A whole lot of ALS packed into 24 hours

     Recently I had a very busy rescue shift. If I remember correctly, we did 9 calls in 24 hours. That may not seem like a very large number of calls, but it was more of when each call came in and what was involved. Still that is a call every 2 hours and 35 minutes. Our first call came in literally 8 minutes into our shift. So we hit the ground running. Our first call wasn't anything super exciting. Just the timing of it was bad.
     Call number two was a simple yet fairly interesting call. We were dispatched to a physician's office for a diff breather. Upon arrival we come to find that our pt has a spontaneous pneumothorax and will require a chest tube to remove the trapped air. This pt didn't require much from me during transport. Just increasing his current O2 therapy from 2 to 4 litters to maintain sats above 95% was all that was required from me. However, I did have my thoracostomy needle ready in case he required emergent decompression. But just monitoring was all he required. Too bad we didn't have a student, it would have been a good teaching moment.
    Now our most notable and invasive call of the day was for a cardiac arrest at a specialty nursing facility for someone who was not terribly old but had a laundry list of medical conditions. Getting dispatched to a "CPR in progress" is always a lot of work. So we get there and the staff that are providing BLS are not doing what I would call very effective CPR. So we have them swap out for someone with a bit more of an ability to push hard and fast. As far as our airway, breathing, circulation treatments go, this pt had a trach so the airway was being easily managed effectively by the staff. However, this pt was a vascular nightmare so my partner popped in an I/O in to the pts tibia and we started our ACLS drug therapy. The monitor showed asystole in 2 leads, but since this was a "fresh arrest" we worked it. Shortly after a few minutes of CPR and some epi and atropine (I know 2010 AHA guidelines say no more atropine in PEA, but our protocols are not up to date with those changes yet) the pt changed from asystole to PEA. It was confirmed PEA because pt had no pulses. So we continue our ALCS treatment and exhaust that particular algorithm to include a gram of calcium and an amp of NaHCO3 (sodium bicarbonate). All the while, one of the staff members keeps asking me when we are going to call it. The question kept getting avoided with strategic phrases like "Let's reassess after this round of CPR" or "We'll take a look after this round of drugs".
     Then wouldn't you know it, we get a sinus tach on the monitor. We do our additional 2 minutes of CPR and check. My partner states this pt has a very weak pulse but it is there and correlating with the monitor. So I mix up a dopamine drip and calculate it with some down and dirty math tricks they taught us in school. And then wouldn't you know it, our pt goes into VT with a pulse. Sync cardio version at 100J is done and the pt goes from VT with a pulse to VT without a pulse. CPR is continued and we start our VT/VF algorithm. The pt is shocked and given 300 of amiodarone and we get a "gee wiz" blood sugar which ends up reading "HI". Nothing we can do about that except note it. The pt is still in VF and gets another does of DTE and an additional 150 of amiodarone. This then brings us back to asystole. And now that we have exhausted the drug box and our H's and T's, it was time to contact OLMC (Online medical control) for pronouncement orders. We get permission from the doc and call it. Since I am overly optimistic and try and find the silver lining in everything, I was happy to know that it was not my turn to do the paper work. I think the documentation took longer than the whole code. My partner and I were both mentally drained from that call and required supplies, lunch, and a cup of coffee.
    Oh something interesting to not on that call was that we didn't have any EtCO2 readings. I am not sure what was going on with our detector, but it wasn't reading. It would have been a good predictor of resusitative efforts and good experience for my partner. Oh well.
    The rest of the shift required a lot of posting and c-spine immobilization. We actually picked one pt up twice with in 4 hours. The first time we responded, it took what seemed like forever to find their location in the maze of an apartment complex they live in. The second response was much quicker and much more basic. Thankfully once we finally got back to the station, we were not called for the remainder of the shift. That means I got paid to sleep for about 5-6 hours. Gotta love a paid nap. All and all my partner during the day and I really earned our money.

Broken ankles and chest pain

     So the last shift I worked literally consisted of about 7 or 8 calls with nothing but chest pain or broken ankles. First, our most critical pt of the shift was a gentleman with classic signs and symptoms of an MI before we even took vitals or put him on the monitor. He was gray, ashen, diaphragmatic, had nausea and vomiting, and actually passed out a few times. He was also hypotensive (even though the newbie basic that was there told me his pressure was 120/60...sure). Anyway, we throw him on the monitor and see a heart rate of 45, he had a pressure of 88/50, and just looked like crap. If nothing else, this guy was really sick. He did also mention that he had a "bacterial infection" and was taking meds for it but could not tell us what type of infection. So we start an IV and get him going to the area's only trauma center. Enroute my partner does a 12 lead. The 12 lead showed elevation of about 2mm in the inferior leads as well as V2, V5, and V6. So we then bump it up to a priority one and my partner starts the MONA regiment. Unfortunately, since our pt's pressure was still low, he was only able to do the "O" and the "A". The rest of the transport is without further incident.
    Now, on to the ankles. It seemed as though everyone was breaking their ankles in our response area. One genius even thought it was a good idea to drink and rollerblade on an icy driveway. As the title of this blog entry suggests, it didn't end well. His ankle looked like a grapefruit and it was quite painful. The funny thing was that he kept saying "Shy-zah". He was German and didn't like the situation one bit. Sorry about the phonetic spelling, I didn't take German in high school or college. This gentleman had much ETOH on board and was still in a lot of pain. So we take him to the hospital and on the way there, he didn't want anyone to know he was drunk. Sure...we won't tell. Even if we didn't, it doesn't take a neurosurgeon to figure who is sober as a judge and who is drunk as a skunk.
    Well, that was my most resent paid adventure in the world of prehospital medicine. It is never a dull moment in this job. Hopefully I can further my career along with obtaining my FP-C and get a kick ass flight job. Bye for now.

A productive day...

     Today actually turned out to be a fairly productive day. It did not start out that way though. When my partner and I got on shift, we checked the truck as usual and were just about to go on the air when the supervisor stops us and has us swap out trucks. Then after much flip flopping, we finally end up taking a very old "beater" truck down to another station to swap it out and take their truck. So that killed about 2 hours or so.
     We finally get everything straightened out and get our first call. BLS Non-emergent. Fun. We did our fair share of the BLS stuff today. The interesting part about today was that on the way to the floor, as we are going through the required motions to gain access to the rest of the hospital, my partner and I hear "I need a crash cart over here!" coming form triage. We look at eachother and I figure I will give a quick look to see if I can lend a hand. As I turn the corner, I see about 6 nurses, a crash cart, defibrillator, and a guy lying on the floor not looking very good. They just started CPR and placed the pads to find course VFIB. POW! they send 200J through the guys chest  and CPR is started again. I cut his clothes off and start looking for a line, so is another RN. 2 minutes later, they look at the moniter (Thanks AHA and ACLS) to find a sinus rhythm. Sweet. Even better we find ROSC, ROSV, and a conscious pt. The doc places an quick EJ and the pt gets 150mg of Amio. He is then swooped off by the staff to the resus room.
     That was exciting and the best part was we didn't have to do any type of documentation. Woot! Otherwise today was just a priority 2 day at best. Still, most won't see it, but we acutally helped save a life today. Thanks local hospital for the opportunity to help.