Case Review: House Arrest

What is the pit crew approach to CPR, and how can it save lives?

The Attack One crew has had a busy night, with five calls since midnight, when they are dispatched to a reported “medical emergency” at one of the department’s fire stations. The dispatcher has no further information.

The crew leader hopes this will be a minor problem with a person who walked in to the station. That station’s personnel have also been busy all night, and the station’s equipment is still out on another call. But as Attack One pulls up in front of the station, the crew is waved into the bays by a police officer who appears very distressed. They have an uneasy feeling as they pull the vehicle head-first into the equipment bay, and the officer tells them the station captain is in cardiac arrest in his bunk room.

Crew members grab the equipment from their vehicle and rush to the back of the station. There, a department paramedic is alone performing CPR on the male station captain, who is about 50 years old.

“I just got here for my shift and noticed all the equipment was out,” the medic relates. “I was taking my gear to the bunk rooms when I heard a funny noise in the captain’s quarters. It was the captain, who seized momentarily, then went into cardiac arrest. I only had the station phone to call in on, and then I started CPR. This police officer wandered in to use the restroom, and I asked him to flag you down.”

The paramedic is tired from doing CPR, so the Attack One crew takes over for him. “Start the pit crew process,” the Attack One paramedic directs the crew.

As they take over chest compressions, they hook up a defibrillator and find the patient in ventricular fibrillation. After a two-minute cycle of compressions, they administer the first defibrillation shock, then immediately resume chest compressions. The second shock converts the rhythm to a fast narrow-complex tachycardia, and the patient has a rapid and thready pulse.

The crew performs a rapid assessment. The patient is unresponsive and not breathing. He does not have a gag reflex, but is being bagged easily with an oral airway in place. The cardiac monitor shows a fast narrow-complex rhythm that is regular. So far the patient has needed no medications. His neck veins are not distended, and there are no signs of injury.

“Let’s prepare him for transport and continue to assist his respirations,” the crew leader begins. Then he looks up and sees there is now a larger group of people gathered. The entire crew from this new day’s shift is in the hallway, and the crew from the captain’s platoon has arrived back, unprepared for what they’ve found. The initial paramedic on the scene is trying to explain but is very upset. “I just walked in and found him,” he says. “I was by myself, and there was no equipment. I felt helpless and couldn’t do enough quickly enough. I only had the house phone to call the dispatch office.”

Now the entire group starts to work in unison. Some retrieve a backboard, some move furniture, someone backs the ambulance into the bay. But as soon as the patient is strapped onto the board, his rhythm returns to fibrillation. Another shock restores his rhythm and pulse.

The paramedics agree it’s time to give lidocaine, and they deliver the initial bolus and start a drip, monitoring carefully. Before they can get the patient onto the stretcher, he goes in and out of ventricular fibrillation two more times. At the direction of the Attack One crew leader, one of the station paramedics steps out of the room and calls the hospital emergency department on a station phone to give a report. They want to pass on the information and prepare the ED for the incoming patient without using department radios. The ED emergency physician takes the call. “Doc, his rhythm is so unstable,” the paramedic reports. “He keeps going back into fibrillation.”

“Continue to shock him using the lowest voltage possible,” the physician instructs. “Give him a second bolus of lidocaine and run the drip at 2 mg a minute. We will prepare for your arrival.”

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