Full cardiac arrest during Pack Test

A firefighter in Indiana suffered a full cardiac arrest while taking the Work Capacity Test, or Pack Test, in March. Thankfully, as a result of the precautions that were in place, including the presence of an Automatic External Defibrillator (AED), there was a positive outcome.

Here is the text of an After Action Review.

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March 6, 2012

This AAR was prepared for Drew C. Daily, State Fire Coordinator for the Indiana Department of Natural Resources, Division of Forestry, Fire Control Headquarters by Stephen W. Creech (State Fire Coordinator Retired). Drew is serving as the Operations Section Chief for the Department of Homeland Security following the tornado events that took place on Friday, March 2, 2012. I was present during the medical emergency and Drew requested that I prepare this document.

After Action Review for Medical Emergency during Work Capacity Test

On Friday, March 2, 2012 the IDNR, Division of Forestry held one of their “Annual Refresher” training courses at Prophetstown State Park, Lafayette, Indiana. Due to impending severe weather the Work Capacity Test (WCT) scheduled immediately following the training was moved up to 0900 hours. Weather forecasts indicated that a severe line of strong thunderstorms were scheduled to move through the area at approximately 1030 hours. The course that was selected for the WCT had been accurately measured and marked and was a closed loop course. Participants completed their health screening questionnaire and they were checked by Drew Daily and Darren Bridges and signed. There were no indications that any of the participants suffered from any conditions that would preclude them from participation. The test was started at approximately 0915.

A lead vehicle was provided to guide participants through the course and the Emergency Medical Technician (EMTB) was in this vehicle. A trail vehicle was used to follow the final participant and was operated by one of the Prophetstown employees. The lead vehicle was equipped with an Emergency Warning System (EWS) and VHF mobile radio. The trail vehicle was only equipped with a VHF radio. The medic was also equipped with an 800 MHz portable radio and had contact with the ambulance service. Timers were provided and time splits were given at .5 mile increments. I was personally stationed at the 2.5 mile marker and had cleared all but a couple of participants when the medical emergency occurred.

Approximately 100-meters short of the 2.5 mile marker one of the participants suddenly fell forward and landed face down on the pavement. The medic was approximately 100-meters in front of the victim and was at the victim’s side within seconds. The medic assessed the situation and immediately called for assistance on the radio. The medic advised that the victim was in “full arrest”. Cardio Pulmonary Resuscitation was started immediately and 911 dispatch was notified via the 800 MHz radio. The medic hooked up an Automatic External Defibrillator (AED) and intubated the victim. The AED indicated that a “shock” was advised. Aid givers cleared the patient and the shock was administered. After the shock, CPR was resumed but we could not get a pulse nor was the victim breathing on his own. During the next several minutes (2 – 3 minutes) the AED analyzed the patient several times, but advised that a shock was not recommended. Just as we were getting ready to switch individuals providing CPR the patient seemed to involuntarily convulse a single time. Immediately following this episode the patient started to breathe on his own and a carotid pulse was detected. At this point we could still not get a radial pulse. The approximate time lapse from full cardiac arrest to now was 3 – 4 minutes.

The victim had labored breathing, but was beginning to indicate discomfort from the intubation tube. The medic removed the tube and the patient continued to breathe on his own. We were now able to get a radial pulse on the victim. The ambulance arrived and the victim was strapped to a back board as a precautionary measure. (When the victim fell he was wearing the 45-pound weight vest and had suffered several contusions and was bleeding from his cheek and forehead.) The patient was loaded into the ambulance and was transported to the local hospital (Saint Elizabeth East). As the victim was being loaded he began to mumble words that were not intelligible.

When the victim arrived at the Emergency Room the doctors found that he had arterial blockage. The left coronary artery was 100% blocked and the right was 70% blocked (This information was provided through a document the wife received from the ER doctor). A stent was implanted shortly after the victim’s arrival at the hospital. By the end of day 1 the victim was sitting up on the hospital bed and conversing with relatives. The doctor commented that had he seized anywhere else (on the job, in the car, at home, etc.) he would more than likely died before he could have been transported to the hospital.

The victim was a 57-year old male and had no indication that he suffered from a blocked artery. This was the first indication that anything was wrong. The victim was released from the hospital on Sunday, March 4th.

NOTE: The protocol for administering the WCT is well documented. Indiana has been administering the WCT since its inception, has tested thousands of firefighters, and never had a single issue. Had the established protocols not been in place, had the medic not been on scene, had there not been good communication established, and had the employees of Prophetstown State Park not managed this situation correctly the victim would have died. Most of the credit for this positive outcome goes to Doug Sears, EMTB at Prophetstown State Park. He did everything he had been taught, in a timely manner, and directed the assistance of others to ensure this outcome. The staff at Prophetstown State Park should be commended for their professionalism and for their precision emergency response to this incident!

AAR Key Points:

What was planned? A safe, accurate, and timely Work Capacity Test to fulfill annual refresher requirements for wildland firefighters.

What actually happened? The test followed prescribed protocol for course length, safety parameters, and emergency procedures. At approximately the 2.5 mile mark one of the participants suffered a heart attack and went into full arrest. The emergency medical technician assigned to the WCT responded along with course monitors and administrators. The victim was revived, transported to a local hospital and is recovering.

Why did it happen? The victim had a blockage of a major artery that was to date undiagnosed. There were no prior indications to the patient that he had any medical issues. His condition had never been detected in previous health screenings.

What can we do next time? Short of having participants go through a detailed physical / medical exam there is nothing that could have prevented this incident. All protocols were followed with a positive outcome. The WCT is a physical endurance test to assess the ability of the participant’s body to sustain physical exertion over an extended period of time. There is simply no way to detect or eliminate all potential health issues. Physical exams are expensive and in some cases would not detect underlying issues. WCT administrators should simply follow established protocol when administering the test. I would recommend that at least one other individual with first-aid / CPR training be on the course to assist in the event of an emergency.

Timeframe in minutes: (Times represent actual AED clock times). They do not correspond to the time of day, but are accurate regarding lapsed time in minutes and seconds.)

00:51 AED Turned on (time starts at 00:51); 00:55 Pads on victim (4-second lapse time); 01:07 Shock Advised: (additional 12-seconds)

01:08 AED Armed (additional 1-second); 01:14 Shock Delivered (additional 6-seconds); 12:08 Pads Removed AED Turned Off (total time 11-minutes 17-seconds)

Respectfully submitted by:

Stephen W. Creech, CF

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Thanks go out to Dick