It's Pronounced Frahnk-en-steen...

As these stories often seem to begin, I was working overtime at another station when this call went down. We were responding to a call for an unknown medical with an unknown age patient. What else is new? En route we got an update that the patients wife was calling because her husband had fallen in the other room but was behind the door, blocking it, so she couldn't get in. She stated that he was making snoring sounds earlier but now wasn't making any noise at all.

Yeah. That's not good.

On arrival we were met by a surprisingly calm older woman who relayed that same story to us again. I asked when this had occurred and she said at noon. It was now 12:25! Not sure why she waited so long to call but it didn't matter now. 

     

The next thing she said was that it was really "crowded" in the house. As we entered we realized what an understatement that was. It was a full on hoarder house with a strong smell of cat urine, even through our P-100 masks. A couple cats bounded out of the way as we went in. My firefighter was ahead of me and had the large airway bag on his back and the cardiac monitor in his hand. I was carrying the drug box and trying in vain to catch all the things he was knocking over as he tried to maneuver through the debris field and stacked towers of god knows what. I told him just to ditch the gear if he could find a spot because it wasn't going to make it through.

We reached the door and it was indeed blocked. Whether strictly by the patient or by an avalanche of possessions and garbage, we didn't know. We asked the wife if there was window to that room and she said yes and told us to follow her. She was still very calm and slow as she led us through the back of the house and outside. We found the window but it was locked and while the firefighter attempted to jimmy it loose I went back around the outside of the house to enter the front door again and see about forcing the bedroom door and get access to the patient.

My firefighter apparently had the same idea and abandoned the window but wound his way back through the house and was already pushing his way into the room when I got there. He was able to squeeze in and lift the patient enough that we could push the door open.

The patient then basically flopped half way out of the room landing at my feet. A quick check for pulse and breathing revealed what was already very obvious, that he was dead. He had a large purple shiner around one eye from a previous fall and just didn't look healthy...on top of being dead that is.

My captain asked if I wanted to work this call right there and I responded with an emphatic no. There was no room at all and it was awful everywhere. So, I grabbed his wrists and the firefighter grabbed his ankles and we worked our way through the mess to the front lawn. Outside, out of the corner of my eye, I saw an ambulance employee standing there; the first bit of good news. My captain said we should set him down in the shade to work and I said we should carry him straight to the gurney. I then realized that the guy on the lawn was an EMS supervisor and that the transport ambulance wasn't there yet. He had heard the call come in and was close by and thought it sounded serious. He was right and it turned out to be good news anyway because he was able to help out with initial treatment and speed things up.

Out on the lawn I did another pulse check and a check for rigor or lividity or any sign that would let us pronounce him dead and not have to work up this obviously futile resuscitation attempt. No such luck. So we put the automated cpr device on him and began rescue breathing with a bag valve mask. The supervisor applied the cardiac monitor while I made a long shot IV attempt. I had the sup set up for an IO in case the IV attempt failed, which it did. He was able to get an IO established in the humerus so we were good to go. Our first rhythm check showed the patient was in asystole, as expected.

The protocol for an asystolic arrest is to give three rounds of epinephrine, each ten minutes apart, and if no change after 30-40 minutes we can pronounce death in the field and discontinue resuscitation efforts. It was clear this was the route the call was going. I administered the first round of epi as the ambulance arrived and took over managing the patients airway and dropping in an et tube.

We all agreed that this was pretty much going to be a three rounds and out call and there were no other treatments to add to the protocol we were working with. I did ask one of the medics to check a blood sugar for me just to rule it out. Turns out his sugar was very high, in the 400s, despite us being told he was not diabetic. This didn't change the course of treatment though may have been indicative of a metabolic reason for the arrest.

At the next rhythm check there was some electrical activity on the heart monitor but no pulse (pulseless electrical activity or PEA). Still no change in treatment and that can often happen as a side effect of the medications we were giving. We call them Epi beats. They say with enough epi you can get electical activity from a rock. After ten minutes I administered the second dose of Epi. It's always an odd part of the code when the machine is doing most of the work, all procedures are in place, and you have ten minutes until you can give the next drug. It seems like an eternity of standing around doing nothing. I went ahead and drew up the next dose of Epi for when the ten minutes was up.

But...

After another two minutes of cpr we paused for the next rhythm and pulse check. To all of our surprise, the medic said, "I've got a pulse." 

What?!?

The monitor confirmed a consistent sinus rhythm tracking with the pulse he was feeling. The patient still was not breathing on his own so the rescue breathing continued as we slid him onto a tarp and moved him to the gurney to head to the hospital. 

I jumped on board as a rider and took over rescue breathing. A reassessment of vitals showed a strong regular pulse, a more than sufficient blood pressure, and (probably due to the amount of fluid we'd given through the IO) a blood sugar now in the high 200s. It was about a ten minute ride to the hospital during which there was nothing to do but monitor the patient and breathe for him. The ambulance medic and I both marveled at the turn of events and how neither of us thought this call was going in this direction at any point.

The patient was delivered to the ER and their staff took over from there. He still had a good blood pressure and pulses but was still not breathing on his own. Based on the 20 plus minute downtime I wouldn't expect him to come out of this neurologically intact and if he does survive he's going back to that hoarder house which is no place to be cared for or to recuperate and get healthy. But, we did our job and executed all of our procedures pretty seamlessly, worked well as a team, and essentially re-animated the dead (for a little while at least). 

I doubt I will find out what the ultimate outcome ends up being for this patient and whether his resuscitation will have turned out to be a good thing or a bad thing. But it's always interesting to see the protocols and procedures work as intended and (for good or bad) be able to restart a heart, especially without defibrillation. It certainly changes the tone of the resuscitation in the end as well.

I'll Tumble For Ya

As my station is one of the water rescue houses, in addition to the dispatch radio, we monitor the coast guard radio. This radio is down the hall at the other end of the station so sometimes we just hear snippets of broadcasts or static filled conversations.

Today I heard what sounded like a frantic young woman's voice coming over the radio but couldn't tell what was being said. I went down the hall and turned up the coast guard radio so I could copy down the traffic and see if we had a water rescue on our hands. To my surprise the voice came over the dispatch radio repeating the same message and still with a distinct sense of urgency, "medic 4752, we've been t-boned in the intersection of Lewis and Howard and the ambulance flipped on its side".

Wow, an ambulance struck in an intersection and sent flying? I hope no one was in it.

                               

I called out to the crew, "Holy crap! Are you guys hearing this?". I got no response so I walked down to the kitchen to fill them in. As I got some distance from the radio I heard one of our other rigs asking dispatch if that was the ambulance that just left with their patient. I didn't yet know the importance of that question.

In the kitchen I filled the crew in on what I'd heard and we grabbed a portable radio to listen in on the call via the tac channel. Our crews had a quick response and we started hearing odd bits of radio traffic, "Engine 44 we have your firefighter on our tailboard". We listened for a while, but there wasn't much info coming over the radio and it sounded like, whatever the call was, it was winding down despite multiple patients being transported.

But then info started to trickle in via texts and radio and other sources that one of our guys had been riding in to the hospital with the ambulance and was hurt in the crash.  This brought the portent of the previous radio traffic asking which ambulance it was into clear understanding. That must have been a horrible feeling for that captain as he realized what had happened. Those two crews who were on the initial medical call were the first ones to respond to the crash. I can only imagine what that long three minute ride must have been like for them.

Then the tones went off in our station and we were dispatched to that same intersection.
What?
We were then informed that we were needed to stand by in place of the original engine until the investigation and clean up was done at the scene. The crews who performed the extrication and rescue of all involved in the wreck were headed off to a CISD (critical incident stress debriefing) to make sure they were doing okay.

The scene was a mess still and we still didn't have all the information about what exactly had happened. Analyzing the accident scene, looking at the vehicles, and talking to the chiefs on scene we started to piece it all together:

Initially, Engine 44 and our rescue unit had responded to a code blue (cardiac arrest). When they arrived they found family members giving cpr to an elderly patient. They took over cpr, started an IV, and gave a couple of rounds of meds and ended up getting pulses back at some point (or so I believe but can't confirm). I don't know if the patient was breathing on their own or not but I understand that their heart was possibly beating. They loaded the patient into the ambulance and took one of the firemen with them for assistance en route to the hospital.

They were headed down a major street on the way to the freeway and were crossing a large intersection when they were struck on the passenger side by a car who continued through the intersection. Witness reports state that the ambulance had lights and sirens going and that while other vehicles pulled over this car sped up to try to make it through. The investigation, traffic cams, and the black box from the ambulance will eventually tell the whole story but it sounds like the ambulance was doing the right thing. I certainly hope so.

The force of the impact and the top heavy nature of the ambulance sent it over on its side and sliding across the intersection. The driver was trapped but conscious and able to radio in the accident and their exact position. That got our crews moving and to the scene quickly.
In the meantime a rush of bystanders flocked to the ambulance to try and help get people out. The drivers door was on the ground and the back doors jammed. Our firefighter (with what we later learned were two broken ribs and a large gash to his head) was able to climb out the side door which was now the roof. No access could be made back into the ambulance and he wound up rendering medical care to the driver of the car that had hit them.

From the look of the ambulance when we arrived I guessed that when the fire crews got on scene they cut the windshield out of the ambulance to get to the driver and used the rescue tools (jaws of life) to pry open the rear doors and get the other medic and the patient out. The patient did not survive (assuming they was alive in the first place). Both ambulance crew members had only minor injuries thankfully and our firefighter had moderate but non life threatening injuries and was patched up and released from the hospital pretty quickly. We were told he was in good spirits and doing well shortly after. Adrenaline is an amazing thing.

We remained on scene through the entire investigation (which took a couple of hours) and the righting of the ambulance (which was impressive in its own right - no pun intended) and removal of both vehicles from the roadway. Even seeing what we could inside the ambulance from where our engine was parked you could see what a nightmare it must have been. The gurney had broken loose from its mount and was upside down, equipment was thrown about everywhere (oxygen bottles, two heavy cardiac monitors, etc). It's incredible that the crews weren't hurt worse. And of course there was no way to continue life saving measures on the original patient until the extrication was done and I'm sure at that point it was too late. The question remains if the patient died because of the crash or from her original heart failure. That will become an important legal question and this mess is not likely to go away anytime soon. The investigation and lawsuits could be intense.

The poise and control of all the emergency crews was certainly impressive and they should all be commended. I'm glad they sent the responding engines to a CISD after. Given the nature of these guys and the fact that our firefighter was okay I doubt any of them went home after and they probably continued to work and do their jobs but I'm glad they all had an opportunity to talk about it and were given the option to take care of themselves as well. It could be that the department would send them home anyway, which I believe would be advisable.

Definitely a shit show and one we will hear much more about in the coming months I have no doubt.

PSA: If you see an emergency vehicle with lights and/or sirens on pull to the right and come to a complete stop. If you see other vehicles pulling over to the right and stopping and don't yet see or hear the emergency vehicle...still pull to the right and come to a complete stop. Thank you.