Extreme Extrication

On a December afternoon, just days before Christmas 2002, Lakeview Hospital EMS paramedics and 10 other agencies found themselves fighting to save the life of a three-year-old boy who survived a horrific accident involving the car he was riding in, a school bus and a large panel truck. Both his grandmother and older brother were killed in the initial impact. What follows is not only a case study in teamwork and the capabilities of the EMS system that serves the mid-St. Croix Valley area of Minnesota, but, more important, the dedication and willingness of the Lakeview Hospital paramedics and other responders who put their lives on the line in an attempt to save a little boy’s life.

Timeline

At 12:15 p.m., a 9-1-1 call reported a school bus vs. car crash, with two people trapped. In less than 30 seconds, Lakeview Hospital’s first paramedic unit was en route to the accident, which was located only two minutes from their base. By the time the unit was en route, additional calls were flooding the dispatch center at the Washington County Sheriff’s Department (WCSD). There were now reports that a truck was also involved, and a second Lakeview paramedic unit was dispatched, along with law enforcement agencies and units from both the Lake Elmo and Bayport Fire Departments.

Lakeview Hospital’s EMS Medic 5 was the first to arrive on scene, with paramedics Aaron Hartman and Terri Ritchie on board, followed by Lakeview Medic 2, with paramedics Dave Halvorson and Jason Richter. Seeing what appeared to be the car crushed underneath the school bus and multiple children on the bus, Medic 5 began calling for additional resources. Within minutes of the initial call, Lakeview Hospital’s Medic 3, with paramedics Mark Tiffany and Scott Tomek on board, Lakeview’s Medic 1 (Jon Muller, EMS director), multiple Stillwater Fire Department units, and both an engine and ambulance from Oakdale FD were on their way to the scene. Minutes later, LifeLink III launched one of its helicopters toward the scene 20 miles away.

Scene Size-up and Initial Triage

As Medic 5 began its scene size-up and initial triage, both paramedics realized this accident was beyond the realm of a typical MVA. Medic 5 was initially faced with three patients in the car, which was crushed under the school bus, the driver of the panel truck, and two children on the school bus, along with its driver. Both the grandmother and a five-year-old in the car were triaged as black (dead); the truck driver was triaged as green (minor) and appeared to be suffering from the psychological and emotional impact of experiencing or witnessing severe trauma. The two children and bus driver were also triaged as green. With clearance from Lakeview Hospital’s EMS director, the medics decided that, once Oakdale FD EMS arrived on scene, the patients on the school bus would be treated as a separate incident. This would allow Lakeview paramedics to focus on the critically injured three-year-old boy trapped in the car under the school bus. As the incident grew in magnitude, criticality and difficulty, Minnesota State Patrol shut the highway down in both directions.

Lake Elmo, Bayport, Stillwater and Oakdale FDs reached a consensus that the school bus needed to be lifted and simultaneously moved away from the little boy if their traditional extrication tools were going to be of any use. It was determined that heavy wreckers would be needed, and the request was made to the WCSO dispatch center. Before two WCSO deputies could be sent to escort the heavy wreckers to the scene, the wreckers were already en route. Stillwater Towing had been monitoring the law enforcement channels, and, upon hearing the request, began responding with their two largest wreckers. Within less than five minutes, both wreckers arrived on scene.

The wrecker operators positioned themselves and began running steel cables to first secure the bus and then prepare to move it. Lakeview Hospital’s Director of EMS selected Terri Ritchie, who had years of service overseeing extrication with Oakdale FD EMS, to coordinate the integrated and complex extrication process with Bayport FD, Lake Elmo FD and Stillwater Towing. During the extrication process, paramedics Richter and Tomek continued to assess and provide care to the little boy. Constant reassessment and, at times, incremental movement of the bus ensured the safety of the paramedics operating under it. Following 30 minutes utilizing both wreckers and the Jaws of Life, the little boy was extricated, backboarded and moved to the waiting LifeLink III helicopter for the eight-minute flight to the trauma center at Regions Hospital in St. Paul, MN.

The Fight of Their Lives

The first EMS person to arrive on scene was an off-duty Stillwater firefighter, who was only a few cars behind the accident. He immediately began trying to help the trapped child. When Richter and Tomek assumed care, they both realized they were in the fight of their lives if this little boy had any chance at surviving.

Initially, the boy presented with agonal respirations at 4–6/minute. Tomek suctioned blood from the airway, assisted by Tiffany, until the airway was clear, then initiated bag-valve-mask ventilation. The patient’s initial heart rate was in the low 70s; he had a delayed peripheral capillary refill time and an SaO2% of 78. Initial assessment beyond the ABCs was made difficult by the boy’s position in the car, the lack of space, a car seat bar and the boy’s snowmobile suit. Both the neck and chest were unremarkable for injuries, with equal and clear bilateral breath sounds.

Once the airway was suctioned clear and bag-valve-mask ventilation begun with a modified jaw-thrust, the SaO2% rapidly increased to 88%; with further suctioning and ventilation, it continued to climb to 100%. It was noted, but not considered an initial priority, that the little boy’s left foot was by his jaw. Both paramedics expected the worst—that the leg had been amputated in the initial impact; however, once the boy’s SaO2% reached the mid-90s, the leg and foot began to move and Richter began looking for an available extremity for vascular access. IO was not an option, since access was unavailable to the lower extremities. The only other option for vascular access, which would have been extremely difficult, was an external jugular IV, but Richter was able to slide a 22-gauge protective catheter in the only visible antecubital vein on the boy’s left arm. Then things began to spiral downward. Once the SaO2% reached 100, the boy began to clamp down, and bag-valve-mask ventilation became more difficult and suctioning was impossible.

A Moment in Time

At that moment, the paramedics determined that they had exhausted all BLS options for managing the airway and knew they had to secure it. With the approval of their EMS director, they decided to perform a rapid sequence induction/intubation (RSI). Initially, the plan was to perform it in Medic 3, but, once it was determined that it could be another 30–40 minutes before the little boy could be extricated, the decision was made to perform it in the car, under the bus.

Paramedics estimated the boy’s weight to be 34 lbs., or 15 kilograms. Paramedic Dave Halvorson prepared 15 mg of lidocaine as a preinduction agent for head injuries, 0.15 mg atropine as a preinduction agent to prevent bradycardia, 4.5 mg etomidate for initial sedation, and 30 mg succinylcholine as the initial paralytic. At the same time, Tomek was preparing the necessary airway, including a #4 endotracheal tube sized by using the boy’s nostril. A weight-based resuscitation tape was useless, due to the position of the boy, and, at the time of the call, the patient’s age was unknown. Other equipment included a pediatric ETCO EasyCap, a Thomas tube holder and a laryngoscope. Tiffany stood by with the portable suction.

Richter began administering the RSI medications and calling off the times as he administered them. Forty seconds after administration of the paralytic, the intubation attempt began. During the first attempt, a large amount of blood was suctioned from the posterior oropharynx, and the epiglottis was visualized, but there was difficulty in visualizing the vocal cords. The intubation attempt was aborted and the patient oxygenated. The second attempt began with suctioning blood from the posterior oropharnyx and, again, the epiglottis was evident, but the vocal cords still could not be visualized. This time, because the boy’s car seat was tilted to the left, his tongue was swept to the left and then, as the laryngoscope blade was advanced, it was lifted to the right, the vocal cord came clearly into view and the #4 ET tube was slid into place. Tomek began BVM ventilation, while Richter assessed breath sounds, which were slightly decreased on the left. The SaO2% rapidly climbed back to 100% and the pediatric ETCO EasyCap was placed on the ET tube and rapidly changed to yellow, confirming the actual visualization during the ET intubation and bilateral breath sounds without abdominal sounds post-intubation. The ET tube was then secured with a Thomas tube holder.

Reassessment and Extrication

Once the airway was secured, ABCs were checked, followed by reassessment of the neck, chest and upper extremities, and re-confirming location of the ET tube and that the IV was still patent. Extrication continued during the ET intubation. Once intubation was completed, the section of roof that was not under the bus was finally removed and an attempt was made to pull the boy out of the car. This time, he started to slide out. A short backboard was placed just above his head, and he was slid onto the board with manual c-spine stabilization. Once the boy was secured to the backboard, ABCs and ET tube placement were reassessed, and he was turned over to the waiting flight crew and loaded into the LifeLink III helicopter. A head-to-toe trauma survey was done en route to Regions Hospital trauma center in the heated environment of the helicopter’s cabin, along with further sedation and administration of a long-acting paralytic. The boy arrived at the trauma center eight minutes later.

Lessons Learned

Individual knowledge, skills and attitude played key roles in managing the boy, but equally important was the ability of 10 EMS, fire department, police and civilian responders to operate in a time-stressed environment with effective communication as one integrated team. What Lakeview Hospital EMS learned from this devastating accident focused around three areas: communication, both in communicating the need for additional resources early into the event and ongoing communication on the scene during the event; coordination—assigning the right people to the right roles to get not only the best and highest performance out of each individual team member, but also the synergistic performance of partnering the right team members together; and developing a shared goal that all individuals, teams and responding services could understand. In this case study, it was keeping the child alive and getting him out of the car.

Following an incident like this, honest critiquing by all individuals needs to occur for two reasons. First, to review what worked, what was learned and what areas could be improved for future incidents of this magnitude. Second, everyone who was there wants to—and probably needs to—express what they saw, what they did and how they felt.

Lakeview Hospital EMS conducted a critical incident stress debriefing (CISD) a week later. CISD is currently somewhat controversial, but at the time of the incident, it was common practice in Minnesota following an incident of that magnitude. The responders felt that the debriefing was of significant value. If you choose to conduct a critical incident debriefing, remember all responders, including civilians. In this case, the members of Stillwater Towing, who operated the heavy wreckers during extrication, were invited and did attend.

The End and Beyond

The three-year-old boy survived until the following day, when he died from his injuries, including head, abdominal, left femur fracture and left tib/fib fractures. A few days later, we learned that his organs had been harvested and placed in five waiting children. To this day, some of the responders are still haunted by one question: On that December day, did we lose one child or ultimately save five?