are many ways to re-position the attendant, but in this article I’m describing simple set-ups.)

Patient Packaging

Prior to transport, placing a commercial or improvised victim harness on the patient allows you to quickly secure the patient inside the basket with a simple internal lash. Rescuers can use two 12′ lengths of webbing girth-hitched to the D-ring or main connection point of the harness to secure the patient to the litter.

For the external lash, which prevents the patient’s extremities from moving within the litter rescuers can use a 25’–30′ length of webbing. Lashing can begin at the top or the bottom, but when you’re done, make sure that if the patient slides around inside the basket, the webbing won’t obstruct their breathing.

The webbing begins and ends with a round turn and two half hitches. The webbing doesn’t take a turn around the upright posts on the litter; rather, it just passes over them. One end is secured and once the slack is pulled out of the webbing, the other end is secured. Tip: When performing the lashing, avoid wrapping the top rails. If the basket rubs on a structure or rocks, the webbing may become abraded.

Often rescuers use a long-tail bowline daisy chain or pick-off strap as a “patient safety.” If you use the litter pre-rig as shown in the photos, this may not be necessary, because the patient is secured with an internal and external lash.

Once the patient is secure, the litter is attached to the main litter attachment by three to four legs of the spider. A steel ring is used as the main litter attachment point. The belay line is attached to the steel ring and the litter spider is attached to that in case of a mainline failure.

Patient Protection

During transport, patients must be protected from both the elements and their rescuers. It’s easy to accidentally dislodge a rock from above when lowering a patient, and I’ve seen more than one portable radio land on a patient. To avoid accidents, rescuers must check their harnesses for loose and/or unneeded equipment. Patients should be provided with a helmet and safety glasses at minimum. A Lexan litter shield does an excellent job of protecting a patient’s face. A hockey helmet with a catcher’s metal mesh screen in the front will also reduce the patient’s likelihood of visiting an oral surgeon if you’d rather not spend the money on a litter shield.

Rigging Right

Check five different rope rescue books, and you’ll find five different ways to attach main and belay lines. Is there just one right way to do these things? Of course not. There are many ways to perform these and other tasks and many different tools to help you accomplish them. For example, there are commercial pre-rigged litter bridles with sewn straps and there are bridles cut and tied from rescue rope and accessory cord. Litter spiders can be made from 1″ tubular webbing and/or 8-mm accessory cord, even though these smaller rigs are usually used when improvising a litter or when trying to travel very light. If your team must frequently carry rigging gear on their back, they’ll most likely use a minimal approach and go light and simple whenever possible.

Important: The members of your team must be on the same page when overseeing or inspecting your rigging. This means your department must have SOGs with drawings that show the accepted techniques. If the safety officer checks the system and doesn’t recognize the rigging technique but the rigger says it’s correct because he read about it in a magazine last week, your team has a problem. All members must know the accepted techniques for their organization. Some agencies specify only one way to perform each task, while others give their technical rescue team several options. Tip: If you have trouble remembering your SOGs at first, keep laminated copies of the rigging drawings in your rigging bag.

Whatever technique your agency uses, it should be documented and referred to throughout the incident. More than once I’ve heard voices raised over rope rescue rigging. Written SOGs with drawings will help eliminate confusion and frustration.

The Main Line
When rigging the main line, you must first tie the line to the steel ring with a long-tail bowline using a short prusik loop or mechanical ascender. The bowline should be long enough to allow the attendant to travel just below the litter if needed. Examples of small short ascenders include the Petzl Rescuecender, the Gibbs Cam and the SMC-PMI Grip. Larger ascenders aren’t as desirable due to their length.

To release these devices, the tension must be released from them. To do this, I use an etrier. If the etrier is too short, girth hitch a piece of webbing or a prusik to it as an extension. Then clip the etrier to the steel litter ring.

The Belay Line
When rigging the belay line, use a long-tail bowline and secure the tail to the attendant’s harness with a direct tie-in. This prevents you from using a carabiner and, more importantly, in the event the belay line has to be loaded, a side-loaded carabiner won’t be in the system. A carabiner attachment for a belay line always has the potential to side-load.

As with the main line, the length of the long-tail for the belay must allow the attendant to move below the basket. If there’s more slack than is reasonable due to a long litter spider, apply a prusik to the long-tail (you can clip it to the attendant’s harness) after it’s tied to the attendant and use it to take up unneeded slack. I like to attach the belay line to the harness in the front. On Class III (full body) harnesses, there’s often an upper and lower D-ring attachment. When this configuration is present, I tie the belay to the upper D-ring. Note: The attendant can’t hang from the belay line, nor can you use the long-tail of the main line for the belay. Try these things and you’ll find that if the litter attendant is hanging on the tail of the belay, the belay line will keep becoming weighted. If you attach the long-tail of the main line as the belay, you’ll be unable to make any adjustments because it’s under a load.


There are many ways to perform patient packaging. For team or department operations, it’s best to have a set way of packaging or a couple of options for your members to select from depending on the situation.

Whichever strategy you determine appropriate for your agency, make drawings or photos of the rigging and keep them with your rigging gear to help the newer members.

When considering several different types of rigging, troubleshoot each type, making sure it will meet your needs. Draw out how you would use each type on a dry-erase board, and when you’re done, perform a training drill that replicates your illustration to see if it will work for you.

So what happened to the team training in Joshua National Park? Well, first of all, the litter attendant endured a brutal raise up a less-than-vertical slope. Then, once the Sked reached the top of the crevice, the team transferred the patient from the Sked to a Stokes basket, which was extremely time consuming and frustrating to the trainees, not to mention a totally unnecessary step. Subsequently, their eye for detail deteriorated. They strapped the litter spider under the external lash webbing—three times. (I wasn’t there, but I received a blow-by-blow account from the lead instructor who relayed the activity to me over his portable radio and was near tears at times watching the team perform certain tasks.)

The lead instructor didn’t want to interfere with the drill, so he waited, hoping the team would catch their mistake and start again. The whole team was using their headlamps, as the sun had long ago set.

Once the patient was successfully packaged, main and belay lines attached, and a safety inspection performed, the patient was lowered down the other side of the crevice without incident.

The lessons: In this scenario, too many cooks were spoiling the broth. They had all hands performing the packaging. Use only the manpower you need during patient packaging so you can keep track of each step. Also, if you ever have a patient packaged in a Sked and plan to lower them in a litter, there’s no reason to take them out of the Sked. Perform an internal and external lash and you’ll be moving in no time.

Author’s note: The author would like to thank Jarod Trow of the Bellingham (Wash.) Fire Department Jolie Paterniti of the Mukilteo (Wash.) Fire Department and John Giddings of Fire District 1 (Wash.) for their assistance in obtaining photos for this article.