Underwater Response

   At 10:02 p.m. on April 13, 2008, Washington County Sheriff's Office (WCSO) dispatchers received a 9-1-1 call from an occupant of a car that had driven off the road into the St. Croix River near Stillwater, MN. Speaking in broken English, the caller cried, "We're near the boat area, the car's sinking, the doors are stuck, we can't swim!" As WCSO dispatched Stillwater Police (SPD) units to the riverfront area, along with the Stillwater Fire Department (SFD) and the Washington County Fire Department Dive Team, they were also trying to determine if the caller could get out of the vehicle and where exactly the vehicle had gone in. Then they received a second 9-1-1 call from another passenger in the same vehicle, who reiterated what the first caller told them: They couldn't get out of the vehicle and couldn't swim. Neither could give their exact location. Shortly thereafter, the line went dead!

Initial Response

   Following the first 9-1-1 call, SPD units began looking for the vehicle, but without a definitive location, they could only search the riverbanks for any signs of a vehicle entering the river. As more 9-1-1 calls came into the dispatch center, one caller, who said he heard the crash and could see submerged headlights in the river, began helping dispatchers guide SPD to the location. At about the same time, SPD officers Nate Meredith, Ryan Mitchell and Andrea Olson saw headlights facing shore from where the vehicle was submerged about 30 to 40 feet from shore.

   During the initial SPD dispatch, on-duty SFD firefighter Jonas Werpy began gearing up for a water rescue in his drysuit and face mask, while Captain Chris Zeuli and firefighters John Bell and Rob Peltier readied the SFD rescue boat as other firefighters arrived at the station. At the same time, the first Lakeview Hospital EMS (LVHEMS) paramedic unit, No. 802, with paramedics Matt Milder and Wade Watson, reached the river, followed by LVHEMS unit 806 with paramedics Jason Richter and Nic Barratt. Units from the fire departments that make up the Washington County FD Dive Team began responding from their stations throughout the county. Within six minutes of the initial call, the sport utility vehicle had been located and units were converging on the scene.

Rescue and Expanded Response

   By 10:13 p.m., diver Werpy entered the St. Croix River off the docks of the Stillwater Yacht Club, which provided the quickest access to the vehicle. Werpy entered the 30°F water while Zueli, Bell and Peltier launched the rescue boat. The vehicle was in about 8-10 feet of water, with the roof about one foot under water.

   Werpy reached the vehicle and attempted to open the door, but it was locked. He pulled his knife in an attempt to gain entry, but it snapped and broke. He then returned to the surface, got a spring-loaded window punch and returned to the vehicle. He placed the punch against the window and shattered it, but there was no rush of water, which meant only one thing--there were few, if any, air pockets left in the vehicle.

   In the dark, frigid water he reached into the vehicle with his ungloved hand and touched the first occupant. He pulled the 27-year-old female to the surface, where SFD firefighters pulled her into the Zodiac. Werpy returned to the submerged vehicle, reached in and found the second occupant--a 25-year-old female--whom he pulled from the vehicle and handed off to the Zodiac crew.

   Werpy went back to do a final sweep of the vehicle and found a third victim. With his body fighting the cold water, he used his remaining strength to pull the victim from the car and to the surface, where he handed him off to the Zodiac crew. As they reached shore, CPR was initiated and the third patient was moved to LVHEMS Medic 803, which had just arrived on scene with paramedics Kevin Olson and myself. The first two patients were already in LVHEMS medic units receiving BLS care until ALS care could be initiated. Since the number of patients was growing and the actual number of victims in the vehicle was still unknown, two additional ambulances were requested from Mahtomedi Fire, which was already en route, and one from Oakdale Fire.

   Preparing to do a final sweep of the vehicle, firefighter/diver Tim Bell went in wearing a cold water rescue suit and a mask. As he reached the vehicle and began to sweep the inside with his hand, he felt a leg. He pulled on it and, to his surprise, the leg pulled back. As Bell resurfaced for breath, he called out, "We've got one alive!" Taking a large breath, Bell returned to the vehicle. Using both hands, he reached in, grabbed the ankle and pulled the female victim from the vehicle and to the surface. As they pulled her into the Zodiac, she told them there had been four people in the vehicle. As they raced the last patient to shore, Bell went back, broke out two more windows, and swept the vehicle one more time to make sure no one was left.

Resuscitation

   Within 17 minutes of the initial 9-1-1 call, the first patient was in Medic 802 undergoing CPR with ALS interventions being initiated. The second patient was placed in LVHEMS Medic 806 under CPR at roughly the same time. Patient No. 3 was placed into LVHEMS 803 under CPR at 2228, roughly 10 minutes after the first two. All three patients were managed in a similar fashion: CPR was initiated, followed by bag-valve mask ventilation, and all three required suctioning of the airway, predominately of water. Following establishment of solid BLS interventions by SFD personnel who assisted on-scene and during transport, the first two patients were intubated endotracheally on the first attempt by one paramedic, while the second medic established an intraosseous infusion utilizing the EZ-IO tibial approach. Mahtomedi Fire and Lower St. Croix Valley Fire personnel had difficulty in opening the third patient's mouth due to jaw stiffness, and a decision was made not to attempt ET intubation, but to go directly to the King Airway, which was placed without difficulty on the first attempt. This was followed by placing an EZ-IO in the left tibia.

   Patients' #1 and #3 initial rhythms were asystole; patient #2's initial rhythm was pulseless electrical activity, which rapidly degraded into asystole as well. Following BLS, ALS airway interventions and IO access, all three patients received 1 mg of 1:10,000 epinephrine and 1 mg of atropine IO, which resulted in all three regaining pulses with presenting rhythms of sinus tachycardia. All patients were c-collared and secured to long backboards for transport to Regions Hospital, the Level 1 trauma center on the east side of St. Paul. During transport, the first two patients made attempts at spontaneous respirations; all three required intermittent suctioning during the 20-minute transport.

   The fourth patient, who had apparently found an air pocket in the vehicle, was handed off to Mahtomedi Fire Medic 850 with paramedics Chad Thompson and Tim Deans and EMTs Albrecht and Tubbs. Their patient was conscious, alert and spontaneously breathing on her own. Following the initial assessment, her wet, frigid clothing was removed and, as spinal immobilization was being completed, hot packs and blankets were applied. She was placed on a non-rebreather mask, due to her oxygen saturation of 93%, a cardiac monitor was applied, and two large-bore intravenous lines were initiated during transport to Regions Hospital. The patient continued to breathe on her own and remained neurologically intact. All four patients were off the scene 37 minutes after the initial 9-1-1 call was received.

Lessons Learned

   Three important lessons were learned from this incident. First, even though the Washington County Fire Department Dive Team is well-organized, well-trained and well-equipped, they cannot anticipate nor train for every possible scenario. This incident unfolded and expanded rapidly over the period of a few minutes, and would have had a completely different ending if the vehicle's headlights had not been on and the incident had occurred farther from the SFD's station. The reality for dive rescue teams is this: Unique, challenging and highly improbable scenarios need to be discussed and carried out. As in this case, the three on-duty SFD firefighters were faced with a rescue situation with limited resources. Knowing the victims were alive as they were gearing up, they had to decide whether operational merit would put the safety of the team at risk.

   The second lesson learned that night is to constantly reevaluate your equipment. The first rescue diver entered the water without gloves, which, in many incidents, would not be a factor. In this incident, the diver's hands became cut and cold very quickly due to the multiple victims he removed, the poor lighting he was operating in and the water temperature at that time of year. This was again a question of operational merit that had to be addressed immediately and could only be answered by the rescue diver himself. From this incident, as is often the case, real-world missions bring to light equipment, training, policy and response issues that often cannot be realized from training scenarios. Following the incident, SFD and the Washington County Fire Department Dive Team reviewed the above areas and made adjustments to improve upon their level of readiness, expertise and capabilities.

   The third lesson learned: Though the docks at Stillwater Yacht club provided the easiest access for the divers to access the patients, they were not necessarily the easiest and safest way to remove them. Consideration has to be given to a number of variables that are often unique to each incident. For this incident, the size of the docks had to be considered: How many responders could safely operate on the dock at one time, and did one crew have to wait for another crew to extract their patient before they could proceed onto the dock? Was there adequate lighting, or could it be set up quickly? Where was the staging area in relation to the incident? Were there enough lifejackets for all personnel operating on the docks? Sometimes, as in this case, the incident is determined by resources or the lack thereof. That is, initially, with one diver in the water, his only option was to hand off patients to the boat crew. The boat crew's only option was to take the patients to shore, where incoming units were staging.

Outcome

   It remains unclear how the vehicle ended up in the river. It is believed that instead of stepping on the brake, the driver inadvertently stepped on the gas and accelerated the vehicle in reverse into the river. Of the four patients who were pulled from the submerged vehicle, two died and two made full recoveries, but had no memory of the event. Two months following the tragic event, the two survivors, their families and more than 40 of the responders gathered for a reception at the Stillwater Fire Department. It was the first time the survivors had a chance to meet and thank the firefighters who pulled them from the submerged vehicle and the paramedics who resuscitated them.

Services Involved

• Allina Medical Transportation (dispatchers)
• Lakeview Hospital EMS
• Lower St. Croix Valley Fire Department
• Mahtomedi Fire Department
• Minnesota State Patrol
• Oakdale Fire Department
• New Scandia Fire Department
• Stillwater Police Department
• Stillwater Fire Department
• Washington County Dive Team
• Washington County Sherriff’s Office (dispatchers)

   Scott Tomek, MA, EMT-P, has been a paramedic for 25 years, 23 with Lakeview Hospital EMS in Stillwater, MN. He is a faculty member with the Century College paramedic program, and a curriculum development specialist.