Abstract
In August 2016, on a hot and humid day at the height of the New England summer, 54-year-old Brian Bissell and his daughter set off to hike 965 m (3165 ft) Mount Monadnock in southern New Hampshire (42°51′39″N 72°6′29″W). Neither Brian nor his daughter had any idea of the remarkable events that would occur that day. Halfway to the summit Brian began feeling weak, dizzy, and dehydrated. He was experiencing an inferior ST-elevation myocardial infarction (MI). Mountain rescue was activated, and 2 ventricular fibrillation (VF) cardiac arrests on the mountain were aborted thanks to the fast actions of park ranger Sylvia Dunne, who had arrived only minutes earlier with an automated external defibrillator (AED). Brian was whisked off the mountain thanks to the effort of numerous volunteers who stopped to help.
He arrived to our emergency department via helicopter, where an electrocardiogram revealed an acute MI (Figure 1). Initial troponin was <0.02 ng·mL−1. He was taken to the catheterization laboratory where 2 drug-eluting stents were placed, one in a completely occluded right coronary artery and another in a partially occluded left anterior descending coronary artery (Figures 2 and 3). He experienced multiple episodes of VF during percutaneous coronary intervention and subsequently required a temporary transvenous pacemaker and vasopressor infusion for severe hypotension. His clinical course included an additional episode of VF arrest requiring brief cardiopulmonary resuscitation (CPR) with continued episodes of sustained ventricular tachycardia requiring antiarrhythmic administration. He was discharged 4 days later and walked out of the hospital neurologically intact.
Initial electrocardiogram upon emergency department arrival showing profound ST elevation in leads II, III, and aVF with reciprocal changes in anterolateral leads, meeting diagnostic criteria for inferior myocardial infarction.
Coronary angiogram of patient before percutaneous coronary intervention. Critical lesion of right coronary artery highlighted with black arrow.
Coronary angiogram of patient after percutaneous coronary intervention. Stent placement and subsequent resumed right coronary artery perfusion highlighted with black arrow.
The following article is an interview of both the patient and the park ranger about that day that illuminates some of their inner thoughts and emotions. This unique perspective is a view medical professionals rarely have the chance to experience.
Names contained within the article were used with the permission of all parties involved. The following is the interview with Brian Bissell.
What was your hiking plan that day and why did you pick Mount Monadnock?
My daughter wanted to meet up somewhere that was equidistant for both of us. We picked a trail and planned to hike to the summit and back down to make a loop.
What supplies did you have with you?
I had two 500 mL water bottles, a jacket, a map, and that was about it.
How far into the hike were you when you felt like something was wrong?
We were short of halfway. We had stopped for a break, and I felt like I couldn’t stand up. I had my hands on my knees, and when I went to straighten up I felt drunk, dizzy, and disoriented. I thought at the time I was dehydrated. I had no pain or trouble breathing.
What happened after that?
I drank more water and asked some other hikers for help. The 2 people who stopped were registered nurses. They said to lay with your head downhill to get some more circulation going.
Why did you ask those 2 people for help?
It was my daughter who made the call. I felt like I was having trouble but I thought that if I could get some salt, some Gatorade, then I would be fine. She said, “You don’t look right. I’m calling 911.” My daughter had to catch me from falling over, so she wanted to make the phone call but also wanted help holding me up at the same time. So that’s what inspired her to ask for help.
What else do you remember?
I kept trying to get comfortable, get into a better position. The nurses were checking my pulse. They weren’t sure what was up. But as things progressed, at one point, I remember one of them saying, “Just send everything you’ve got.” They were talking to the rangers about what kind of equipment they have. At that point, I don’t think they were identifying heart attack. Fortunately, they did send up everything, including a defibrillator.
What do you remember about the defibrillator?
I don’t remember losing consciousness. I don’t remember the arrest. I remember coming back to.
Tell me about right after you had the arrest.
I remember the rangers arriving. I said hello to them. There were people around saying, “Talk to us,” so I was just talking to them. I was conscious but foggy.
How did they get you off the mountain?
They had a basket with sides on it and had me climb in that. They started an IV, oxygen, and tucked everything in the basket. About 6 people picked it up. They rotated—there were more people, lots more. It was hard walking, so they kept switching off pretty often.
Do you remember roughly how many people there were?
There had to be several dozen. A lot of people had just volunteered. They were hiking by and volunteered to help, just waiting to be of use, to give assistance. So it was largely volunteers that actually carried me down.
What’s going through your head at this time?
I was in awe. I was really just overwhelmed with how good people are. They were just out minding their own business, going out for a hike, and now they’re helping me. It was really a wonderful feeling.
Describe your arrival to the emergency department.
We landed on the roof. They said, “We are going to take you out with the rotors turning because it’s quicker.” They wheeled me into the hallway; there was a whole lot of people there. One guy asked me to sign a release, and I was thinking, “I have no idea what he means by this procedure. I’d like my daughter to be here.” I knew I was foggy and not sharp, so I wanted her to be in on it. But then at the same time, I’m looking at all these people and this is the reason I’m here, so let them do their work. My brother said later, “Wow, that was pretty rude of you. These people saved your life, and you’re holding them up for a signature?” I didn’t think of it that way at the time. I know they were prepping me, but I lost consciousness pretty soon after that.
A lot a people will say that you look at life differently after an event like this. Do you think that holds true for you?
Yes, I think so. Well, one thing I thought of was holy cow. I thought a lot about the gratitude of how good people are in general. You know, in some ways it seems to cut through a lot of the stuff that I get riled about because at the core, people are pretty decent. I feel like we have that in common. Also, the community, family, friends—they just donated money so I could have time to recuperate, and it just hasn’t stopped. It’s a really welcoming world we have going on. I’m more conscious of that.
What is life like for you now? Have you made any big changes?
I did have to quit smoking; that was a big life change, I guess. That was a no-brainer. I replaced that with going to the gym. I have never done that in my life, so I’m certainly spending a lot more time daily actually working out, basically improving my health. The rehab has been good, but it’s been necessary. I think I spend more time talking to people, just appreciating them. A lot more time.
What do you wish that you did differently or wish that you had with you?
Well, I should have brought more water with me. That’s for sure.
Do you plan to go hiking again or specifically do you plan to return to Mount Monadnock?
Now, when I go out walking or exercising, I think about it more. It was a pretty remote location, and so I’m still gaining confidence in not having another heart attack. I wouldn’t go someplace remote. At this point, I would stay closer to roads, services.
Any pieces of advice or words of wisdom to share with anyone after such a significant event?
I guess the main thing I got from this is just how good people are to each other and how much everyone has been willing to help me. Even after 30 years, I’ve smoked cigarettes, and people have tried to get me to stop and I wouldn’t listen. I guess just listen to other people more.
Anything else?
Just thanks, thanks for doing what you guys do.
The following is the interview with park ranger Sylvia Dunne.
For how long have you been a ranger at Mount Monadnock?
Since 2011. I did an AmeriCorps internship prior to that in 2010 and helped out with mountain patrol.
What kind of medical training is required for the job?
None, actually. It’s highly recommended, but you pursue a wilderness first responder, which is generally enough. I have my emergency medical technician-basic.
What makes up the bulk of emergencies on Mount Monadnock?
Ankle injuries, that’s the most common. In the summer, we see a lot of heat-related emergencies, dehydration. Minor broken bones here and there, mainly musculoskeletal injuries.
How common is it for there to be an event like what happened with Brian Bissell?
That happens yearly. There are about 2 to 3 evacuations a year.
In your time on the mountain, how often have you been in a similar life-threatening situation?
Probably 10 serious incidents: several cardiac, several heat-related, several lost hikers that were just very vulnerable in really bad conditions. I assisted with someone who had a lung collapse; that was unique. A few years ago, we had a man in his young 40s that died due to heat illness—killed him. Two years before that, a young teenager died from the same thing. It’s stuff that you don’t forget. You realize how quickly things can go south.
Do you ever engage in any drills to prepare for events like this?
Nothing that’s required. We primarily drill on our own time.
What advanced equipment do you have at your disposal?
We carry oxygen, basic airway supplies. Generally, the AED is the biggest piece of equipment. The other thing that is really important is knowledge of the terrain and the ability to belay. That’s not a thing but rather a skill.
What do you remember about the weather that day?
Very hot, muggy. We were very crowded and had a whole lot of people hiking. I just remember kind of everyone was slowly getting there. All of our volunteers were coming in a little late because it was so hot. Those days make us a little nervous.
Run me through what happened that day.
Well, we got the call requesting assistance, and I was still getting my backpack ready. We had an emergency medical technician-basic who had just started the week before volunteering with us, so I sent him and another volunteer up to assess the situation. They had a lot of water with them and were prepared to help cool Brian down because the original call came in as a heat-related illness. I was at base and met with the assistant manager and told him, “I think we’re going to need the litter. I need you to round up anyone that can help carry. I’m going to run my AED up just in case they need it.”
So you are mobilizing the team and then ran up the mountain with the defibrillator?
Yes, it was funny because I was running and some other hikers thought they would just race me and didn’t realize we had something going on. I ended up running up with this group of people that had no idea what they were getting into. They helped, so it worked out really well. They got there and were a little shocked because I pulled the AED out and 5 minutes later Brian arrested.
What else did you have with you?
I grabbed my basic first aid kit, basic life support meds, inhaler, EpiPen—all that stuff you typically carry. Also a lot of extra water to cool him down if we needed it, easily a gallon (3 L). I stash water on the mountain so I don’t have to carry that much every time. That way, if I end up giving away everything, I can always go get more for myself.
You find Brian sitting down. Describe what you saw.
Brian looked like hell. He was kind of off the trail; his daughter was sitting there, too. The nurses that happened to be on scene were awesome. They were helping him and were very concerned because he had just vomited and they could not get him to cool down. It was a busy trail. There were people trying to get by; there were people walking over us. It was chaotic.
You get the AED pads on him. Describe the next 5 to 10 minutes.
Oh goodness, well, we were sitting there talking. Brian was joking about being the fat guy at the end of the trail having a hard time. We had his shirt off, and we got the pads on him. Everyone gave him space; he arrested and then it shocked him. We went into CPR, and he came around. He made some more jokes, and then it happened again. At that point we had the litter, so we got him in that and got him moving.
What’s the next thing that went into your head after that point?
We need to move him; we need to get him out of here. We had a big litter that takes 6 people to carry. I instructed the other volunteers to help carry. At that point we had enough people to help, so we started heading down the trail.
How many people do you think you were with?
Oh gosh, people are so wonderful at that point. When they’re hiking and they come across this crazy incident, it’s really scary, so they all jump in to help. At one point I’d say we had maybe 20 to 25 people marching along and assisting. We had a small handful of park employees, about 6. The rest of the people that helped were primarily hikers.
What was the evacuation plan once you got him out off the mountain?
That’s where it was a little confusing because we have assistance from the local ambulance service. They are very used to taking command on the street, which is completely appropriate, but on the mountain that comes down to the rangers. That’s kind of our jurisdiction, if you will, because it is wilderness protocol. They got on the radio and asked us to actually hike up the mountain with him, and I said absolutely not. They thought we could hike up to the landing zone. We were only halfway to the summit; our only choice was to go down. That was hard to do because I’m technically only a basic and they had a paramedic who was insisting that we go up, but I knew the mountain and my rangers know the mountain. We know how to get people down, we know the right trails to take, and we know where to belay the patient when it gets really steep.
What happened once you got him off the mountain?
We eventually got him down to the base where we had an ambulance waiting. Then the ambulance drove him down to the Monadnock Bible Conference, which is our landing zone close to base.
What was it like having his daughter there?
Not an issue. I couldn’t believe how brave she was. I just remember that when we were going to shock him, I put my hand out and she just grabbed it really hard. I couldn’t imagine being in her shoes and seeing a family member in that situation, but she was incredibly brave and helpful.
What piece of advice would you give to other first responders who might find themselves in a similar situation?
Trust your instincts.
And for other hikers?
Be as prepared as you can. Help in what way that you can.
How do you feel knowing you saved another person’s life?
I think at the time I felt very scared. You never feel adequate in those situations, but at the end you find that you are. I’m amazed that everything worked out as beautifully as it did, and I’m very grateful that he is alive. His story is incredible.
Discussion
According to the most recent statistics from the American Heart Association, 12% (42,000) of the 350,000 annual out-of-hospital cardiac arrests survive to hospital discharge. This number increases to 46% with bystander CPR. 1 Our case supports the known correlation between bystander CPR/AED use and improved mortality. However, these statistics represent the general US population and are not focused on cardiovascular emergencies in austere and wilderness environments. Much of the literature regarding MI and sudden cardiac death occurring in mountain locations focuses more on high-altitude areas such as Nepal,2,3 Mt. Kilimanjaro, 4 and the Austrian Alps. 5 In addition, much of the literature focuses on high-altitude illnesses such as acute mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema, with little describing acute MI. 4 Our case highlights that difficulties in the recognition, treatment, and evacuation of those experiencing cardiac emergencies can be precipitated and exacerbated by less than extreme conditions and do not necessarily need to occur in austere or higher elevation environments.
Participation in hiking and mountaineering activities has steadily risen in the last few decades both nationally and internationally. Annual arrivals to Nepal, a major hiking and climbing destination, have soared from 162,897 in 1980 to well over 1,000,000 as of 2015, 6 and Mount Monadnock is reported to be one of the most climbed mountains in the world with over 125,000 hikers annually. 7 As this trend increases, it is reasonable to expect more cardiac emergencies to occur in areas considered to be wilderness or inaccessible.
A recent literature review by Burtscher looked at the risk and protective factors for sudden cardiac death among those participating in mountain activities, specifically examining activity type, population, and environmental components. 8 The report details that the death rate increases based on activity type, from downhill skiers to mountain climbers up to rock/ice climbers. The article also reports that male sex imparts a near 20-fold increased risk for sudden cardiac death when compared with women in this setting. Not surprisingly, the article reported a correlation between increasing age and underlying cardiovascular disease and increased rates of sudden cardiac death. Likewise, the findings suggest that regular high-intensity exercise more than once per week granted an 80% risk reduction for sudden cardiac death. Burtscher concludes that those over the age of 34 years with prior MI, coronary artery disease, and/or cardiovascular risk factors should be considered the highest risk individuals and suggests preventative measures like preparatory physical training and regular exercise as well as control of underlying systemic disease for those who plan on participating in mountain activities. It is interesting to note that Burtscher’s review found that although sudden cardiac death differs between male and female sex, there does not appear to be a significant difference in sudden cardiac death between high-altitude and low-altitude activity for based on sex.
Cardiac arrest is a rare emergency within the backcountry but carries a high rate of morbidity and mortality. Data from the US National Parks reveal that out of the total 73,525 emergency events that occurred between 2007 and 2013, 464 (<1%) were cardiac arrests; an AED was subsequently used in 299 patients (64%), with 130 surviving to hospital discharge (28% survival rate).9,10 It is unclear from these statistics why an AED was used in only just over half of arrest victims; however, the authors of the data propose that it is due to lack of AED access and training. Asystole, pulseless electrical activity, or rigor mortis are potential reasons why an AED was either not used or was applied and not used due to nonshockable rhythm. Enhanced awareness and use of AEDs is a facet of mountain rescue we believe can be improved. The International Commission for Mountain Emergency Medicine recommends mountain rescue teams and first responders be equipped with an AED and knowledge of its use as outlined in their 2006 guidelines. 11 They advocate for AED placement in high-use areas like popular ski destinations, highly frequented mountain huts and restaurants, and in mass participation events in the mountains.
There are varying opinions on the pragmatism of widespread, nondiscretionary placement of AEDs in the wilderness. A recent editorial by Joslin and Biondich discusses the limitations of AED use in the backcountry and is summarized by the idea that first responders need to be in the “right place at the right time.” 12 They opined that it is unlikely a first responder will arrive within the critically short timeframe during which an AED would be helpful; that weather and temperature extremes play an important role in the functionality of an AED given its operational temperatures of 0–50°C; and even if defibrillation is successful, definitive care may often not be achieved within an effective time period. They recommended that an AED be included in medical kits when all of the following criteria are satisfied: 1) the patient can be reached in a short timeframe or is located within a geographically confined area, 2) environmental conditions favor AED storage/use, and 3) the patient can be evacuated and transported expediently to definitive care. Drawing conclusions from the available literature, an ideal wilderness AED should be lightweight, waterproof, easy to use, and operate at temperatures of less than 0°C. Additionally, the authors felt that the AED is a lifesaving tool that should be included in wilderness rescue medical kits and made accessible at frequented, and practical, wilderness and mountain locations. Although it is known that AEDs save lives, logistical concerns regarding appropriate use of AEDs in the wilderness and mountain rescue is a topic of ongoing debate.
This case is exceptional due to the severity of this patient’s condition and his subsequent favorable outcome. It demonstrates some of the ambiguity of acute MI diagnosis in the wilderness as well as the obvious barriers to care. Interestingly, Brian never experienced chest pain or shortness of breath throughout his ordeal; his MI masqueraded as the common wilderness malady of dehydration. The case also illustrates that early defibrillation and hasty transport to definitive management during such a life-threatening disease process are inherently more difficult within the backcountry. The popularity of the mountain in our case allowed for an abundance of volunteers to assist in the difficult conveyance of a patient-loaded litter over mountainous terrain (Figure 4). Even with abundant volunteers, extrication from a wilderness location involves time, resources, and planning for transportation to definitive care. Awareness of MI during both high- and low-altitude mountain activity is paramount to prevention and proper treatment of the disease. The quick decision to continue down the mountain rather than to ascend to the upper landing zone exemplifies that there is no substitute for the experience of trained rescuers familiar with the location and terrain. Lastly, the AED in this case almost certainly saved the patient’s life and preserved neurologic function by aborting a nonperfusing cardiac dysrhythmia and should be considered an essential piece of gear in mountain rescue.
Cell phone image of rescue operation taken by patient’s daughter. Faces blurred to protect bystander identity.
Acknowledgments: The authors gratefully acknowledge Brian Bissell, his daughter Sam Bissell, and park ranger Sylvia Dunne for their time and effort in helping with this publication. Written and signed authorization for content contained within the publication was obtained from both Sylvia Dunne and Brian Bissell prior to publication.
Author contributions: Study concept and design (ND), acquisition of the data (BC), analysis of the data (BC), drafting of the manuscript (BC), critical revision of the manuscript (ND BC), approval of final manuscript (ND).
Financial/Material Support: None.
Disclosure: None.