Cases With a Twist: Powderful Distractions

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This case began at 10 p.m, when a woman driving home after a large stir-fry dinner veered off the road and into a building. Her son, following in his own car, witnessed the event and called 9-1-1: “My mother just crashed into a building. Hurry, I think her van is about to explode!”

The 9-1-1 call was unneeded, as two police officers witnessed the crash from the community hospital across the street and responded immediately. They entered the building through the big hole in the side, trying to find the patient in the haze of grey smoke and a thick white cloud. 

The first-arriving fire engine was met by the patient, who was already out of her car and following the building’s exit signs toward the front door.

“Where are the officers?” the crew asked the patient.

“I don’t know,” the patient answered. “I wasn’t trying to rob the place.”

Within minutes paramedics arrived on scene to find the patient on the front lawn, being cared for by the fire crew, and two more police officers running into the building, still enveloped by a white cloud and thick, smoky haze.

“Where are they going?” asked the paramedic as he approached the patient.

“Putting out the fire, I’d guess,” responded the firefighter.

What followed next no one expected: A steady stream of humans covered in white powder came walking out of the building.

“It was like the night of the walking dead,” said the patient’s son. “It’s like the cops were abducted by aliens and were walking out like zombies.”

A paramedic student intern who’d arrived on the ambulance was uncomfortable. Afraid to question his preceptor, he entered the scene silently wondering, Why are we this close? Shouldn’t we retreat to safety? But real cases don’t come with a rewind button. This rapidly changing scenario was unfolding without warnings. The responders were following their instincts until it seemed unbelievable. If the zombies were attacking, retreat was no longer an option.

The Facts

The patient’s van was not on fire. The accelerator was stuck, and the tires were spinning loudly and burning rubber. The police officers were trying to turn the car off while warding off “zombies” with expired fire extinguishers from the trunks of their squad cars. The white powder covering the “walking dead” was harmless: The building was an unmarked (illegal) bakery. Imagine the surprise when our patient crashed into an employee appreciation party, smashing her van into a storage room full of large sacks of bleached flour and powdered sugar.

After canceling the hazardous-materials teams and extra police, the crew turned their attention to the patient: a 59-year-old female complaining of chest pain. She was conscious and begging for pain relief; the responders believed she might have been intoxicated. A three-pack-a-day smoker, she sported a diabetic alert bracelet. Her son reported she had a severe headache and arm numbness after taking depakote earlier in the evening. The police also reported a starred windshield and bent steering column.

The woman’s initial vitals were BP 80/50, pulse 120 and respiratory rate 24. The paramedic student thought to ask, “Should we go to a Level 1 trauma center?”

But once again the scene unfolded quickly, and before he could realize it, the back doors to the ambulance were closed and the driver was pulling into the ER across the street.

There was only time for the student to begin establishing an IV and his preceptor to put ECG patches on for a 12-lead that was still being acquired when the ambulance reached the ER garage. The ER crew, having watched the event from across the street, was ready. They rapidly interpreted 1 mm of elevation in V2 as a STEMI, starting heparin and sending the patient to the cath lab.

It was the cardiology team that, upon finding no coronary blood flow obstructions, finally slowed down long enough to assess the patient properly. That team discovered and fixed a pericardial tamponade, but more astutely sent the still-hypotensive patient to surgery after interrogating the aorta. The patient was really having a dissecting aortic aneurysm.

Case Discussion

While it might be tempting to say the scene was not safe and the crew should not have entered, the reality is that we take calculated risks every day. At first glance, with other responders on scene, this scene appeared (and eventually was proved to be) safe. We can’t get out of ambulances in full hazmat suits on every call. This case evolved so quickly that responders could not keep up with changing conditions. If this happens to you, it may be time to slow down, take a step back and think. Regaining situational awareness is key to ensuring safe operations. Experts suggest using three Rs: react, regain, reconstruct. A good rule to live by is “Slow is smooth, and smooth is fast.”

In many aviation crashes investigators discovered that someone on scene knew things were going badly but was afraid to speak up. In this case the paramedic student may have had valuable input that could have prevented hours of wait time and dangerous anticoagulation therapy in a patient having a surgical emergency.

Using a flat hierarchy and promoting the use of appreciative inquiry by this paramedic student may have helped mitigate potential errors. Removing one’s ego may be the hardest thing to do. In EMS we tend to place a lot of emphasis on seniority and street experience. This encourages the assumption that senior members must know what they’re doing and does not empower junior members to speak up.

The case also had a wide set of differential diagnoses—from uncomplicated angina to chest trauma, head injury, stroke and seizure. This is the detective work of EMS, making the job more interesting and challenging. The hypotensive presentation with possible hemorrhage or circulatory compromise made the patient critical. Rapid transport was indicated, and the community hospital across the street may have been the right choice, but always consider that destination hospital’s capabilities—they can really change the outcome.

In this case there was a bit of tunnel vision, which can occur when we initiate a prehospital procedure such as a 12-lead and fail to take a wider look at our assessment. While it is unlikely the ambulance crew would have detected a dissecting aortic aneurism, it would have been reasonable to suspect chest and head trauma and potential bleeding.

Last but not least, during our critical handoff reports, ED staff should be encouraged to stop and listen. Many trauma centers that are attuned to the culture of safety have adopted a “moment of silence.” And of course, once we have the floor, we need to ensure we start with our leading differentials. If we begin with the classic “We were called for…” and cite a dispatch reason that is of little consequence to the condition we ultimately found, we are simply wasting precious time and diverting attention in a way that may confuse the next care provider.

CRM Tips

Flat hierarchy: When it comes to safety, even junior or novice crew members have equal rights and responsibility to speak up. Everyone’s input is valuable. This does not mean rank or seniority is ignored. On the contrary, command structure is key to good teamwork. It means leaders have a responsibility to listen, leave their egos behind and make changes based on team member input.

Appreciative inquiry: Advocacy for safety and good patient care is essential. Learning four simple steps to respectfully raise a safety concern can save many lives. Begin with getting the attention of the leader, then state the problem as you see it, propose a solution and obtain agreement from your team.

E.V.E.N.T.

Help identify errors and near-miss events that affect the safety of EMS providers and patients by reporting anonymously at www.emseventreport.com. Data collected will be used to develop policies, procedures and training programs.

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.