Critical Thinking Put to the Test and “Take Five to Stay Alive”

This article was originally published in the inaugural year of WCHM 10 years ago. Darren Mazza has reviewed the content to ensure its applicability to today’s environment.

As a CHT/Safety Director I often use phrases such as “stand by-1” or “A-firm” around staff that reflect my days spent on an ambulance as an EMT. But for me, the phrase “take five stay alive’’ has been the most influential and a phrase that truly means just that. Take five seconds to survey the scene before entering the scene. This will keep you alive, and will potentially save the lives of others.

Every hyperbaric center designates a Safety Director that is responsible for keeping the hyperbaric patient and the entire staff safe. The Hyperbaric Safety Director conducts monthly emergency procedure drills. These emergency drills pertain to hyperbaric patient safety during an emergency.

Recently, I found myself with two emergency situations that were never rehearsed or practiced. The first incident is one that most CHTs will never encounter in their career — at least, I hope not!

Critical thinking put to the test

The patient is a 65-year-old male with s/p L fem arterial graft placement along with a hematoma adjacent to the graft that was evacuated leaving the arterial graft exposed. The sartorius muscle was rotated to cover the graft, and the patient then underwent a split thickness graft to cover the wound. The split thickness graft began to fail, and NPWT was ordered over the L groin wound site as well as hyperbaric therapy for a compromised graft.

One morning this patient arrived with his wife, had no complaints, and was in relatively good spirits. The patient disconnected his wound V.A.C. line in preparation for his hyperbaric treatment and ambulated to the gurney. Meanwhile, I was imputing patient’s profile into the computer-driven chamber. As I turned to face the patient, I noticed he was sitting on the gurney with his wound V.A.C. line hanging towards the blood-covered floor. The patient was hemorrhaging from his left groin through the V.A.C. line. I estimate there was around 1000 cc on the floor and still pouring through the V.A.C. line. I immediately reached down, clamped off the line, and placed the patient in trendelenburg. I had another tech get help and call 911. I placed the patient on high-flow O2 with a non rebreather that is used for oxygen challenges during a TCOM.

I held direct pressure while staff took vitals and prepared a face sheet and other necessary paperwork. The EMS arrived within three minutes and I gave a report to the paramedic. I continued to hold pressure to the ambulance, through the ER, and all the way to the OR. It was exhausting, physically and emotionally. This patient went from being outpatient to critical in short order. The good news is that this patient’s life was saved and he made a full recovery. It turned out that the fem graft had torn, and the femoral artery ruptured.

Conclusion: Although we conduct monthly emergency training drills specific to emergencies in the chamber, I urge outpatient hyperbaric safety directors to do a risk assessment specific to your location and think beyond hyperbaric emergencies. Thinking critically to prepare yourself and your team above and beyond the chamber is crucial.

“Take Five Stay Alive”

Approximately two weeks after the arterial bleed incident, another life-threatening event took place.

I work in a facility that is located off-site from the hospital a block away. Our hyperbaric center is on the second floor of a professional plaza building shared by multiple dental and outpatient surgical businesses. The building sits in the center portion of a parking lot with two busy roads on the south and west side of the building.

At 1:30 pm, I had one patient in the hyperbaric chamber. The patient and I heard a loud bang and felt the floor shake. Initially, I thought one of the clinics next to ours was changing out one of their oxygen cylinders and the banging sound was the cylinder striking the ground. This was a sound I have heard several times before. I told the patient not to worry and that I would investigate it further. As I was preparing to have someone sit with the patient so I could check it out, I could hear a faint humming sound coming from outside the building, possibly in the south parking lot area that is directly below my hyperbaric room. I looked outside of the window and I could see a truck with the front end of the vehicle through the wall. The humming sound was coming from the trucks rear tires that were spinning on the ground and billowing out blue smoke.

The phrase “take five stay alive” became a reality after all. Who would have thought this would ever happen? Most CHT’s go through their whole career without ever having anything happen but the potential is always there. My first thought was to call 911, end the patient treatment, and bring them to surface. I had two concerns:

  • The tires were spinning and could potentially ignite the vehicle and catch fire to the building. This could be particularly problematic considering the vehicle has impacted the wall just below an outpatient surgery center as well as other patient-populated areas.
  • The driver might be unconscious from the impact or from something else, needing immediate medical aid.

I immediately ran to the chamber room door and got the attention of one of the hyperbaric providers. I told her what was going on and had her watch the hyperbaric patient. I had the front office call 911 as I grabbed a fire extinguisher.

Before running down, I told the provider to keep an eye on me through the window. I would signal her with a thumbs up if she needed to abort the hyperbaric treatment and evacuate the clinic due to a potential fire. When I arrived at the vehicle, there were two other people in scrubs assessing the patient. Someone from one of the clinics arrived with an AED, O2, and a BVM.

I then assisted the gentleman with assessing the driver, who was a physician from the outpatient surgery center. We began CPR on the driver, and we then placed the AED on him. A “shock” was advised and delivered. The EMS arrived shortly afterwards and took over care of the patient. We found out later that the patient did not survive.

The driver of the truck had drifted off of the main road approximately 25 yards down through the flower beds, and into our building. It was suggested that he may have had a syncopal episode that caused him to veer off and crash. I conducted a risk assessment of the incident and found several scenarios that could have changed the overall outcome.

  1. The truck impacted the wall exactly 23 feet from the oxygen lines that feed the chambers. if the truck hit the lines, the scenario and outcome could have been different.
    WCHM Fall 2019 Critical 01
  2. It was raining that day; had it been dry outside, the tires from the truck could have caught fire.
    WCHM Fall 2019 Critical 02

Conclusion: When an outpatient hyperbaric facility designates a Safety Director, their role is often perceived just as a title or an NFPA 99 chapter 20 (20.3.1.3.2) requirement. It has been by my own experience and observation that the entire wound care and hyperbaric team may depend on you as the Safety Director for more than simply providing monthly emergency drills. The entire team may look to you for leadership in a crisis situation, whether it is within or outside of the hyperbaric environment.

Regardless of the situation, remember to take five seconds to survey the scene before responding. This will not only keep you safe and alive, but will possibly save the lives of others and will definitely determine the overall outcome. 

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