Tech Support

The Attack One crew reports for duty on an icy-cold day. It’s been busy across the system, and in the late afternoon the crew is asked to post at a rural station while a multiple-casualty accident is managed on the interstate. The crew is disappointed it doesn’t get to assist at that accident scene—it seems lately they’ve been missing all the high-acuity calls.

They’re finishing an early-evening meal when the dispatch tones summon them to a possible ice-rescue call. The dispatcher can only provide a call site in the area of a certain road, with the promise of more information to come.

The crew bundles up as they head out the door, driving toward a location that’s not familiar to any of them. They note the dispatch response includes a heavy-rescue crew, a ladder truck and a boat. They are told by dispatch that the air ambulance will be unavailable due to the accident on the interstate.

“Glad I wore my long underwear today!” the EMT teases the paramedic.

“Hope you don’t need more than that,” the paramedic responds.

The response to the scene area is at least 15 minutes, during which the dispatcher relays a more precise location. “Crews responding. The location of this call is a rural pond where a man fishing is reported to have fallen through. We can only locate the call by tracking the mobile phone of the caller, and that gives us an area about a mile square. From the caller’s description of the pond and using our satellite maps, we believe the location will be on the north side of the road, in the area of…”

The dispatchers have done an incredible job just finding that location. Based on the information, Attack One is likely to be the second unit on the scene, following a rural fire engine. The heavy-rescue unit will be at least 10 minutes later, and the ladder truck behind it.

The paramedic is about to ask for further information when one of the EMTs reports, “I found the location on my smart phone. We can get there quicker using a cut-through gravel road, which looks fine to support our vehicle. That pond will be best accessed if we approach from the west side, and it looks like there’s a set of cabins on the driving path that leads to the pond.” She shows the paramedic the map on the phone.

“Incredible that you found that,” the paramedic replies. “Let’s lay out a plan for a rescue if the engine company hasn’t pulled the victim out yet.”

The EMT proposes they locate and light the scene, and if possible use ladders and ropes to perform rescue. They will attempt to dry the patient, and warm him if possible prior to transport. If the cabins are open and he is not in bad shape, there may be a chance to warm him inside one and make transport decisions then. There are warmers for oxygen on the ambulance, but none for fluids. They will keep all needed equipment in the warmed ambulance and use an oximeter to evaluate pulse rate and perfusion.

The shorter paths to the scene are a huge time-saver, and they find the path to the west side of the pond. There are lights on in the cabins, so there may be warmth. But there is no one flagging them, and for a moment they are concerned this is not the correct location. Farther down the path, however, they notice someone motioning with a flashlight. They turn on their spots and see the flashlight-bearer on the pond and another dark figure in the pond. They appear to be about 50 feet from the water’s edge.

They pull their vehicle up safely on the frozen soil to the edge of the pond and focus spotlights out onto the ice. The man waving the flashlight is grasping the end of a long pole; the man in the water holds its other end.

“Help us! He can’t hold on much longer,” the man on the ice yells. “The ice is very thin out to where I am. He must have walked onto a thin pocket and fallen in. I heard him yell and ran out. He is really cold and barely holding on.”

The first difficult decision to make: Is it safe for any rescuers on the ice? The paramedic knows it’s been cold enough that the ponds have been safely frozen for some weeks, and no other ice rescues have occurred.

“How deep is this pond?” they yell at the man.

“About 6 or 8 feet in this area. Doesn’t get deep until much farther out.”

The paramedic is pulling every piece of potentially needed equipment off Attack One. The sounds of the heavy rescue are not yet audible, and the siren from the first-responder engine can just be heard in the distance. The heavy rescue has insulated ice-rescue suits made for these types of incidents.

The paramedic advises dispatch that the victim’s been located and is still in the water, and asks that all units follow the shorter routes they found to the scene. He requests ETAs for the other responding units. The dispatcher says the closest engine is about five minutes away, the rescue eight minutes, the ladder truck 12.

The paramedic is concerned they may not have time to wait. He assigns the two EMTs to take a couple of small rescue tools out to the man on the ice and establish a safe route to get that far. They will use the ladders and more rope from the engine when it arrives, and only perform the final rescue when the heavy rescue arrives with proper equipment.

“Tie yourself off with a 50-foot section of rope. Place our longest ladders out onto the ice and take two plastic backboards. Don’t either of you get closer to each other or the man on the ice than 6 feet. One of you go 20 feet out and stop, the other take out rope and our rescue poles to the man out there. Again, stop about 6 feet away and slide the stuff to him. He can tie himself off with one rope while you hold the other end, and then throw the rope in the throw bag to the victim. Slide him our rescue pole and have him get the victim to stick it into or around his clothing. Even if he loses his grip on the other stick, we can pull him in with the pole. Slide the backboards out afterward, as we may need them for rescue.”

The paramedic believes it can be lifesaving—and as safe an operation as possible—if he strings the rescuers together, but far enough apart that their weight doesn’t break any more ice. The ladders distribute weight across a larger surface. If the victim loses consciousness, they want as many ways as possible to keep him above the surface until safe rescue can occur.

By the time the EMTs carry out the operation, the engine has arrived. The heavy rescue is audible; the good directions from Attack One shave a couple minutes off both arrival times. While the heavy-rescue members don their ice-rescue suits, the engine crew strings together the ladders and more ropes, with everything anchored on the side of the pond.

The EMT closest to the victim relays information that indicates he’s close to being lost. He’s a man of about 40, and while his level of consciousness was originally normal, in the water he is now almost completely silent and losing his grip on the original pole. He can’t tie the rope around himself, but fortunately is able to stick the end of the Attack One rescue pole through his shirt and a pair of suspenders. His head lies on top of the two rescue poles, which are crisscrossed under his arms.

The two heavy-rescue members, outfitted in suits, slide about 8 feet apart, parallel, onto the surface toward the victim, each tied off and dragging additional rescue rope and a life preserver. They move quickly and away from the other rescuers. One arrives at the edge of the ice near the victim and can reach in, float a preserver under the victim, tie it securely and then slide him partially onto the Attack One backboard. The heavy-rescue duo works together to get the victim stable on the sliding board and guide him back toward the rescuers on shore. The others help slide him closer. The victim is not able to assist.                             

The paramedic has been working ahead, preparing for victim care. Several persons have arrived from the shore-side cabins and offered to help. They are asked to warm some bags of intravenous fluids in a microwave and warm some blankets on a heater. The cabin of the transport ambulance is heated, and a small tarp is hung and prepared outside the ambulance as an area to rapidly strip and dry the victim before placing him on the stretcher in the vehicle.

The patient is moved carefully across the ice to avoid a lethal dysrhythmia. A dry crew is in place on soil to carry him to the side of the ambulance, where his wet clothing is removed, he is dried rapidly, and warm blankets are placed over him as he is gently placed on the stretcher.

The patient is not speaking and responds to painful stimuli by withdrawing. The pulse oximeter can’t get a reading. Pulses are present at a slow rate. The patient’s arms are ice-cold, so an intraosseous line will be the best choice for therapy with warmed fluids. The vehicle has a warmer for oxygen therapy, and warm fluid is put in a nebulizer cup to humidify the oxygen. The interior cabin of the ambulance is warmed as much as possible. The patient is protecting his airway and breathing on his own. He has no injuries other than some abrasions from the ice.

The paramedic directs the crew to begin transport and contacts medical direction. They agree the victim’s altered level of consciousness and time in the water indicate his hypothermia is moderate to severe. It will take slightly longer to get there, but they agree care will be best provided at a hospital that has cardiovascular bypass capability, as that is the most effective method to warm a victim of severe hypothermia. That hospital is given an alert for this unstable patient to allow them to assemble the team and equipment for a rewarming intervention.

During the 30-minute transport, the Attack One crew feels warming is being accomplished with warm IV fluids, humidified oxygen and rotating warm blankets. The man’s heart rhythm is stable, and he begins to move a little and open his eyes.

Hospital Course

The ED is prepared for the patient’s arrival, and rewarming continues there with a warming blanket, fluids and humidified oxygen. The cold-temperature thermometer initially measures the patient’s rectal temperature at 88ºF, so it’s likely his core temperature on removal from the water was even lower.

The cardiovascular team is prepared to place the patient on cardiac bypass, but his rewarming is carried out successfully without the need for that further therapy, and his mental status improves over the first hour. He is admitted to the ICU and within a day recovers and is released.

Case Discussion

The best management path for this patient was rapid assessment, immediate movement to a warm environment and immediate intervention. The lower a patient’s temperature, the more susceptible he or she is to deterioration if they’re moved in rough fashion. Rescuers must package and move victims very carefully.

Our current knowledge is that best outcomes occur if the victim is only rewarmed once. Hypothermic patients need to be dried to prevent rapid heat loss. Intravenous access may be difficult in very cold patients, and intraosseous access is a good option. Administer IV fluids and humidified oxygen only if they can be warmed.

Bystander intervention allowed the use of locating technology by the 9-1-1 center, then timely access by rescuers with the correct equipment. Radio communications allowed for safe access to the patient and safe operations for the crews involved.

The process of rapid response to the correct location, timely access to the patient and intervention for dangerous illnesses and injuries has been improved by the use of a wide range of technologies. This patient likely would not have been rescued without the presence of a mobile phone and its embedded locating capability. The Attack One crew reduced response time and sped access to the patient using mapping technologies. They faced critical and dangerous rescue conditions that were made less hazardous using new forms of rescue gear. Treatment of the patient was enhanced by newly developed tools for warming.

The use of technologies is especially important in rural or wilderness rescue and emergency medical services. The development of live audio and video feeds between rural providers and emergency physicians will offer even more support for EMS when victims have long prehospital times. Exchange of data has already enhanced the care of patients with severe trauma, acute myocardial infarctions, strokes, sepsis and pediatric illnesses. The next generation of EMTs will have more tools to assess and deliver care in a wider range of patients.

The care of patients with accidental hypothermia has improved with the development of more products to rapidly and safely deliver warming treatment. The nation’s best EMS guidelines were just published by authorities in Alaska. Their latest set of cold-injury treatment guidelines, dated June 2014, is available for download at https://dhss.alaska.gov/dph/Emergency/Pages/ems/downloads/treatment.aspx.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.