By A.J. Heightman, MPA, EMT-P & Carolyn Gain, EMT-P
March 9, 2011 was a pivotal day for paramedic Andrea Dominguez and for the resuscitation of critical asthma patients.
Dre, as she’s known to her friends, is a 34-year-old veteran firefighter/paramedic with San Diego Fire Rescue Department (SDFD). She teaches EMT classes at Miramar College in San Diego and works for First Aid Services Inc. covering special events. A gifted athlete, Dre attended the University of Toledo on a softball scholarship and is a former world Flow Barrel Surf champion.
She’s currently a member of the San Diego Sabers, a female international baseball team. Frequently wakeboarding, skateboarding, snowboarding and dirt biking, she also trains along with hundreds of the world’s most elite and fit athletes in Cross Fit.
Dre felt her most challenging and physically demanding activity was her training in Cross Fit. That is, until an asthma attack nearly took her life, suddenly and without warning.
We as EMS providers experience so many remarkable, challenging and heartbreaking cases in our profession—life-and-death moments in which we aren’t privy to prior or post events. We get a 30-minute glance and possibly a follow-up report in the aftermath, if it is a sensational case. But that’s it.
The difference in this case is that this struggle involved one of our own—a friend and colleague—willing to allow us into her story, life, struggle to survive and strong will to live. It’s also a way Dre has decided to give back to the medical staff that saved her life and to educate her colleagues about the effect of acute asthma on their patients.
Dre’s physicians credit her physical condition as helping to save her life. The only medical history she had prior to her near-fatal asthma attack was mild, allergy-induced asthma, usually triggered by contact with cats and dogs but easily managed with over-the-counter medications.
Dre spent the two weeks prior to her medical crisis feeling a little under the weather. She had a bit of a cough, felt a little sleepy and, at times, felt some heaviness in her chest. She brushed it off as a slight cold.
Working in a busy, multi-apparatus fire station, it seems that someone on shift is always fighting illness. So Dre thought it was simply her turn. Even while feeling sluggish, however, she kept up all her normal activities. She even participated in the “Fight for Air” firefighter challenge, which includes climbing 31 stories in the San Diego Omni hotel as a fund-raiser for the American Lung Association.
The morning of March 9, Dre arrived at work feeling more run down that usual. Before she had time to focus on herself, she was dispatched on a medical call. At the scene, she began to realize she was more than just a little run down; she was struggling to breathe.
The SDFD ALS engine 1 crew immediately took Dre aside and began to assess her vital signs. Her oxygen saturation (SpO2) was in the low 90s; she had tight, wet, junky, diminished lung sounds and flushed skin. They offered to work her up right there and transport her to the hospital, but like most emergency responders, she was more concerned about the primary patient and said she would go see her primary physician after the call.
She signed off shift and went home sick. Once at home, she realized this was no ordinary asthma attack; she was getting progressively worse. She was dyspneic on exertion and seriously “tripoding.”
She finally gave in and asked her roommate to drive her to the emergency department (ED) of Sharp Memorial Hospital. This is where the story of her survival takes an amazing, unexplainable turn. The ED near her home, and in her normal response district, is fantastic. She knows everyone there by name and is completely comfortable there. Yet, in a strange twist of fate, she asked to be taken to the Sharp Memorial Hospital, where they do heart transplants and other extraordinary medical and surgical procedures with equipment and devices not found in other hospital facilities. This was just one in a string of extraordinary events that led to her remarkable care and survival.
Dre experienced two additional unusual occurrences before she reached the medical team at the ED. When she arrived at the hospital, no ambulances were parked at the ED entrance and no patients were waiting in the waiting room. From her past experience as a paramedic, she knew that happens as often as Haley’s Comet.
She arrived weak, dyspneic, flushed and with a heart rate of 100. Over the next two hours, she was given at least nine breathing treatments and Benadryl. Despite the constant treatment, however, her condition continued to deteriorate.
Dre’s friend, a seasoned paramedic, was there by her side every moment and knew that it was going to be bad. Dre’s friend became even more concerned when Sharp pulmonologist Richard S. Sacks, MD, walked into the room. He exuded a commanding presence and gave several simultaneous orders to staff, including ordering continuous positive airway pressure (CPAP) and Dre’s immediate transfer to the intensive care unit (ICU).
Once his firm orders were presented to the ED staff, Dre’s friend remembers that Sacks personally began to focus 100% of his attention on Dre, explaining his thoughts on why Dre was deteriorating and telling her what the Sharp team would be doing to attempt to turn her condition around.
CPAP was applied, but it didn’t give her any relief—nor did bi-level positive airway pressure (BiPAP). By now, she was consistently presenting an accelerated heart rate of 170 and a blood pressure of 200/100. She was placed on Solumedrol and was now fighting to breathe.
Sacks then told Dre she was going to be intubated. She knew what that meant and initially refused. So a small table and pillow were placed in front of her to facilitate a tripod position. Once her head started bobbing and her stare became vacant, she was told it was time for a tube. Dre’s reply to her friend was, “Please don’t let them intubate me. I won’t come back.” She remembers experiencing an overwhelming feeling of impending doom.
Another Sharp pulmonologist, Thomas E. Lawrie, MD, performed the intubation with several of Dre’s medic friends present. Dre was intubated via rapid sequence intubation. Lawrie successfully intubated with an 8.0 tube and no issues. When the pulmonologist began to dial in the ventilator settings, however, trouble occurred. Dre wasn’t taking to the vent at all.
Dre’s friends recall the next 90 minutes of heroic efforts by Lawrie—making adjustments, intermittently bagging her and performing forced exhalation to raise her SpO2 levels, which soon plummeted down into the 40s.
It was determined that after CPAP and BiPAP, Dre had lapsed into status asthmaticus. She continued to try to breathe against the tube but could not. But he refused to give up on his efforts to calm her down and enable her to breathe.
Dre then began to develop extensive subcutaneous emphysema. She soon had no distinguishable facial features; she was swollen down to her toes. But there was no actual pneunomothorax present, just overwhelming intrathoracic pressure that was inhibiting her ability to breathe. The decision was made to put her on heliox, a blend of helium and oxygen at a 60/40 ratio, in an attempt to decrease that pressure. That treatment was started, but Dre’s condition continued in a downward spiral.
What happened next is what many patients report when they recover from a near-death experience. Although unconscious and in critical condition, Dre could hear everything that was going on around her and everything that was being said during the staff’s attempt to resuscitate her.
She remembers her family and friends telling her, “We love you. We are all here. Everyone is praying for you. You are strong. Relax. You can do it.”
Although unconscious, she was still able to squeeze a hand and shake her head to questions being asked by her sister. Then she began to fight to breathe, sat up, tried to pull out her tube and had to be chemically paralyzed and physically restrained. Sacks pointed out that during that time period, as Dre continued to struggle to breathe, he was forced to administer enough meds to “knock out” a small horse.
Once sedated and controlled, the hospital team continued their efforts to determine the cause of her declining condition. Her respiratory rate dipped to just six breaths a minute. They suctioned out her bronchioles several times, extracting bright yellow sputum from her but were unable to definitively determine the etiology.
The staff tested her for bronchitis, pneumonia, swine flu and H1N1. They found Methicillin-resistant Staphylococcus aureus in her nares, but not in her trachea or lungs.
Dre wasn’t improving and was, in fact, rapidly deteriorating. Her mother constantly told the hospital staff, concerned about Dre’s worsening condition, “She can beat this.”
But Dre’s mom and her friend were soon taken aside by Sacks and told that the hospital team didn’t know the cause of her critical condition, that they had done everything they could, and that she continued to fail to respond and would eventually end up with one or both lungs having a pneunomothorax that wouldn’t be able to re-inflate. Her mother was then told that, if she had not yet done so, it was time to make phone calls because Dre would most likely die.
The phone calls started, and the news made it through the fire department quickly. Friends and family came in from out of town, and the waiting game began.
Three people, however, didn’t participate in the waiting game. These were members of her Sharp’s critical care pulmonology team, particularly David C. Willms, MD.
Willms brought up the idea of using a highly specialized extracorporeal membrane oxygenation (ECMO) unit on Dre. ECMO has been used primarily for meconium babies, cardiac bypass, H1N1, swine flu and respiratory syncytial virus—most often, on pediatric patients. It has also been used on cadavers to increase the viability rate of transplanted organs (read more about the ECMO machine at jems.com/ECMO).
An ECMO machine is similar to a heart-lung machine. To initiate ECMO, cannulae are placed in large blood vessels to provide access to the patient’s blood. Anticoagulant drugs, usually heparin, are given to prevent blood clotting. The ECMO machine continuously pumps blood from the patient through a membrane oxygenator that imitates the gas exchange process of the lungs (i.e., it removes carbon dioxide and adds oxygen). Oxygenated blood is then returned to the patient.
Willms told Dre’s mother that this was the first case the team had been confronted with in which the patient was healthy and fit enough to try the ECMO treatment for a severe asthma condition.
There are several forms of ECMO, the two most common of which are veno-arterial (VA) and veno-venous (VV). In both modalities, blood drained from the venous system is oxygenated outside of the body. In VA ECMO, this blood is returned to the arterial system; in VV ECMO, the blood is returned to the venous system. In VV ECMO, no cardiac support is provided.
Dre was a candidate for the VV approach. The pulmonary team explained the procedure to Dre’s mother, father and sister, along with the risks associated with the procedure, which included blood clots, exsanguination, brain hemorrhage, possible multiple organ dysfunction and the potential for cardiac arrest. They also advised her that there was only an approximate 20% probability for success.
The Sharp pulmonary team immediately rushed Dre to the operating room (OR) and began the ECMO procedure. Ironically, one of the ECMO techs was an old classmate of Stacey Nichols (Dre’s MICU “spokesperson” until her family arrived) and saw Nichols in the hallway. The tech said he had to excuse himself to proceed to the OR where they had just brought in “a train wreck of a patient.” Nichols explained that the “train wreck” was her friend and to take care of her.
During the two-hour ECMO procedure, a member of the research group came out to the friends and family to give a thorough explanation of the procedure and the ECMO machine. After the complex surgery to place the ECMO on Dre, a nurse came out, took Dre’s friend aside and asked her to clear the halls so Dre’s mother wouldn’t see Dre with all the tubes inserted in her external jugular. Dre was placed in the MICU, and it was several hours before friends and family were allowed back in the room. She was placed on a Dolphin bed, which rotates and moves to help keep the pressure off the lungs and the body and assist in pulmonary circulation.
While on ECMO, Dre was cared for on a 24/7 basis by a perfussionist and four nurses, two of which were permanently assigned to her case. Her nurses, friends, fellow paramedics and SDFD supervisors were amazed by the remarkable quality of care she received.
She received high doses of Heparin and 72 hours of ECMO to take her off the ventilator and allow her lungs to take a break from the status asthmaticus and hopefully reduce the interthorastic pressure she had built up during her worsening state.
As day three on the ECMO machine approached, it was still unclear how she would do when ECMO was stopped. Her doctors reported that this was uncharted territory. Cardiac, thoracic, vascular surgeon Sam Baradarian, MD, inserted the massive 27 french, double-lumen catheter (referred to as “the garden hose” by her friends) through her neck—another first for this research team. Normally the large catheter is inserted through the femoral artery, so this was going to require a new removal procedure and present additional potential complications for the pulmonary team.
The transition to having Dre breathe on her own again was anticipated to be tenuous at best, and it was thought that she wouldn’t be able to handle having the ECMO reinserted. She was now on propofol, versed, fentanyl, steroids and antibiotics.
The Transition from ECMO
Dre vividly remembers the process of removing the ECMO machine. While the extubation was occurring, Dre reported seeing a red light come up out of her, leaving through her mouth. She was certain that she was dirt bike riding with her friends in the desert and had run out of gas. She heard “waiting for the doctor” and began to think she was in a crazy dream because she saw a bright white light that changed to red. Then the red changed to reality.
She remembers the desert tent she was in with her friends morphing into the ICU room. She remembers having no pain, looking at Willms and asking, “I’m dirt bike riding, right?”
It was then that she was told she was actually in the ICU at Sharp Memorial. Her friends then started putting all the pieces together for her. She immediately thanked Willms and the rest of the Sharps pulmonary, ECMO and critical care teams for saving her life.
The Long Road to Recovery
Medically, the worst appeared to be over for Dre, but mentally, it had just begun. After days of heavy narcotics and sedation, she began to feel the effects of withdrawals. She was diaphoretic and began to vomit out her NG tube. This caused anxiety-induced chest pain that she described as getting hit by a truck, or having a myocardial infarction.
The staff tried to use fentanyl and zofran to help with the pain and her nausea; they ended up putting her on a propofol drip, hoping she would relax and sleep. After two days of what Dre described as horror, she asked to have all meds stopped. As her athletic background and training began to kick back in, she began to rebound physically and mentally. She felt after all the meds had worn off that she had to reconnect her brain to her body.
She was released from the ICU 24 hours later and started on a regiment breathing treatments and extensive physical therapy to help her sit, stand and walk. This well-conditioned firefighter/paramedic and athlete found it extremely exhausting just to walk from her bed to her chair.
Her mother was told to expect 60 days in the hospital and 60 days of physical therapy. But this gifted athlete was out in just 12 days and back on the job in four months. She was put on lovenox and coumadin for one and half months to help with clots to her arm and neck, as well as prevention for future risk of pulmonary embolisms.
Dre still has occasional periods of memory loss and stumbles on her words, but she considers these complications minor, and they don’t interfere with her profession or personal activities.
Dre knows that at any point, it all could have turned on a dime. While talking about all of her activities and accomplishments, she said, “I never waited for a tragic event to start living my life.” She would have been at peace if she had died, knowing she had accomplished so much and meant the world to so many people.
A.J. Heightman, MPA, EMT-P, JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, has a background as an EMS director and EMS operations director. He specializes in MCI management.
Carolyn Gain, EMT-P, is currently a single-role paramedic for San Diego Fire-Rescue Department, Mercy Air flight medic, EMSTA primary instructor and JEMS advisory panel member.
>>Read the article that gave the 2012 JEMS Games team members knowledge on how to treat patients with severe asthma.