Tim Nuttall - Direct

MR. NUTTALL: I do.

MR. NUTTALL: Yes, sir. Yes, ma'am. Excuse me.

MR. NUTTALL: Good morning, sir.

MR. NUTTALL: So my name is Timothy Nuttall. I'm 28 years old. I've been a firefighter paramedic ever since I graduated high school. I graduated in 2015. I took my EMT class and got my certification while I was actually still in high school. From there I moved on to the BLS transfer side of EMS. There's 911 EMS and then there's transfer, which is basically back and forth from hospital to hospital. I was brand new and very young, so I started on the transfer side, kind of learning the job. I started primarily in the city of Chelsea, Everett, Mald, and Somerville up there. And then after a little while, I got my feet wet in the 911 side. So I was running BLS 911 in those cities as well. And then I progressed on to becoming a paramedic.

MR. NUTTALL: I kind of grew up in a first responder household. My father was a firefighter in a local town. So we spent kind of a significant amount of time at the station when he was on shift. It's just kind of how I grew up, kind of learning the ins and outs of public safety. That's just kind of how I came to be interested in the profession, and then I took it from there.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: So to become an EMT — there are two sides of EMS and then there are two sides of providers. There's EMT basic and then there's paramedic. To answer your question, sir, to start as an EMT it's about a 4-month process. You take classes. I believe mine was Tuesday, Thursday, every other Saturday — learning just anatomy and physiology, basic pharmacology, and kind of how medications interact with the body and different disease processes. From there you start learning basic interventions — backboarding, C-collars. As part of your work in learning to be an EMT, are you active in the field? The initial training — like I said, that's mostly classroom-based. But once you sit your national written test and you're able to pass all that and pass practical, then you're able to progress into the field.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Yes, sir. So after a little while I worked for about a year and a half in the field and decided that I genuinely enjoyed the work that I was doing. I then made the decision to progress to the paramedic level.

MR. NUTTALL: Yes. Paramedic training — I would say it generally takes people about two years to complete. There's about one year of classroom. It delves far deeper into not only diseases but how they interact with multiple body systems, multiple different treatment modalities that we can pursue, multiple different interventions, a whole host of medications — far more medications than a BLS. As a paramedic, I have a much wider range of drugs that I would be able to select to treat different patients.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: They hired me as a firefighter paramedic.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: The Canton Fire Department — the vast majority of the employees of the Canton Fire Department are paramedics. I believe there are — I want to say five EMTs. But now, as a requirement to remain employed by the Canton Fire Department, you have to become and maintain a paramedic certification.

MR. NUTTALL: So we would cross-man trucks. We were always fire suppression personnel, but we were also cross-trained as paramedics. So, for example, if a fire call were to come in in the town of Canton and I was assigned to ambulance one for the day, I would take all my equipment off ambulance one and I would transfer it to ladder one and then we would take ladder one to the fire call and operate as fire suppression personnel. If a medical call were to come in, I'm assigned again to ambulance one — then we take on the role as EMS. I take my paramedic skills and put them to work in the town on ambulance one.

MR. NUTTALL: Yes, sir. It's typically an engine — the engine of that district — and the ambulance of that district. Depending on call volume, that can change. But if all is — not to use the word "quiet," it's kind of a taboo word — but if everybody's in quarters and there's a dispatch in district 1, it'll be Canton Engine 3 and Canton Ambulance 1, and they go as a unit together.

MR. NUTTALL: Yes, sir. So that particular morning, I arrived at work earlier than I normally do. There was inclement — excuse me — inclement weather that morning. So I left earlier than normal just to get in before the roadways got particularly difficult to travel, and to relieve anybody that may need to get out if they needed to get home before the roads got particularly bad. I arrived just before 6:00 a.m. I was walking in. I was assigned to ambulance one for that oncoming 24. I was scheduled to be there at 8 a.m.

MR. NUTTALL: It wasn't great. I was driving — it's about a 35-minute ride for me to get to Canton. The roads were starting to get — they weren't great. They had been treated, but they weren't pristine. The wind was starting to pick up. The snow was starting to come down a little heavier, which is the reason that I left at the time I did.

MR. NUTTALL: So the tones went off right as I entered the building.

MR. NUTTALL: So the tone is the emergency alert tone. In Canton, we have three. We have one for fire, we have one for investigation, and we have one for EMS. The EMS tones went off and the lights came on. Whenever the tones go off, the lights come on as well. I was just walking into the building when the tones went off and the lights came on.

MR. NUTTALL: Yes. So after the tones had cleared, there's an overhead dispatch — our dispatch center communicates to us before we get in the trucks and on the air responding — basic nature of the call. In that particular instance, we were dispatched to an unresponsive male in a snowbank, with no real further information to follow up on.

MR. NUTTALL: So as I said, I arrived pretty early that morning. But hearing that dispatch and that nature of the call, those typically tend to be more involved both personnel-wise and work-wise. The crew that was working that morning was getting on the truck — it was firefighter paramedic Anthony Flatley and firefighter EMT Matt Kelly. Matt Kelly has since become a paramedic, but at the time he was an EMT. So off the bat, that crew — not to say that they were at a disadvantage — but paramedic Flatley was the only paramedic on that ambulance.

MR. NUTTALL: So I made the decision — I checked with the shift commander and I jumped on ambulance one to just give a second set of hands, as being a paramedic myself, just being

MR. NUTTALL: So I got in the back of the truck. I was actually still in civilian clothing at the time because I had just walked in the door. So I got in the back of ambulance one in the patient compartment. The other two gentlemen were up front driving to the scene. I actually had to don my turnout gear because again I was in civilian clothing. I wasn't quite ready to go. So I had to put all my structural turnout gear on and then my Canton fire jacket. Once I was sufficiently dressed for the call, I started prepping all the gear that we might need for a call such as that for an unresponsive male in the snow. In this case, it was our first-in bag, our airway bag, and our cardiac monitor. Everything was all together. They're all in three separate bags. But I just on the way there, I just got in.

MR. NUTTALL: I didn't know how their night had gone. So I just took a real quick look at everything just to make sure everything was there and everything was exactly how it needed to be. So I was able to just grab all three bags, put them on my person, and get ready to — as soon as the ambulance was on scene, just step off and go to work.

MR. NUTTALL: Just basic scenarios. I mean, again, unresponsive male in the snow could mean several things. Not having much to go off on the dispatch — it left much to be desired in terms of what we might need. So in gathering all the equipment together that can kind of cover all the major bases, if you will, in terms of what we were expecting to meet once we got on scene.

MR. NUTTALL: I was ready to go. A dispatch like that, any unresponsive male in the snow — it can kind of up the level because you just don't know what you're walking into. You know, it could really be — it could be anything.

MR. NUTTALL: Again, being in the back, as you noted, it just seemed to be taking a little bit longer than normal. I really had no visibility at all. Like I said, I was in the patient compartment. It's very limited visibility in the back and it's limited visibility. There's like a peephole that's maybe a foot and a half by foot and a half to kind of peek up front. But again, I was so busy getting everything together. I really didn't notice, but I did know it took a little bit longer. We were going not slow, but we were going cautiously.

MR. NUTTALL: So as I mentioned, I had the two bags and the cardiac monitor. Three pieces of equipment with me and I stepped out of the back of the side of the truck. There's a back compartment or a back door and a side door. I stepped out of the side door. And I immediately noted the wind had picked up and the snow seemed to be heavier and I could hear like a distant screaming off in the distance. Wasn't exactly sure where it was coming from.

MR. NUTTALL: It wasn't great. It was still dark out. The sun had not come up yet. The snow was coming down, as I said, heavily. And it just wasn't great all around.

MR. NUTTALL: It was cold. Yes, sir.

MR. NUTTALL: I started making my way kind of towards the sound, following the sounds. I couldn't see anybody yet, so I just kind of followed the sounds. And then once I was able to get around the side of the truck, that's when I was able to see a group of three individuals with Canton police and I started making my way over to them to see where the patient might be located and what was going on.

MR. NUTTALL: So as we approached the scene, as I said, there were three individuals and Canton police were on scene as well. And then there was what appeared to be a human figure laying supine in the snow. I'd say about six to eight feet — kind of where the sidewalk meets the front lawn of a residence.

MR. NUTTALL: So that he was laying on his back.

MR. NUTTALL: From there I made my way directly over to that individual and started checking for signs of life.

MR. NUTTALL: Yep. So I knelt right at his head. Typically to check for any signs of life — it's just as you see on TV or anything like that — you check the carotid pulse and you check for any signs of breathing or anything like that.

MR. NUTTALL: So the carotid pulse would be right in the neck — and just real quick, two seconds, you can check either side. They're on both sides. Those are the strongest pulses that you can grab quickly. So I just real quick went right to that gentleman. Like I said, I looked for any signs of breathing. I found none. I checked a carotid pulse and I found none.

MR. NUTTALL: He was very cold to the touch. He wasn't warm. No.

MR. NUTTALL: Yes, sir. Correct.

MR. NUTTALL: So I found — like I said, I checked for signs of life, the carotid, the signs of breathing — I found none. From there we had ascertained that there were no signs of life. As I was checking that, the other two individuals on the ambulance came and met me and they began doing the same thing just to check. I mean, sometimes you can look and you can miss. So the other paramedic, Anthony Flatley, started checking my work and then we kind of went from there, but I found no signs of life on my initial.

MR. NUTTALL: Yes, sir. I was the first one to actually put hands on the individual and check for signs of life.

MR. NUTTALL: I did.

MR. NUTTALL: John O'Keefe.

MR. NUTTALL: I did. So as being a second set of hands on the call, it's really not my call in terms of treatment modalities and how we want to progress. So after I found no signs of life, I got up to look around real quick. I went over to the three individuals that were there and just said, "Hey, we've — I've just found no signs of life. We're gonna see the next steps." And as I was saying that, that was when Anthony Flatley, who is the lead paramedic on this, made the decision: this is a workable cardiac arrest.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Correct. He was the lead paramedic on this call.

MR. NUTTALL: Yes, sir. So we typically switch off. We'll do one and then once my rotation is complete, we'll do the next one. So it's patient for patient typically.

MR. NUTTALL: Yes. So in medicine there is a term: you're not dead until you're warm and dead. Meaning your core temperature, your core body temperature has to be within normal limits for it to be considered a futile attempt at resuscitation. Noting that Tony — the other paramedic, Tony Flatley — realized that this gentleman was very cold to the touch and that this was now a hypothermic cardiac arrest, or cardiac arrest in a hypothermic setting, which means as providers, we have a duty to initiate life-saving measures — CPR, ventilation — and continue those efforts until we get him to a hospital and a physician is able to take over and they are able to monitor his core body temperature for a certain amount of time.

MR. NUTTALL: No, sir.

MR. NUTTALL: Just because of the conditions. He was extremely cold to the touch and he was in the elements. We didn't know how long. So taking the fact that he was extremely cold to the touch and he had been outside for an unknown amount of time — that quantifies it to us as a hypothermic arrest or a cardiac arrest in a hypothermic setting.

MR. NUTTALL: His fingers were quite cold. They were not well perfused at all. They were very — I mean — I don't know.

MR. NUTTALL: There was — there did not appear to have been any blood flow at all. Just because he was again presumably being outside, his fingers were very, very white. Um, they were very stiff, which can be signs of hypothermia and frostbite. And again, touching the neck — so typically when you get cold you kind of work back from your extremities in. So again I noted his fingers were quite cold, but also when I checked his carotid, his neck felt quite cold as well. Um, that just kind of tipped us back further down the road of a hypothermic cardiac arrest.

MR. NUTTALL: Yep.

MR. NUTTALL: So when I was told that this is what we're doing, I turned around and I went right back to where I previously knelt, which was right at Mr. O'Keefe's head. And then I took over the ventilation aspect of a cardiac arrest. So I was in charge of the airway. So I began giving him positive pressure ventilations with that valve mask, which is just a glorified balloon that you can push oxygen through and down into your respiratory tracts to get oxygen moving. Um, while I was doing that, I believe firefighter EMT Kelly had begun CPR.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Very much so.

MR. NUTTALL: Yes. Yeah, we work in conjunction with each other. Um, typically the most well-defined roles in a cardiac arrest in EMS is your airway monitor, which was myself in this situation, and then your cardiac and medication administration, which is — that would be Anthony Flatley, that would be Tony. Um, just because of my position at the head, I just took over the ventilation aspect and that was where I remained throughout the call.

MR. NUTTALL: Yes, sir. I was kneeling at his head.

MR. NUTTALL: Yes, sir. Very much. Um, getting information on medications, history, and allergies are our top priorities in any call — not even this call, just really any run-of-the-mill fall or chest pain — those are typically the first questions that we ask. What medications are you on? What medical history do you have? And do you have any allergies? Um, the medical history is important because if you've had heart attacks in the past — just using a generalized example — if you've had heart attacks in the past, does this feel like a previous heart attack? It kind of gives us something to go off of.

MR. NUTTALL: I did.

MR. NUTTALL: Um, I saw a middle-aged — sorry, middle-aged female, um, with blood on her face. And I, real quick, as I was in the process of providing ventilations, I said, do you know this person?

MR. NUTTALL: Yes, sir.

MR. NUTTALL: In between Mr. Jackson and — or next to Mr. Jackson.

MR. NUTTALL: I hit him. I hit him. I hit him.

MR. NUTTALL: I remember it very distinctly.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Thousands.

MR. NUTTALL: I remember aspects of various calls, but not all of them. No.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: It did, just because of the setting. I mean, it was the weather, it was the unknown factors, and it was the attempting to try and get information and not really being able to glean anything from that.

MR. NUTTALL: I really didn't get a chance to because following that, the individual just kind of walked away or just kind of went in a different direction. I wasn't able to ask any follow-up questions.

MR. NUTTALL: No, sir.

MR. NUTTALL: No, sir.

MR. NUTTALL: No, sir.

MR. NUTTALL: At that time, in this particular instance, because I was at the airway, that is a pretty critical aspect of a cardiac arrest. I really was — I was stuck there. I couldn't get up and kind of follow up on that at all. I was there doing that ventilation.

MR. NUTTALL: Just the information.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: To save lives.

MR. NUTTALL: In this instance it was. Yes, it was attempting to restore circulation and breathing.

MR. NUTTALL: We did.

MR. NUTTALL: So we put them on — it's called a scoop stretcher. It's basically just a hard plastic moving device with some seat belts on it, just to get the patient up and onto the stretcher. And then from there we can move from the stretcher to the ambulance.

MR. NUTTALL: Um, so we put Mr. O'Keefe on the scoop stretcher and we were able to get him onto the stretcher itself and then off to the ambulance. Um, from there, I maintained my role as the airway individual on this call. Um, so we made our way to the ambulance. I got in the tech seat, which is directly behind where the stretcher locks in. So I had access to the airway again. Um, I was continuing to provide positive pressure ventilations to Mr. O'Keefe, and we had put in an OPA as well, which is just a plastic hook, if you will — it just keeps the tongue from falling back into the airway so we can continue to provide positive pressure ventilations. Um, once we got him in the truck and we continued that effort, we set up a suction system and we prepared to intubate Mr. O'Keefe.

MR. NUTTALL: Um, we prepared a suction system just because, as I was ventilating outside of the ambulance, there were some secretions in the airway that I could see, and you could kind of hear it as you go to squeeze in breaths into the individual — you can kind of hear the secretions getting bubbly and stuff like that. So we knew we were going to need to suction him. So we got him in the truck, we really quickly suctioned him, and then we were able to intubate him successfully, to definitively give him an advanced airway and give him better ventilations, get more oxygen into his system.

MR. NUTTALL: No, he was still very cold.

MR. NUTTALL: Um, the most basic thing that we did — we turned the heat on as high as it would go. Um, we also stripped all of his clothing off. Um, just getting all of that wet clothing off of him. I didn't really have a role in that particular part of it, just because once you're on the airway, that is kind of yours. Nobody can breathe for him. So every time I squeeze that bag, he gets a breath. So I'm kind of tied to that airway for the duration of the call.

MR. NUTTALL: No, I'm maintaining the airway. If an endotracheal tube is dislodged for whatever reason, it is typically more difficult to get one in. So the integrity of that tube staying where it is and not being dislodged — that is another key aspect of airway management.

MR. NUTTALL: Like I said, they were working on clothing removal. Um, I believe they were also getting intravenous or intraosseous access on this individual to begin medication administration. But again, I was quite focused on that airway, just making sure that it was maintained and we didn't lose the tube, we didn't lose any end-tidal CO2, which is just another monitoring device that we use to confirm that that tube is in place.

MR. NUTTALL: I honestly couldn't give you an accurate estimate. It didn't seem to be out of the ordinary realm, though. We were able to move within the flow.

MR. NUTTALL: Um, so I noted that he had a hematoma right above his right eye.

MR. NUTTALL: Yep. It's just — for lack of a better term — it's just a big egg. He had a pretty good bump over his eye.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: No. No, sir. No idea. No.

MR. NUTTALL: There were also several scratches on his right arm, just below his shoulder and traveling down his right humerus. They terminated right about his right elbow, just above it.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Nope. These were — they were deep, and they were not bleeding, but they were notably deep.

MR. NUTTALL: I did.

MR. NUTTALL: No, sir.

MR. NUTTALL: No, sir. Those were the only ones that we noted. As I mentioned, we suctioned a little bit of blood out of the back of his airway as well. I believe it was blood, mucus, and saliva. But those were the extent of the injuries that I was able to note.

MR. NUTTALL: Actually, yes, I did. I apologize. There seemed to be a little bit of matted blood around in his hair around there. Really didn't see anything too obvious at the time. He was also placed in a cervical collar as well, following intubation, and that was kind of there just to maintain his cervical spine. But there was, like I said, noted to be a little bit of dried blood on the back of his head.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: So after we got there, we handed off care to Good Samaritan Medical physicians and ER nurses. We were able to give a report to the physician of just basic what we've done, what we've given for medications, and in my case, what he was intubated with and how he was being ventilated, how well he was being ventilated, and any other further pertinent information. Typically we noted that Tony was the lead paramedic, so that is typically his — he kind of holds the room for a minute when we get in there and gives a big rundown, and then we back off and let Good Samaritan take over.

MR. NUTTALL: No, sir.

MR. NUTTALL: No, sir.

MR. NUTTALL: Okay.

MR. NUTTALL: It really didn't help at the time. Again, we weren't — I wasn't able to chase anything down from that. I just kind of took it, noted it, and moved on with my aspect of the cardiac arrest.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Presumably those would be ambulance one.

MR. NUTTALL: Those are the lights for ambulance one.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: That is the same.

MR. NUTTALL: Sorry, sir. Repeat the question.

MR. NUTTALL: I believe that's a flag pole, sir.

MR. NUTTALL: At the present time, no.

MR. NUTTALL: Yep, there they are.

MR. NUTTALL: I'm sorry, sir. Can you back it up like 10 seconds?

MR. NUTTALL: I believe that's me, sir.

MR. NUTTALL: Yes, sir. This is ascertaining any signs of life or breathing.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: So right after that, when I turned around, that was when Tony said, "Hey, we're working. We're working this."

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Yeah, it was right there.

MR. NUTTALL: There was, as I noted when I got out of the truck, quite a bit of screaming. It was quite chaotic. The wind was also a factor, but there were people around — they were speaking within themselves too. But there was screaming, there was wind, and there were different side conversations as well.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: No, sir.

MR. NUTTALL: Yes, sir. I'm kneeling at the head of the patient.

MR. NUTTALL: I am not, sir. I have actually exited to the side with the bags. I believe I'm entering the ambulance at this point.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Yes, sir. Those are the scratches on Mr. O'Keefe's arm.

MR. NUTTALL: That appears how they were to me at the time of the incident.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: It does.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: Yes, sir.

MR. NUTTALL: I do.

MR. NUTTALL: The street appears to be plowed. There's bare pavement. The weather conditions are significantly better. It is also daytime.

MR. NUTTALL: Yes, sir.