Patient Care, Training, Trauma

EMS Providers Use Detective Skills to Solve Case

Issue 9 and Volume 36.

The EMS headlines lately seem to weigh heavier on missed opportunities to make a difference than on the exceptional work performed by emergency crews. The buzzword in EMS training these days also includes “critical thinking”—how we teach it, how we ensure our crews practice it and why it matters so much.

From the first day a 5-year-old discovers a cool bug or a teenager takes apart the lawn mower engine, humans demonstrate the inherent curiosity they’re born with. I watched my 5-year-old dissect a sheep eyeball at the “Who’s Your Daddy Fest” in Durango, Colo., this past spring and was impressed with his level of inquisitiveness to the instructor and his determination to get the lens and retina out of the globe. This slimy object was a mystery to him, and he was bound and determined to find out how the eyeball worked and what it was made of.

I thought to myself, what a powerful learning event and wondered how one could harness that inquisitive nature to ensure it’s used on every EMS and fire call. When I returned home, I was surprised and excited to learn about an equally fascinating piece of detective work by an emergency response crew at the Farmington, N.M., fire department that showed how their inquisitive nature and critical thinking at a scene saved multiple lives.

Syncope or near syncope is a sentinel event in the human body and a tremendous opportunity for good detective work, because the symptoms require the skills similar to those needed to solve a complex puzzle.

Syncope is a temporary fall in blood pressure with a loss of consciousness. Near syncope is a temporary drop in blood pressure, resulting in the onset of weakness without a loss of consciousness.

Syncope is responsible for one out of every 30 visits to the emergency department (ED). Many syncope or near syncope calls never make it to the ED for a full evaluation. A disruption in blood flow to the brain due to a loss of blood pressure results in a corresponding loss of oxygen to the brain, which triggers syncope. The detective work is about what triggered the fall in blood pressure.

When the Farmington Fire Department was dispatched to a Safeway Store at 4:45 p.m. on May 7 for a 14-year-old female who had passed out in the store, a mystery began to unfold. However, the crew’s solid detective work and critical thinking skills averted a potentially catastrophic outcome.

On-Scene Detective Work
When the Farmington fire unit arrived on scene, they found a young female on the floor, awake, lying in her mother’s lap. The patient was alert with no obvious severe or acute symptoms. The mother had described the event as a “fainting spell.”

Firefighters, as a part of their assessment regimen, applied a RAD-57 monitor on the patient to assess her pulse oximetry (SpO2) level. They were immediately surprised to have the device’s automatic carbon monoxide (CO) assessment alarm go off at 15% CO saturation, a parameter they didn’t initially consider based on dispatch information and “clear” air at the scene. The crews looked at each other, and someone said, “That’s weird.”

The first responder crews wondered whether the patient’s near syncope could possibly be from CO poisoning despite the fact that the setting and circumstances weren’t typical of the environment in which one would find a CO poisoning. Nevertheless, they became suspicious and pursued the logic to solve the discrepancy. Paramedics arrived from the San Juan Regional Medical Center ambulance service, and fire crews took a second reading on the patient. The RAD-57 monitor continued to sound the alarm for a CO reading around 15%.

CO treatment protocols were initiated, and crews placed a non-rebreather mask at 15 liters per minute (LPM). She was prepared for transport to the San Juan Regional Medical Center for evaluation and treatment.

Her 18-year-old sister was also present with their mother. Both remained in the store and were screened by the fire unit for CO. Elevated CO readings were identified on both of them (8–9%). The crews found out that both were smokers. Even though both patients were asymptomatic, fire officials remained suspicious of a CO leak in the facility because the mother’s level was elevated above 5%, and the 18-year-old’s level was even higher. So the Farmington fire crew pulled out its CO atmospheric assessment meters and checked the atmosphere in the store. No dangerous CO levels were detected.

The ambulance crew then applied the traditional, basic pulse oximeter to assess the patient’s SpO2 reading, which was 96%. However, the RAD-57 reading on the youngest patient continued to be alarming.

The crew was convinced there was CO poisoning—although the mystery of the origin of the CO remained elusive—and decided to transport all three patients to the ED to be treated for CO poisoning.

Many EMS/fire crews would declare a call of this nature “over” as soon as the ambulance left to go en route to the hospital, and the mysterious CO alarm source would remain unsolved. This now becomes a moment of truth in which the human mind experiences something called cognitive congruence, or in plain terms: It just doesn’t make sense.

At some point during their assessment and “detective” work at the scene, a Farmington firefighter had gained a history from the mother that she had purchased a used 1992 Ford Econoline van one week earlier. The Econoline has an engine cover located between the front driver and passenger area, which is best described as a large hump extending from the engine compartment into the passenger area.

The firefighter also learned that the family had been traveling in the van for several hours before stopping at the store. Firefighters located and checked the vehicle in the parking lot to attempt to find a source of CO.

One firefighter started the van and immediately heard the sound of an exhaust leak. A quick application of the air gas monitor presented a reading of 40 parts per million (ppm) within one minute, with the windows of the van open (15 ppm is a dangerous level). The firefighters confirm the CO leak in the van and shut down the engine. The CO source had been located, so it would seem the mystery case was closed. Not quite.

One of the crew members remembered the mother had five more children at home. Part of the history taken inside the store revealed that several other family members were in the passenger van earlier that day on a road trip. Although only the mother and two daughters were in the van recently, the crew learned that the 14-year-old patient had slept in the van the night before, and a three-year-old male who was at home had also been in the van. Because of these details, the Farmington fire department dispatched a ladder truck, an engine and additional ambulances to the family’s home.

When they arrived at the house, they found the 3-year-old male, a female infant, 18-year-old and 9-year-old males and a 12-year-old female inside along with several other adults.

The 3-year-old male was found “sleeping” on a couch and wasn’t able to be aroused with verbal commands. His inability to hold his head up and his altered level of consciousness continued to raise suspicions about CO poisoning. Head bobbing, lack of muscle tone and alertness and the inability to hold their head up are key indicators of a sick child.

The RAD-57 reading on the young male indicated 15 ppm of CO saturation. The elevated levels coincided with symptoms presented by the first patient. Fortunately, none of the other family members had been in the van. The emergency crews evaluated the other adults and children in the home as a precaution and determined they all were asymptomatic and had normal CO readings. Just to be sure, however, a firefighter checked the house thoroughly for CO and found no traces.

The 3-year-old boy was transported to the San Juan County Regional Medical Center on high-flow oxygen. All patients were transported to this facility and were discharged without any serious problems. They will continue to be monitored for any long-term consequences from the exposure.

Even as the technology available to fire and EMS personnel increases in sophistication and function, it’s still essential that crews use their critical-thinking, scene-safety and assessment skills to know when to apply and interpret the devices. Whether it’s a 12-lead ECG, non-evasive CO monitoring or sampling the atmosphere with gas monitors, knowing when to apply these devices is the key to a successful outcome.

As illustrated by this case, it’s that level of investigatory and scene-assessment follow-up that can make a significant effect on morbidity and mortality in the field.

Syncope should trigger the full application of available equipment and technology, as well as an exhaustive interview by the EMS provider. In this case, the thorough scene and patient assessments conducted by Farmington crews prevented a catastrophic outcome for four patients. These CO poisoning cases could have gone undiagnosed, and a common call for near syncope easily could have been passed off without a definitive diagnosis. JEMS

This article originally appeared in September 2011 JEMS as “Thorough Assessment Saves Lives: How a complete scene and patient history assessment saved multiple lives.”

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