Burning Man is a massive event held around every Labor Day in the Black Rock desert in northwestern Nevada. The encampment is an official city called Black Rock City, and although it exists for only a week or so each year, it becomes the third-largest city in Nevada. The event attracts in excess of 50,000 attendees.
The purpose of Burning Man is radical self-expression in various art forms. It’s truly a one-of-a-kind event. Black Rock City operates as a functional geopolitical entity with fire, police and EMS systems. Each is dispatched from a manned communications center that’s constructed and deconstructed annually.
In 2011, Humboldt General Hospital EMS in Winnemucca was contracted to provide medical care for Burning Man. Medical care included a fully staffed and operational EMS system, as well as a field hospital called Rampart General and two BLS aid centers.
A total of 2,307 patients were treated. Three-hundred and eighty-two requests for ambulances were made, with 185 patients being transported to Rampart General. Only 33 patients were transported out of the desert for care. The following highlights one of those cases that took place during the event.
Remote Care
On the final day of the Burning Man event, EMS is summoned to a chest pain call in a trailer within the encampment. On arrival, paramedics find a 60-year-old male in acute distress. He’s pale and diaphoretic and in extremis. The patient describes the pain as “tearing” and can’t get into a comfortable position. The EMS crew extricates him from his trailer and moves him to the awaiting ambulance for a more detailed assessment.
He becomes unresponsive shortly after they place him in the ambulance. Paramedics check his pulse, take a quick look at the monitor, and note the patient is in a non-perfusing v tach. On a hunch, they administer a precordial thump, and it works. The patient converts to a sinus rhythm. He’s transported to Rampart General in Black Rock City. Once the patient arrives at the field hospital, the emergency staff rapidly assesses him. He’s alert and oriented, but his blood pressure is undetectable. He’s writhing in pain on the stretcher. IV fluids are given, and his blood pressure is finally detectable at a systolic pressure of 72 mmHg and then up to 76 mmHg. He remains mildly tachycardic. He receives IV fentanyl for pain. Rampart General has X-ray capabilities and a stat chest X-ray is obtained. The emergency physician notes that the mediastinum is wide at 10.5 cm–consistent with a thoracic aortic aneurysm and dissection. A medical helicopter is summoned and the patient is closely monitored and stabilized by the emergency staff.
As soon as the helicopter arrives, the patient is moved to the aircraft and transported to a major medical center about 150 miles away. Once he arrives, he undergoes a computed tomography angiogram (CTA) that confirms the suspected aortic dissection. The patient is emergently taken to surgery where the aneurysm is repaired. The operation is successful, and the patient is moved to the intensive care unit (ICU). Following surgery, the patient suffers a second cardiac arrest and is taken to the cardiac catheterization lab for evaluation and subsequent stenting of a coronary artery lesion. He’s returned to the ICU and remains stable. He’s discharged home with appropriate provisions for follow-up. Despite his ordeal, he’s already planning his next trip to Burning Man.
Discussion
First, this is not a true “case from University Medical Center” because it didn’t happen at UMC. However, emergency physicians, emergency medicine residents and medical students from the University of Nevada School of Medicine provided much of the medical care at Burning Man. As you can tell, this patient had all the cards stacked against him. He had a critical thoracic aortic dissection, and he was in the middle of a Nevada desert more than 150 miles from a medical facility with cardiothoracic surgery capabilities. Furthermore, he suffered a cardiac arrest. Yet despite all of this, he survived.
Thoracic aortic aneurysms and dissections are life-threatening conditions that affect the thoracic portions of the aorta. An aneurysm is a dilation of an artery greater than 50% of its normal diameter. They’re classified based on the region of the aorta affected (e.g., ascending aortic, aortic arch, descending aortic and thoracoabdominal), and are at risk for rupture.
A dissection results from a tear in the interior lining of the aorta (the tunica intima). This tear, referred to as an intimal tear, causes the layers of the aortic wall to separate thus forming a false lumen. The pressure from the blood within the aorta causes the false lumen to expand, or dissect.
As the dissection progresses, blood flow to various blood vessels is affected, causing ischemia to the tissues they supply (e.g., the coronary arteries and spinal cord). Thoracic aneurysms most commonly occur in persons older than age 65. Death from a ruptured aneurysm is typically one of the top 10—20 causes of death annually. The incidence of thoracic aneurysmal rupture is approximately 3.5 per 100,000 persons.(1)
Patients who develop cardiac arrest from a thoracic aneurysmal dissection rarely survive. Furthermore, resuscitation with a precordial thump is even less common.(2) Hypotension is common, and hypertension should be avoided. This patient received enough fluids to restore perfusion as determined by monitoring his mental status and a maintaining a systolic blood pressure between 76—78 mmHg.
Consideration was given to adding vasopressors, but because dissection was suspected, they weren’t administered. A thoracic aortic dissection is characterized by widening of the mediastinum on chest X-ray. Fortunately, limited X-ray capabilities were available at Rampart General. The diagnosis was later confirmed by a CTA at the receiving hospital.
Teaching Points
It’s often difficult to diagnosis aortic dissection, either thoracic or abdominal, in the prehospital setting. Because of this, EMS providers must have a high index of suspicion when patients present with signs and symptoms consistent with thoracic aortic dissection. The most common presenting sign is pain–either in the chest or between the scapulae in the upper back. With large aneurysms, the superior vena cava can be compressed, causing distended neck veins. A murmur may be heard. Sometimes hoarseness, cough and wheezing may be present. In other instances, such as this one, shock and cardiac arrest may be present.
So much of quality EMS is identifying injuries and illness in the field, recognizing the potential severity and ensuring the patient is rapidly transported to an appropriate medical facility. The concerns of EMS crews and a presumptive field diagnosis can also aid emergency department personnel in directing appropriate resources to critically ill or injured patients. Quality emergency physicians will listen to the concerns of field crews and react accordingly.
Summary
This was a miraculous case that illustrates the importance of seamless interaction between field EMS crews and physicians. First, this case occurred in one of the most austere and hostile environments imaginable. Next, it included a patient who was resuscitated from pulseless v tach with a precordial thump performed by a paramedic crew. The patient was subsequently evaluated and diagnosed with a thoracic aorta dissection by medical staff in a tent (with a diagnosis made by plain chest X-ray) and emergently transported 150 miles to a hospital where successful surgery was carried out. It truly was a “perfect storm,” or perhaps, it was the general goodwill and spirit of Burning Man. Or maybe those crystals that were everywhere actually worked. This article originally appeared in May 2012 JEMS as “Miracle in the Desert: Cardiac case at remote Burning Man event presents challenges.” JEMS
References
1. Rogers RL, McCormack R. Aortic disasters. Emerg Med Clin North Am. 2004;22(4):887—908.
2. Haman L, Parizek P, Vojacek J. Precordial thump efficacy in termination of induced ventricular arrhythmias. Resuscitation. 2009;80(1):14—16.
