From Fire Scene to Cath Lab

Around 5 p.m. on a mid-September afternoon, three local volunteer fire departments were dispatched to a reported structure fire. Along with the fire crews, an EMS unit was also dispatched, consistent with our emergency responder rehabilitation program.

Upon arrival of the first volunteer fire chief, the scene, which was in the southern portion of our rural county, was marked a working fire. Once crews arrived, they initiated their attack and the fire was quickly contained. When the fire was extinguished, the fire crews began their clean-up routine, consisting of cleaning tools, rolling hose and performing final checks for fire extension.

While performing "mop up," as it is commonly called, a firefighter began feeling pressure in his chest and felt overheated. This firefighter was a healthy 48-year-old without any previous medical history.

Fire command had already cleared the EMS unit, but felt it was appropriate to summon the paramedic crew to return to evaluate the firefighter. Although he insisted he was only overheated and complained of vague symptoms, EMS performed an ECG and recognized an ST elevation myocardial infarction (STEMI). The paramedic encountered an agitated patient who adamantly refused transportation, but who utilized the assistance of fire command to convince the patient to receive proper treatment.

EMS initiated transportation to the appropriate facility 30 miles away, by-passing three community hospitals that did not offer the capability of performing a percutaneous coronary intervention (PCI).

On arrival at the hospital, the EMS crew escorted the patient to the cath lab, where he received a stent in his left anterior descending artery, breaking the heart center's record with a 14-minute door-to-balloon time. The firefighter did well and was discharged home a few days later.

Discussion

This case was successful because of programs that have been placed into action in this rural county. Not very long ago, there would have been a different outcome for this firefighter and his family. First, no ambulance would have been dispatched to a structure fire unless there was an injured civilian. If an ambulance was called for a sick firefighter, it would not have had standards or equipment for obtaining a 12-lead ECG, even with vague symptoms, and the patient would have been transported to one of the three local facilities where he would not have received a PCI. Now, because of programs working together and a very observant EMS crew, a life was saved. Let's look a little closer at each component that led this call to a positive outcome.

Firefighter Rehab

Our county initiated this protocol two years ago in an effort to assist local fire departments with meeting the standard NFPA 1584 guidelines for emergency responder rehab.

Once our protocol was adopted and the policy in place, we encouraged all 24 fire departments to begin a rehab program and vowed to be the "EMS component" as referenced in the standard. This met resistance at first, and is still accepted only to various degrees. Some fire departments participate and some continue to operate without rehab policies, but all dispatched structure fires get an ambulance. Even without all fire departments fulfilling the standard, the success of our program from an EMS perspective is that an ambulance responds hot to all reported structure fires, and EMS crews are trained to observe firefighter safety. When responding with departments that do not have a rehab policy, EMS crews understand they should at least be standing in the cold zone with their jump bag, defibrillator and oxygen, ready if a firefighter collapses.

As we see with many smaller rural fire departments, there was no formalized rehab on this scene; rather, EMS was standing by with equipment ready and prepared for the worst. Another point of this scenario is that fire command released the crew as cleanup started. Once the crew returned, they recognized specifics signs they had been trained to notice when assessing responders on fire scenes. Statistics from as recent as 2009 show us that 43% of firefighter fatalities are caused by cardiac events (the leading cause), and most deaths occur during fire ground operations, with 56% linked to overexertion. This should be evidence enough to perform rehab on the fire scene and keep EMS crews standing by until crews are completed with all tasks at the scene.

STEMI Program

When the firefighter complained of not feeling well, members of his department recommended that he sit in an engine cab for air-conditioning. Command then asked EMS to return to the scene to "check him out." On EMS's return, the patient said he had been "too hot" and did not need EMS. He said he had a "little chest pressure" but would not elaborate on the pain. The paramedic performed a 12-lead ECG and found elevation in the septal and anterior leads.

Within the last two years, our system has implemented a STEMI program with the assistance of the North Carolina RACE project, AHA Mission Lifeline and WakeMed Health and Hospitals. This program faced several hurdles from its inception. First, we had to ensure our equipment was capable of performing 12-lead ECGs throughout the entire system and that each paramedic was trained on interpreting ECGs and diagnosing STEMI while factoring many imposters. Each paramedic in the system was required to take a class dedicated to this concept and pass a final exam. Next, our system implemented a STEMI Destination Plan that allows us to bypass local facilities that are not capable of PCI. Several political factors were encountered as the program became reality, but with the dedication of our medical director and EMS administration we were allowed to continue with the philosophy of doing that which is right for patients.

Our perimeters are now set, and paramedics are expected to perform a 12-lead within 10 minutes of arriving at the side of a patient experiencing chest pain. Once a STEMI is recognized, our goal is to be off-scene within 15 minutes of arrival and proceed straight to WakeMed, our specialty center for PCI, located in neighboring Wake County. Our transport times to this facility range from 15–55 minutes, depending on location within our rural county. We have worked with WakeMed and the hospital in declaring a "Code STEMI" based on the call from EMS along with transmitted 12 leads. This designation mobilizes their cath team, reserves room for an emergent cath and prepares the emergency department team to move quickly. Working together with EMS, the ED is no longer performing repeat 12 leads or x-rays as a matter of routine. Rather, the patient is going quickly through the ED, still on the EMS stretcher and monitoring equipment, before being transferred to the cath lab table. As an added education component, the EMS crew is allowed to stay during the procedure and observe the catheterization from the control room.

Despite explaining the seriousness of the event to the patient, the firefighter was persistent that he was fine, did not need EMS, and he "did not believe our machines." The paramedic elicited the assistance of the fire chief and scene commanding officer, who helped encourage transport. The crew was extremely clear about possible outcomes, including death. After attempting for several minutes to encourage transport, the patient agreed and transport was initiated to the appropriate facility for specialty care. Because this location is in the southern portion of our county, three community EDs were bypassed, with a total transport time of 31 minutes. On arrival at the specialty facility, the EMS crew assisted in delivery to the cath lab. The PCI facility, WakeMed, actually broke its reperfusion time with a door-to-balloon time of 14 minutes. The first medical contact-to-balloon time was 67 minutes, well within our goal of 90 minutes 75% of the time.

Conclusion

This case is an excellent example of successful partnerships and programs that have saved lives. This includes EMS involvement on fire scenes, where MI accounts for the leading cause of firefighter death, and a successful STEMI program. All of these programs consist of working together with other agencies that have their own needs. The common link between all stakeholders is taking care of people, as in this case of a firefighter having a STEMI.

Although we will never know for certain, statistics from firefighter deaths and knowledge of MIs affecting the left anterior descending artery (LAD) tell us this patient would have become a line of duty death (LODD) had he not received appropriate and timely care that day.

The author would like special recognition to go to the EMS crew of paramedic Lawrence Kennard and EMT Zack Alexander, who with assistance from the fire department, recognized the seriousness of this event and insisted the patient receive proper treatment. These EMS providers should be proud in not only making these programs effective, but in saving a life on this day.

Joshua B. Holloman, MHS, NREMT-P, is the training officer for the Johnston County EMS system in North Carolina. As a chief officer of the system, Holloman oversees the training and performance improvement program and is the primary liaison to the medical director. Holloman is also a certified firefighter, rescue technician and fire-EMS instructor. He teaches fire and EMS topics for both local and surrounding communities and is an advocate for increasing education, professionalism and leadership within emergency services.