Operational hazards are typically predictable, and EMS providers train constantly to safely learn to negotiate and minimize hazards in the performance of their duties. However, some hazards are so well hidden, that even with maximum training and awareness; they may still develop into an unsafe and life-threatening situation.
Modern training tenets promote consistent and frequent evaluation of situational awareness. This particular case involves a San Diego Fire-Rescue Department firefighter/paramedic who was responding to a condominium fire. The call was initiated by neighbors who could see smoke coming from a nearby condominium complex.
Unexpected Danger
On arrival, the initial crew, including the firefighter/paramedic, made forcible entry through the front door of the involved condominium, initiated a fire attack and search and rescue. While the crew moved through the smoke-filled condo on the first floor, the lead firefighter/paramedic was sweeping left to right with his arms and hands when he felt what he immediately realized were a set of human legs. He quickly grabbed the ankles to pull the victim to safety, when the victim sat up and lurched toward him with a sizeable knife. The knife grazed near his face mask and toward his torso. Luckily, the paramedic was able to block a second attempt to slash him, and then he used the nozzle of his water line to knock the knife from the attacker’s hand.
Fortunately, the attacker/victim didn’t harm the firefighter paramedic and was removed from the building to waiting paramedics, who were outside. The providers quickly realized that the victim wasn’t in a condition to physically resist, and they learned that earlier the victim had set his own home on fire, and after ensuring it was sufficiently ignited, used the knife to cause a self-inflicted laceration from one side of his neck to the other, injuring his external jugular vessels. Estimates of blood loss were approximately 1.5 L at the time he was discovered.
The paramedic/firefighter resumed his firefighting duties after turning the patient over to San Diego City-Rural Metro paramedics for treatment and transport. The patient had progressed into a hemorrhagic shock state.
Treatment
The patient’s blood pressure was barely obtainable, and the patient had lost consciousness. Faint carotid pulses could be felt. Direct pressure was applied to the areas of the great vessels with care not to occlude the carotid arterial flow. Because the patient was now unconscious, he was placed in full spinal precautions and soft wrist and leg restraints were applied. Paramedics were also aware that the patient might make efforts to harm another person who attempted to intervene or interrupt the suicide process, so they ensured the maintenance of a safe scene.
Other treatment consisted of high-flow oxygenation, intraosseous access and delivery of normal saline fluid bolus, as well as proper elevation of the lower portion of the spine board to help increase venous return to the heart. Paramedics prepared for advanced airway insertion and measured end-tidal carbon dioxide (EtCO2) levels and respiratory rate.
The local level I trauma center was alerted, and transport was initiated with an estimated five-minute transport time. The transport presented no further challenges, and the patient was delivered to the trauma team with mild improvement from treatment rendered. Advanced airway insertion wasn’t attempted in favor of an appropriately maintained and patent airway and evidence of satisfactory oxygenation and gas exchange.
The patient was admitted to the trauma center’s operating room resuscitation unit and was successfully resuscitated over the course of several days. During his hospital stay, he was charged with felony assault and arson, and is currently awaiting trial. The first responders suffered no injuries as a result of the patient’s attack.
