Technical rescue encompasses a broad range of challenging environments, including structural collapse, machinery, caves, mines/tunnels, and swiftwater. While the focus is often on the rescue aspect of a technical rescue incident, the clinical aspects for both the victim and rescuers must also be considered. The confined space environment is one of several austere settings that the EMS physician may encounter. Whether a collapsed structure or similar urban search and rescue setting, or an intact electrical vault, grain silo, or other hazardous area, the EMS physician must be able to operate safely and effectively as part of a rescue team. An understanding of OSHA confined space regulations, confined space medicine, and atypical clinical issues such as dust airway impaction is essential for all EMS physicians.