Tag Archives: smoke inhalation

Backdraft Postscript

post·script

1 – a paragraph added to a letter after it is concluded and signed by the writer; or any addition made to a book or composition after it had been supposed to be finished, containing something omitted, or something new occurring to the writer

As it turned out, Missy was a WUS. That’s not a disparaging comment about her intestinal fortitude – it’s a classification of stroke known as a “Wake Up Stroke.” According to a recent article in the American Heart Association / American Stroke Association entitled Thrombolytic Therapy for Patients Who Wake-Up With Stroke, approximately 25% of all strokes are WUS. Given that people may sleep 25%-30% of their life it can only be expected that a stroke will happen during that time in a proportionate number. EMS currently deals with a short (4-hour) window of time to rush a patient to a stroke center for thrombolytic therapy – if a stroke has a known onset of four hours or less, the patient is eligible for thrombolytic therapy. Outside of that window it is considered a “cold stroke” and thus ineligible. If the onset time of the stroke cannot be verified, such as in the case of a WUS, the patient is automatically ineligible for thrombolytic therapy. This latest article, however, states that the therapy may be safe in longer periods of time from onset of symptoms. Further studies are being conducted to explore the possibility of an extended time period for this treatment.

I recently attended a lecture series by a panel of neurologists on strokes and the latest trends in therapy. During the session the extension to the thrombolytic window was explained in greater detail. To paraphrase four hours of lecture, in the event of an ischemic stroke there is a proportion between necrotic (dead) brain tissue and the surrounding ischemic (under-perfused) brain tissue which can be visualized with a Functional MRI. With a proportion of 80/20 thrombolytic treatment would have very little effect. With a proportion of 25/75 thrombolytic treatment may have a greater effect and the potential benefits of extending the window would then outweigh the possible risks. The ramifications of this line of research is that every patient has their own personal window of opportunity for thrombolytic therapy which can only be viewed once that patient reaches a stroke center. This same research is showing that an extension of the window to as long as sixteen hours may be safe in some situations.

In the case of Missy I took her into the hospital running Code-3 because of the smoke inhalation and potential for an airway that may be in the process of closing. Yet I transported her to a stroke center, bypassing a regular ED with no specialties, to ensure that neurologists would be on hand to quickly evaluate her recent stroke symptoms. Unfortunately the extension to the thrombolytic window is still in the research phase and has not progressed to cover the WUS scenario at the local hospitals. The deficits from Missy’s stroke did not immediately resolve and she was not a candidate for thrombolytic therapy. She will undergo extensive physical therapy in an attempt to regain some of her left-side functionality.

Meanwhile, Stacy, the fire medic/RN who got caught up in the excitement of the fire to the point that she missed an obvious stroke in her patient, has since been promoted to Lieutenant…

 

 

Backdraft

back·draft

1 – a reverse movement of air, gas, or liquid

2 – an explosion that occurs when air reaches a fire that has used up all the available oxygen, often occurring when a door is opened to the room containing the fire

Missy woke up a little early and from the start she knew something was wrong. She just didn’t feel right and the world seemed just a little more confusing than usual. She tries to get up out of the bed but the weakness is just a little more pronounced than usual and she never makes it all the way out of bed. Thinking maybe it would help to bring the world into perspective Missy reaches for a morning cigarette with her left hand, but finding she can’t quite make that work she finally reaches across her body with her right arm, grabs the cigarette, puts it between her lips, and lights it while laying in bed. With the smoke inhaled deep into her lungs she starts to relax again and nod off.

There’s shouting from outside the house – someone is yelling at her. She opens her eyes and sees the flames overhead – gently rolling across the ceiling with the smoke starting to burn her lungs on every breath. She tries to get up but again the weakness is stopping her from getting out of bed. Suddenly there is light in her bedroom, as the door opens, this is quickly followed by intense heat as the flames erupt as if seeking the oxygen from the open door. Strong arms grab Missy and start to drag her out of the house. Once on the front lawn she can see the flames well above the roof as firefighters are breaking windows and drenching her house with water.

As we roll into the neighborhood my partner and I stop following street signs and just follow the smoke to the location of the medical call. We have to park a block away as the small residential street is full of fire apparatus and supply lines. We roll the gurney closer to the house, avoiding the standing water and six inch fire hoses that snake across the road. Sitting in front of a burned-out house is my patient, leaning forward in a tripod position, sucking hard on an oxygen mask, with both arms being held out to either side.

Stacy, the fire medic, is supervising two Explorers who are simultaneously taking blood pressures, one on each arm. Our county has a Fire Explorers program for youth who someday want to be firefighters – it gives them the opportunity to volunteer with a local fire unit and learn the basics of the job. Both of the Explorers seem distracted by the commotion of the fire; they glance repeatedly from the blood pressure dial to the flames. It’s obvious they would rather be squirting water than taking care of this woman.

Finally, Tracy has had enough and asks each of them for their findings – she knows I’m not going to hang out here all day waiting for kids to check a vital sign that I’m going to recheck regardless of their findings. The kid on the left gives us a report of 90 over 60, the kid on the right tells us it’s 180 over 110. I have a dead pan stare on my face as I wait for Stacy to give me a report.

Stacy is writing the two sets of blood pressures on the patient care form and handing it to me. “Yeah, I know, you’ll have to check the BP again. Basically she was smoking a cigarette in bed and fell asleep. The blinds caught fire and the whole house went up. She got caught in a backdraft when they went in to get her. She had moderate smoke inhalation without any visible burns. That’s about it. Are you good?” Am I good? Hell no I’m not good. But I’m absolutely ready to leave.

Having moved Missy onto the gurney we start the long trek back to the ambulance. We have to double back a few times because of standing water creating small lakes in the street and fire hoses blocking our way. Throughout the ordeal I’m grumbling to myself about the poor treatment of Missy. Yeah, great, they got her out of the fire, but her treatment stopped there. Stacy knows better, she’s also an RN at a local Emergency Department, yet she released her helpers to let them fight the beast while the Explorers tried in vain to take vital signs. She didn’t have a history and knows almost nothing about this patient except she was in a fire.

Once we’re back in the rig I can start over and give Missy a proper check-out prior to going to the ED. Looking her over I can’t see any obvious burns but I’m more concerned with her breathing and airway at the moment. I slip the oxygen mask off and shine a flashlight in her mouth and nose and find singed nose hairs with soot extending the visible length of the nares – not good. Soot in the mouth and on the lips – not good. Oxygen saturation of 86% on room air – not good. Wheezing in the apex of each lung with a stridorous noise starting to come from the throat – really, really not good!

As my partner prepares the Albuterol and Atrovent nebulizer to affix to the mask I put an end tidal carbon dioxide nasal cannula on her nose so I can keep a good record of her respiration trends and quality of breathing, but looking at her face something just isn’t right.

“Missy, we’re going to give you a breathing treatment to help you breathe a little better but I have to ask about your medical problems. First off, have you ever had a stroke?” I’m seeing the telltale facial droop on the left side with an eyelid that looks like it’s being pulled down in the corner.

“Yeah, I had me a mini-stroke a while ago. They said it’s because of the A-fibs. But I all better now.” Now that I hear her speak I can tell there’s a bit of a slur to her speech.

“So you’re saying you didn’t have any lasting deficits from the stroke; like facial droop or weakness on one side?” My partner just finished setting up the nebulizer but I need to finish this line of questioning before putting it on and obscuring her face with a mask. He moves up to the front and starts getting us out of the neighborhood; I haven’t given him a destination yet – we both know that destination will be critical with this woman – yet we need to get moving.

“You know, now that you say it, it feel kinda like that mini stroke right now. I could’t get out of bed and my arm jus’ seem like it don’t want to move like it should.” That’s enough for me. I run Missy through a series of stroke tests; facial droop, slurred speech, left side weakness, change in sensory appreciation from left to right side and minor cognitive disassociations (how many wheels on a tricycle, what color is an orange, that kind of thing).

I glance out the front window as I place the mask over Missy’s head and see that we’re just exiting the neighborhood. Rechecking her blood pressure I discover that the Explorer on the left was closest – she’s 84 over 48. I start to set up the Sodium Thiosulfate drip for the IV.  “Okay, you ready for this?” I yell up to my partner.

“Yeah, go ahead, where we headed?” He yells over his shoulder as he lights up, turns on the siren, and heads for the freeway.

“Well, you already guessed we’re going Code-3. We’re going to Hilltop ED; 44 year old female, moderate smoke inhalation, hypotensive, tachycardia, tachypnea, Albuterol/Atrovent/Sodium Thiosulfate running. She’s also got a cold stroke, unknown onset time, left side weakness, with a history of.”

“Seriously?”

“Yeah, seriously, that’s what started the fire.”

 

 

Paralanguage 3/3

Six hours later.

“Medic-40, respond code-3 for the unknown, you’ll need to stage out for this.”

“Medic-40 copies we’re en-route and we’ll stage.”

Scottie had the last tech so this is my call. Scottie is driving us through the suburban neighborhood as I navigate using my iPad. Looking down at the map; “Hey, this is the same section-8 complex we went to three weeks ago for the 18 year old who was hyperventilating. Remember – it was your tech and we found her collapsed in the stairway?” Scottie had that call so fortunately I just drove that day. It was a ridiculous situation for a girl that had nothing wrong with her yet felt she needed to take an ambulance to the ED. It’s unfortunate but that’s what we deal with some days and we just strike it up to an easy call as we escort the patient to the lobby of the receiving ED. I really wish there was more I could do to help alleviate the system from abusive calls.

Scottie pulls over maybe three blocks shy of the complex as I’m pulling up the satellite view on google maps to refresh my memory on the apartment complex layout. Trying to get my bearings I’m looking in the direction of the complex. Three police cars pass us on the main arterial with their lights on and running fast. Then, with the windows cracked, I hear multiple fire engines and trucks approaching the same block. We can see the apartment complex roof from our staging post and I can see flames coming off the roof. A few seconds later I pick up the mic; “Medic-40, it looks like this is a structure fire, PD and FD are on scene; we’re going in.” The dispatcher acknowledges and tells us to advise on conditions.

As we pull up to the complex we have to park on the street as the fire engines/trucks/police cruisers are taking up the whole parking lot. We walk up to see what’s going on and to check in with the BC to tell him where we are and help out if there are injuries. I can see the building where the fire fighters are attempting to put out a third story apartment that seems fully engulfed in flames. There’s a woman standing on a balcony right next to the fire engulfed corner apartment. A fire crew is tilting up a very tall ladder to attempt a rescue.

Just then a woman runs out of the building next to us and literally throws her three year old son into Scottie’s arms. “He was is the fire, it started in the living room, please help him!” Then she runs back inside the building. The only problem is that it’s not the same building that’s on fire. This is a confusing fire scene with all of the people standing around, presumably evacuated from the burning building. The police are holding a perimeter to limit access to the area and and fire crews are clearing apartments, fighting a fire, and attempting to do a rescue. I’ve got to get to the BC; he’s the one calling the shots here and he needs to know where we are.

I turn to Scottie, “Take him back to the rig and check him out, I’ll check in with the BC.” As Scottie is carrying the kid back to the rig I keep going to look for the white hat that signifies the BC.

I finally find the BC and his two helpers on this scene; three white hats standing at the epicenter of all of the commotion. As I’m approaching them I see that one is a captain and two are lieutenants – one of which is LT from earlier in the day. So this is a three alarm fire and they brought out the more experienced captain to run the fire scene.

I acknowledge the two lieutenants and address the captain. “Captain, I’ve got one unit doing stand by on…” He cuts me off by holding up his hand as he heard something on his radio.

Speaking into his microphone. “Truck 5, cut a vent above unit 306, and one above the hallway. Engine 12, clear the first floor starting from the west. Engine 18 clear the second floor starting from the west.” Looking back at me. “I’m sorry, you were saying?”

He’s a busy man, I need to keep it short. “I’ve got Medic-40 doing a stand by on Halcyon with two medics on board. So far we have one possible patient but he came out of an adjacent building; not sure what’s going on with that, my parter is checking him out.” Looking over at the ladder against the building I see that they are half way down with the victim. “I’ll take her back to the rig and check her out. If we have any transports I’ll handle calling in other units. I’ll be on-scene until you tell me different.”

“Perfect, thank you.” He’s a man of few words. Then back to his mic, “Engine 8, lay supply lines from Halcyon to the number two exposure. Truck 3 – you’re clear to cut power.” As I’m walking closer to the ladder a fire fighter is escorting the rescued woman towards me. I’m thinking about the job that the captain is doing; coordinating six teams involved in – fighting the fire, rescuing people, searching for victims, overhauling burned out buildings. It’s overwhelming to me – I’ll stick with medicine.

The firefighter hands off the woman to me and goes back to the fire. As I’m walking her towards the rig I’m having a hard time communicating with her; she has a thick Indian accent and shakes her head when I ask some questions. She seems to have very limited understanding of English. Another woman from the crowd runs up to us as I get closer to the ambulance and starts talking with her in Hindi.

“Hey, do you know her?” I ask the young woman.

“Yes, she’s my neighbor, I was just asking if she’s ok.”

“Can you walk with us and translate for a little while?” She agrees and I hand the old lady off to Scottie in the rig along with a translator.

Looking up at Scottie, “Hey, where’s the kid?”

“His family came by and took him. He was totally fine, no soot in the nares or mouth, no burns. He wasn’t any where near the fire. Either his mother was just flipping out or she was setting up a law suite. Whatever…”

“Weird. So, this lady was just taken off of the balcony adjacent to the fire. Maybe 15 minutes of smoke exposure. She doesn’t speak English but I brought you a translator. If you can check her out I’ll see if there are any more victims.”

I walk back through the police perimeter to check in with the BC. Looking up at the building I see there are no more flames and just a few apartments seem to be burned with black soot ringing the windows like mascara. The rolling black smoke from before has turned to lighter wispy smoke coming from smoldering burnt wood that’s saturated with water.

Standing near the three BCs I quietly take in the sights; firefighters walking around with tanks on their back and carrying tools, ladders being taken down, hoses being drained and stowed on trucks. The captain is still coordinating things on his radio. “Truck 5 your clear to begin overhaul in unit 306. Engine 8 and Truck 3 are clear for station.” It’s looking like they’re just about finished.

The Captain turns to me. “We just had the one rescue from the balcony; no other vics. What do you have?”

“The kid wasn’t involved and checked out fine. His family took him. My partner is working up the woman from the balcony; minor smoke inhalation. We’ll get her transported but it’s just precautionary; she looks good. I can continue to stand by during overhaul if want us here.”

“No, that’s ok; you’re clear to transport.” He comes up to shake my hand. “I just want to say that I appreciate you’re professionalism, you guys did a good job, and that helped us do our job. Thank you.”

“Thank you sir, that means a lot to me.” I’m at a loss for any more words. That was high praise from a very competent man.

He turns to LT. “Can you go out to the rig and get information on the woman?” LT nods and we start walking back to the rig. They need patient info for their paperwork.

We talk about the fire and the crowd and the fire that we both went to this morning. It’s a good conversation and it seems that we’re past the point of having any bad feelings between us. I’m sure the high praise from his Captain reminded him that even good people make mistakes and our world is too small to let bad feelings continue. We’re two colleagues having a water-cooler conversation in the aftermath of a fire – quietly walking through the crowds of people, police officers, firefighters in smoky turn out gear, and the ever present street vendor selling popsicles and churros.