'HOW MANY CAN YOU TAKE?'

Updated: August 21st, 2007 11:00 AM PDT
From the August 2007 Issue of Emergency Medical Services

'HOW MANY CAN YOU TAKE?'

A medical mass-casualty incident requires consultation and coordination in its response.
The nursing supervisor says several patients are bleeding from their dialysis catheter sites. One patient has become unresponsive and the staff is concerned she's bleeding in her head. There is a crisis evolving, without a clear cause.

By Jim Augustine, MD

It's late in the afternoon on a rainy day. Preparing for rush hour traffic, the Attack One crew makes an early exit from a hospital continuing-education event to get back in service. As crew members make their way out through the emergency department, they talk to the emergency physician about the potential for an evening rush hour full of motor vehicle accidents.

En route back to quarters, they are instead dispatched for a report of a stroke at a community dialysis center. As they arrive at the building, there is an unusual amount of activity with the staff. Urgency is apparent in the voice of the nursing supervisor, a lady they recognize from prior calls. She says they have a number of patients who seem to be getting ill, and several who are bleeding from their dialysis catheter sites. One patient has become unresponsive while waiting for her ride home, and the staff is concerned she's bleeding in her head. They place her in a bed in the back service area.

As the crew walks through the area where the machines are working, the staff moves quickly from patient to patient, and the "code cart" is being pulled out for another patient who's slumped down in a chair. There is a crisis evolving, without a clear cause. The supervisor needs to peel away to contact the center's medical director, and the Attack One crew splits up to deal with the two patients. The patient in the dialysis chair became suddenly unresponsive at the end of her treatment and complained of a severe headache. She has very irregular breathing, and the code cart is pulled over to access the oxygen and bag-valve mask. One crew member moves to assist the center staff. The others proceed to the back room, where they find the original patient they'd been called to assist.

That patient is an older lady who has just vomited profusely and appears to be unresponsive and breathing irregularly. She had also complained of a sudden headache after her dialysis treatment. The staff members with her reported her pupils became widely dilated, then she vomited "across the room." Everyone recognizes this as a set of signs associated with a sudden bleed into the brain. As they start to assist her breathing, another nurse arrives to report that a third patient has started seizing in the main dialysis area.

Establishing Command, the Attack One crew leader calls for three additional medics. The crew reports to dispatch that some form of sudden illness is affecting patients in the center, and a number are now very ill and in need of emergent care. They request a hazardous-materials response in case the etiology is something in the building. They quickly consider bailing out of the building, but it appears the problem is limited to the dialysis patients only. If there were a building problem, the staff, who had been in the building all day, would also be ill.

As crew members work to resuscitate the original two patients and assess the third, the nursing supervisor returns to report more patients are ill, and the cause appears to be something in the dialysis process itself. Each of the patients has become ill at the end of their regular treatment, and all are having trouble getting the bleeding to stop at their catheter sites. The ill patients all have signs consistent with bleeding in their heads, which would occur if some unusual form of blood thinner were present in the dialysis fluid.

The supervisor has been in contact with the center's medical director, and they are immediately suspending all dialysis. They request that all patients be removed to the hospital for evaluation.

"How many patients will that be?" asks Command.

"Eighteen are in the center, and we called seven others at their homes to tell them to go to the hospital directly."

The count of sick patients rises by the minute. Several patients are now having stroke-like symptoms, with weakness in an arm or leg, facial drooping or difficulty speaking. One additional patient who had recent surgery on his leg is bleeding profusely from his surgical site, and the treating nurse is not able to control the bleeding with direct pressure.

Additional equipment is just arriving when the Attack One member in Command declares a multiple-casualty incident and requests seven additional medics. The hazmat crew is requested to perform a quick building assessment, but at this point it appears the problem source is the dialysis process. They monitor for carbon monoxide and other substances, but detect nothing. The fire crews are put to use in performing patient care, and one is assigned to establish a Transportation area.

One of the Attack One crew members will need to serve as Transport Sector Command, and his immediate concern is how to arrange the removals across various hospitals. This incident involves a growing number of patients who are bleeding or have neurologic symptoms. It is not a trauma incident, but several of the patients will need to be managed by neurosurgeons if, in fact, they are bleeding inside their heads. The crew member is also concerned that the trauma center may be dealing with a number of MVA patients due to the weather conditions. However, the city has a non-trauma hospital that typically manages dialysis patients and has an active neurosurgery service. It happens to be the hospital the crew just left.

Transport Command has the responsibility to determine destination hospital sites, make contact with the hospitals and track the patient removals. As he contemplates these responsibilities, he feels the emergency physician at the non-trauma hospital would be a great help in determining appropriate sites for removal of the patients and what other assessments or treatments might be beneficial at the dialysis center. This is an unusual conversation:

"I have a number of patients. Some are unresponsive, one is seizing, and others are bleeding. We don't know what's going on yet, but it appears something occurred during the dialysis treatments."

The Attack One crew member and the emergency physician decide it would be appropriate to talk with the nursing supervisor and find out which specialty physicians have been contacted regarding the dialysis problems. The nursing supervisor has an initial impression that an unusual amount of heparin, a potent blood thinner, has been placed in the dialysis fluids, and all the patients on the afternoon cycle have had the thinner in their treatments. This would cause the bleeding, including intracranial bleeds, the patients appear to be exhibiting.

The fluid shipment in question has been locked up, but the emergency physician and nursing supervisor want a bag of it brought to the hospital with one of the first medics transporting there so it can be tested in their lab for heparin. The emergency physician and Transport Command agree on the number and type of transports to each of the four hospitals that will receive patients, and the doctor advises that the only necessary treatments are extremely careful handling and absolutely no needles used on the patients. The dialysis staff will have to show the transporting EMTs how much pressure to use to control the bleeding from the catheter sites.

Command and the triage crews have now assessed a total of 18 patients, and many have conditions that appear to be worsening by the minute. There are now four critical patients, each appearing to be bleeding into the head. An additional eight are having difficulty breathing or stroke-like symptoms. Another six are having bleeding problems.

Command organizes the transport crews, and a traffic pattern is established through the rear doors. The transport crews are advised of the specific instructions: "no sticks, no needles and careful handling." The four Red victims are prepared for the first transport units.

Transportation and Hospital Course
A total of 18 victims are transported, with 15 medic units ultimately needed for removal to four hospitals. Transport Command has arranged for the emergency physician who was originally contacted to advise the other hospitals about the nature of the problem and what is found on assessment of the dialysis fluid. This will be a complicated medical management situation, and will require the presence of the group of nephrologists who collectively manage all the patients receiving care at the involved dialysis center.

In essentially all areas of America, there are groups of these specialists who provide management of the complicated patients who receive dialysis as a treatment for failed kidneys. Nephrologists are generally very bright internal medicine specialists, but are not typically involved in multiple-casualty incidents. In this incident, the entire group is activated and, with the guidance of the emergency physician, disperses across all four hospitals. They coordinate the necessary sharing of information between the dialysis center, the lab testing the fluid and the blood bank providing the necessary treatment fluids to reverse the blood-thinning effect of the heparin.

The four victims who were critical at presentation all die very quickly. The others survive, a few with permanent brain injuries. Heparin accidentally mixed into the dialysis fluid caused the patients to be extremely anticoagulated, and the worst bled terribly into their brains, causing their initial symptoms and ultimate deaths.

Learning Point: Unusual presentation of a multiple-casualty incident with a medical (not trauma) etiology. The nature of the emergency and the complicated medical conditions required careful coordination with medical control and the distribution of patients to multiple hospitals. There are many circumstances where complicated medical decision-making can be coordinated with the emergency physicians providing online medical direction.

Case Discussion
This medical incident rapidly evolved into a multiple-casualty incident with a variety of medical problems. It is good management practice to approach every scene with an open mind!

All EMTs function as a delegated practice of a licensed physician. Only a physician can practice medicine, and only in the state in which he/she is licensed. So all emergency service providers must operate within the constraints of their state-granted permission to practice.

Provision of high-quality prehospital medical services by EMS providers must occur under the auspices of an experienced and appropriately trained physician who acts as the ultimately accountable medical authority as well as a source of information, confirmation and problem-solving. EMS providers utilize protocols and standing orders developed for their specific functioning environments. Such protocols provide a framework for initial and ongoing care, and also for provider testing and the derivation of continuing quality improvement standards.

But even with established protocols and standing orders for emergency medical care situations, there are patient encounters that necessitate contact with an online medical control physician. Such episodes can include:

* Medical conditions or situations not included in current operational protocols/standing orders requiring real-time physician-level assistance in evaluation and management. Example: When a prehospital provider encounters the possible malfunction of an implanted new-technology medical device in a patient recently discharged from the hospital.
* Problematic medico-legal situations requiring physician consultation. Example: A terminally ill minor patient with a DNR form has two disagreeing custodial parents on scene while in a near-arrest situation.
* Coordination of resources across higher levels to assist incident management by a prehospital provider. Example: EMS requires coordination services during a difficult multiple-casualty incident.

EMS providers should discuss with their medical directors what situations will prompt crews to have direct conversations with online medical control (if that is not part of their day-to-day practice). If needed, it is best to advise the person answering the radio or phone, "This is prehospital provider X of the Y service. I need to speak directly with the emergency (or medical control) physician because of a patient-care situation that involves special circumstances."

Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

Jim Augustine is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.

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