Airway & Respiratory, Major Incidents, Patient Care

Rogue Waves Leave Surfer Unconscious

Issue 8 and Volume 36.

On Jan. 22, Jake Trette, 30, was surfing Mavericks, a stretch of ocean near Half Moon Bay (Calif.), when a rogue wave of more than 25′ pummeled his body to the ocean floor. He managed to push off from the bottom and reach the surface, but another wave at least 30′ hit him, knocking him unconscious. Within moments, surfing photographer Russell Ord saw Trette and sped over to him on his jet ski, finding him face down in the water. Ord and a kayaker brought Trette to the shore.

EMS Arrival
Ord and a trauma nurse who happened to be visiting the beach initiated CPR as soon as the patient was brought to shore. A flood of 9-1-1 calls were placed from others on the beach, and within minutes, EMS crews were en route. Responding agencies included the Coastside Fire Protection District, San Mateo County Harbor District, San Mateo County Fire Department, San Mateo County Sheriff’s Department and American Medical Response (AMR). A California Shock Trauma Air Rescue (CALSTAR) helicopter was also dispatched to the scene.

On scene EMS crews inserted an oropharyngeal airway (OPA) device and suctioned Trette’s airway, placed him in C-spine precautions and inserted an IV. Within minutes, the CALSTAR crew—composed of pilot Sim Mason and critical-care flight nurses Alana Gibson and Ellen Gott—landed on the beach.

On arrival, the CALSTAR flight team found Trette secured in full spinal immobilization, unresponsive with involuntary extremity movement and a Glasgow Coma Scale (GCS) rating of 6. The OPA that had been placed by the first responders elicited no gag reflex.

While Gott checked the patient’s overall condition, Gibson prepared to administer medications and begin to intubate. Unaware whether the patient’s altered level of consciousness was caused by the submersion or the patient striking his head of the ocean floor, Gibson administered 135 mg of lidocaine via IV to dampen any potential increase in intracranial pressure during intubation. Gibson then began rapid sequence intubation (RSI) with 27 mg of etomidate and 135 mg succinylcholine. This optimized oxygenation and eliminated carbon dioxide (CO2), and it prevented possible aspiration of stomach contents, a common and potentially lethal complication of near drowning. The RSI was followed by the administration of 45 mg of Rocuronium Bromide and 1 mg of Versed.

Once Trette’s airway was stabilized, bag-valve ventilation was provided until the patient was transferred into the helicopter. The ground first responders helped the CALSTAR crew load Trette into the helicopter.

Air Transport
During the flight, ventilation was provided via controlled mechanical ventilation (CMV) at a rate of 10 breaths per minute, FiO2 at 100% and a positive end-expiratory pressure of 3. Pulse oximetry and end-tidal carbon dioxide (EtCO2) monitoring guided optimal ventilation. The patient’s EtCO2 was maintained at 35 and pulse oximetry at 100%. His blood pressure stabilized at 120–140 systolic and his heart rate at 70–80. Gibson inserted an oral gastric tube to decompress Trette’s stomach. Throughout the transport, Trette’s GCS was 3 as chemical paralysis and sedation was maintained.

Mason set a course for Stanford Medical Center in Palo Alto, and they arrived there in less than 10 minutes. Physicians and nursing staff were waiting for Trette, who was admitted in extremely critical condition.

Trette was released in good condition five days later. Ross Fay, San Francisco regional director of CALSTAR, calls it an incredible result. “This is a perfect example of how EMS teams, working in concert, can save lives,” he says. “All of the respective agencies responded quickly and all played a significant role in saving Trette’s life.”

Trette, a single father, has expressed gratitude for those who saved his life. “Obviously, I received excellent care at Stanford,” he says. “But had it not been for the large number of people who first responded, I no doubt wouldn’t be here today.”

Despite everything, Trette plans to continue surfing. “But surfing the Mavericks again? I’d have to give that very serious thought.” JEMS

This article originally appeared in August 2011 JEMS as “In Over His Head: Swift EMS response saves surfer’s life.”