Cases With a Twist: Culinary Complications

It’s a hot summer day, and crews receive a call for a patient on the eighth floor of an apartment building where the elevator is out of service. As the crew climbs the last few stairs, they hear the rush of air from a bag-valve mask swooshing, and someone counting, “One and two and three.”

On arrival the crew finds a morbidly obese (around 350 kg) female in cardiac arrest on the floor of her kitchen. Their size-up notes a large quantity of “dark red fluid surrounding and on top [of] the patient,” as a first responder says, “We can’t find where she’s bleeding from, but it looks like it’s inside the mouth.”

The crew notes extreme rigidity of the neck and jaw when trying to open the airway, and food particles “everywhere,” clearly indicating large amounts of red-bluish-violet emesis.

As the team continues the resuscitation, the monitor shows asystole and the crew discovers  the patient is of Eastern European descent. Compressions are difficult to perform due to size and slipperiness of the chest. They place a supraglottic airway after being unable to visualize the airway. Later they report the “moisture never seemed to go away, and we kept sliding off the sternum.”

An intraosseous line is placed, and one crew member hands the other a syringe with 10 ml of clear fluid. “Here’s your epi,” he says. “I had to draw it up and dilute the 1:1 because the 1:10 in the bag is broken.” The medication is administered quickly. Soon thereafter medical control approves cessation of efforts; however, during cleanup several twists become evident.

Case Discussion

It turns out that the fluid was not blood, but borscht, a beet soup the patient had served her family the evening before. Once a younger family member arrived on scene to translate, the crew also discovers the patient had probably collapsed the night before after serving the family meal, but was not found until this morning. While a language barrier certainly confused this case, the family on scene could speak enough English to communicate this, but was never interviewed well enough by the responding crews to convey this information.

Why was the patient warm enough that the crew chose to begin resuscitation efforts? The floor of the kitchen was very thin and easily heated due to the downstairs neighbor’s hot water pipe. The ambient temperature and warm wood floor gave the sense the patient had not been down for long.

Last but not least, the crew discovered the multidose vial they used to draw up epinephrine was in fact a vial of amiodarone. Drug shortages had forced a change in supplier, and the vials of multidose epinephrine and amiodarone looked very similar.

Preventable Factors

EMS providers are tested on each case we respond to. Are you capable of quickly climbing eight floors and taking care of a cardiac arrest patient with a clear mind? Staying in shape is certainly a job requirement, but knowing when to slow down enough to regain composure is key. Practicing mental acuity training while your heart rate is near maximum can help keep you stay sharp.

Recent research has pointed to serious concerns with the accuracy of medication administration in EMS. Medication labeling, storage and inventory are key to creating a system that minimizes the chance of error. The fewer calculations needed on a scene, the better. This crew did not notice the broken epinephrine vial during their initial checks. More important, pausing to double-check a medication with a partner might have caught this error.

After promoting a culture of safety, where errors can be reported without fear of repercussion, Sedgwick County EMS, in Wichita, KS, has done a great job creating a checklist that helps crews double-check with each other before administering any medication. The cross-check takes 20–30 seconds and should be done during any case. Even during a cardiac arrest, we can afford to spend the time to ensure the right medication is administered. You can see this cross-check with accompanying video at www.emsreference.com/checklists.

CRM Tips

CRM techniques have led to improved communication, teamwork and safety in the military, commercial aviation and now EMS/fire agencies.

• Task saturation—When multiple key processes are going on at once, EMS providers need to guard against becoming overwhelmed. Critical tasks require us to stop and regain focus. The first responder’s strong belief the patient was covered in blood led the crew to think that was the case, instead of interviewing the family.
• No-blame culture—In a culture of safety, who committed an error is not as important as what caused the error and how to fix it. In this case there were a number of potential blame recipients. The medic who drew up the wrong medication could be blamed for improperly verifying the medication, and the medic who pushed the drug could be blamed because he neglected to verify the medication, especially in light of the fact that there was a noted variance from the normal packaging and concentration. In addition, both crew members could receive some blame for attempting to resuscitate a dead person. It is easy to be a Monday-morning quarterback and assume we would have done something differently, but it is hard to know for sure. 

Report Events

Please help us identify errors and near-miss events that affect the safety of EMS providers and patients. Report events anonymously at www.emseventreport.com.

E.V.E.N.T. is an anonymous tool designed to improve the safety, quality and consistent delivery of EMS. The data collected will be used to develop policies, procedures and training programs. A similar system used by airline pilots has led to important system improvements based upon pilot-reported “near-miss” situations and errors.

Editor’s Note

Cases are obfuscated and amalgamated to protect patient privacy and provider anonymity. While staying as true as possible to the actual event, creative license is used to better explain the lesson(s) in the case.

David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area.

Will Krost, MBA, NRP, is a fourth-year medical student and a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences. He has over 23 years of experience in EMS operations, critical care transport and hospital administration.