House Arrest

The Attack One crew has had a busy night, with five calls since midnight. They’ve just completed an MVA response when they are dispatched to a reported “medical emergency” at one of the department’s fire stations. The dispatcher has no further information.

The crew leader hopes this will be a minor problem with a person who walked in to the station. That station’s personnel have also been busy all night, and the station’s equipment is still out on another call. But as Attack One pulls up in front of the station, the crew is waved into the bays by a police officer who appears very distressed. They have an uneasy feeling as they pull the vehicle head-first into the equipment bay, and the officer tells them the station captain is in cardiac arrest in his bunk room.

Crew members grab the equipment from their vehicle and rush to the back of the station. There, a department paramedic is alone performing CPR on the male station captain, who is about 50 years old.

“I just got here for my shift and noticed all the equipment was out,” the medic relates. “I was taking my gear to the bunk rooms when I heard a funny noise in the captain’s quarters. It was the captain, who seized momentarily, then went into cardiac arrest. I only had the station phone to call in on, and then I started CPR. This police officer wandered in to use the restroom, and I asked him to flag you down.”

The paramedic is tired from doing CPR, so the Attack One crew takes over for him. “Start the pit crew process,” the Attack One paramedic directs the crew.

As they take over chest compressions, they hook up a defibrillator and find the patient in ventricular fibrillation. After a two-minute cycle of compressions, they administer the first defibrillation shock, then immediately resume chest compressions. The second shock converts the rhythm to a fast narrow-complex tachycardia, and the patient has a rapid and thready pulse.

The crew performs a rapid assessment. The patient is unresponsive and not breathing. He does not have a gag reflex, but is being bagged easily with an oral airway in place. The cardiac monitor shows a fast narrow-complex rhythm that is regular. So far the patient has needed no medications. His neck veins are not distended, and there are no signs of injury.

“Let’s prepare him for transport and continue to assist his respirations,” the crew leader begins. Then he looks up and sees there is now a larger group of people gathered. The entire crew from this new day’s shift is in the hallway, and the crew from the captain’s platoon has arrived back, unprepared for what they’ve found. The initial paramedic on the scene is trying to explain but is very upset. “I just walked in and found him,” he says. “I was by myself, and there was no equipment. I felt helpless and couldn’t do enough quickly enough. I only had the house phone to call the dispatch office.”

Now the entire group starts to work in unison. Some retrieve a backboard, some move furniture, someone backs the ambulance into the bay. But as soon as the patient is strapped onto the board, his rhythm returns to fibrillation. Another shock restores his rhythm and pulse.

The paramedics agree it’s time to give lidocaine, and they deliver the initial bolus and start a drip, monitoring carefully. Before they can get the patient onto the stretcher, he goes in and out of ventricular fibrillation two more times. At the direction of the Attack One crew leader, one of the station paramedics steps out of the room and calls the hospital emergency department on a station phone to give a report. They want to pass on the information and prepare the ED for the incoming patient without using department radios. The ED emergency physician takes the call. “Doc, his rhythm is so unstable,” the paramedic reports. “He keeps going back into fibrillation.”

“Continue to shock him using the lowest voltage possible,” the physician instructs. “Give him a second bolus of lidocaine and run the drip at 2 mg a minute. We will prepare for your arrival.”

A battalion chief has arrived and works with the new shift’s captain to clear the room and clear a path to load the ambulance. “C’mon, Captain!” the members urge as they wheel him into the vehicle. “C’mon, Captain, we need you!”

The engine is pulled out, blocking the street. The ambulance driver notes that the street ahead is full of police cruisers, and as he begins to move toward the hospital, cruisers block each intersection he passes.

In the back, the crew works continuously to ventilate, watch the rhythm and defibrillate three more times. But they note that each time they regain a perfusing rhythm, the patient’s blood pressure improves, and he begins to breathe on his own. The paramedic had performed an endotracheal intubation, and the tube is clear and easy to ventilate through.

The captain has a pulse and a regular cardiac complex as they enter the ED, and his blood pressure is palpated at 90 mmHg. He is breathing about 8 times a minute, and oxygenating well on the pulse oximeter. “C’mon, Captain!” the two paramedics continue to urge as they push him into the resuscitation area.

Hospital Course

The emergency department is completely prepared. The cardiologist and emergency physician rapidly conduct an assessment, have a quick chest x-ray done, and wheel the patient to the cardiac intervention lab.

The Attack One crew retreats to the EMS room in the ED, and the crew leader addresses the group. “I am proud, and we should be proud,” he tells them. “We just gave the captain every chance we could. Everyone did a great job, and we have to trust the hospital staff now to do their best. I will do the patient care report, and we have another crew that is going to come and put our equipment back together. We are putting everyone out of service until a counselor can come and debrief. Call your spouse and let them know you are OK.”

The ED manager knocks on the door and asks to come in.

“We have no family yet, and we have called an extra chaplain for you guys,” he tells the group. “We all know the captain from his days as a paramedic, and we know this must be hard on all of you. We have set aside a separate waiting area for his family when they arrive, and the ED conference center is for your crew and department personnel. Please let us know how we can help.”

A few of the night- and day-crew ED members are with the manager, and they come into the EMS room to share a few tears and a prayer for the captain. Everyone knows this man, and how many patients he’s helped in his career.

As they compose themselves, they exit the room and join with the many other department personnel, police officers (who also knew the captain and were sharing stories of how they worked so well with him) and hospital personnel assembling.

The Attack One crew leader organizes the group. “Who is in contact with the family?” he asks.

The shift lieutenant who worked with the captain advises the group that he and the battalion chief have made those arrangements. The wife and children live about 30 miles away, and the lieutenant knows the family well. He called the captain’s wife, and the battalion chief has arranged for the fire department in the jurisdiction where they live to transport the family to the hospital. He thinks they will arrive in about 15 or 20 minutes.

The group agrees the family should be given a moment of privacy, so the large group moves to the arranged conference center room. The family will be greeted by the lieutenant outside, because they know him. He will be joined at the right time by the Attack One crew leader, the emergency physician and a nurse, who will explain the medical story. Then the family will be taken to the cardiac waiting area, where the chaplain will provide support and communication with cardiology personnel.

Just before the family arrives, some good news comes by messenger from the cardiac lab: The patient is doing well, his rhythm has stabilized, and he is beginning to move around and will need to be sedated for the completion of his treatment. The team there was anxious to let the family know.

The Attack One crew leader recognizes that one group of staff members is unusually distressed: The members of the captain’s shift, including the lieutenant, have been too quiet and are talking very little. The crew leader calls the group aside and asks them to share some feelings. After a minute, he deciphers what they’re distressed about. They share stories about the captain’s behavior during the shift, and they all feel they missed some warning signs. The captain had been unusually quiet all day, and mentioned how tired he was. He let them go on their last call, at about 0530, without him. They were feeling a collective guilt that they didn’t detect anything unusual. “We should have prevented this from happening!” was a common theme.

“I appreciate your feelings. Over time, we all have seen these events happen to patients we have cared for,” the crew leader begins. “And we all know the captain would say he was OK, and would only get aggravated if we tried to tell him we were taking him to get checked. We will all talk with the grief counselor together, but we could not have prevented this. We all gave the captain our best care, and will continue to take care of his family and each other.”

The family arrives and is greeted and ushered to their waiting area. They want to be with the department members, and want the news from the cardiology team to be shared with everyone at the same time. When it comes, it’s positive: The captain did very well in the intervention lab, had a blockage removed, and doctors anticipate no permanent damage. He has been placed in sedation and a hypothermia protocol started, but they expect a good recovery. The cardiologist credits the crew for excellent resuscitation care, and thinks the patient will be in the hospital for a week or so.

In fact, he is there for five days, and the family and department members keep watch during his ICU stay. They are present when he awakes, and he recovers rapidly.

The captain and his family meet with the cardiologists at the end of his stay, and he retires from the department after that discussion.

Case Discussion

This patient had an unexpected cardiac arrest, and his successful resuscitation began with rapid recognition by the sole paramedic on scene. That individual “felt helpless” but in fact performed the critical actions of notifying help and initiating chest compressions. The subsequent rescuers provided ongoing chest compressions and rapid and sequential defibrillation.

The “pit crew model” represents an organized system of CPR that has been developed and promulgated in the scientific literature. Using a popular model for organizing a work crew and anticipating problems with fatigue while doing compressions, leaders at Texas’ Austin-Travis County EMS, led by medical director Paul Hinchey, MD, MBA, developed a way of dividing labor and scripting duties throughout the process. The protocol used by Austin-Travis County is available at https://atcomdce.org. The site also contains training videos on the process.