Hold Your Fire!

   A quiet midafternoon has just become very busy. The dispatch was for a person down along a busy residential street, but when Attack One arrives at the scene, bystanders are doing chest compressions on a man lying partially beneath a large lawn tractor. Some are preparing to lift the tractor by hand.

   The Attack One crew pulls its resuscitation gear off the vehicle and starts to work controlling the scene and carrying out victim care. The woman doing chest compressions says she's a respiratory therapist at a local hospital, and arrived to find bystanders looking at the unconscious victim. She found no pulse, so immediately initiated chest compressions and, following the new guidelines for cardiac resuscitation, compressed continuously without breaths. The victim is lying on his side, so she rolled him over as best she could, as his legs are trapped between the tractor and ground. He appears to be an older man, and on quick scan has no signs of injury.

   No one seems to know what actually happened, so the crew initiates its protocol for a blunt trauma cardiac arrest. The therapist offers to continue compressions while the crew frees the patient's legs, places a cardiac monitor and provides ventilations.

   The first responder fire engine crew and bystanders are anxious to lift the lawn tractor off the patient, but the engine crew's captain urges caution—the tractor's gas tank is already leaking fuel, and lifting the tractor will increase the flow. He notes fuel is already covering the victim's pants.

   The Attack One paramedic has placed the victim on a three-lead monitor and finds him in ventricular fibrillation. One EMT is bagging him, and the other has substituted in for the respiratory therapist and is now providing compressions.

   The crews quickly agree that rapid extrication is needed, so they will stop compressions, quickly lift the tractor, slide the patient out and onto a backboard, then resume compressions and prepare for defibrillation.

   "What about this gasoline?" the EMT asks. "There's fuel all over him—he's going to light up if we use that defibrillator!"

   With that realization, the crews modify their plan. Now they will separate the man from his gasoline-soaked pants, cover his lower body with a moist sheet to reduce any off-gassing of the fuel, and move the backboard and patient about 20 feet onto the street, where he can be defibrillated away from the fuel. They will try to blow air across his lower body to keep fumes moving away and make sure the defibrillator pads are absolutely secure on the body to reduce any potential spark. Compressions will continue between all actions.

   Bystanders work with crews, and the fire captain ensures every action is done safely. The patient slides out as the tractor is lifted. A sheet covers his lower body. No serious injuries are found to his lower extremities. One firefighter quickly wipes down the patient's legs with some towels to remove as much of the fuel as he can. The patient goes on a backboard, and it's moved to the street. Once it's there, the crew members smell little gasoline odor. The defibrillator pads are placed, with no back injuries noted and no spots of gasoline seen on the patient's back, buttocks or groin. Compressions continue.

   The paramedic carefully checks each pad to ensure it's securely placed. The rhythm remains v-fib. The fire captain detects no significant fuel smell around the patient, so he gives the go-ahead. The paramedic clears everyone away and administers the first charge. The patient remains in his rhythm. The fire captain again smells no significant fuel, so the area is again cleared, and another shock delivered. This second defibrillation produces a straight line signal, which evolves into a few complexes, then a regular rhythm. The paramedic asks the crew members to resume ventilating the man, and the EMT who had been doing compressions feels for and finds pulses matching the electrical beats on the monitor.