The most routine fire and EMS call types can develop rapidly into a complex incident. A good friend used to say something to the effect of, “In the next 30 seconds, a normal run could turn into the most exciting run of your career.”

Although not every run may turn out to be memorable, particularly after a career of answering thousands of calls, the sentiment behind the saying is what’s important: At any given moment, personnel might be tasked with responding to a typical emergency yet face extremely atypical situations.

Therefore, it’s important to establish incident command, consider potential challenges and mobilize resources early.

Rooftop myocardial infarction

One June day, the Columbus, OH, Division of Fire (CFD) received a 9-1-1 call for a male in his 40s who was experiencing chest pain. Remarks from the call-taker included that the patient was a “service worker” with a “history.” 

On arrival of an engine company and a medic unit, crews were directed to the flat roof of a movie theater that was surrounded by a 15-foot parapet wall on all four sides. They climbed a 30-foot vertical ladder and gained entry through a roof-access hatch. When members located the patient, they reported that he was diaphoretic and experiencing extreme chest pain.

While crews brought ALS equipment to the roof, the engine company officer upgraded the assignment to a working rescue incident, which dispatched multiple ladder companies, heavy rescue companies, EMS officers/supervisors (EMSOs) and battalion chiefs to the scene. In retrospect, the engine company officer made an excellent tactical decision based on the severity of the patient presentation and concern that a rope rescue would be required to safely extricate the patient off of the roof.

Paramedics began a full ALS assessment. The initial 12-lead electrocardiogram (ECG) showed extreme ST segment elevation in leads V2 through V4, indicating an anterior myocardial infarction. Moderate elevation was shown in leads I, AVL, V5 and V6, indicating lateral involvement.

Immediately upon completion of the ECG, the patient decompensated into ventricular tachycardia with a pulse. As the therapeutic pads were applied, the patient went unconscious, and crews lost palpable pulses.

CPR was initiated, and defibrillation was performed. A supraglottic airway was unable to be placed because of trismus. However, adequate ventilations were provided via bag-valve-mask aided by nasopharyngeal airway. Bilateral antecubital IVs were placed, and Advanced Cardiovascular Life Support medications were administered at prescribed dose and times.

Manual before LUCAS device

While medical care was being performed, the ladder company accessed the roof via its aerial, bringing a Stokes basket and other rescue essentials. Two EMSOs arrived. They brought their specific equipment, including a LUCAS compression device, a video laryngoscope and rapid sequence intubation (RSI) medications, to the roof. They also brought an additional automated external defibrillator (AED) in anticipation of a potential need for double sequential defibrillation (DSD).

The EMSOs tactically split themselves between the roof and ground. This accomplished two things. First, it allowed clear communication on a separate radio channel between the EMSOs with real-time patient medical updates as well as seamless transition of patient care from the roof resuscitation team to the transport team.

Of course, the immediate goal of every cardiac arrest is return of spontaneous circulation (ROSC), but this scenario made that even more important: The EMSOs knew that rescuing an ROSC patient might be less complex than rescuing a patient who is actively in cardiac arrest. For this reason, placement of the LUCAS device was deferred in favor of manual compressions to minimize any potential interruptions in compressions or defibrillations.

After two defibrillations, the patient remained in ventricular fibrillation.

Per CFD protocol, DSD is performed following the second defibrillation. (In national literature, DSD has proven to increase survival in patients who are experiencing refractory ventricular rhythms, a situation that the team quickly found with this patient.) In performing DSD, two sets of therapy pads (one anterior-posterior, one anterior-lateral) are attached to separate monitors or AEDs. Instead of defibrillating only once, two defibrillations are provided very quickly one after another, not simultaneously.

CFD protocol emphasizes placing the first set of pads in the anterior-posterior location. This position is shown to be more effective in initially defibrillating patients out of ventricular arrhythmia, because the arrhythmia often originates in the posterior aspect of the heart and because it allows for easier placement of the anterior-lateral pads for DSD, particularly when the LUCAS device is in place.

After three more DSD defibrillations, the LUCAS device was placed on the patient, because obtaining ROSC on the roof was deemed a lower priority than was extrication and transport to definitive care. The patient was placed in the Stokes basket and secured by rescue personnel for extrication.

With the patient still exhibiting trismus, the decision was made to perform rapid sequence intubation using the video laryngoscope to secure a definitive airway prior to moving the patient.

Extrication

The patient was lowered utilizing a long-line method attached to the aerial. The cardiac monitor was secured in the Stokes basket along with the mechanical CPR device and an oxygen cylinder. A rescue-paramedic was tethered to the bridal and ventilated the patient throughout the duration of the rescue operation.

Once on the ground, the second EMSO transported with the medic crew to the hospital, where care was transferred to the awaiting ED staff. Unfortunately, despite the efforts of the team, ultimately, the patient didn’t survive.

Phases & tasks

Although the outcome wasn’t what was desired, this incident highlights the importance of establishing incident command, recognizing challenges and mobilizing resources early. Further, at the heart of solving a complex problem is the division of the problem into phases and then tasks that independently are routine. Every responder has a task to perform. Some tasks might be simple, others might be more complex, but not one task is more important than the other.

Performing these tasks at a high level regularly on simple runs prepares for when they are dispatched on “the run of your life.”