At some point after he entered a home that was ablaze as part of the first-arriving unit, a 24-year-old Houston firefighter’s regulator disconnected from his SCBA mask. The reason for this is unclear — he may have bumped into something that knocked the regulator loose, or the regulator may not have been locked fully in place. What happened next is clear, however: The firefighter was overcome by smoke and lost consciousness. A mayday call was issued and the firefighter was dragged out of the building by fellow firefighters.
The firefighter wasn’t breathing and lacked a pulse. An ambulance was on the way to the scene, but it was too far away, so his fellow firefighters began to administer CPR. It was at this point that the firefighter caught an enormous break. A captain who is a paramedic supervisor had arrived on scene. He wasn’t part of the firefighter’s crew, or even his station, but had heard the call and being an amateur photographer had stopped by to take a few images.
Not only was he the only paramedic on the scene at that particular moment, he also had in his possession a Cyanokit, which is designed to treat hydrogen-cyanide poisoning as a result of smoke inhalation. At the time, the fire department only was issuing the kit — which is manufactured by Merck and distributed in the U.S. by Meridian Medical Technologies — to paramedic supervisors.
There was only one problem: This supervisor had no experience in administering the Cyanokit. In fact, no one in the department ever had administered the kit before. Nevertheless, he recognized that this was the time.
“I don’t remember how long we had it at that point, but it probably only had been a handful of months,” said David Persse, medical director for the Houston Fire Department. “All of my paramedic supervisors are sharp, but this guy is one of the sharper ones and he knew that it probably was indicated. But because he had never given it, he called through the base station and got hold of me. When he ran the case by me, I told him, ‘This is the exact indication for it.’”
However, before the paramedic supervisor could apply the kit, the ambulance arrived at the hospital, which meant that the firefighter’s treatment now was in the hands of the emergency-room doctors, who knew that a Lilly kit was inappropriate in cases of hydrogen-cyanide exposure but were unfamiliar with the Cyanokit, Persse said. So, the paramedic supervisor got Persse back on the phone and — in another stroke of good fortune for the firefighter — Persse knew one of the doctors.
“It didn’t take me long to convince her that administering the Cyanokit was the right thing to do,” he said.
The kit — which the Houston Fire Department has been using for about two years — consists of a powder that is mixed with intravenous solution to create two 2.5-gram doses, both of which are administered to adults, according to Persse. Halfway through the first dose, the firefighter — who had regained his pulse by the time he arrived at the hospital — started to wake up and began to move his arms and legs. Though he endured a long hospitalization, the firefighter fully recovered and today is back on the job.
“We frequently start to see a return of neurologic function halfway through the first bottle, which is within a minute,” Persse said. “In my limited experience, it has worked very fast, right in front of our eyes.”
Another case where the Cyanokit was used to great effect involved a captain who was battling a house fire when a flashover occurred.
“Only three guys came out, so they quickly realized that the captain was still inside, and after gathering themselves went back in,” Persse said. “It took a little while to find him. He somehow had ended up in the kitchen, with no helmet, no SCBA and no gloves.”
He also had no pulse. “After they pulled him out, he was on a monitor that confirmed he was asystole — flatline,” Persse said.
Just as in the above case, CPR was administered, which brought back the firefighter’s pulse, but this time the Cyanokit was administered on the ride to the hospital. Once again the firefighter began to move his arms and legs halfway through the first dose, Persse said.
In yet another case, two children fell victim to a house fire, and weren’t discovered until the secondary search. “It was amazing that they were alive at all,” Persse said. “They got a lot of smoke.”
The Cyanokit was administered to both children, who ultimately recovered. While he couldn’t state with certainty that administration of the drug by itself was the difference between life and death in each of these instances, Persse believes that it was an enormous factor.
“It’s kind of hard to argue that, when you see them go from being completely limp to blinking their eyes and moving their hands and feet within minutes of starting the drug.”
Just about the only downside to the Cyanokit, in Persse’s mind, is its cost, which has caused the Houston Fire Department to limit its issuance to district-chief cars. “We didn’t put them on the paramedic units because we have way more paramedic units than we have district-chief cars, but there will be a district chief at every working fire and every paramedic has been trained on the Cyanokit,” Persse said. “That’s how we balance the expense problem with the availability challenge.”
That said, Persse advised that fire departments shouldn’t let the cost issue prevent them from arming themselves with the Cyanokit.
“I know that there are a lot of fire departments across the nation that are hesitant to use it because of the cost, and that’s a decision they’re going to have to make,” Persse said. “But if it was my family member, I’d want them to get it.”
Mike McEvoy, EMS coordinator for Saratoga County (N.Y.) Emergency Services, which has been using the Cyanokit to treat firefighters for 2½ years, agreed that cost is an issue, one that is compounded by the fact that the kit has an expiration date. However, McEvoy said that his agency came up with a clever strategy for solving this dilemma.
“We place them along the Interstate corridor, and so we’re able to get them to any scene within 15 minutes,” he said. “That helps us to turn them over so that we’re replacing them before their expiration date.”
McEvoy’s agency is so sold on the Cyanokit that it now is administered to anyone who shows “significant evidence” of smoke inhalation, firefighter and civilian alike.
“When you look at the number of people who die in the United States from structure fires each year, very few of them are burned; most of them die from inhalation injuries,” McEvoy said. “Every time we read about one of those we wonder if the care for that patient included giving them [the Cyanokit], and if not, perhaps that’s the reason the patient did not survive.”
In Hillsborough County, Fla., in which the city of Tampa is located, four firefighters in the last four years have been treated for hydrogen-cyanide exposure using the Cyanokit. In one instance, the firefighter was overhauling a small structure fire.
“It was a shed and all of the walls were down, so they didn’t think they needed to be on air packs,” said Robert Marschall, training officer for Hillsborough County Fire Rescue.
The firefighter was at the center of the structure knocking down a hotspot when the fire “smoldered up,” according to Marschall, who added that the firefighter started to become symptomatic immediately after inhaling the smoke. There were a lot of symptoms.
“He had periods of shortness of breath, his heart rate went fast and then slow, and he had periods when he was awake and then unconscious,” Marschall said. “He had a headache, he had some weakness and confusion, he was restless and anxious, and he had a metal taste in his mouth.”
Marschall took a Cyanokit to the hospital, spoke with the emergency-room doctor and convinced him that it was the treatment of choice for hydrogen cyanide exposure through smoke inhalation.
“He was very receptive and within four hours, our firefighter was ready to go home,” Marschall said.
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