Things That Go Bump in the Night

The Attack One crew members have finished dinner and are preparing to orient an EMT student who will accompany them for the evening’s operations. The tones drop, and they are dispatched to an office complex for a “possible heart attack.”

The paramedic reflects to the student that the complaint of a “possible heart attack” is one that can be almost anything once the patient is accessed. “Frequently it’s an uncomplicated medical problem,” he tells the student, “but sometimes we get there and they’re doing CPR. Especially in an office complex, we just never know.”

Tonight it is a complicated medical problem. The 58-year-old man was working into the evening and reported to his coworkers that his chest pain began about an hour ago. He was sitting at his computer when he abruptly slumped over and was found to be pulseless. The workers around him lowered him to the floor and started doing chest compressions as they called 9-1-1. The office had no AED.

The only history the coworkers are aware of is that the patient has diabetes, because he is very proud of taking his blood sugars and administering appropriate doses of insulin as he works through the day. They are not aware of any heart problems other than the chest pain he reported prior to slumping over.

The Attack One crew begins its organized system of chest compressions, hooks up the defibrillator and finds the patient in ventricular fibrillation. They administer the first defibrillation shock, then immediately resume compressions. The third shock converts the patient to a slow, wide rhythm, and he regains a faint pulse. After a minute he is back in ventricular fibrillation. He is defibrillated again but has no conversion. The crew does a two-minute cycle of compressions and tries another shock. He converts, this time with a rate of about 100 beats a minute and a strong brachial pulse. After a minute, though, that deteriorates again to fibrillation, and the pulse disappears. Another defibrillation shock and no success, so compressions resume with plans to rotate among the Attack One crew, the student and the fire engine company that has arrived.

The Attack One paramedic 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. His neck veins are not distended, and there are no signs of injury. So far they have administered no medications, so the paramedic gives a dose of lidocaine and sets up for an ongoing drip. The cardiac monitor shows a coarse fibrillation pattern.

“Thanks for doing great compressions,” the crew leader announces. “Give me a minute to intubate him, so we can protect his airway and use end-tidal carbon dioxide monitoring. As I do that, let’s prepare him for transport. He keeps going in and out of fibrillation, so he needs to be moved quickly to the heart hospital, where they can find something that converts him and keeps him in a rhythm.”

The entire group starts to work in unison, including the coworkers, who are moving furniture and clearing the way out of the office. A backboard is passed into the room, and the patient is strapped on. The endotracheal tube is in place and secured, and end-tidal values are in the mid-20s, so the patient is perfusing with the chest compressions. The stretcher is loaded, and the paramedic chooses to do one more defibrillation, which is again successful, converting the patient’s rhythm to a fast narrow-complex tachycardia. He has a pulse, and for a few moments his carbon dioxide readings move into the 30s.

“OK, everyone, his rhythm is back, so let’s move him quickly to the ambulance and get going,” the paramedic directs. “Everyone move quickly, but don’t lose the endotracheal tube.”

The ambulance is head-in in a small driveway close to a side door into the office building. This close location allows them to zip out the door, load the patient into the ambulance and close the doors before his rhythm changes again.

The paramedic notes that the EMT student appears to be a little uncomfortable doing compressions. Over the radio he requests that one of the EMTs from the fire engine join them for the transport to the hospital, so they can do rotating compressions safely and effectively in the ambulance should the patient go into fibrillation again.

They are providing ventilations and have affixed the endotracheal tube and secured the IV fluid bags, and the paramedic in charge is calling the hospital. The student is asked to begin the patient care report and keep notes on the times. The vehicle operator notes that everyone seems in place and begins to back the ambulance out of the driveway.

Suddenly there is a scream from outside the ambulance, and the backing motion abruptly stops. The operator pulls forward, puts the vehicle in park and jumps out. He runs to the back and finds the firefighter-EMT who was running up to join the ambulance on the ground. “Are you all right?!” he asks frantically. “Are you OK?!”

That firefighter had walked back to his engine to take off his gear when he was directed by his captain to get into the ambulance to assist during transport. He put the equipment he was carrying on the tailboard of the engine and walked around the back of the EMS supervisor’s vehicle that had arrived and parked on the passenger side of the ambulance. As he did, the ambulance began backing and caught him between the sides of the vehicles.

“I’m OK—just hurt my legs,” he says. “Didn’t know you were backing, and the strobe lights on the vehicles were making it difficult to see.” He climbs to his feet and is checking his legs when the rest of the personnel arrive to see what’s happening.

The operator sits on the ground, shaken. “I didn’t see you at all. I didn’t know that vehicle was there, and the sun blinded me in that mirror. I was paying attention to what was going on in the back. I should have had a spotter. I almost hurt you bad!”

The paramedic leans out the back of the ambulance. “What’s going on?” he asks. “This patient is back in fibrillation. We need someone to help and to get to the hospital!”

The fire captain is able to direct: “The ambulance operator and my EMT need to stay here to get checked and complete reports. I’ll send the rest of my crew with you and to drive the ambulance. Plan to come back here when you’re done. Get that patient back!”

Hospital Course

En route to the hospital, the patient receives ongoing cardiac compressions, and EtCO₂ monitoring shows values in the range of 28–32 mmHg. The cardiac team is brought into the ED, and they direct the patient to the cardiac intervention lab. He has a cardiac catheterization performed and an assist device implanted. After about 65 minutes of cardiac arrest, he has return of spontaneous circulation. He undergoes therapeutic hypothermia. After three days he awakens with a complete recovery of neurologic status. A defibrillator in his chest, he returns to work.

The EMT who was pinned between the vehicles does not wish to be evaluated at a hospital. He has some bruises on his legs but remains on duty.

The ambulance operator asks to remain out of his position for the shift. He attends a vehicle operations safety course before returning to his role as a vehicle operator. The crews complete a “near miss” report, and the incident is reviewed at a safety meeting several weeks later. The next week the department conducts a retraining on vehicle backing operations.

Safety in Practice

An essential role of EMS is the movement of EMTs to an incident site, and in many cases subsequent movement of a patient. As such, vehicle safety is an element of almost all patient encounters. A vehicle safety program includes vehicle maintenance, vehicle operation and incident scene processes. Vehicle operations in roadways have an inherent set of risks, particularly at higher speeds and when operating in lights-and-siren mode. Training for vehicle operation is part of an overall EMS safety management program.

Operations at incident scenes can be dangerous in many ways. All EMS personnel must be involved in scene operation safety. Even at low speeds, vehicles may be moving in forward and backward directions, between people, objects and surfaces that create difficulties for the operator. There are often issues of lighting and darkness and additional law enforcement and fire personnel moving around, as well as actions being taken in transition to care that will take place in the vehicle. The driver alone cannot be responsible for safe movement.

In particular, backing is fraught with hazards. Many EMS agencies require backing be done with a spotter. Many ambulances now have rear-view cameras, but those alone do not manage all the risks of backing operations. Spotters are a safety practice that takes a little extra time and may get someone wet or cold on a lousy day, but promotes the highest level of safety in vehicle operation. The spotter provides a dedicated set of eyes at the back of the ambulance, controls pedestrian movement in the area and identifies any hazards to the driver and others.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH.