Hold Your Fire!

   A quiet midafternoon has just become very busy. The dispatch was for a person down along a busy residential street, but when Attack One arrives at the scene, bystanders are doing chest compressions on a man lying partially beneath a large lawn tractor. Some are preparing to lift the tractor by hand.

   The Attack One crew pulls its resuscitation gear off the vehicle and starts to work controlling the scene and carrying out victim care. The woman doing chest compressions says she's a respiratory therapist at a local hospital, and arrived to find bystanders looking at the unconscious victim. She found no pulse, so immediately initiated chest compressions and, following the new guidelines for cardiac resuscitation, compressed continuously without breaths. The victim is lying on his side, so she rolled him over as best she could, as his legs are trapped between the tractor and ground. He appears to be an older man, and on quick scan has no signs of injury.

   No one seems to know what actually happened, so the crew initiates its protocol for a blunt trauma cardiac arrest. The therapist offers to continue compressions while the crew frees the patient's legs, places a cardiac monitor and provides ventilations.

   The first responder fire engine crew and bystanders are anxious to lift the lawn tractor off the patient, but the engine crew's captain urges caution—the tractor's gas tank is already leaking fuel, and lifting the tractor will increase the flow. He notes fuel is already covering the victim's pants.

   The Attack One paramedic has placed the victim on a three-lead monitor and finds him in ventricular fibrillation. One EMT is bagging him, and the other has substituted in for the respiratory therapist and is now providing compressions.

   The crews quickly agree that rapid extrication is needed, so they will stop compressions, quickly lift the tractor, slide the patient out and onto a backboard, then resume compressions and prepare for defibrillation.

   "What about this gasoline?" the EMT asks. "There's fuel all over him—he's going to light up if we use that defibrillator!"

   With that realization, the crews modify their plan. Now they will separate the man from his gasoline-soaked pants, cover his lower body with a moist sheet to reduce any off-gassing of the fuel, and move the backboard and patient about 20 feet onto the street, where he can be defibrillated away from the fuel. They will try to blow air across his lower body to keep fumes moving away and make sure the defibrillator pads are absolutely secure on the body to reduce any potential spark. Compressions will continue between all actions.

   Bystanders work with crews, and the fire captain ensures every action is done safely. The patient slides out as the tractor is lifted. A sheet covers his lower body. No serious injuries are found to his lower extremities. One firefighter quickly wipes down the patient's legs with some towels to remove as much of the fuel as he can. The patient goes on a backboard, and it's moved to the street. Once it's there, the crew members smell little gasoline odor. The defibrillator pads are placed, with no back injuries noted and no spots of gasoline seen on the patient's back, buttocks or groin. Compressions continue.

   The paramedic carefully checks each pad to ensure it's securely placed. The rhythm remains v-fib. The fire captain detects no significant fuel smell around the patient, so he gives the go-ahead. The paramedic clears everyone away and administers the first charge. The patient remains in his rhythm. The fire captain again smells no significant fuel, so the area is again cleared, and another shock delivered. This second defibrillation produces a straight line signal, which evolves into a few complexes, then a regular rhythm. The paramedic asks the crew members to resume ventilating the man, and the EMT who had been doing compressions feels for and finds pulses matching the electrical beats on the monitor.

   The paramedic prepares for postresuscitation care. The patient gets an oral airway, a complete examination, an intravenous line and a fingerstick blood sugar (result: 150). The pulse oximeter begins to sense a pulse and produce the regular audio signal of a perfusing patient. The captain returns his attention to the overturned tractor and spilled fuel.

   The respiratory therapist makes her way back to the medic, accompanied by another bystander. This woman had witnessed the whole event. The therapist asks the woman to tell the crew what she saw.

   "I was walking by when I noticed this man doing yard work with his tractor," she says. "He was coming slowly toward the street when he seemed to grab his chest and pass out. He slumped over the wheel, and the tractor turned very slowly, hit a small hole and then just rolled gently over. He didn't hit the ground hard, and the tractor just gently turned onto his legs. Another man came by and shut the tractor off, and I called 9-1-1. It looked like he was unconscious as it all happened. Then the fuel spilled on him, and everyone else moved away."

   After a few questions, the crew is convinced this was a medical event, with minimal if any trauma involved. They relay the story to the fire captain so he can manage the tractor and questions from any family that might show up. So far, no one knows the patient, and he has no identification.

   The crew rapidly prepares the man for transport. He begins fairly quickly to breathe on his own, so no intubation is needed. His heart rhythm is stabilized with a lidocaine bolus and drip, and he is undressed. There is little to no fuel smell left on his body. His blood pressure stabilizes without medication.

   The man is unchanged on the trip to the hospital, and arrives in the ED in a stable rhythm with a good pulse oximeter reading. His ED and hospital evaluation find an acute myocardial infarction occurred, and he has a stent placed in the heart lab. No traumatic injuries are found, except for a few small leg contusions. He recovers well, regains consciousness that evening, and returns home. His family members contact and thank the bystanders who contributed to his good outcome.

Case Discussion

   Most emergency conditions EMTs face are managed by rapidly identifying the emergency, applying the proper treatment to stop the danger, and then performing a variety of support measures to reduce any damage. For a few years, we have been unsure whether rapid defibrillation is the best treatment for patients in the rhythm in which this man was found (VF). Studies were conducted to investigate outcomes when defibrillation was delayed to give a couple minutes of chest compressions first. This delay, some hypothesized, could allow the heart muscle to get "primed" with oxygen and glucose and thus allow the rhythm to be more responsive to electricity. However, those studies did not find improved outcomes, and our best knowledge of heart dysrhythmias indicates that early defibrillation produces the best prospects for the victim.

   This case demonstrates the value of rapid defibrillation, but also that it requires care for safe application. The use of electrical interventions can in some circumstances be dangerous, and rescuers should always have respect for flammable liquids, pastes and creams, and incidents where conductive liquids could carry current to rescuers. For example, in drownings where the victim is still wet and lying in a puddle of water, care must be taken to avoid accidental administration of current to rescuers also in contact with the water.

   As the standards for CPR are updated, EMTs must be prepared for its application in a wide variety of circumstances. Timely defibrillation is a treatment that has dramatic implications for the victim. As demonstrated in this case, scene safety can be accomplished in concert with rapid victim care.

Initial Assessment

   A 79-year-old male involved in an accident with a large lawn tractor and found to be in ventricular fibrillation.

• Airway: Unresponsive.
• Breathing: Not originally breathing.
• Circulation: No circulation; pink appearance.
• Disability: Not originally responsive.
• Exposure of Other Major Problems: Patient has rolled a large lawn tractor, likely when he became unresponsive from a cardiac dysrhythmia. He has some skin trauma, but no obvious major injury. He is defibrillated into a perfusing rhythm and becomes more responsive as his airway is maintained.

VITAL SIGNS

AMPLE ASSESSMENT

• Allergies: Unknown.
• Medications: Unknown.
• Past Medical History: Not available.
• Last Intake: Unknown.
• Event: Accident likely due to sudden episode of ventricular fibrillation.

   Customer Service Opportunity

Bystanders can be significant contributors to emergency care, and in certain circumstances may be able to provide critical information for a good history. Bystanders can have a significant "investment" in the patient and event, and should be listened to carefully for information that may improve rescuers' understanding of what happened. When possible, interview them quickly. If anyone took any important actions, those should be determined and recorded.

   The privacy of patient care needs to be respected. There are many barriers to releasing patient outcome information to a bystander who says they assisted in care. In most circumstances, hospitals will not be able to release outcome information. But the patient or family is free to do so. The rescue actions of bystanders can sometimes be communicated to the patient or family at a later time, and the patient or family given the opportunity to provide a follow-up on the patient's outcome. If the outcome is good, that can be a joyous moment for all.

   Learning Point

Rapid defibrillation is the preferred treatment for ventricular fibrillation and pulseless ventricular tachycardia. Safe application of that treatment is important for the victim and rescuers, and in certain cases quick actions must be taken to ensure a safe environment for the defibrillation to occur.

   James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. Contact him at jaugustine@emp.com.