Anthony Flematti - Direct

MR. FLEMATTI: I do.

MR. FLEMATTI: Good morning, sir.

MR. FLEMATTI: Correct.

MR. FLEMATTI: On arrival, positioning the apparatus is going to be our most important thing — trying to figure out where our patient is and parking our apparatus close enough, especially at night time, that we can light up the scene as well as we can, try and figure out how to approach a scene, because if we have to track equipment farther distances it can slow our response down. So we try and make sure our arrival and positioning is as best as we can put it.

MR. FLEMATTI: So I would have been the passenger of the ambulance. Usually the tech that's leading into the call will sit on the passenger side to try and mentally get ready for what's going on, whether it's reviewing protocols or just trying to assess the information coming across the radio, so you can update your treatment plan as much as you can before you even see the victim.

MR. FLEMATTI: So we have our fire apparatus that are helping light up the scene, but we also have two female parties going to the victim on the side of the road, going back and forth between that person and the side of the road.

MR. FLEMATTI: You can see a shape of a person. So we know that's where the patient is, because we reported that there was a party on the side of the road. So seeing a body shape clued us that that was where we were headed.

MR. FLEMATTI: When I get there, I believe it is Engine 3 and Car 5.

MR. FLEMATTI: If I remember correctly, it was just a personal vehicle. I don't remember if there were any police cars on scene at that time.

MR. FLEMATTI: Something to my left.

MR. FLEMATTI: So then it's going to be bringing all the equipment over to the patient side — to be able to extricate them from that situation, whether it's a house or a street or a road. We assess where they are, and then the best tools to get them out into the ambulance to be able to work effectively on the patient.

MR. FLEMATTI: Yes. We will try and get a general idea of the age of the patient, the positioning of the patient, how they were found, and then when we get them into the ambulance we can start identifying ways to register that patient in the emergency room. So identifiers, whether it's a license or witnesses, we try and figure out who they are so they can get registered at the hospital.

MR. FLEMATTI: That's correct. His wallet was in his pocket and we were able to grab his license.

MR. FLEMATTI: That was John O'Keefe.

MR. FLEMATTI: I'd say approximately 10 feet away from the road.

MR. FLEMATTI: I'd have to — but I believe he was supine, on his back.

MR. FLEMATTI: So we're trying to determine if it's a cardiac arrest, whether it's a viable transport or workable arrest. We have certain protocols within the Massachusetts protocols for whether we work the patient or we leave the patient on scene — it's a police matter if there are injuries not sustainable with life. So we're trying to make that assessment before we make any decisions.

MR. FLEMATTI: So cardiac arrest, to the best of my knowledge, is just the cessation of electrical and mechanical activity in the cardiac muscle. So the cardiac muscle pumps blood throughout the body, and when that stops, all life stops after that.

MR. FLEMATTI: So cardiac arrest, depending on where they're found, we try and figure out what led them to be at that point. So we're looking at weather conditions as well. That can also affect viability of resuscitation. So due to the extreme weather, extreme cold, we will attempt resuscitation on that patient due to the fact that it'll prolong viability of the arrest, or ability to recover from cardiac arrest afterwards. So weather is definitely a key factor, and where they are found.

MR. FLEMATTI: Correct.

MR. FLEMATTI: Hypothermia is the exposure to extreme cold that lowers your core and extremity temperatures down to below 95 degrees. — usually.

MR. FLEMATTI: So, like I said before, it'll prolong — it'll preserve the body after. So if somebody's found in a cold water situation, there have been multiple reports of patients recovering after being drowned in cold water for up to an hour. So viability is definitely improved by the cold weather.

MR. FLEMATTI: So we're looking at obvious signs of death. So we're looking at exposure of brain matter, we're looking at traumatic injuries, decapitation — things that would basically be non-life-sustainable. We're looking at signs of lividity and rigor, to basically show us how long the patient has been down for.

MR. FLEMATTI: So it'll show the extent of frailty the patient has. If somebody's an elderly patient, severe cancer patient, their ability to sustain a cardiac event like that is less. So somebody that's younger, middle-aged, will have a much better chance of recovery afterwards. But that would really be the only key that we're looking at.

MR. FLEMATTI: Just said he was a middle-aged male, and that was all we had.

MR. FLEMATTI: So with viability, we were looking at any rigidity or rigor in the body, or lividity or separation of blood — you would have a pooling of blood or bruising, it would look like, at the lower parts of the body, depending on how the person's positioned. Basically if they're supine you'd have positioning or pooling underneath the body, and then you would have stiffness of the arms, legs, jaw, neck — to be able to move the body. We're looking to see if they don't have those things present, it's another check mark of saying this is viable, we can work this.

MR. FLEMATTI: So his limbs were able to be moved, jaw was able to be moved, the posterior of his body was red — so not indicative of lividity that we're looking for. So he deemed it to be a viable arrest and continued to work.

MR. FLEMATTI: So equipment initially is going to be our scoop stretcher, to be able to pick the patient up, break apart, put it underneath him. We have a first-in bag, an airway bag, cardiac monitor — we'll bring all that over to the patient side to be able to do as much as we can in that situation. But due to the weather we wanted to get him out of the weather, because that was one of the things that was hurting him at that point — getting him into the warmer ambulance and beginning the warming process. So getting into an area where we can assess the patient thoroughly with good lighting, and to be able to expose a patient, begin the warming process.

MR. FLEMATTI: So I have Matt Kelly with me and Tim Nuttall. I also have Frank Walsh, Katie McLaughlin, and Greg Woodbury, and Captain Roby.

MR. FLEMATTI: I'd have to review specific interventions as far as who did what when, but that's why we document things immediately afterwards so it's all fresh. So CPR was initiated by me, and ALS assessment as well. So I can go over individual interventions if you'd like.

MR. FLEMATTI: It says page 25 of my EMS report, but there's also the

MR. FLEMATTI: report on the top as well.

MR. FLEMATTI: So in the area we have the first responders, and then we have the two female parties on scene.

MR. FLEMATTI: So as we're approaching the scene they were kind of in between us and the patient. So we tried to gather as much information as we could from them.

MR. FLEMATTI: So we're beginning CPR, we're trying to establish good quality CPR, get the patient onto our stretcher, begin an IO, start medication, start ventilating the patient — all of the conditions that the body has we're trying to remedy through intervention. So we're trying to breathe for the patient, we're starting to press on his chest to do CPR, to cause the cardiac muscle to compress, spread blood through the heart, cardiac muscle, cerebral brain, and we're trying to reverse what's happening in the body.

MR. FLEMATTI: So snow was probably up to the mid-axillary point, so we're looking at probably halfway up his rib cage. Top of his body was clear.

MR. FLEMATTI: I'd say probably about four to six inches.

MR. FLEMATTI: I'd say he was pretty underdressed — long sleeve t-shirt, jeans — nothing really substantial to be out in that type of weather.

MR. FLEMATTI: By the time we — so our first priority is obviously going to be treating the patient. His clothes do matter but it's on the list of priorities, not huge. So by the time we figured out he was missing one of his shoes, we were already at the hospital at that point.

MR. FLEMATTI: I don't, I don't.

MR. FLEMATTI: Nothing would have been done through the feet. It would have been just exposure of the patient to see possibly the extent of frostbite, if it had started affecting extremities — fingers, nose — that type of thing, of a hypothermic reaction.

MR. FLEMATTI: If it would have been removed, both of them would have been removed, to assess that. It wouldn't do much good to just remove one and leave it there on scene.

MR. FLEMATTI: They kind of cleared a little bit away from the scene — I would say they moved off to the right of the apparatus so we could work on the patient at that time.

MR. FLEMATTI: So how the patient was found and what brought them to that situation is critical. So we're trying to figure out as much information, past medical history that we can of the patient. So we're trying to find somebody who has knowledge of the event. So as we approached the scene, we began to talk to one of the females — what is going on, why are they there, what's going on, just what happened.

MR. FLEMATTI: That's correct.

MR. FLEMATTI: That's correct.

MR. FLEMATTI: That was Ms. Read.

MR. FLEMATTI: She seemed to be the one that was most personally affected by it, so figured she had the most information about why the person was there.

MR. FLEMATTI: She was the most distressed on scene — obviously upset — so personally related to or had a relationship with the person.

MR. FLEMATTI: So I would characterize it as an attempted resuscitation — they were attempting to — she was attempting to do CPR. But due to the erratic behavior, she was running back and forth between the other female on scene and the body, back and forth, trying to press on his chest, wake him up, talk to him — just to no avail.

MR. FLEMATTI: So the only response that I was personally given was just, "I hit him, I hit him, oh my God, I hit him."

MR. FLEMATTI: She was within two feet of me, but very loud.

MR. FLEMATTI: She just repeated the phrase over and over again: "I hit him, I hit him."

MR. FLEMATTI: This was as we're bringing equipment over to the patient. The interventions are going to be started basically by whoever gets over to the scene first. I'm trying to gather information as a lead paramedic to try and coordinate interventions and therapy — to kind of holistically be the team leader in that situation and treat and transport the patient. So it was on approach to the patient, probably halfway between the ambulance and the patient.

MR. FLEMATTI: So we try and document through our flowchart all of the interventions that we're doing. So CPR is obviously going to be our first priority. CPR was initiated — unchanged but successful in the actual intervention itself, no complications. We do our ALS assessment that we talked about, of any further indications that this is not a viable arrest. We determined it was a viable arrest and we move on, and we're going to start — we refer to it as a bag valve mask at 15 L per minute on oxygen. The patient's not breathing on their own so we're trying to assist ventilating that with high-flow oxygen as well. And EZ-IO, which is a needle we put into the bone of the tibia of the patient — that was on that right tibia, was the first one we put in.

MR. FLEMATTI: We're going to be putting in warm fluid; we have a warmer in the back to be able to bring up the core temperature. Then we start with epinephrine, 1 milligram, through that IO.

MR. FLEMATTI: So we have two different methods we can do. We have a — a drill, a power drill that drills through the outer layer of the bone into the capillary area of the bone, the soft spongy material. So we drill through that, or we can do it by hand if that fails.

MR. FLEMATTI: So that medication will improve — it's a constrictor, it'll cause the vasculature to constrict, so it'll improve the quality or effectiveness on the cardiac muscle, cardiac vasculature, and the cerebral area.

MR. FLEMATTI: So it's going to be serial — every 3 to 5 minutes during the cardiac arrest to try and bring them over to the hospital — so it continues that entire time, unless there's a rhythm change, or that can change our algorithm of how we approach the patient, if there's a rhythm regain or return of spontaneous circulation.

MR. FLEMATTI: So I have epinephrine at 6:20, 6:25, 6:30, 6:35, 6:40, and 6:45.

MR. FLEMATTI: Would be dependent on transport time. So our first — we're at patient side at 6:15, transport 6:27 — so best estimation would have been inside of the ambulance at that point.

MR. FLEMATTI: Yeah. So first round of epinephrine — after that we would drop in with — it's called an OPA — that would be to push the tongue out of the way, open up the airway, to improve our bag valve mask so it has an open airway to get the oxygen into the lungs. We begin external warming, stripping the patient, getting the heat turned up in the back of the ambulance. We would then switch over from manual CPR done by hand to a mechanical CPR device to ensure adequate, consistent CPR compressions of the chest — that was a Lucas device — put that on the patient. And then we continue with another round of epi. Patient's starting to warm up this time, so we would do suction at that point to try and suction fluid out of the airway to improve ventilation efforts. Another round of epi is done.

MR. FLEMATTI: Have another suction — this time through a deep suction via the et tube. Sorry — at 6:22, after warming, we intubated the patient. We have a 7.5 tube placed at 27 cm, then verified through various means — through chest rise, auscultation, waveform, and tidal CO2. So we had complications listed as patient vomiting, aspirating. Suction was then done with a rigid tip suction device. After successful intubation we then suctioned via French catheter through the airway. Established — jump back up to 6:31 — another IO line was established on the opposite tibia on the left side, and then another three rounds of epi, and then arrival at the hospital.

MR. FLEMATTI: Destination was 6:45.

MR. FLEMATTI: Good Samaritan Medical Center.

MR. FLEMATTI: Yeah, asystole is going to be a cardiac rhythm where there's no electrical activity in the heart, and is referred to as flatline.

MR. FLEMATTI: So that was the rhythm he was found in. Yeah, from initial rhythm, I have on the EKG at 6:32 as asystole. So we basically observe that for any changes — whether it's increase of electrical activity, regain of adequate pulses — all of that can kind of be hinted at with the cardiac rhythm. And then we would change our algorithm based on whether we go down the ROSC protocol or we continue down the cardiac arrest protocol.

MR. FLEMATTI: So patient care will have to do with level of training and also proximity on the patient. Where you get into the ambulance is just logistically — if you have the training, it's not a huge open ER, it's a small environment, so we try and not have people jump over each other as best as we can.

MR. FLEMATTI: In the back of the ambulance, specifically?

MR. FLEMATTI: In the back of the ambulance, Tim Nuttall was managing the airway. I was the team lead, coordinating all of the interventions. Matt Kelly was assisting in gathering equipment, doing CPR before the mechanical device was placed on — basically acting as an assistant to hand equipment, place things in strategic areas around so we can actually work without having to go get those physical things ourselves.

MR. FLEMATTI: Yes.

MR. FLEMATTI: So removal of clothing is actually pretty standard for any cardiac arrest, any traumatic injuries — we're basically trying to get further clues because this is all happening very quickly. So we're trying to get more evidence of why are they here. We're looking for extremity injuries, crush injuries, bruising, anything that we could document that we could pass on to the emergency room staff and doctors. So we would strip most patients.

MR. FLEMATTI: Yes.

MR. FLEMATTI: Condition seemed pretty well intact, but just wet and cold.

MR. FLEMATTI: It would really just be the exposure to the weather would be our biggest trigger off of that, or if you had protruding injuries through the clothing, compound fractures, things like that. The clothing was intact but we knew it was wet and cold, so as we strip things off of him we can see underneath — basically if there are any subcutaneous — not every fracture breaks through the skin, not everything causes obvious signs, so as we strip the patient we can begin to further assess.

MR. FLEMATTI: That's — injuries are pretty tough to see outside of the ambulance just due to the weather, due to the lighting. We have lighting on the ambulance as well, but —

MR. FLEMATTI: He was still out in the weather at that point, so bleeding wasn't really obvious at that point. As soon as we get him into the back of the ambulance, then we start noticing hemorrhage from different areas of his body.

MR. FLEMATTI: Mostly from his mouth, his eyes, nose.

MR. FLEMATTI: Bleeding, external bleeding.

MR. FLEMATTI: Correct.

MR. FLEMATTI: Suctioning from the airway is mostly blood, blood sputum.

MR. FLEMATTI: We have a canister that has marks of milliliters so we can determine as we're suctioning how much is in that container at different times.

MR. FLEMATTI: The initial suctioning with the Yankauer tip was about 150 mL, and subsequently — so that would have been above the airway, in the mouth, in that type of area — we established the intubation— —and then deep suctioning with that soft tip through the intubation tube would have been another 50 mL of fluid.

MR. FLEMATTI: What? Sorry.

MR. FLEMATTI: Yes.

MR. FLEMATTI: That would have been redness of the skin on the posterior of the body.

MR. FLEMATTI: Redness of the skin — if it's general across the body can mean certain things. If it's just a particular area, and due to the fact that it was cold outside, that would have been— —the initial stages of frostbite or exposure to cold.

MR. FLEMATTI: As far as cold exposure, we're looking at the most exterior parts. Extreme cold exposure can lead to frostnip and frostbite in different areas. The first affected areas are going to be your fingers, your ears, your nose, your toes, that type of. So that was a cold, waxy, pale, stark white substance basically — or condition of his skin — and on each of those areas that you— —just described. Yes.

MR. FLEMATTI: Correct. Well, his mouth, yes.

MR. FLEMATTI: His eyes were pretty well swollen. We were trying to clear areas of blood to figure out if there were any contusions around the head. I believe there was a contusion on his forehead. He also had some markings on his extremities as well.

MR. FLEMATTI: Bruising.

MR. FLEMATTI: Abdomen, we noted significant distension, or swelling of the belly.

MR. FLEMATTI: It's another of our detailed assessments. We go through the body in a more detailed way to try and find more clues that we can pass on for the assessment. Distension in the belly could be due to trauma or bloating. Those are usually our biggest triggers for distension.

MR. FLEMATTI: We had the cold rigid fingers, hands, feet, and we had multiple dried blood lacerations to the right arm.

MR. FLEMATTI: Would have been his upper arm.

MR. FLEMATTI: Yes.

MR. FLEMATTI: No.

MR. FLEMATTI: We had active bleeding from other areas in the body. So the fact that it had already stopped and clotted, I would assume that would have been several hours before the incident that led him to be there. But I would guess earlier in the evening. —would guess earlier in the evening.

MR. FLEMATTI: Once we get the patient into the ambulance, there was no family, no bystanders in the back of the ambulance. So then it's going to be solely based on physical assessment.

MR. FLEMATTI: That would have been Katie McLaughlin.

MR. FLEMATTI: Katie was one of our senior paramedics at the time. So we had enough skilled hands working on the patient at that time. So to direct her — I wasn't able to get as much information and still had a skill to do, or still had a task to do, to run the cardiac arrest. So I — I directed Miss Read over to Katie to try and gather more information as to why they were there, if you could get any more information about who he was, events leading to the injury, how long he was down for, any type of information, and then moved on to the patient at that point.

MR. FLEMATTI: That's correct.

MR. FLEMATTI: It was a very quick process. So I start the conversation — wasn't productive, wasn't moving forward — moved her over to firefighter McLaughlin, continued on to the patient, and then started treatment, moved the patient in, and then Katie came into the back of the ambulance to help. So it's a very quick— —process.

MR. FLEMATTI: Both eyes were swollen and bleeding.

MR. FLEMATTI: Pupils — I have documented as 4 millimeters and non-reactive.

MR. FLEMATTI: We're looking for equality between the two. So signs of bleeding can be demonstrated by unequal pupils. Or if they were restricted, could lead us to believe it was as a result of an opioid interaction. But we're looking at whether they react to light as well. If there's brain activity, if there's still something causing the body to react, you'll have some type of pupillary response. So we shine light — there was no response — so was fixed, and at 4 millimeters.

MR. FLEMATTI: That's correct.

MR. FLEMATTI: Back of the ambulance in transport would have been firefighter Kelly, firefighter Nuttall, and myself.

MR. FLEMATTI: That'll be determined by basically just positioning on the engine. So the step driver for that position would then drive as the detailed person over to the ambulance. That was firefighter McLaughlin.

MR. FLEMATTI: We started transport at 6:27. So between 6:27 and 6:45, treatments included epinephrine, additional suctioning, managing the airway, placing another IO line, and then three additional rounds of epinephrine while the mechanical CPR is continuing.

MR. FLEMATTI: No changes.

MR. FLEMATTI: Not normally. Due to the weather it was pretty slow driving, even though the ambulance was a smaller vehicle than the engine. Slow transport compared to normal.

MR. FLEMATTI: Every medical call that goes on, we try to give the hospital staff a heads up basically of what's— coming in. We'll have different alerts that we would give them, whether it's a cardiac arrest, a stroke, a STEMI, to have the certain appropriate teams come in and be ready — whether it's a trauma alert, there's different specialties within the hospital that'll treat those different particular cases. So we call them 5 to 10 minutes prior to give that team time to get down into the emergency room, to get ready to work.

MR. FLEMATTI: So we're continuing interventions from the ambulance through the bay into their cold room. We were then met by registration, a registered nurse, and the doctor that took care of the patient, as well as a team of other assistants and CNAs.

MR. FLEMATTI: So that's referred to as a transfer of care. So there's different people — like I said, it's a team base where different people are in charge of different things. We'll have the nurse in charge that's in charge of documenting our interventions that have been done so far, time of down, the patient was down, and then she starts documenting all the different interventions that were done by the hospital staff as well. You also give a report to the doctor who's then taking over as lead for the cardiac arrest. They're going to start issuing orders for the patient in treatment, and then you have registration that will get the information to register the patient so that they can tie all of their interventions to.

MR. FLEMATTI: To add that assessment, I believe it was at a core body temperature of 80°.

MR. FLEMATTI: Typical core body temperature is going to be in the high 90s. A body temperature being at 80, with a rectal temp — core temp — is going to be extreme hypothermia.

MR. FLEMATTI: Correct.

MR. FLEMATTI: So as we talked about before, with the hypothermia and the extreme cold, they're going to work that for an extended period of time. Most cardiac arrests, I will try and hang out by the patient or in the area — — the doctors and nurses might have follow-up questions, so I try to stay available as an asset that they can bounce those questions off, at least for 10 or 15 minutes afterwards, to make sure the whole process is completely transferred from all the interested parties.

MR. FLEMATTI: We didn't learn anything. While we were at the hospital, we then cleared the hospital, returned back to quarters to decon the ambulance, and to replenish all the equipment that we had used, get back in service, and move on with the shift.

MR. FLEMATTI: Personally, no. It would have been for an additional medical call if there were any calls for service afterwards.

MR. FLEMATTI: I don't recall.

MR. FLEMATTI: The house.

MR. FLEMATTI: Correct.

MR. FLEMATTI: I see blood, snow, general area.

MR. FLEMATTI: Yes, very much so.

MR. FLEMATTI: Yes.

MR. FLEMATTI: [Pointing.] Initially arrived would have been in this area here.