I had a call recently where I had to use a pair of magill forceps to clear out a patients airway. The call was also a bit of a challenge because the pt had a valid DNR/DNI and we were only able to provide supportive care. Nothing super ALCS or BLS other than suctioning, removing the obstructions, and BVM ventilation.
At any rate, it got me thinking about a few things I have read about, heard from other medics, and have seen in my time in medicine. I understand that just about anything can be an airway obstruction, but these are the ones that stuck with me. Here they are in order of worst to not as bad.
1.) Gel caps
I heard about this from JEMS magazine and it was probably the worst call the responding crew had to deal with. I will spare the details of the call, but it is important to note that once gel caps (pills) get wet or come in contact with wet surfaces, they can become very sticky if they are not allowed to completely dissolve. Imagine that in the airway of child. It can and will completely occlude the airway making an immovable obstruction and cementing the airway shut. No bueno. I have to say thank you to JEMS for the teaching moment on that one.
2.) Watermelon
I bet you were not thinking about that. A nurse friend of mine told me a story of a patient took care of that choked on some watermelon. Think about the flesh of a watermelon for a minute. It's fairly soft and mostly fluid. The problem with that is that once it becomes lodged in a confined space, like in someone's airway, you will have a heck of a time pulling it out. If you try and pull it out with your trusty magills, it will just fall apart. The one good thing about it (from my point of view) is that you might be able to push an ETT through it to initially get the airway some what open. Still a nasty situation.
3.) PB&J
This was my pt. They were eating a PB&J sandwich and started choking. The problem with PB&J is that once it gets all mushed together with saliva and what not, it forms a very thick paste. It looked similar to a hair ball the cat I had as a kid coughed up. The other bad thing about this is particular hazard is that it conforms to the shape of the airway very well and can pile up quickly and compact well completely occluding the airway. Another problem I see with it is that if you do the himlech, it has enough play where it could expand with the increased pressure from abdominal thrusts and not actually move out of the airway. The one good thing about this is that it can be removed fairly easily with magills and direct laryngoscopy if you get there in time.
4.)Bananas
This choking hazard shares a similar shape of the airway and can occlude it easily if it fell into the trachea. The good thing about bananas, (other than the fact that they are high in potassium) is that they can be broken up easily and pushed down into the airway and at one lung can be ventilated until definitive care can be started. Pulling out an overly ripe banana with forceps may be an exercise in futility since it may not have enough structure to it to be pulled out in one or two pieces.
5.) Hotdogs
If/when I have kids I don't want to give them hotdogs. Not because of the risk of developing HTN and all other sorts of badness, but because a hotdog cut up in to coins or medallions is perfect for occluding an airway. Sure a whole hotdog can do this too, but most people don't eat hotdogs like they owe them money. They are a bit easier to remove because they usually stay intact and do not break apart as easily as the previously mentioned foods. Still bad, but a bit more manageable.
I think that this was the first time I did a "top 5" or so post. I don't expect to be doing that very often, or even again. But you never know.
Thursday, September 29, 2011
Monday, September 26, 2011
555 and some unexpected orders.
So a couple of things today. First of, as a "part timer" I have run 555 calls to date. I will not go into the who, what, when, where, or why that number was brought up, but it is still an interesting bit of information.
Now for what I feel is the more interesting topic of one of my latest rescue shifts. We were busy pretty much all day. I didn't even have a chance to eat until about 6pm. I ended up getting pad tai. Now I am not sure if it really was that delicious or I was that hungry, but man was it good. I will have to hit that place up again. Anyway, as I digress...we finally get back to the station around 9pm. Just in time to watch an episode of American Dad and grab some shut eye.
Unfortunately, the tones go off about an hour and change later for "one unresponsive" in our coverage area. So we hop in our trusty rescue truck and roll out priority one. En route we hear over the radio via the FD radio that we have a priority one patient and that CPR was in progress. Great. So I start going though the protocols and algorithms in my head and start my documentation as best I can before we arrive on scene.
Quick question here, why is it that most people die on the toilet? I'm not trying to be disrespectful or callous, but I have been doing this long enough to have run into that situation more than I would like to admit. At any rate, good CPR/BLS care is being provided by one of my favorite FDs in a cramped little bathroom in a nice clean little home to a run of the mill retired medicare recipient. They have also placed a combitube. Not my favorite airway, but hey it was working and it didn't perforate the trachea. Works for me. Oh and the AED stated "no shock advised". PEA at a rate of 50 in what appeared to be a junctional-ish rhythm.
So the ABC's of BLS care are all taken care of. Now it is time for some ALS interventions.With such cramped conditions, starting the IV was a bit of a backwards affair. I placed a 14g EJ. Partially because I could and partially because I could justify it for the resuscitation attempt. So the line is good and we get our first epi on board and swap out our CPR pumpers (thanks again guys). As we go we hook up the EtCo2 monitor to the combitube and get a reading of 25. Not bad. Since this was a pseudo witnessed arrest with minimal down time, I could see this possibly being a case that we transport.
As time goes on and epi after epi is pushed and people are switching out to do CPR, we start to reach the point where we should probably terminate resusitative efforts. After all, five epis is a lot. So I get medical control on the phone at one of our friendly neighborhood ERs and give them the scoop. Old person, down approx. 10 prior to EMS arrival with 30min of ACLS care and no ROSC at any point. The pt was still in PEA which was kind of odd. I am attributing that to the short down time. So the doc orders 2 amps of Bicarb and an amp of Calcium chloride. OK, I could see that. I would probably tried it anyway. Then came the order out of left field.
The MD asked me to do bilateral needle decompressions and let him know what the response was in 5 minutes. He would stay on the line. It was a bit odd having the phone to my ear and actively running a code at the same time. So the needles are place in the 2nd intercostal space at the mid-clavicular line and no drastic rush of air is noted. Conclusion, no pneumos. The pt is still in PEA at a rate of 30 in the same junctional-ish rhythm. I was surprised to have him call it at that point and not request us to transport. So we discontinued resusitative efforts at that point and printed our final strip (asystole) and broke the news to the family. They were very understanding. My heart goes out to them.
I have to say it was a bit of surprise to have such a stubborn arrest pt that never went into v-fib. We then spent the next hour and change cleaning up the truck and finishing the documentation for our code. Goes to show you that you never know what will happen on call or in a code for that matter. Until next time.
Now for what I feel is the more interesting topic of one of my latest rescue shifts. We were busy pretty much all day. I didn't even have a chance to eat until about 6pm. I ended up getting pad tai. Now I am not sure if it really was that delicious or I was that hungry, but man was it good. I will have to hit that place up again. Anyway, as I digress...we finally get back to the station around 9pm. Just in time to watch an episode of American Dad and grab some shut eye.
Unfortunately, the tones go off about an hour and change later for "one unresponsive" in our coverage area. So we hop in our trusty rescue truck and roll out priority one. En route we hear over the radio via the FD radio that we have a priority one patient and that CPR was in progress. Great. So I start going though the protocols and algorithms in my head and start my documentation as best I can before we arrive on scene.
Quick question here, why is it that most people die on the toilet? I'm not trying to be disrespectful or callous, but I have been doing this long enough to have run into that situation more than I would like to admit. At any rate, good CPR/BLS care is being provided by one of my favorite FDs in a cramped little bathroom in a nice clean little home to a run of the mill retired medicare recipient. They have also placed a combitube. Not my favorite airway, but hey it was working and it didn't perforate the trachea. Works for me. Oh and the AED stated "no shock advised". PEA at a rate of 50 in what appeared to be a junctional-ish rhythm.
So the ABC's of BLS care are all taken care of. Now it is time for some ALS interventions.With such cramped conditions, starting the IV was a bit of a backwards affair. I placed a 14g EJ. Partially because I could and partially because I could justify it for the resuscitation attempt. So the line is good and we get our first epi on board and swap out our CPR pumpers (thanks again guys). As we go we hook up the EtCo2 monitor to the combitube and get a reading of 25. Not bad. Since this was a pseudo witnessed arrest with minimal down time, I could see this possibly being a case that we transport.
As time goes on and epi after epi is pushed and people are switching out to do CPR, we start to reach the point where we should probably terminate resusitative efforts. After all, five epis is a lot. So I get medical control on the phone at one of our friendly neighborhood ERs and give them the scoop. Old person, down approx. 10 prior to EMS arrival with 30min of ACLS care and no ROSC at any point. The pt was still in PEA which was kind of odd. I am attributing that to the short down time. So the doc orders 2 amps of Bicarb and an amp of Calcium chloride. OK, I could see that. I would probably tried it anyway. Then came the order out of left field.
The MD asked me to do bilateral needle decompressions and let him know what the response was in 5 minutes. He would stay on the line. It was a bit odd having the phone to my ear and actively running a code at the same time. So the needles are place in the 2nd intercostal space at the mid-clavicular line and no drastic rush of air is noted. Conclusion, no pneumos. The pt is still in PEA at a rate of 30 in the same junctional-ish rhythm. I was surprised to have him call it at that point and not request us to transport. So we discontinued resusitative efforts at that point and printed our final strip (asystole) and broke the news to the family. They were very understanding. My heart goes out to them.
I have to say it was a bit of surprise to have such a stubborn arrest pt that never went into v-fib. We then spent the next hour and change cleaning up the truck and finishing the documentation for our code. Goes to show you that you never know what will happen on call or in a code for that matter. Until next time.
Thursday, September 22, 2011
Of all the words to say...
The other day I was working the back half of a rescue shift at one of our out stations. It was looking as though we were going to end up with a "no hitter". In other words, no calls. Our one and only call was about 10 hours into the shift at 0400. Of course it was. Why wouldn't be?
So my partner and I are dispatched priority one for a "man down". Don't get too excitied. That could be everything from a cough to a cardiac arrest. Usually they are something in between and they usually have medicare and want to be taken to the hospital. We are enroute to the location of the call when a little bit more information is given to us by that little black box that likes to tell us what to do. Apparently our pt has been lying in bed for an extended period of time (days) but is conscious and breathing. Great. We might as well down grade to a priority 3 at this point.
Upon arrival we find the typical disheveled house with way too much um...stuff all over the place that is an all too common setting for a majority of our calls in the area. Or pt is indeed conscious and has been in the same place for at least 12 hours. However, this pt was not answering questions and appeared confused. So we do the typical ALS assessment stuff. ECG, BP, SPO2, CBG, and so on. Turns out the pt was tachycardic (135 bpm) and borderline hypotensive (90ish/60ish) and was breathing about 30/min. Oh and the sugar was normal. Now these findings as well as environment this pt was in supported the idea that they were indeed lying in bed for about a day or more. Also upon further investigation, the pt is a chronic abuser of ETOH and it usually exacerbates bouts of pancreatitis. But the pt has yet to say a word to me other than a few mumbling of what I am certain were requests to turn on the Tivo'd NASCAR race.
So after some creative manuvering of a stairchair by the FD on scene we get our pt out into the truck for transport and further care. The pt was a bit of a vascular challenge, but not the worst I have ever seen. Mean while the pt is still watching me the whole time and is pseudo cooperative. So our emaciated ETOH abuser was the now the proud owner of an antecubital intravenous line with some NACL going to hopefully bring down that heart rate a bit. As soon as the IV is in, suddenly I get a request for dilaudid. Umm...Really? You don't say a damn thing to me the entire time you are under my care and then suddenly "can I have some drugs"?
Now I don't want to sound like I am with holding pain meds to someone that needs them. However, if you are not going to talk to me the entire time and not even answer questions like "Are you in pain", "does this hurt [pushes on abdomen]", or "on a scale of 1-10, what is your pain" then I cannot just assume you are hurting and send you off into La-La land.
The rest of the transport was uneventful and we transport her to the local hospital. I don't want to sound bitter, but the whole time I kept asking myself "I had to get up for this"? Just another day in the life...
So my partner and I are dispatched priority one for a "man down". Don't get too excitied. That could be everything from a cough to a cardiac arrest. Usually they are something in between and they usually have medicare and want to be taken to the hospital. We are enroute to the location of the call when a little bit more information is given to us by that little black box that likes to tell us what to do. Apparently our pt has been lying in bed for an extended period of time (days) but is conscious and breathing. Great. We might as well down grade to a priority 3 at this point.
Upon arrival we find the typical disheveled house with way too much um...stuff all over the place that is an all too common setting for a majority of our calls in the area. Or pt is indeed conscious and has been in the same place for at least 12 hours. However, this pt was not answering questions and appeared confused. So we do the typical ALS assessment stuff. ECG, BP, SPO2, CBG, and so on. Turns out the pt was tachycardic (135 bpm) and borderline hypotensive (90ish/60ish) and was breathing about 30/min. Oh and the sugar was normal. Now these findings as well as environment this pt was in supported the idea that they were indeed lying in bed for about a day or more. Also upon further investigation, the pt is a chronic abuser of ETOH and it usually exacerbates bouts of pancreatitis. But the pt has yet to say a word to me other than a few mumbling of what I am certain were requests to turn on the Tivo'd NASCAR race.
So after some creative manuvering of a stairchair by the FD on scene we get our pt out into the truck for transport and further care. The pt was a bit of a vascular challenge, but not the worst I have ever seen. Mean while the pt is still watching me the whole time and is pseudo cooperative. So our emaciated ETOH abuser was the now the proud owner of an antecubital intravenous line with some NACL going to hopefully bring down that heart rate a bit. As soon as the IV is in, suddenly I get a request for dilaudid. Umm...Really? You don't say a damn thing to me the entire time you are under my care and then suddenly "can I have some drugs"?
Now I don't want to sound like I am with holding pain meds to someone that needs them. However, if you are not going to talk to me the entire time and not even answer questions like "Are you in pain", "does this hurt [pushes on abdomen]", or "on a scale of 1-10, what is your pain" then I cannot just assume you are hurting and send you off into La-La land.
The rest of the transport was uneventful and we transport her to the local hospital. I don't want to sound bitter, but the whole time I kept asking myself "I had to get up for this"? Just another day in the life...
Monday, September 5, 2011
The good, the bad, and the very ugly.
Being a paramedic is not all intubation and cardioversion. However, every day on the job is different. And unfortunately, every time you put on the uniform you have the possibility to be one of the first people on the scene of something horrific. Thankfully everyday is not like that, but there is always the possibility of it.
For example, I was working rescue recently when my partner and I were dispatched for a cardiac arrest. As odd as this may sound, it was really no big deal. Working an arrest is fairly routine but does make for tense situations and has it's own sets of challenges. On our way there we hear the FD state over the radio that the situation is under control and all other responding units can downgrade. This usually is done for a person that has been down for a very long period of time or injuries that are incompatible with life. Like a GSW to the head. Now I know what you're thinking..."A GSW to the head does not always mean obvious death". And you are correct. However, when the top of the pts skull is on the roof of the house they were found leaning against and their parietal lobe was exposed and lying on the ground, it usually means resusitative efforts would be futile. And this particular incident was self inflicted...with a shotgun. Now I am no ballistics expert, but there is a simple equation that 99.9% of the time holds true. [Fire arm + Face or mouth = Death]. Call it being cavalier about the situation, but the damage done, whether it be fatal or not is still pretty catastrophic.
At any rate, it was an easy call. Just a quick phone call to medical control to obtain a time of death and then document the whole thing. As with most cardiac arrests, the documentation takes longer than the actual resusitative efforts. Or in this case, the pronouncement.
For example, I was working rescue recently when my partner and I were dispatched for a cardiac arrest. As odd as this may sound, it was really no big deal. Working an arrest is fairly routine but does make for tense situations and has it's own sets of challenges. On our way there we hear the FD state over the radio that the situation is under control and all other responding units can downgrade. This usually is done for a person that has been down for a very long period of time or injuries that are incompatible with life. Like a GSW to the head. Now I know what you're thinking..."A GSW to the head does not always mean obvious death". And you are correct. However, when the top of the pts skull is on the roof of the house they were found leaning against and their parietal lobe was exposed and lying on the ground, it usually means resusitative efforts would be futile. And this particular incident was self inflicted...with a shotgun. Now I am no ballistics expert, but there is a simple equation that 99.9% of the time holds true. [Fire arm + Face or mouth = Death]. Call it being cavalier about the situation, but the damage done, whether it be fatal or not is still pretty catastrophic.
At any rate, it was an easy call. Just a quick phone call to medical control to obtain a time of death and then document the whole thing. As with most cardiac arrests, the documentation takes longer than the actual resusitative efforts. Or in this case, the pronouncement.
Friday, September 2, 2011
Gotta love unannounced protocol change...
Since April, the area that I currently run ALS in has revamped their protocols and added a few new drugs to our advanced life support arsenal. Normally I am all for this sort of growth/change in an EMS system. However, I don't think that this should be slipped in under the radar and no one being told of the change. Granted, I understand that it is the responsibility of the EMT-Whatever to know their local protocol. However, I think if there are changes, especially substantial ones, that there should be some sort of notice. Now, with that being said let me tell you about my latest ALS adventure...
So we were dispatched to an elderly female with abdominal pain. Let me just say this now, I hate abdominal pain calls. Most of the time dispatch and the pt might as well just say "I don't know what's wrong, just take me to the hospital". Mainly because it could be so many different thing and a large majority of the time we can't do much about it. This call was the exception to my previous ranting. Anyway, as I digress...we arrive on scene to find a very sweet little old lady that has called everyone she has encountered from the time she was 50 either "honey" or "sweetie". I have definitely been called worse, so no big deal there. But this poor medicare beneficiary says she has been feeling weak and had some belly pain since last night. Its mid morning at this point. That will be important later. So we do the usual IV, O2, and monitor. This revealed a relatively hypertensive pt with an irregular heart rate between 180-209. No wonder she has been feeling weak. There were several follow up questions to which the pt looked at us blankly or answered no. One of which was, "Do you have A-fib?" to which I received a blank stare. Gotta love that. I guess if you don't have anything nice to say, don't say anything at all. Or in this case, if you don't know the answer, don't say a damn thing.
Now that we have a better picture of what is going on, we decided to start treatment in the back of the truck. That gave the FD time to get the pt loaded up and my partner and I time to get the meds, tubing, and math ready. The only medicine we have that can be used to treat A-Fib with RVR is Amiodarone. The funny thing with that is that using it for treatment in this such scenario is considered "off label". However, after 150mg over 10 minutes she went from tachy and irregular to tachy and sinus and eventually normal sinus. We were not too concerned about the whole clot thing due to the time in which her symptoms started.
She did fine for the rest of the trip to the hospital and on our subsequent return trips, she was still in normal sinus rhythm and doing well. Gotta love it when you have a positive outcome on calls like that. No big rants, insights, or epiphanies in this post. Just sharing a war story.
So we were dispatched to an elderly female with abdominal pain. Let me just say this now, I hate abdominal pain calls. Most of the time dispatch and the pt might as well just say "I don't know what's wrong, just take me to the hospital". Mainly because it could be so many different thing and a large majority of the time we can't do much about it. This call was the exception to my previous ranting. Anyway, as I digress...we arrive on scene to find a very sweet little old lady that has called everyone she has encountered from the time she was 50 either "honey" or "sweetie". I have definitely been called worse, so no big deal there. But this poor medicare beneficiary says she has been feeling weak and had some belly pain since last night. Its mid morning at this point. That will be important later. So we do the usual IV, O2, and monitor. This revealed a relatively hypertensive pt with an irregular heart rate between 180-209. No wonder she has been feeling weak. There were several follow up questions to which the pt looked at us blankly or answered no. One of which was, "Do you have A-fib?" to which I received a blank stare. Gotta love that. I guess if you don't have anything nice to say, don't say anything at all. Or in this case, if you don't know the answer, don't say a damn thing.
Now that we have a better picture of what is going on, we decided to start treatment in the back of the truck. That gave the FD time to get the pt loaded up and my partner and I time to get the meds, tubing, and math ready. The only medicine we have that can be used to treat A-Fib with RVR is Amiodarone. The funny thing with that is that using it for treatment in this such scenario is considered "off label". However, after 150mg over 10 minutes she went from tachy and irregular to tachy and sinus and eventually normal sinus. We were not too concerned about the whole clot thing due to the time in which her symptoms started.
She did fine for the rest of the trip to the hospital and on our subsequent return trips, she was still in normal sinus rhythm and doing well. Gotta love it when you have a positive outcome on calls like that. No big rants, insights, or epiphanies in this post. Just sharing a war story.
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