The other day I was working one of the rescue station when we received a call for syncope. So we respond priority one to the local race track for someone who was probably betting on the ponies.
So we arrive to find our pt, a sixty-ish cantankerous male that actually would not let the FD even touch him before he dropped a deuce. I think the FD and my partner were a bit over zealous and followed the guy all the way to the stall and would have probably sat on his lap if he let them. So he does his business and walks out in a hurried and a "I can't be bothered" type of way but agrees for us to take a look at him.
The usual test/procedures are done. V/S, ecg, 12 lead, cbg. All which came back mostly normal. He didn't have any elevation or depression on 12 lead but tells us he was complaining of some heaviness in his chest. So we get an IV going and start the MONA protocol. Since he was stable with no ECG findings consistent with badness, I was comfortable with transporting him to the hospital of his choice that was a super hospital about 20 miles away.
While we are enroute I ask my pt about his pain, when it started, and how it feels. Getting answers out of this guy was like pulling teeth. He did not want to give up any information. Either he didn't know the answer or he was just in denial about the situation. At any rate, NTG number one had a slight affect on his BP. Nothing too exciting. 5 minutes later NTG number two is given and his pain feels different and he has the typical nitro headache. His pain is now going across his chest from left to right and his BP is 90/40-ish. He gets placed in "ambulance trendellenburg" and gets a fluid bolus. He had clear lungs, it's cool. But his BP continues to fall along with his heart rate and mental status. His v/s are now: BP 74/33, HR 30 and irregular, resp 12 and labored and he looks very ill. Now what?
Pacer pads! That's what. I get the pads out and put them on this guy and get ready to deliver some "Edison" transcutaneously. However, he converts back to a borderline Brady/sinus rhythm with a rate that goes from 56-61. When we got our initial vitals, he had a similar heart rate when he was pissed. Fluid resuscitation is still going at this point and his BP is still 70s/badness and serial 12 leads do not show any ST changes, flipped T waves, or ectopy. WTF? Oh and at this point we just passed the exit on the interstate that would take us to our parent hospital if we needed to divert to a closer facility. So we are committed to the long haul to the super hospital. I ask my partner to light it up and upgrade to a priority one because I don't want our pt to code. Granted we have an auto pulse on our truck but I don't want to use it.
I have to say, that stretch of interstate is bad luck for me. I had a pt with a subdural hematoma stop breathing on me on the way to the "D" from the boonies. Gotta love that.
At any rate, I call a head and give a quick report while I am trying to get a second IV. I tell all my students and new medics "Everyone misses IVs. It happens". It was my turn to miss that day. I tried twice while we were going priority one but no dice. He had good ones too. I was just off that day. Oh BTW, his pressure had reached pucker factor. It was 54/30! Heart rate was maintaining though. I hooked up a quick pressure bag and informed the pt what was happening.
Thankfully the boluses were finally working and his pressure was climbing. By the time we got to the super hospital his pressure had improved but I was still very concerned. We roll into the facility and I give report. And in true fashion of this place one of the RNs say question why we brought him in priority one. One even said "he doesn't look like a priority one pt". What the "F" ever! I'm just glad he was feeling better. It was an interesting call and a bit of a learning experience.
Sunday, July 31, 2011
Thursday, July 21, 2011
Narcan = dose of reality
I just have to say that it was way too hot the other day. Yet my company doesn't think we should change uniforms and continue to wear winter weight uniforms all the time. OK, enough complaining...
Anyway, my partner, our students, and myself get dispatched to what is basically the wild wild west of the area. This was very much out of our regular response area. But like good Paramedics we took our call and tried to do our part to save the world, one priority one at a time. The area we responded to usually requires us to have some sort of police presents at all times. Like I said, not the safest place in the world.
So we show up to the little police substation to be met by one of the officers. He stated that they found a known heroin user in the back of their station semi conscious and "not breathing right". He was able to get him up and inside. Oh and did I mention it was approaching 100 degrees that day too? It sure was. It was so hot my balls were sticking to both of my legs!
When we actually encounter our pt he was sitting/lying on a couple of chairs and was apparently feeling very good. He would just say "yup" to everything and had a big stupid grin on his face. Not that he was stupid, but it was one of those faces you would make if you just pulled a prank or are drunk and thought of something funny. But our altered mental status pt we have before us was very cooperative. Well, he didn't really fight us but wasn't really doing anything either. His vitals were mostly stable, but he was a bit tachycardic. Probably from the heat. He was sweating like pig. But then again, everyone was. Like I said, it was hot!
I was proud of my student for getting an 18g IV on a known IV drug user. Our pts pupils were so small that almost looked like he didn't have any. So we did the usual AMS work up, IV, o2, EKG, CBG, and some fluid. We then started with a small dose of Narcan, the wonder drug. We did this enroute to the hospital. Started with one milligram and titrated to effect. He didn't have any real airway problems, but he wasn't breathing that fast so we figured we would give him a dose of reality.
So we give the drug and a few minutes later our pt that was high as a kite came back to life with a very animated display. He suddenly goes from just saying "yup" to "What in da hell! Where am I at?!". We talked him down and told him the story and filled him in on the who, what, when, where, and why. He was cool with it and was all and all a nice guy.
Now this may sound a bit jaded, but I am pretty sure he lied right to my face. He said he was clean for 9 months and that he is trying to quit. Now I am not a figure of authority so you don't have to blow smoke up my ass. The cops even know that he is a regular abuser of narcotics and that he does this all the time. But its not a good idea to accuse people of things like that when you are in a confined space with them. Narcan calls are always interesting.
Anyway, my partner, our students, and myself get dispatched to what is basically the wild wild west of the area. This was very much out of our regular response area. But like good Paramedics we took our call and tried to do our part to save the world, one priority one at a time. The area we responded to usually requires us to have some sort of police presents at all times. Like I said, not the safest place in the world.
So we show up to the little police substation to be met by one of the officers. He stated that they found a known heroin user in the back of their station semi conscious and "not breathing right". He was able to get him up and inside. Oh and did I mention it was approaching 100 degrees that day too? It sure was. It was so hot my balls were sticking to both of my legs!
When we actually encounter our pt he was sitting/lying on a couple of chairs and was apparently feeling very good. He would just say "yup" to everything and had a big stupid grin on his face. Not that he was stupid, but it was one of those faces you would make if you just pulled a prank or are drunk and thought of something funny. But our altered mental status pt we have before us was very cooperative. Well, he didn't really fight us but wasn't really doing anything either. His vitals were mostly stable, but he was a bit tachycardic. Probably from the heat. He was sweating like pig. But then again, everyone was. Like I said, it was hot!
I was proud of my student for getting an 18g IV on a known IV drug user. Our pts pupils were so small that almost looked like he didn't have any. So we did the usual AMS work up, IV, o2, EKG, CBG, and some fluid. We then started with a small dose of Narcan, the wonder drug. We did this enroute to the hospital. Started with one milligram and titrated to effect. He didn't have any real airway problems, but he wasn't breathing that fast so we figured we would give him a dose of reality.
So we give the drug and a few minutes later our pt that was high as a kite came back to life with a very animated display. He suddenly goes from just saying "yup" to "What in da hell! Where am I at?!". We talked him down and told him the story and filled him in on the who, what, when, where, and why. He was cool with it and was all and all a nice guy.
Now this may sound a bit jaded, but I am pretty sure he lied right to my face. He said he was clean for 9 months and that he is trying to quit. Now I am not a figure of authority so you don't have to blow smoke up my ass. The cops even know that he is a regular abuser of narcotics and that he does this all the time. But its not a good idea to accuse people of things like that when you are in a confined space with them. Narcan calls are always interesting.
Monday, July 18, 2011
A priority one trauma, a young pattawan, and 100mg dose of reality.
One of my most recent shift I was working one of the rescue stations with both a new medic as well as a student. No big deal, I have worked with a whole gaggle of students before and have kept them intellectually stimulated and gainfully employed. So I didn't have an issue with it at all. Now, I hate to drive. However, the good thing about this particular shift was that I didn't have to do any of the documentation.
The one issue I did have was that there was way too much talk about how we shouldn't take this call or bad mouthing other services and hospitals. now I am not a fan of a few facilities and services just like everyone else is. However, I have also been doing this a while and have formed my own opinions based off of experience.
For the most part the day is steady with a good amount of posting and calls that require little more than IV, 02, and monitor. However, our last call of the day was a trauma call with a significant mechanism. We were second unit in for a head on collision with vehicle roll over going about 45 mph with entrapment. It was a pretty gnarly scene. Not the worst, but a good one for experience for both the student and the young pattawan.
I will spare the details for the sake of time and for the ego of young medic working with me. But it boiled down to a few key points:
Scene safety
Let those in turnout gear do the extrication
Working as a team
Sense of urgency
You don't have to be in charge
Communication
As you can see from the list above, these are topics and issues that classroom instruction may touch on but will not go into great detail about them or how important they can be. Well, other than scene safety. Point being that you have to truly experience these things in order to learn from them. Mistakes are going to be made by everyone. It is up to the person that made them to either learn from them or get upset. I think it was a learning experience for the rookie.
Now with all that being said, I was not going to let him get hurt or chewed out for no reason. I made sure that he was going to ask all the questions that needed to be asked and have as many of the answers as possible at the hospital without taking over report or care of the patient. After all, the best way to learn is by doing.
It was an interesting end to an otherwise vanilla day. Hopefully this was seen as a learning experience and not as a failure. All and all, good job.
The one issue I did have was that there was way too much talk about how we shouldn't take this call or bad mouthing other services and hospitals. now I am not a fan of a few facilities and services just like everyone else is. However, I have also been doing this a while and have formed my own opinions based off of experience.
For the most part the day is steady with a good amount of posting and calls that require little more than IV, 02, and monitor. However, our last call of the day was a trauma call with a significant mechanism. We were second unit in for a head on collision with vehicle roll over going about 45 mph with entrapment. It was a pretty gnarly scene. Not the worst, but a good one for experience for both the student and the young pattawan.
I will spare the details for the sake of time and for the ego of young medic working with me. But it boiled down to a few key points:
Scene safety
Let those in turnout gear do the extrication
Working as a team
Sense of urgency
You don't have to be in charge
Communication
As you can see from the list above, these are topics and issues that classroom instruction may touch on but will not go into great detail about them or how important they can be. Well, other than scene safety. Point being that you have to truly experience these things in order to learn from them. Mistakes are going to be made by everyone. It is up to the person that made them to either learn from them or get upset. I think it was a learning experience for the rookie.
Now with all that being said, I was not going to let him get hurt or chewed out for no reason. I made sure that he was going to ask all the questions that needed to be asked and have as many of the answers as possible at the hospital without taking over report or care of the patient. After all, the best way to learn is by doing.
It was an interesting end to an otherwise vanilla day. Hopefully this was seen as a learning experience and not as a failure. All and all, good job.
Wednesday, July 13, 2011
You gotta be kidding me...
Recently I worked with a shift with a fairly new medic who apparently knew everything. Now I am pretty easy going so for the most part it was an easy shift. However, constant complaining can be a bit of a downer. The silver lining to this 12 hour piece of my life was that we did not have to do a single dialysis transfer. However, we did get held over for a list minute call, but that was nothing super interesting.
So we do a few calls that morning and are dispatched priority 2 to a residence in the "D" for a CHF exacerbation. As we pull up we see a typical house in a typical neighborhood in this area of town with a 60ish year old person waving us down. So we walk in and find a retirement age female talking, ambulating, and having breakfast. Btw, breakfast smelled amazing. Our pt told us that she had just made breakfast and if it was alright if she ate breakfast. We said it was fine since she in no immediate distress. However, the meal she had consisted of three different pork products that were all probably fried in some sort of grease and some white bread. Oh and she salted it too. It probably tasted like hypertension and same, which incidentally smelled delicious. I just thought it was funny how she was complaining of shortness of breath for a few days after admitting to not taking her meds and eating the caloric equivalent to what most people should have in a day. Then she wonders why she was short of breath...I don't get it.
So we do our usual assessments, treatments, and diagnostics and take her to the hospital. She even said she was a hard stick. Of course she was. Why wouldn't she be? Who would have thought that 6 different cardiac, pulmonary, and endocrine disorders would mess with your peripheral circulation? At any rate, I think it is odd how people can either ignore their health conditions or better yet have the mentality that "I already got it, why change now?". Job security, job security, job security...puppies and Jesus, puppies and Jesus!
Oh and if you think having a baconator for breakfast wasn't good enough, she was also telling us a story about how one of her eyes popped out of her head last week. WTF!?! Really? Who, what, when, where, and why to that. I calmly sat there putting info into my tablet and said "I have been doing this for 8 years and that's a new one for me". She said it was no big deal and continued to demolish her pig in a blanket-esk breakfast. Just another day on the job in EMS.
So we do a few calls that morning and are dispatched priority 2 to a residence in the "D" for a CHF exacerbation. As we pull up we see a typical house in a typical neighborhood in this area of town with a 60ish year old person waving us down. So we walk in and find a retirement age female talking, ambulating, and having breakfast. Btw, breakfast smelled amazing. Our pt told us that she had just made breakfast and if it was alright if she ate breakfast. We said it was fine since she in no immediate distress. However, the meal she had consisted of three different pork products that were all probably fried in some sort of grease and some white bread. Oh and she salted it too. It probably tasted like hypertension and same, which incidentally smelled delicious. I just thought it was funny how she was complaining of shortness of breath for a few days after admitting to not taking her meds and eating the caloric equivalent to what most people should have in a day. Then she wonders why she was short of breath...I don't get it.
So we do our usual assessments, treatments, and diagnostics and take her to the hospital. She even said she was a hard stick. Of course she was. Why wouldn't she be? Who would have thought that 6 different cardiac, pulmonary, and endocrine disorders would mess with your peripheral circulation? At any rate, I think it is odd how people can either ignore their health conditions or better yet have the mentality that "I already got it, why change now?". Job security, job security, job security...puppies and Jesus, puppies and Jesus!
Oh and if you think having a baconator for breakfast wasn't good enough, she was also telling us a story about how one of her eyes popped out of her head last week. WTF!?! Really? Who, what, when, where, and why to that. I calmly sat there putting info into my tablet and said "I have been doing this for 8 years and that's a new one for me". She said it was no big deal and continued to demolish her pig in a blanket-esk breakfast. Just another day on the job in EMS.
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