It was that time of the week for me. I did was working my agreed upon extra shift and I was lucky enough to grab a 24 hour rescue shift. Hopefully I can get some sleep and some studying done. But If I have to only choose one, I will go with sleep every single time. I can always do homework the following day. And since I have not mastered that whole doing homework in my sleep thing, I will have to make the sacrifice. Too bad for us there was not a whole lot of time for either one of things. Gotta love rescue shifts for that.
We stayed pretty busy throughout the day. Nothing too exciting or challenging, just busy. Before we knew it, we missed lunch and were probably going to miss dinner too if we didn't make something happen soon. Most of that shift was blur so I think we just broke down and gave into the golden arches or some other poly-saturated fast food, deep fried guilt.
It is now 2 hours past my bed time and we FINALLY get cleared back to the station to hopefully get some sleep. Apparently Murphy and his damn law were watching because no sooner did I get my boots off did the tones drop. Great. As I am tying my boots up again the radio/pager is going off in that "explain to me why this was a good idea" kind of way. I don't catch most of the call, but I do hear CPR in progress. GREAT!
My partner and I respond priority one to the location which happens to be very close to one of the local fire departments. This is actually a very good thing for the pt. We get there to find a moderately old person in full arrest with the FD doing a great job as usual with the BLS care. We get the story as we work on our ALS stuff. It was a sudden and witnessed arrest and CPR was started right away.
We throw the pads on for our monitor, my partner is working on getting a definitive airway, and I start working on getting vascular access. We have some trouble obtaining both of these thing initially but the tube gets placed and we get a line. And now it's about that to do a rhythm/pulse check. And wouldn't you know it, we got a pulse and a fairly good looking sinus rhythm. TIME TO GO!
As the pt is getting packaged up for transport and loaded into the ambulance, he arrests again. Thanks buddy. I could have done without that. But we do some CPR, give some epi, and shock him back out of vfib and into NSR. This time I take advantage of the decent BP and throw in a second line. And by the time this is all said and done, we are pulling into the ambulance bay.
As we are unloading, giving report, transferring to the gurney, and swapping leads, the second IV I placed enroute gets pulled out. WTF!? But it's OK, he still has a pulse and a perfusing rhythm. The 12 lead shows elevation in II, III, and aVF. Sounds like my friends from the cardiac cath lab are going to be getting a call very shortly.
As the cath team starts to show up, we are starting to get more of a story and history on our ROSC pt. Apparently this person is the proud owner of 13 previous stents and a slew of other medical issues. I swear he was being kept alive by beta blockers, Metformin, and medicare.
Once all the players were in place and the pt was placed in the cath lab, I was able to start my report. But I wanted to watch the cath too, so I did my documentation from the comfort of the control room. When they shot their first films, I could see the RCA before any dye was pushed. The Pt's entire RCA was stents. It was amazing. Not to mention the fact that he ended up with an additional stent as well.
I have to admit, it is nice to be able to put one in the the proverbial win column from time to time. Especially when they go from dead to a live. And in true EMS fashion, it took longer to do the documentation than it did to do the call. But that is OK, because we spent the rest of the shift bouncing from post to post like zombies with drivers licenses but instead of brains we just wanted sleep.
Saturday, December 8, 2012
Thursday, December 6, 2012
Costumes, kegs, and brides maids, oh my!
So there I was, right...sleeping at the rescue station, minding my own business at 0'dark thirty when the tones go off. I release a string of profanity that I am sure most of the block heard. But hey, we gotta job to do, right? Right. No earning money sleeping (see what I did there?) tonight.
While enroute to the location of our call for a car v/s tree, my partner and I coming to full consciousness and start asking the obvious question. Why are they at this particular location so late, how did they hit a tree, and how drunk do you think this person is? Much to our eventual and retrospective surprise, all of those questions were actually answered. So we do our lights and siren thing and pull up on scene to a complete melee of "WTF"?
At first we assume that there is some sort of party going on due to the amount of people out and about. However, it's not your normal party when the first person you notice is a man in a dress. Again, WTF? There painted faces, a lot of beer, and a group of women wearing matching dresses. As it turns out, there was a wedding and a Halloween party going on at the same time. You can't make this stuff up.
Now our pt is what many would call a "good ol' boy". All 290 lbs of him. And he is about as drunk as you can get without being in a coma. Now alcohol can make people do many things. For some people, it causes them to regress to an earlier state of consciousness. In other words, it makes them act like children. Judging from the amount of ETOH this Appalachian American had ingested, I figured he had regressed to about 5 years old. He was barely cooperative and when you would tell him to sit still, he would for about 3 second, move his arms while you are taking a blood pressure or doing some other medical procedure, and then say that he didn't or something else to that remark. Ugh! Frustrating to say the least.
However, drunky McDrunkerton had very abnormal vital signs and needed to go to the hospital whether he liked it or not. The problem was that he was probably not going to go willingly. Thankfully the police officer on scene gave the guy two options: ER or jail. And with a lot of hemming and hawing, "Cletus" opted for the hospital. Don't worry. You can get arrested once you sober up. Oh and when he finally blew for the cops, I thought the machine was going to explode. It was waaayyy too high. I would be dead with a level like that. It was almost 0.5! I don't know how he was even conscious...well, yes I do. He was a big fat redneck with years of beer drinking experience. I'm sure he has a story or two of getting too drunk in a deer stand and falling to the ground. But I digress.
So after way too much talking, this guy finally gets in the back of our truck. There he proceeds to try and insult my partners medical abilities as well as his general intelligence. He wasn't exactly please and I am sure he got in a few zingers that went way of this drunk guys head. Probably for the best.
Since I was driving us to the hospital, you would think I was the lucky one. Not so much. One of the bridesmaids rode with us to the hospital. Great. Nothing like a drunk redneck woman who is half crying and trying to explain to me what was going on and further perpetuate the myth that the guy in the back of the truck wasn't driving the car that struck a tree. We have "Cletus" in the back and "Brandine" in the front. If my ambulance was any more classy at this point, it would have turned into a limo. I also kept getting the question "Is he going to jail?" I don't know. I'm not a cop. Do I look like a cop? Well now that I think of it, most people do think we are either cops or fire fighters.
At any rate, we show up to the hospital to a thrilled ER staff and hand off care to the clinical team. As soon as he was moved over to the bed, "Click" went the hand cuffs. It only made the situation worse, but that is not my department. A big "I'm so sorry" to the ER that had to deal with this guy, but unfortunately it was their turn with Drunky McRealtree.
While enroute to the location of our call for a car v/s tree, my partner and I coming to full consciousness and start asking the obvious question. Why are they at this particular location so late, how did they hit a tree, and how drunk do you think this person is? Much to our eventual and retrospective surprise, all of those questions were actually answered. So we do our lights and siren thing and pull up on scene to a complete melee of "WTF"?
At first we assume that there is some sort of party going on due to the amount of people out and about. However, it's not your normal party when the first person you notice is a man in a dress. Again, WTF? There painted faces, a lot of beer, and a group of women wearing matching dresses. As it turns out, there was a wedding and a Halloween party going on at the same time. You can't make this stuff up.
Now our pt is what many would call a "good ol' boy". All 290 lbs of him. And he is about as drunk as you can get without being in a coma. Now alcohol can make people do many things. For some people, it causes them to regress to an earlier state of consciousness. In other words, it makes them act like children. Judging from the amount of ETOH this Appalachian American had ingested, I figured he had regressed to about 5 years old. He was barely cooperative and when you would tell him to sit still, he would for about 3 second, move his arms while you are taking a blood pressure or doing some other medical procedure, and then say that he didn't or something else to that remark. Ugh! Frustrating to say the least.
However, drunky McDrunkerton had very abnormal vital signs and needed to go to the hospital whether he liked it or not. The problem was that he was probably not going to go willingly. Thankfully the police officer on scene gave the guy two options: ER or jail. And with a lot of hemming and hawing, "Cletus" opted for the hospital. Don't worry. You can get arrested once you sober up. Oh and when he finally blew for the cops, I thought the machine was going to explode. It was waaayyy too high. I would be dead with a level like that. It was almost 0.5! I don't know how he was even conscious...well, yes I do. He was a big fat redneck with years of beer drinking experience. I'm sure he has a story or two of getting too drunk in a deer stand and falling to the ground. But I digress.
So after way too much talking, this guy finally gets in the back of our truck. There he proceeds to try and insult my partners medical abilities as well as his general intelligence. He wasn't exactly please and I am sure he got in a few zingers that went way of this drunk guys head. Probably for the best.
Since I was driving us to the hospital, you would think I was the lucky one. Not so much. One of the bridesmaids rode with us to the hospital. Great. Nothing like a drunk redneck woman who is half crying and trying to explain to me what was going on and further perpetuate the myth that the guy in the back of the truck wasn't driving the car that struck a tree. We have "Cletus" in the back and "Brandine" in the front. If my ambulance was any more classy at this point, it would have turned into a limo. I also kept getting the question "Is he going to jail?" I don't know. I'm not a cop. Do I look like a cop? Well now that I think of it, most people do think we are either cops or fire fighters.
At any rate, we show up to the hospital to a thrilled ER staff and hand off care to the clinical team. As soon as he was moved over to the bed, "Click" went the hand cuffs. It only made the situation worse, but that is not my department. A big "I'm so sorry" to the ER that had to deal with this guy, but unfortunately it was their turn with Drunky McRealtree.
Thursday, November 1, 2012
From one to another...
It was what started out to be just another typical day on the MICU. Now that I think about it, most of the time days like this start out as "just another day". You really don't think too much about them then you get "that call" that changes the feeling, tempo, and even vibe of that day. And that call was one of them.
We did our first call of the day. It was a simple transfer from a physicians office to a local hospital. Other than the morbid obesity, it was a very simple call. Nothing exciting except for the fact that everyone was dressed up for Halloween. You have to love going to scene where everyone is dressed up as something crazy. The nurse that gave us report was dressed like a zombie. Go figure...
Ok, so we got our first call out of the way thinking that we were going to do the usual priority 3 purgatory calls that we were sure dispatch has holding for us due to a lower than usual ambulance deployment thanks to a certain hurricane on a certain coast. But instead we get a call for a fall. Perhaps it is not going to be that kind of a day after all.
I will spare you the details of our pt that fell 10ft off of a ladder for the sake of getting to the point. So we clear that call and head on out to again be man kind's last hope for survival. While enroute to our predesignated post, we get a call over the radio to start heading priority one to an MVA at the very south west of our coverage area. And with the application of that damn law Mr. Murphy came up with, ther was no quick way of getting there. There was even traffic on roads that never have anyone, ever! So after some dodging and weaving, we are just about there. As we reach the crest of the hill before the intersection of the MVA, we see a melee of trucks and twisted metal.
Apparently we are the third ALS unit in and don't have a patient. However, the other two ambulances and FD personnel are busy with extrication and care. We provide some help, "go for" style. Moving trucks, getting equipment set up, and heavy lifting. We get everyone out of the wreckage and hear that there is another wreck just down the road. Great. However, since we are the closest ALS truck to the scene with no patient, we hop in our truck, flip the lights on and blair the sigren to the next call.
It literally is only about 2 miles down the road. But is seemed as though it was taking forever. Probably since the adrenalin was still flowing from the first call. The good thing about adrenalin is that a little bit of it gives you a heightened sense of things. The bad thing about it is that a lot of it causes you to think from your brain stem and you tend to loose fine motor skills. Thankfully I have been doing this long enough were I have a sense of urgency and I can still remember how to spell my own name. Ok, now that my own horn has been tooted, back to the call.
We roll up to find two heavily damaged vehicles and immediately call for a second ALS unit. At first glance, I thought one of them was actually up on it's side. In fact it was actually right side up with such major damage that it intruded into the passenger compartment trapping the driver. The other vehicle was also a heap of twisted metal and broken glass. from the looks of it, both vehicle hit each other head on and there were no skid marks. Who knows why they collided, but the driver in the first vehicle was dead. He probably died on impact, judging by the damage to the vehicle. On to vehicle number 2.
With damage just as extensive, the FD was going to have to cut the car apart. My partner asks me if I want to call in the bird. I tell him absolutely and he gets on the radio. Meanwhile, I climb into the back seat of the car to get access to my patient. This pt is semi-conscious with obvious deformities to the lower extremities and does not have palpable radial pulse and weak carotid. It looked as though my pt had two sets of knees. That is how angulated his legs were. C-spine stabilization is taken and I start talking to this patient to keep him awake as best I could while we are literally cut out of the vehicle. We cover up our pt and the FD starts popping, splitting, shearing, and shattering everything they can in a very efficient manner. It still took us a good 20 minutes or so to get the pt out of the vehicle. While inside I kept talking to him asking him question after question to make sure he stayed awake. I also started to cut off his clothes to make the ALS portion of this call slightly easier. When we did finally get him out of the vehicle, it was from the seat to the back board/gurney. And of course he goes unconscious! Great. "Hey! Sir! Wake Up! <sternal rub>". He wakes up and looks at me puzzled. "Do that again and we won't be cool any more".
Now that we are finally out of the vehilce, my partner tells me that the weather is too bad and that the bird isn't flying. Great. Looks like we have a long bumpy drive to the closest trauma center. We get our first set of good vitals and expose our pt to see everything. I use the term good loosely here. They were accurate, but they were far from good. Initial set of vitals was 60/30 and a heart rate of 130. Can we say hemorrhagic shock? One of our sister company medics jumps up in the back of the a truck with the rest of us and lends a hand with all the rapid trauma stuff. We are now set to do some low level flying. It is what my partner refers to driving priority 1. And we do everything else enroute.
Two big IVs, cardiac monitor, high flow O2, and so on. We even attempted to straighten out his legs and get them splinted. However, they were so angulated that it was impossible too. He also had an unstable pelvis. We attempted to manage that as best we could as well. I call a head to active the trauma team and we continue to reassess and reevaluate everything that happened,what was done, and what else can we do. I kept talking to the patient to make sure that he stayed awake and that he was still breathing. V/s were taken every 5 minutes and they were not much better. You know it is a bad call when the best bp you get is 88/40. Holy hypotension, Batman! We even hung blood tubing for trauma team. Our pt is now profused enough to be a pain in the ass. He kept trying to pull off his oxygen mask. I told him to stop or we are going to tie his arms down. He still tried. Of course.
As we turn into the the trauma center and get our pt ready to go inside, I make a mental list of my report that I am going to spout off to the trauma team. When you roll a critically ill or injured pt into any ER, you are the center of attention for about 1 minute. You give a brief description of what happened, any history you have on the pt and what you did. Some of the staff was surprised to see the open tib/fib fractures and asked why we didn't splint them. We tried. Believe me, we tried. They take over, intubate the pt, and do all the other trauma resus stuff that they do.
After it was all said and done, it turns out there was bilateral tib/fib fractures (duh!) and a shattered pelvis. Not broken, shattered. Like a bag of pasta. Not sure what happened from there, but I have to say that as much as I love a good trauma call, it is probably for the best that we don't do that everyday. The burnout rate would be exponentially higher. And in true EMS fashion, on to the next call.
We did our first call of the day. It was a simple transfer from a physicians office to a local hospital. Other than the morbid obesity, it was a very simple call. Nothing exciting except for the fact that everyone was dressed up for Halloween. You have to love going to scene where everyone is dressed up as something crazy. The nurse that gave us report was dressed like a zombie. Go figure...
Ok, so we got our first call out of the way thinking that we were going to do the usual priority 3 purgatory calls that we were sure dispatch has holding for us due to a lower than usual ambulance deployment thanks to a certain hurricane on a certain coast. But instead we get a call for a fall. Perhaps it is not going to be that kind of a day after all.
I will spare you the details of our pt that fell 10ft off of a ladder for the sake of getting to the point. So we clear that call and head on out to again be man kind's last hope for survival. While enroute to our predesignated post, we get a call over the radio to start heading priority one to an MVA at the very south west of our coverage area. And with the application of that damn law Mr. Murphy came up with, ther was no quick way of getting there. There was even traffic on roads that never have anyone, ever! So after some dodging and weaving, we are just about there. As we reach the crest of the hill before the intersection of the MVA, we see a melee of trucks and twisted metal.
Apparently we are the third ALS unit in and don't have a patient. However, the other two ambulances and FD personnel are busy with extrication and care. We provide some help, "go for" style. Moving trucks, getting equipment set up, and heavy lifting. We get everyone out of the wreckage and hear that there is another wreck just down the road. Great. However, since we are the closest ALS truck to the scene with no patient, we hop in our truck, flip the lights on and blair the sigren to the next call.
It literally is only about 2 miles down the road. But is seemed as though it was taking forever. Probably since the adrenalin was still flowing from the first call. The good thing about adrenalin is that a little bit of it gives you a heightened sense of things. The bad thing about it is that a lot of it causes you to think from your brain stem and you tend to loose fine motor skills. Thankfully I have been doing this long enough were I have a sense of urgency and I can still remember how to spell my own name. Ok, now that my own horn has been tooted, back to the call.
We roll up to find two heavily damaged vehicles and immediately call for a second ALS unit. At first glance, I thought one of them was actually up on it's side. In fact it was actually right side up with such major damage that it intruded into the passenger compartment trapping the driver. The other vehicle was also a heap of twisted metal and broken glass. from the looks of it, both vehicle hit each other head on and there were no skid marks. Who knows why they collided, but the driver in the first vehicle was dead. He probably died on impact, judging by the damage to the vehicle. On to vehicle number 2.
With damage just as extensive, the FD was going to have to cut the car apart. My partner asks me if I want to call in the bird. I tell him absolutely and he gets on the radio. Meanwhile, I climb into the back seat of the car to get access to my patient. This pt is semi-conscious with obvious deformities to the lower extremities and does not have palpable radial pulse and weak carotid. It looked as though my pt had two sets of knees. That is how angulated his legs were. C-spine stabilization is taken and I start talking to this patient to keep him awake as best I could while we are literally cut out of the vehicle. We cover up our pt and the FD starts popping, splitting, shearing, and shattering everything they can in a very efficient manner. It still took us a good 20 minutes or so to get the pt out of the vehicle. While inside I kept talking to him asking him question after question to make sure he stayed awake. I also started to cut off his clothes to make the ALS portion of this call slightly easier. When we did finally get him out of the vehicle, it was from the seat to the back board/gurney. And of course he goes unconscious! Great. "Hey! Sir! Wake Up! <sternal rub>". He wakes up and looks at me puzzled. "Do that again and we won't be cool any more".
Now that we are finally out of the vehilce, my partner tells me that the weather is too bad and that the bird isn't flying. Great. Looks like we have a long bumpy drive to the closest trauma center. We get our first set of good vitals and expose our pt to see everything. I use the term good loosely here. They were accurate, but they were far from good. Initial set of vitals was 60/30 and a heart rate of 130. Can we say hemorrhagic shock? One of our sister company medics jumps up in the back of the a truck with the rest of us and lends a hand with all the rapid trauma stuff. We are now set to do some low level flying. It is what my partner refers to driving priority 1. And we do everything else enroute.
Two big IVs, cardiac monitor, high flow O2, and so on. We even attempted to straighten out his legs and get them splinted. However, they were so angulated that it was impossible too. He also had an unstable pelvis. We attempted to manage that as best we could as well. I call a head to active the trauma team and we continue to reassess and reevaluate everything that happened,what was done, and what else can we do. I kept talking to the patient to make sure that he stayed awake and that he was still breathing. V/s were taken every 5 minutes and they were not much better. You know it is a bad call when the best bp you get is 88/40. Holy hypotension, Batman! We even hung blood tubing for trauma team. Our pt is now profused enough to be a pain in the ass. He kept trying to pull off his oxygen mask. I told him to stop or we are going to tie his arms down. He still tried. Of course.
As we turn into the the trauma center and get our pt ready to go inside, I make a mental list of my report that I am going to spout off to the trauma team. When you roll a critically ill or injured pt into any ER, you are the center of attention for about 1 minute. You give a brief description of what happened, any history you have on the pt and what you did. Some of the staff was surprised to see the open tib/fib fractures and asked why we didn't splint them. We tried. Believe me, we tried. They take over, intubate the pt, and do all the other trauma resus stuff that they do.
After it was all said and done, it turns out there was bilateral tib/fib fractures (duh!) and a shattered pelvis. Not broken, shattered. Like a bag of pasta. Not sure what happened from there, but I have to say that as much as I love a good trauma call, it is probably for the best that we don't do that everyday. The burnout rate would be exponentially higher. And in true EMS fashion, on to the next call.
Saturday, October 13, 2012
A few things that hold true...
Though out my travels and just daily life, I have found a few things to hold true no matter where I am or what I am doing. Women will always change their mind, pt's will always place themselves in a location that is going to be a huge pain in the ass to get them out, no one knows how to drive properly except the 16 y/o on their road test (because they have to), and the story that EMS gets is different from that of the RN, and RN gets a story that is different from what the doc is told. It's a frustrating pattern that makes the other levels seem as though they are not doing a thorough job, but in all reality it is just that information is forgotten, remembered, and then given at different stages in care. Again, it's frustrating.
The story that I have involves mostly that last part of that short yet long list of universal truths. Oh and btw, anyone that says they drive the "correct" way 100% of the time is either lying or is obviously not paying attention to their personal driving habits. Ask a cop about and they will tell you that follow anyone for a mile and you will catch them breaking a traffic rule. Anyway, as I digress...
Recently my partner and I were dispatched to a call for an overdose. Usually when some in this industry get such a call, they only really get excited if the pt is unconscious. Per our dispatch information, this one wasn't. So we will still move with the same sense of urgency, but not with the same energy as one would with an unconscious pt. So we do the lights and sirens thing to the scene to meet fire and PD there. So far so good, right? Right. We grab our usual equipment and head on into the dwelling of said pt.
Once we get in there, we find a late 30's to early 40ish person on the couch who looks a bit sleepy but is breathing and conversing when they are not trying to fall back asleep. The FD states that they are having trouble getting a BP. That's not good for this FD. They are usually on it, so I assume that this pt is indeed hypotensive. So bing, bam, boom! We throw on the monitor to get our vitals and sure enough, the pt is hypotensive. Like 64/30. For those of you that are not familiar with the normal BP parameters, that is bad! And of course, the pt is in the basement with very a very narrow staircase and big, heavy furniture everywhere. Moving this person is going to take some muscle. Not because they are 500lbs, thankfully they are not. But because they went to the local furniture liquidator and asked for the bulkiest, heaviest, pain in the ass to move furniture they had. But as I have said before and I say it again, the FD in this area is always go great and got that part of the call done very quickly.
Now that we have emerged from the basement in what seemed like an eternity, we can really start doing all the ALS stuff that we need to. Since there wasn't a huge delay in getting out of the house we opted not to start right then and there. So our pt is still hypotensive, still sleepy, and still wishes for personal bodily harm. While we were redecorating the basement to move this pt we got a story (our EMS version of if) from the family. This individual has tried this before and the current "cocktail" consisted of a TCA, some OTC analgesics, and possibly some other medication. They were not sure.
So 2 big IVs, O2, the cardiac monitor, and a large bolus of diesel fuel are in order. Btw, that last part means driving fast. Just FYI. And we are off! Enroute things don't change very much but they don't get any worse. At least we are preventing this person from getting any worse. Or that is what we tell ourselves anyway.
Upon arrival to the hospital we give report to the RN and the pt actually starts to volunteer information and of course it is different than some of the stuff that we originally had. Thanks! And then the doc and the family show up. Now the whole truth comes out. See how that feels, RN? Just saying. Anyway, with this polypharmacy mess we brought in they started giving a lot of calcium. I won't go into the details as to why or how it works, but if we were given that information earlier we could have started giving that medication sooner. Ugh! It's a bit frustrating from time to time.
The same thing happens with heroin OD pts. They tell me "I don't do drugs". They tell the nurse, well I just wanted to try it" or "I am trying to quit". They tell the doc "I have been an IV drug user for 20 years. I usually get a vein in my thigh but have been known to sniff it and I am Hep A,B,C positive as well as have HIV". Perhaps EMS is viewed as an authority figure in such situations? Who knows, but hopefully my RN and MD colleagues recognize this pattern and take this type of pt behavior for what it is worth.
The story that I have involves mostly that last part of that short yet long list of universal truths. Oh and btw, anyone that says they drive the "correct" way 100% of the time is either lying or is obviously not paying attention to their personal driving habits. Ask a cop about and they will tell you that follow anyone for a mile and you will catch them breaking a traffic rule. Anyway, as I digress...
Recently my partner and I were dispatched to a call for an overdose. Usually when some in this industry get such a call, they only really get excited if the pt is unconscious. Per our dispatch information, this one wasn't. So we will still move with the same sense of urgency, but not with the same energy as one would with an unconscious pt. So we do the lights and sirens thing to the scene to meet fire and PD there. So far so good, right? Right. We grab our usual equipment and head on into the dwelling of said pt.
Once we get in there, we find a late 30's to early 40ish person on the couch who looks a bit sleepy but is breathing and conversing when they are not trying to fall back asleep. The FD states that they are having trouble getting a BP. That's not good for this FD. They are usually on it, so I assume that this pt is indeed hypotensive. So bing, bam, boom! We throw on the monitor to get our vitals and sure enough, the pt is hypotensive. Like 64/30. For those of you that are not familiar with the normal BP parameters, that is bad! And of course, the pt is in the basement with very a very narrow staircase and big, heavy furniture everywhere. Moving this person is going to take some muscle. Not because they are 500lbs, thankfully they are not. But because they went to the local furniture liquidator and asked for the bulkiest, heaviest, pain in the ass to move furniture they had. But as I have said before and I say it again, the FD in this area is always go great and got that part of the call done very quickly.
Now that we have emerged from the basement in what seemed like an eternity, we can really start doing all the ALS stuff that we need to. Since there wasn't a huge delay in getting out of the house we opted not to start right then and there. So our pt is still hypotensive, still sleepy, and still wishes for personal bodily harm. While we were redecorating the basement to move this pt we got a story (our EMS version of if) from the family. This individual has tried this before and the current "cocktail" consisted of a TCA, some OTC analgesics, and possibly some other medication. They were not sure.
So 2 big IVs, O2, the cardiac monitor, and a large bolus of diesel fuel are in order. Btw, that last part means driving fast. Just FYI. And we are off! Enroute things don't change very much but they don't get any worse. At least we are preventing this person from getting any worse. Or that is what we tell ourselves anyway.
Upon arrival to the hospital we give report to the RN and the pt actually starts to volunteer information and of course it is different than some of the stuff that we originally had. Thanks! And then the doc and the family show up. Now the whole truth comes out. See how that feels, RN? Just saying. Anyway, with this polypharmacy mess we brought in they started giving a lot of calcium. I won't go into the details as to why or how it works, but if we were given that information earlier we could have started giving that medication sooner. Ugh! It's a bit frustrating from time to time.
The same thing happens with heroin OD pts. They tell me "I don't do drugs". They tell the nurse, well I just wanted to try it" or "I am trying to quit". They tell the doc "I have been an IV drug user for 20 years. I usually get a vein in my thigh but have been known to sniff it and I am Hep A,B,C positive as well as have HIV". Perhaps EMS is viewed as an authority figure in such situations? Who knows, but hopefully my RN and MD colleagues recognize this pattern and take this type of pt behavior for what it is worth.
Monday, September 24, 2012
Yet another fixed gaze...
So there I was right, working another 24 hour rescue shift. As long as the hours may sound, these shifts can actually be pretty interesting. Sometimes. However, it is very much hit or miss. The first 6 hours or so of the shift seemed to be heading in that direction. Then people started calling 911. So much for having an easy shift. But hey, you gotta earn your money some how.
Now I have to admit I hate it when we get a call for a "fall". I don't know why I hate it. I just do. The funny thing is that some of my better calls have been initially dispatched as "falls". I guess I always associate it with the LOL in otherwise NAD that breaks her hip or pain in the ass drunk people that interrupt an otherwise pleasant Friday or Saturday night at the station.
So we get our call for a, you guessed it! A fall. So my partner and I do the lights and sirens thing to the call. No new information pops up over our super high tech notification devices we in the business refer to as pagers. These little throw backs to the the 90s are prime examples of why some people think EMS is stuck in the past while other say simplicity is a beautiful thing.
Anyway, in a few short minutes we arrive on scene at just about the same time as the local FD. Well all get out of our vehicles with the appropriate equipment and set off to where we thing the pt is. Fire had the right idea and went around to the back. Apparently we missed the memo and decided to enter the house. As I open the door, we are "greeted" by a large, scary looking black dog. SLAM goes the door! Well they are not in there or the scene is not safe. Better double back and reassess the situation. Luckily as we are doubling back we take the road less traveled and discover our pt with the FD on the slope of a small hill.
At first glance it looked as those this patron on of the 911 system had way too much ETOH on board. There was the slurring of speech, the uncooperative nature, and just a general feeling of "WTF" in the air. No matter what the injury pattern or disease process, this pt is getting an IV or two, some O2, and will be wired for sound thanks to Zoll medical. Oh and lets not forget the whole c-spine and assessment deal too.
At this point I "introduce" myself to this pt and discover very quickly that not only do they not want to go to the hospital, but according to what the pt said, it was night time and that our current location was actually a town located across the state. Yup, you're going to the hospital. Sorry but it kind of has to happen.
Now that we have a bit of a better look at this pt, we notice a few things. One, he is unhappy. Two, he is not the most cooperative. Three, he can't move his right side. And to top it all of at four, his eyes are constricted and fixed to the right. However, still alert and oriented times 3. Oh and all of his other vitals check out reasonably well. This pt also didn't know he wasn't moving his left arm. I kind of didn't want to believe that he couldn't move his left arm, but reality slapped me in the face with her right hand, SMACK! Now, I'm no doctor, but sounds to me like this guy has a lot of neuro badness going on at the moment. Not much we can do about this in the field except a diesel bolus. For those of you not familiar with EMS slang, that means going lights and sirens to the closest appropriate hospital.
So c-collar, IVs, monitor, oxygen, v/s, and we are enroute. Lights and sirens. Meanwhile, our pt still thinks they the trip to the ER is totally unnecessary. Really? Ugh! Lucky for me I get to drive this on this call. From what my partner tells me, nothing too much had changed enroute.
Upon our arrival to the ER, we give report to the RN and transfer care over to the clinical staff. No deterioration in the pt's condition while with us and is otherwise stable. However, this pt does require swift intervention. Lucky for all parties involved, there was a known onset time and that there is a good chance for a full recovery.
Now I have to admit I hate it when we get a call for a "fall". I don't know why I hate it. I just do. The funny thing is that some of my better calls have been initially dispatched as "falls". I guess I always associate it with the LOL in otherwise NAD that breaks her hip or pain in the ass drunk people that interrupt an otherwise pleasant Friday or Saturday night at the station.
So we get our call for a, you guessed it! A fall. So my partner and I do the lights and sirens thing to the call. No new information pops up over our super high tech notification devices we in the business refer to as pagers. These little throw backs to the the 90s are prime examples of why some people think EMS is stuck in the past while other say simplicity is a beautiful thing.
Anyway, in a few short minutes we arrive on scene at just about the same time as the local FD. Well all get out of our vehicles with the appropriate equipment and set off to where we thing the pt is. Fire had the right idea and went around to the back. Apparently we missed the memo and decided to enter the house. As I open the door, we are "greeted" by a large, scary looking black dog. SLAM goes the door! Well they are not in there or the scene is not safe. Better double back and reassess the situation. Luckily as we are doubling back we take the road less traveled and discover our pt with the FD on the slope of a small hill.
At first glance it looked as those this patron on of the 911 system had way too much ETOH on board. There was the slurring of speech, the uncooperative nature, and just a general feeling of "WTF" in the air. No matter what the injury pattern or disease process, this pt is getting an IV or two, some O2, and will be wired for sound thanks to Zoll medical. Oh and lets not forget the whole c-spine and assessment deal too.
At this point I "introduce" myself to this pt and discover very quickly that not only do they not want to go to the hospital, but according to what the pt said, it was night time and that our current location was actually a town located across the state. Yup, you're going to the hospital. Sorry but it kind of has to happen.
Now that we have a bit of a better look at this pt, we notice a few things. One, he is unhappy. Two, he is not the most cooperative. Three, he can't move his right side. And to top it all of at four, his eyes are constricted and fixed to the right. However, still alert and oriented times 3. Oh and all of his other vitals check out reasonably well. This pt also didn't know he wasn't moving his left arm. I kind of didn't want to believe that he couldn't move his left arm, but reality slapped me in the face with her right hand, SMACK! Now, I'm no doctor, but sounds to me like this guy has a lot of neuro badness going on at the moment. Not much we can do about this in the field except a diesel bolus. For those of you not familiar with EMS slang, that means going lights and sirens to the closest appropriate hospital.
So c-collar, IVs, monitor, oxygen, v/s, and we are enroute. Lights and sirens. Meanwhile, our pt still thinks they the trip to the ER is totally unnecessary. Really? Ugh! Lucky for me I get to drive this on this call. From what my partner tells me, nothing too much had changed enroute.
Upon our arrival to the ER, we give report to the RN and transfer care over to the clinical staff. No deterioration in the pt's condition while with us and is otherwise stable. However, this pt does require swift intervention. Lucky for all parties involved, there was a known onset time and that there is a good chance for a full recovery.
Sunday, September 16, 2012
That fixed gaze...
No one likes PEDS calls. If anyone tells you that they do, they are a liar. No one likes seeing little kids sick, hurt, or worse. With that being said, everyone (I assume) does like helping kids and making them feel better. Well my partner and I had an opportunity recently in one of the many cities we cover to witness both.
So there we were, sitting at post. Minding our own business. When we hear the tones go off for what we assumed was a seizure. OK, game face. Which also happens to include lights, sirens, and a large amount of diesel fuel. While this is all going down, I am tapping away on my touch screen work laptop trying to save some time and get as much of the documentation done as possible before getting on scene. Just the stuff that will be required for every call. Nature of call, time of call, and so on. Then the call finally gets sent to the pager. I pick it up to glance at it, and the words "blue" and "baby" are present. !@#$! Not good!
Once the string of obscenities my partner and I both let out have been completed, I start to go over dosages in my head for some of the meds we may or may not be giving. OK, got it. Now that I have that preloaded in my skull, hopefully that will help me when we get on scene.
Upon arrival to the call, we find a wide eyed, wide mouthed baby who is not making much noise and has a fixed gaze to left. May not sound all that exciting, but when a little baby is not crying, pooping, sleeping, or eating, there is a problem. So we spring into action and do our ALS thing for this kiddo in acute distress.
Now it is important to point out that when dealing with pediatric patients, math is always required for proper dosing of medications. Parents are usually a good resource for this. Unfortunately, when they are crying and very distraught, it makes it a bit more difficult to get the information you require. Sometimes you just have to guess. Another thing to point out is that it is not always easy to calculate medication doses for kids. Especially if you are under a lot of stress and thinking from your brain stem. Thankfully after a quick weight estimate and some quick math done on the back of a 4X4, we have our dosage. I wasn't super comfortable with it, but it will have to do for now.
I was surprised at how easy of a stick this little one was. Our other option was to give it rectally, but we got the IV in so fast that we were able to give the meds that before we had it drawn up. SCORE! And while all of this is happening in a very stressful and emotionally charged environment the pt also got a set of vitals, an ecg, blood sugar, oxygen, and so on. This all goes down in a matter of minutes
After that is all said and done, the little one stops seizing. Sweet! I then scoop this little bundle of joy up in my arms and get them secured to the gurney for transport and we are off to the local ER for further treatment.
While enroute I can't shake the idea that my math was wrong. People always tend to second guess themselves with pediatric pts and apparently I am no different. But the kiddo is crying, which in my line of work is a great thing. It means that they are alive and breathing. A silent kid is a sick kid. No bueno. The rest of the ride is uneventful and the little one improves. However, I am still doing the math for the medication dosages in my head thinking that I @#$%$ something up.
Once at the hospital and after I give report to the RN, I sit down and do the math for the medication dosage and keep coming up with the same answer. I even have my partner do the math too and he gets the same answer as well. Finally after about what seemed like 20+ times of figuring out the proper dosage, I finally admit to myself that I gave the right dose.
I guess when it comes to kids, most people feel that they have very little room for error. No one wants to hurt a little one. They usually want to do the opposite and help in anyway they can. The lesson here is kids are difficult. No matter what. However, I am glad that little one is doing well today.
So there we were, sitting at post. Minding our own business. When we hear the tones go off for what we assumed was a seizure. OK, game face. Which also happens to include lights, sirens, and a large amount of diesel fuel. While this is all going down, I am tapping away on my touch screen work laptop trying to save some time and get as much of the documentation done as possible before getting on scene. Just the stuff that will be required for every call. Nature of call, time of call, and so on. Then the call finally gets sent to the pager. I pick it up to glance at it, and the words "blue" and "baby" are present. !@#$! Not good!
Once the string of obscenities my partner and I both let out have been completed, I start to go over dosages in my head for some of the meds we may or may not be giving. OK, got it. Now that I have that preloaded in my skull, hopefully that will help me when we get on scene.
Upon arrival to the call, we find a wide eyed, wide mouthed baby who is not making much noise and has a fixed gaze to left. May not sound all that exciting, but when a little baby is not crying, pooping, sleeping, or eating, there is a problem. So we spring into action and do our ALS thing for this kiddo in acute distress.
Now it is important to point out that when dealing with pediatric patients, math is always required for proper dosing of medications. Parents are usually a good resource for this. Unfortunately, when they are crying and very distraught, it makes it a bit more difficult to get the information you require. Sometimes you just have to guess. Another thing to point out is that it is not always easy to calculate medication doses for kids. Especially if you are under a lot of stress and thinking from your brain stem. Thankfully after a quick weight estimate and some quick math done on the back of a 4X4, we have our dosage. I wasn't super comfortable with it, but it will have to do for now.
I was surprised at how easy of a stick this little one was. Our other option was to give it rectally, but we got the IV in so fast that we were able to give the meds that before we had it drawn up. SCORE! And while all of this is happening in a very stressful and emotionally charged environment the pt also got a set of vitals, an ecg, blood sugar, oxygen, and so on. This all goes down in a matter of minutes
After that is all said and done, the little one stops seizing. Sweet! I then scoop this little bundle of joy up in my arms and get them secured to the gurney for transport and we are off to the local ER for further treatment.
While enroute I can't shake the idea that my math was wrong. People always tend to second guess themselves with pediatric pts and apparently I am no different. But the kiddo is crying, which in my line of work is a great thing. It means that they are alive and breathing. A silent kid is a sick kid. No bueno. The rest of the ride is uneventful and the little one improves. However, I am still doing the math for the medication dosages in my head thinking that I @#$%$ something up.
Once at the hospital and after I give report to the RN, I sit down and do the math for the medication dosage and keep coming up with the same answer. I even have my partner do the math too and he gets the same answer as well. Finally after about what seemed like 20+ times of figuring out the proper dosage, I finally admit to myself that I gave the right dose.
I guess when it comes to kids, most people feel that they have very little room for error. No one wants to hurt a little one. They usually want to do the opposite and help in anyway they can. The lesson here is kids are difficult. No matter what. However, I am glad that little one is doing well today.
Tuesday, July 24, 2012
Like a bag of rice krispies
There I was right, at a hospital that I spend a lot of time at...minding my own business. When out of no where my partner pups up and tells me that "There's an arrest at the back door. Let's go"! So thankful for the break from iPhone Facebooking, I slip on a pair of gloves and prepare myself to pull some poor person out of the back/passenger seat of a car that I assumed was parked in the ambulance bay. Apparently I was mistaken. My partner, who is ever the alarmist failed to mention that the code was coming in via another private EMS service and that they should be here in within the next 2 minutes.
So now we wait...with our gloves on. We wait by the door for the ambulance to pull up, throw the doors open with a flurry of CPR, epi, and all that other ACLS blood sweat, and tears type stuff. However, when they rolled up to the bay there was not as much commotion as I thought there would be. Apparently they got a pulse back. However, there sense of urgency dictated that the pt be placed in the resus bay ASAP!
We now have a 60ish year old pt with what appeared to be an extensive medical hx, based solely on the surgical scars that were every where. However, they were kind of breathing but still being hypoperfused thanks to the heart rate of about 30bpm and a BP of 80/badness. Obviously there was more work that needed to be done. Lines need to be placed, ultrasounds/x-rays need to be done, and decisions need to be made. I thought I would be in my element, what with being in the ER again. But I think I now have fully made the transition to prehospital instead of intrahospital clinician. I am used to running the show, not being merely a player in it. However, I did what I could to help out. As did my partner.
Now the medic that brought this pt in to the ER made mention that there was some swelling around the face and eyes. I recognized this right away. As a matter of fact, this pt was presenting with what I thought my very first cardiac arrest as a Paramedic presented with. Lots and lots of subcutaneous emphysema. It makes you look bloated and actually feels like rice krispies under the skin. It truly is an odd sight. So what this means is that there is a huge pneumothroax/pneumomediasteinum, or tracheobronchial tear that was due to either a traumatic intubation with right main stem intubation (my guess), a spontaneous pneumo that grew quickly with positive pressure ventilation, or both. Oddly enough the chest x-ray wasn't the most definitive and really wasn't much help.
So our rice krispied pt is still growing and the heart rate is in the 30s again. Atropine is given and gets it up for a bit. Then it goes back down into a third degree heart block. WTF? I know, that's what we all thought. But as the rate increase, either through drugs or positive thinking it would convert back to NSR. Just another thing to complicate this already "abstract" picture.
The air is building and building in the subcutaneous spaces and this pt is looking sicker by the second. A second IV was eventually placed and even a central line. The crazy thing about the lines was the fact that there was actually bubbles coming out of them. You would place a line or draw blood and that area would deflate a bit and you would even get an audible hiss. I can honestly say that I have never placed an IV and had the pt deflate before my eyes.
Shortly after all of this we were called to sit post, or as my partner calls it "hooking" because we are sitting on a street corner. Unfortunately we never were able to find out the end to what was causing the rice krispie phenomenon. An interesting case, none the less.
So now we wait...with our gloves on. We wait by the door for the ambulance to pull up, throw the doors open with a flurry of CPR, epi, and all that other ACLS blood sweat, and tears type stuff. However, when they rolled up to the bay there was not as much commotion as I thought there would be. Apparently they got a pulse back. However, there sense of urgency dictated that the pt be placed in the resus bay ASAP!
We now have a 60ish year old pt with what appeared to be an extensive medical hx, based solely on the surgical scars that were every where. However, they were kind of breathing but still being hypoperfused thanks to the heart rate of about 30bpm and a BP of 80/badness. Obviously there was more work that needed to be done. Lines need to be placed, ultrasounds/x-rays need to be done, and decisions need to be made. I thought I would be in my element, what with being in the ER again. But I think I now have fully made the transition to prehospital instead of intrahospital clinician. I am used to running the show, not being merely a player in it. However, I did what I could to help out. As did my partner.
Now the medic that brought this pt in to the ER made mention that there was some swelling around the face and eyes. I recognized this right away. As a matter of fact, this pt was presenting with what I thought my very first cardiac arrest as a Paramedic presented with. Lots and lots of subcutaneous emphysema. It makes you look bloated and actually feels like rice krispies under the skin. It truly is an odd sight. So what this means is that there is a huge pneumothroax/pneumomediasteinum, or tracheobronchial tear that was due to either a traumatic intubation with right main stem intubation (my guess), a spontaneous pneumo that grew quickly with positive pressure ventilation, or both. Oddly enough the chest x-ray wasn't the most definitive and really wasn't much help.
So our rice krispied pt is still growing and the heart rate is in the 30s again. Atropine is given and gets it up for a bit. Then it goes back down into a third degree heart block. WTF? I know, that's what we all thought. But as the rate increase, either through drugs or positive thinking it would convert back to NSR. Just another thing to complicate this already "abstract" picture.
The air is building and building in the subcutaneous spaces and this pt is looking sicker by the second. A second IV was eventually placed and even a central line. The crazy thing about the lines was the fact that there was actually bubbles coming out of them. You would place a line or draw blood and that area would deflate a bit and you would even get an audible hiss. I can honestly say that I have never placed an IV and had the pt deflate before my eyes.
Shortly after all of this we were called to sit post, or as my partner calls it "hooking" because we are sitting on a street corner. Unfortunately we never were able to find out the end to what was causing the rice krispie phenomenon. An interesting case, none the less.
For your consideration...
For your consideration, new EMS terms and phrases that I have encountered in the past few weeks.
***Disclaimer*** If you are easily offended, lighten up and do not read this post.
You might be a diabetic if...
You wake up surrounded by at least 2 strange people in matching uniforms.
You automatically spit out the phrase "I'm not paying for this"
have uttered the phrase "Not again" after intravenous D50% has been delivered.
Methasaurus Rex - An extremely large, agitated, and ultimately dangerous meth addict that wants to do bodily harm to you and anyone else within arms reach.
*Note: They can still see you even if you are standing still.
Decaf = blasphemy! - Based on a conversation I had with a friend about the pros and con of going without your cup of Joe for the day or trying to pass the counterfeit as the real thing. The next question is, should it be looked at as blasphemy or for those, much like myself who are apparently sensitive to the vasoactive effects of caffeine, as cardio protective. You know...the same way a beta block is, but without the decreased libido.
Just a few thoughts for now. Thankfully the summer semester is winding down and I will be able to work on a few more stories.
***Disclaimer*** If you are easily offended, lighten up and do not read this post.
You might be a diabetic if...
You wake up surrounded by at least 2 strange people in matching uniforms.
You automatically spit out the phrase "I'm not paying for this"
have uttered the phrase "Not again" after intravenous D50% has been delivered.
Methasaurus Rex - An extremely large, agitated, and ultimately dangerous meth addict that wants to do bodily harm to you and anyone else within arms reach.
*Note: They can still see you even if you are standing still.
Decaf = blasphemy! - Based on a conversation I had with a friend about the pros and con of going without your cup of Joe for the day or trying to pass the counterfeit as the real thing. The next question is, should it be looked at as blasphemy or for those, much like myself who are apparently sensitive to the vasoactive effects of caffeine, as cardio protective. You know...the same way a beta block is, but without the decreased libido.
Just a few thoughts for now. Thankfully the summer semester is winding down and I will be able to work on a few more stories.
Saturday, July 14, 2012
I know you are high right now, but...
Recently working a shift on one of the big white boxes that I call my office, we get dispatched to a location for a possible overdose. The neighborhood was not one that you would assume would have very many drug related issues. Even with us currently being in Beaver Cleaver-ville, we still had to wait for PD to secure the scene. It didn't take too long, so we just sat on the street corner waiting for them to make it "safe" for us.
Well when we finally get inside I notice that the pt is breathing but is being difficult with the FD. I don't mean difficult as in violent, aggressive, or dangerous. I mean difficult in that "I'm gonna act like a 5 year old" kind of way. This pt apparently took 50+ pills of a commonly prescribed flavor of benzodiazapine and an unknown amount of what I am going to describe as "almost a narcotic". So generally, with my experience, if you take 50-70 of anything, you are usually not going to be doing very well. Lucky for this person, that was not the case. They were just being kind of difficult and basically just ridiculous about the situation. Thankfully the police were able to convince our pt to go with us willingly as opposed to in hand cuffs.
Mean while there are two other people that just so happen to be on scene who were almost no help at all. Even though I think they called 911 in the first place. One was not wearing a shirt (of course) and could barely say anything more than "dude" or "bro". I am certain his particular brand of canniboid was similar to what was offered in the movie "Ted". Mind-rape, "they're coming! They're coming!", or "It's permanent". I think he went with the last one and never looked back. Seriously, all this guy did was smile, giggle from time to time, and scratch his head.
Anyway, since pt OD may or may not have taken a bunch of pills, we had to play it better safe than sorry. We put in two IVs, hooked them up to the ekg, and got our vitals going. The typical IV, O2, monitor type situation. The pt was pretty cooperative but was still sleepy and voicing the opinion that there was no need to go to the hospital. Sorry, if you take 50-70 of anything that are not M&Ms or skittles, you are going to the hospital. Whether you like it or not. Thankfully our transport was pretty uneventful. Oh, and Narcan had no effect on this pts status at all. I know, it's not for benzos! So don't even start with that. However, people who overdose usually don't tell EMS the complete truth. It's as much diagnostic as therapeutic. Besides, EMS gets the story of "I don't do drugs and I want your badge number!". The RN gets "Well, I tried the pot once. Can I have some Dilaudid?". The doctor gets "I have been an IV drug user for 20 years and I am currently on angel dust, bath salts, and I vote democratic.
So we finally get to the hospital and I give report to one of the RNs and transfer care to them. And done...right? Not so much. Suddenly the pt feels as though they have had enough and decide to try and leave. Well the 90lbs of RN immediately calls for security. I walk into the room and help restrain what I can only describe as a very lazy attempt at escape. A few other EMS people are helping restrain the pt. The pt keeps trying to tell us that they have had enough and it was time to go home. "I'm leaving. Come on Frank (or whatever the friends name was) get the keys we are out of here". While still holding one of the extremities down I tap the pt on the forehead and say "knock knock". They immediately giggle and give up the fight. Thankfully this was at the same time that security came in with the leathers and we were able to secure the pt to the bed.
Well when we finally get inside I notice that the pt is breathing but is being difficult with the FD. I don't mean difficult as in violent, aggressive, or dangerous. I mean difficult in that "I'm gonna act like a 5 year old" kind of way. This pt apparently took 50+ pills of a commonly prescribed flavor of benzodiazapine and an unknown amount of what I am going to describe as "almost a narcotic". So generally, with my experience, if you take 50-70 of anything, you are usually not going to be doing very well. Lucky for this person, that was not the case. They were just being kind of difficult and basically just ridiculous about the situation. Thankfully the police were able to convince our pt to go with us willingly as opposed to in hand cuffs.
Mean while there are two other people that just so happen to be on scene who were almost no help at all. Even though I think they called 911 in the first place. One was not wearing a shirt (of course) and could barely say anything more than "dude" or "bro". I am certain his particular brand of canniboid was similar to what was offered in the movie "Ted". Mind-rape, "they're coming! They're coming!", or "It's permanent". I think he went with the last one and never looked back. Seriously, all this guy did was smile, giggle from time to time, and scratch his head.
Anyway, since pt OD may or may not have taken a bunch of pills, we had to play it better safe than sorry. We put in two IVs, hooked them up to the ekg, and got our vitals going. The typical IV, O2, monitor type situation. The pt was pretty cooperative but was still sleepy and voicing the opinion that there was no need to go to the hospital. Sorry, if you take 50-70 of anything that are not M&Ms or skittles, you are going to the hospital. Whether you like it or not. Thankfully our transport was pretty uneventful. Oh, and Narcan had no effect on this pts status at all. I know, it's not for benzos! So don't even start with that. However, people who overdose usually don't tell EMS the complete truth. It's as much diagnostic as therapeutic. Besides, EMS gets the story of "I don't do drugs and I want your badge number!". The RN gets "Well, I tried the pot once. Can I have some Dilaudid?". The doctor gets "I have been an IV drug user for 20 years and I am currently on angel dust, bath salts, and I vote democratic.
So we finally get to the hospital and I give report to one of the RNs and transfer care to them. And done...right? Not so much. Suddenly the pt feels as though they have had enough and decide to try and leave. Well the 90lbs of RN immediately calls for security. I walk into the room and help restrain what I can only describe as a very lazy attempt at escape. A few other EMS people are helping restrain the pt. The pt keeps trying to tell us that they have had enough and it was time to go home. "I'm leaving. Come on Frank (or whatever the friends name was) get the keys we are out of here". While still holding one of the extremities down I tap the pt on the forehead and say "knock knock". They immediately giggle and give up the fight. Thankfully this was at the same time that security came in with the leathers and we were able to secure the pt to the bed.
Wednesday, June 27, 2012
That's one way to get out of a car...
So recently I was working my regular shift with a part time employee. She is a great partner and is always nice. However, all we did that day was putz around in wonderful world of transfers. Not a single priority one. Well, until the very end.
We were on our way to do a very easy but not exactly stimulating transfer from here to there when my partner and I get stuck in traffic. I wasn't paying attention and didn't notice the obvious wreck about a block or two in front of us. I thought it was just someone putting their boat in the water. As it turns out, we just happened to have rolled up onto an MVA. A head on collision, to be exact. I guess it was a good thing that I was not driving. Ha!
So there was A LOT of damage to both vehicles. Apparently they were going about 40-50mphs each as they hit one another. There was so much in fact that neither person was able to self extricate themselves. So one was just as simple as "Hey, why don't you crawl out the passenger door". The other pt wasn't exactly as simple. The steering wheel was about 2 inches from their face and actually touching their chest. Oddly enough, this person was pretty lackadaisical about the whole situation. The one problem was the retrograde amnesia that this person was experiencing. At least they were not really in any pain.
At this point, the fire department showed up as well as the EMS company that normally runs in that area. Fire immediately got into extrication mode and came over to assess the situation. They quickly got suited up and busted out all the tools. It's extrication time! Now, I am currently holding c-spine in the back of this heap of twisted metal and talking with this lady about what was about to happen and asking her questions about the event. Then suddenly we are covered with a blanket. Oh yeah! They kind of have to cut us out of this pile of metal that was once your car. It might get a little noisy for a bit. BOOM/CRASH goes the window! and out come the cutting tools. Which were not as noisy as I remember them to be.
Meanwhile, under the tarp...we hear and feel broken glass landing on top of us and hear the cutting of metal and plastic by hydraulic tools that I am sure the FD was more than happy to employ. After all, they are firemen. They got us out in really no time at all. However, as it turns out we were stuck in the car for about 20+ minutes. And that is not including the time before the FD got there.
Once the B post was removed, we get this pt in full spinal precautions and get them into the waiting ambulance to get the ALS part of the call underway. It was a very smooth extrication and allowed us time to get all of our ducks in a row before hand. As we are going to the truck I ask one of the fire guys where is the closest trauma center and he points us in the direction to the closest super hospital.
So we do the eyes and scissors things, put in a big IV (even though the pt said they were "a hard stick") and got our vitals going. Now it is time to apply some high flow diesel to the situation and start rolling priority one per protocol. The pt was currently stable but chancing it was not the greatest idea. It seemed like most of what was done was with the idea that it was "better safe than sorry". However, I would rather be more aggressive and not have it be that bad than write off a potentially life threatening situation. I don't have a CT scanner or x-ray vision so traveling priority one to the hospital will have to do for now.
I call report enroute, reassess my pt, and help my partner get us there. My partner did an excellent job. I didn't really need to do anything to help. And when I called report I said that we were about 10 minutes out. As it turns out, that was a gross underestimate. We were more like 20 minutes out. It didn't really make the trauma team all that happy, but it could have been much worse. It's funny. The entire time the pt seemed to have this "I don't know what is such a big deal" kind of attitude about the whole situation. It was kind of funny.
Upon our arrival, we give report to the trauma team and hand off patient care. I have to say I always love giving a trauma report because you get to yell over everyone and can even put a big piece of tape on their chest and write stuff on it.
It wasn't a bad call to end out the shift with. However, it did keep us over for about an extra hour or so. Oh well, I could always use the extra overtime. Gotta love a good trauma call when all the players involved work together as a team.
We were on our way to do a very easy but not exactly stimulating transfer from here to there when my partner and I get stuck in traffic. I wasn't paying attention and didn't notice the obvious wreck about a block or two in front of us. I thought it was just someone putting their boat in the water. As it turns out, we just happened to have rolled up onto an MVA. A head on collision, to be exact. I guess it was a good thing that I was not driving. Ha!
So there was A LOT of damage to both vehicles. Apparently they were going about 40-50mphs each as they hit one another. There was so much in fact that neither person was able to self extricate themselves. So one was just as simple as "Hey, why don't you crawl out the passenger door". The other pt wasn't exactly as simple. The steering wheel was about 2 inches from their face and actually touching their chest. Oddly enough, this person was pretty lackadaisical about the whole situation. The one problem was the retrograde amnesia that this person was experiencing. At least they were not really in any pain.
At this point, the fire department showed up as well as the EMS company that normally runs in that area. Fire immediately got into extrication mode and came over to assess the situation. They quickly got suited up and busted out all the tools. It's extrication time! Now, I am currently holding c-spine in the back of this heap of twisted metal and talking with this lady about what was about to happen and asking her questions about the event. Then suddenly we are covered with a blanket. Oh yeah! They kind of have to cut us out of this pile of metal that was once your car. It might get a little noisy for a bit. BOOM/CRASH goes the window! and out come the cutting tools. Which were not as noisy as I remember them to be.
Meanwhile, under the tarp...we hear and feel broken glass landing on top of us and hear the cutting of metal and plastic by hydraulic tools that I am sure the FD was more than happy to employ. After all, they are firemen. They got us out in really no time at all. However, as it turns out we were stuck in the car for about 20+ minutes. And that is not including the time before the FD got there.
Once the B post was removed, we get this pt in full spinal precautions and get them into the waiting ambulance to get the ALS part of the call underway. It was a very smooth extrication and allowed us time to get all of our ducks in a row before hand. As we are going to the truck I ask one of the fire guys where is the closest trauma center and he points us in the direction to the closest super hospital.
So we do the eyes and scissors things, put in a big IV (even though the pt said they were "a hard stick") and got our vitals going. Now it is time to apply some high flow diesel to the situation and start rolling priority one per protocol. The pt was currently stable but chancing it was not the greatest idea. It seemed like most of what was done was with the idea that it was "better safe than sorry". However, I would rather be more aggressive and not have it be that bad than write off a potentially life threatening situation. I don't have a CT scanner or x-ray vision so traveling priority one to the hospital will have to do for now.
I call report enroute, reassess my pt, and help my partner get us there. My partner did an excellent job. I didn't really need to do anything to help. And when I called report I said that we were about 10 minutes out. As it turns out, that was a gross underestimate. We were more like 20 minutes out. It didn't really make the trauma team all that happy, but it could have been much worse. It's funny. The entire time the pt seemed to have this "I don't know what is such a big deal" kind of attitude about the whole situation. It was kind of funny.
Upon our arrival, we give report to the trauma team and hand off patient care. I have to say I always love giving a trauma report because you get to yell over everyone and can even put a big piece of tape on their chest and write stuff on it.
It wasn't a bad call to end out the shift with. However, it did keep us over for about an extra hour or so. Oh well, I could always use the extra overtime. Gotta love a good trauma call when all the players involved work together as a team.
Sunday, June 24, 2012
Can I go home already?
This was an entry that I apparently forgot to click "publish" about a year ago. Hopefully I didn't just double post it.
So due to chronic workaholism, I signed up for 36 hours of work in a row. That being a 24 hour shift followed by a 12 that following morning. To the non EMS people out there, this seems like a lot of work. Not all the time. Yes, I am at work for 36 hours, but I am normally working rescue. Meaning we have a station or building to stay in with beds, TV, and kitchen. So when we are not running calls, we can relax. Unlike working a truck that posts, meaning you have to sit in the truck for hours until you get a call.
The first 24 hours was not a big deal. I think we did a total of 5 calls. Nothing super exciting. No big deal. I was able to do a lot of homework and be super productive while getting paid for it. That's cool. It just felt like the first 24 hours took forever and a day.
The following 12 hour shift on the other side of town was slightly busier for the first half. Then there was a significant lull and I was so very bored. I was tapped out on homework and was just waiting for the shift to end in the final hour. Unfortunately, my relief never showed up. This was due to an error on the part of the scheduler and the system they have in place. It wasn't cool. So Shift change came and went. Then we got a call. And then another call. And another. Gotta love the job sometimes. What added insult to injury was the fact that we had a call to Chili's when I was already starving. Ugh!
However, the call to Chili's was actually pretty cool. We had a lady in her 40s who "fell" per dispatch. So we get there and she is laying down in a booth and looking a bit out of it. So I ask her to open her eyes and basically wake up. She does, but I don't know why people that feel well loose the ability to speak up. Whatever. Anyway, the local FD that is there is having trouble getting a BP. She has a very weak and thready radial pulse and she feels ill. So we put her on our monitor and get our stuff rolling. Sats are fine, heart rate is 39-42, and her BP is in the toilet (60/30). The monitor is actually showing first a junctional rhythm which shortly changes to a 2nd degree type II and then to sinus brady. Odd. No real hx but at this point we are very happy that she is sinus. BTW, the place is packed. It's a Saturday night and people are out on the town.
We move out of the very cramped restaurant and bring our pt to the truck. We have a student with us and have an excellent teaching case for her. Low BP+Bradycardia+AMS=IV, O2, monitor, Fluids, Atropine, and TCP. She verbalized that fine, but unfortunately for the student and fortunately for the pt the vitals turned around and we didn't have to go priority one or treat with medicine or Edison. But it was at least an ALS call. I don't mind staying over for those.
So due to chronic workaholism, I signed up for 36 hours of work in a row. That being a 24 hour shift followed by a 12 that following morning. To the non EMS people out there, this seems like a lot of work. Not all the time. Yes, I am at work for 36 hours, but I am normally working rescue. Meaning we have a station or building to stay in with beds, TV, and kitchen. So when we are not running calls, we can relax. Unlike working a truck that posts, meaning you have to sit in the truck for hours until you get a call.
The first 24 hours was not a big deal. I think we did a total of 5 calls. Nothing super exciting. No big deal. I was able to do a lot of homework and be super productive while getting paid for it. That's cool. It just felt like the first 24 hours took forever and a day.
The following 12 hour shift on the other side of town was slightly busier for the first half. Then there was a significant lull and I was so very bored. I was tapped out on homework and was just waiting for the shift to end in the final hour. Unfortunately, my relief never showed up. This was due to an error on the part of the scheduler and the system they have in place. It wasn't cool. So Shift change came and went. Then we got a call. And then another call. And another. Gotta love the job sometimes. What added insult to injury was the fact that we had a call to Chili's when I was already starving. Ugh!
However, the call to Chili's was actually pretty cool. We had a lady in her 40s who "fell" per dispatch. So we get there and she is laying down in a booth and looking a bit out of it. So I ask her to open her eyes and basically wake up. She does, but I don't know why people that feel well loose the ability to speak up. Whatever. Anyway, the local FD that is there is having trouble getting a BP. She has a very weak and thready radial pulse and she feels ill. So we put her on our monitor and get our stuff rolling. Sats are fine, heart rate is 39-42, and her BP is in the toilet (60/30). The monitor is actually showing first a junctional rhythm which shortly changes to a 2nd degree type II and then to sinus brady. Odd. No real hx but at this point we are very happy that she is sinus. BTW, the place is packed. It's a Saturday night and people are out on the town.
We move out of the very cramped restaurant and bring our pt to the truck. We have a student with us and have an excellent teaching case for her. Low BP+Bradycardia+AMS=IV, O2, monitor, Fluids, Atropine, and TCP. She verbalized that fine, but unfortunately for the student and fortunately for the pt the vitals turned around and we didn't have to go priority one or treat with medicine or Edison. But it was at least an ALS call. I don't mind staying over for those.
Welcome home!
I know it has been a while, but I just want to make mention of the fact that the hardest working trauma/ER RN that I know just got back from her deployment safe and sound! Thank you for your service and what you did for the men and women of the military. You have my deepest thanks and gratitude. Now get some rest and enjoy your time with your loved ones. You earned it. Thank you, Angela.
Saturday, June 2, 2012
Volume before thought
I just love it when I have the opportunity to do things that require me to "think outside of the box". In EMS, this can come up pretty often and the more creative you are the more successful you can be. On the flip side, doing something differently just because you can is not a good enough reason most of the time. Putting an IV in a patient's foot just because you could usually doesn't fly.
However, speaking of odd IV placement and thinking outside of the box, it reminds me of an interesting situation during my days working in the ER while on active duty. I forgot if it was day shift or night shift, but the relevant details still remain in my head.
The shift was plugging along with nothing really out of the ordinary, until we get a knocking on the ambulance bay doors. I can see an SUV parked in front of our ambulance with an elderly woman waiting impatiently for us. As I walk towards the doors to see what all the commotion was about, I can see she already has the back doors of this modern day "grocery getter" open and there are feet poking out the back. The first thing that goes through my head is "I really don't want to do CPR right now". So I rush over to find a breathing, circulating, and perfusing man lying in the back of this gas guzzler with an extensive medical hx. And that was just by looking at all the old surgical scars and the trach and old trach scars. I look at the woman that drove the vehicle for answers as a few of the other medics are bringing out a stretcher to get this patient out of the truck and inside. She then tells me "When he gets dehydrated. he goes into A cardiac arrest". Good to know.
As we get him inside for a better look/assessment you can already tell that he is sick. Breathing fast, no radial pulse, and just agitated. Oh and he was cold too. Great. So IV, O2, and monitor treatment are started. Well the IV part was not successful as of yet. This poor guy was about as vascular as a potato and can only be described as a miracle of modern medicine. His v/s were not exactly great. BP of 70/40, heart rate of 140, and resps at about 30. So we need to do stuff to this guy and fast.
The search for the elusive vein was turning up diddly in all the usual spots. No AC, EJ, saphaneous, or hand veins. There was a whole lot of nothing. However, as I was looking for an EJ I notice he has a scalp vein. A decent one at that. So I shrug my shoulders in a very "it's better than nothing" kind of way and stick it. Flash, advance, flush, and secure. BAM! We now have access. Just as I put the IV in the spouse of the patient yells out "What the hell is that"! It is an IV that is desperately needed and a crucial part of the care and resus for this poor patient. Thankfully the MD was right there to explain why it was acceptable practice and not medical blasphemy and she calmed down.
The 20g in the right forehead allowed us to give a liter or two of fluid tank up our guy enough to get normal vital signs and a significantly more comfortable looking patient. Securing this line in place made the guy look like he was wearing a "foam dome", you know the beer dispensing helmets. Minus the beer. So all's well that ends well, right?
Well the ICU called down to have a few words with me later on. They used phrases like "you can't do that" and "what are you trying to pull". My answer was it was either that or an I/O. This line can stay in for 3 days, per hospital policy while an I/O can only stay for 24 hours. Additionally, we do scalp lines on kids all the time. What is the difference between doing so on an 8 month old v/s an 80 y/o? The line went quiet and then was quickly hung up on by their end. I guess I made my point. I decided not to call them back to say that before they increase their volume that they should put some thought into the issue at hand.
The point of this story stresses what I was taught from day one as a medic. You get a line where ever you can. It may not be text book and you damn well sure it is not going to be pretty. As long as it is in a vein and it works, we can address the finer details later. I have to say I was quite proud of that line. Even if it was only a 20g.
However, speaking of odd IV placement and thinking outside of the box, it reminds me of an interesting situation during my days working in the ER while on active duty. I forgot if it was day shift or night shift, but the relevant details still remain in my head.
The shift was plugging along with nothing really out of the ordinary, until we get a knocking on the ambulance bay doors. I can see an SUV parked in front of our ambulance with an elderly woman waiting impatiently for us. As I walk towards the doors to see what all the commotion was about, I can see she already has the back doors of this modern day "grocery getter" open and there are feet poking out the back. The first thing that goes through my head is "I really don't want to do CPR right now". So I rush over to find a breathing, circulating, and perfusing man lying in the back of this gas guzzler with an extensive medical hx. And that was just by looking at all the old surgical scars and the trach and old trach scars. I look at the woman that drove the vehicle for answers as a few of the other medics are bringing out a stretcher to get this patient out of the truck and inside. She then tells me "When he gets dehydrated. he goes into A cardiac arrest". Good to know.
As we get him inside for a better look/assessment you can already tell that he is sick. Breathing fast, no radial pulse, and just agitated. Oh and he was cold too. Great. So IV, O2, and monitor treatment are started. Well the IV part was not successful as of yet. This poor guy was about as vascular as a potato and can only be described as a miracle of modern medicine. His v/s were not exactly great. BP of 70/40, heart rate of 140, and resps at about 30. So we need to do stuff to this guy and fast.
The search for the elusive vein was turning up diddly in all the usual spots. No AC, EJ, saphaneous, or hand veins. There was a whole lot of nothing. However, as I was looking for an EJ I notice he has a scalp vein. A decent one at that. So I shrug my shoulders in a very "it's better than nothing" kind of way and stick it. Flash, advance, flush, and secure. BAM! We now have access. Just as I put the IV in the spouse of the patient yells out "What the hell is that"! It is an IV that is desperately needed and a crucial part of the care and resus for this poor patient. Thankfully the MD was right there to explain why it was acceptable practice and not medical blasphemy and she calmed down.
The 20g in the right forehead allowed us to give a liter or two of fluid tank up our guy enough to get normal vital signs and a significantly more comfortable looking patient. Securing this line in place made the guy look like he was wearing a "foam dome", you know the beer dispensing helmets. Minus the beer. So all's well that ends well, right?
Well the ICU called down to have a few words with me later on. They used phrases like "you can't do that" and "what are you trying to pull". My answer was it was either that or an I/O. This line can stay in for 3 days, per hospital policy while an I/O can only stay for 24 hours. Additionally, we do scalp lines on kids all the time. What is the difference between doing so on an 8 month old v/s an 80 y/o? The line went quiet and then was quickly hung up on by their end. I guess I made my point. I decided not to call them back to say that before they increase their volume that they should put some thought into the issue at hand.
The point of this story stresses what I was taught from day one as a medic. You get a line where ever you can. It may not be text book and you damn well sure it is not going to be pretty. As long as it is in a vein and it works, we can address the finer details later. I have to say I was quite proud of that line. Even if it was only a 20g.
Monday, May 28, 2012
BLS turned very very ALS
So it was just "one of those days" where we seemed to be stuck in BLS priority 3 purgatory. Nothing exciting was happening and the day was dragging along. Then our pagers go off! Is it a rescue? A trauma? Should we launch the bird? No. It's another priority 3 nursing home call. Ugh! So after putting our "happy to be here, proud to serve" faces, we turn our bus (because that is what it is today) and head to the facility.
When we get there the staff doesn't seem excited, but the patient appears to look kind of sick. However, sometimes with this patient population, that could very well be their baseline. So we get our pt packaged up and collect the necessary documentation and get a set of vitals once we start rolling. No sooner as we put the vehicle in drive, things took a turn for the unexpected.
Our patient is hypotensive, tachycardic and septic. This drastically changes our approach to this situation. So I inform our LOL who is no longer considered to be in NAD and is probably not too far off from CTD. Look up the acronyms on Google or urban dictionary, two out of the three are not exactly "official". I tell my partner the situation and he asks if I want to divert to another facility. Not at the moment, as of right now I can still treat this. I put my patient on some oxygen and an IV gets started and then my patient informs me that they have a PICC line. Well, that could have saved me some time, but thank you, LOL who is now in acute distress.
And the fluid resuscitation begins! First bolus goes in kind of slow and there was no real change to the pt's status. So in true ghetto medic fashion, I slap a BP cuff on the IV bag to create a pressure bag to get some fluid in a bit faster. I have to admit, I always love doing that. Mainly because the hospital looks at you like you are crazy when you walk through the door with that hanging. So my Mcgyver set up is getting the job done. However, bolus number two is not. Pt was reassessed and still found to be hypotensive and very tachycardic. I poke my head through the "doorway" up to the cab of the truck and tell my partner to "step it up". I called ahead to the receiving hospital and gave them a quick run down on the situation. At this point we were about 10 minutes out from our destination.
So boluses three and four do not touch the heart rate but bring up the BP slightly. Still hypotensive but higher than what it was. As we roll into the super hospital, the staff looks at my BP cuff pressure bag with a look of "you can't do that" mixed with "I wish I thought of that". I give report and they take over pt care.
Point of all of this is tow fold. One is to always be on your toes , because you never know when you are going to be sucked out of priority 3 purgatory. And two, you have to make the most of your equipment to do the best job you can. After all, as they say in the USAF "flexibility is the key to air power".
When we get there the staff doesn't seem excited, but the patient appears to look kind of sick. However, sometimes with this patient population, that could very well be their baseline. So we get our pt packaged up and collect the necessary documentation and get a set of vitals once we start rolling. No sooner as we put the vehicle in drive, things took a turn for the unexpected.
Our patient is hypotensive, tachycardic and septic. This drastically changes our approach to this situation. So I inform our LOL who is no longer considered to be in NAD and is probably not too far off from CTD. Look up the acronyms on Google or urban dictionary, two out of the three are not exactly "official". I tell my partner the situation and he asks if I want to divert to another facility. Not at the moment, as of right now I can still treat this. I put my patient on some oxygen and an IV gets started and then my patient informs me that they have a PICC line. Well, that could have saved me some time, but thank you, LOL who is now in acute distress.
And the fluid resuscitation begins! First bolus goes in kind of slow and there was no real change to the pt's status. So in true ghetto medic fashion, I slap a BP cuff on the IV bag to create a pressure bag to get some fluid in a bit faster. I have to admit, I always love doing that. Mainly because the hospital looks at you like you are crazy when you walk through the door with that hanging. So my Mcgyver set up is getting the job done. However, bolus number two is not. Pt was reassessed and still found to be hypotensive and very tachycardic. I poke my head through the "doorway" up to the cab of the truck and tell my partner to "step it up". I called ahead to the receiving hospital and gave them a quick run down on the situation. At this point we were about 10 minutes out from our destination.
So boluses three and four do not touch the heart rate but bring up the BP slightly. Still hypotensive but higher than what it was. As we roll into the super hospital, the staff looks at my BP cuff pressure bag with a look of "you can't do that" mixed with "I wish I thought of that". I give report and they take over pt care.
Point of all of this is tow fold. One is to always be on your toes , because you never know when you are going to be sucked out of priority 3 purgatory. And two, you have to make the most of your equipment to do the best job you can. After all, as they say in the USAF "flexibility is the key to air power".
Saturday, May 26, 2012
Oh btw...
I passed my FP-C!!! For those of you that do not know what that is, it is the Flight Paramedic - Certification. I am that much closer to obtaining my dream job. It was not an easy journey. I studied just about everyday for a year. I ended up passing with a 90%. I was so nervous when I was waiting on my results. When I was handed the paper with my fate printed on it, I almost forgot how to read. Ha! At first I thought I failed it because I read the wrong numbers. After a minute or two I realized I actually passed with a great score! I almost kissed the old lady that gave me the paper. That was a great feeling. Now on to the next challenge.
Saturday, May 12, 2012
Complicated NSTEMI is medical terminology for a lot of work!
So in true MICU fashion, we went for a while with nothing exciting to getting a few interesting calls in a row recently. As the title of this post suggests, we took care of a complicated NSTEMI. It is not too often that we take people out of the ICU at our base hospital. Especially on beautiful days with almost no clouds in the sky and minimal wind. Basically this patient should have received a scenic tour to the downtown super hospital via an EC145 or whatever the airframe of the aeromedical provider is utilizing that day. However, we made it happen.
Our patient decided to start having extreme difficulty breathing up there in ICU land and actually had to be intubated. He also decided to say "screw you guys, I'm going into cardiogenic shock"! I'm sure a few of you read that in Cartman's voice. lol. At any rate, this patient who had received a PVC challenge with out paralytics was fighting the tube and required both chemical and physical restraints. Good times.
As it turns out, this pt was having a rather large and complicated cardiac event that required pressors, vasodialators, sedation, pain management, continuous bladder irrigation (CBI), and ultimately a cardiac cath. It was a bit of an ordeal just getting this pt transferred to our equipment and gurney. So much in fact that we had to call for an extra set of hands to drive us priority one to the super hospital where the cath team was waiting.
As my partner starts swapping things over to our equipment, I start asking the friendly neighborhood RN what the story was with this pt. I get a jumbled and some what inadequate report and had to piece the rest together from the chart and the Doc. Oh and we are still trying to get everything swapped.
Just as we are finishing up getting pumps and vents set up and swapped over, our back up arrives. Oh good, we can go now! As we are getting the pt over to the gurney and swapping vents, our "Frankenstein vent" as my partner likes to call it, dies. Great. Not to worry though, the crew that showed up for man power also happened to be a MICU crew that had a vent. So we just borrowed theirs.
Now that we are out of the ICU and what felt like transfer purgatory, we still had a 35-40 minute drive to the cath lab at the super hospital. It's ok. It will just be a bit bumpy until we hit the interstate. Vitals q 5 min and watching the vent should be an easy task. After all, the transfer from the bed to the gurney was the hard part...right? Well I guess we were wrong on that one.
Remember how I said it was a complicated NSTEMI? Well the pt decides to dump their pressure enroute and brady down a bit. Not cool, intubated sick guy! The bradycardia was probably due to the A1 drug we had running but the hypotension wasn't. However, a fluid bolus did help get the pt back on track.Simple solutions for what seems like a complicated problem. Side note ***next time you listen to heart tones, try doing so with either a radio playing or someone yelling in your ear. Just to make it challenging. Because we had lights, sirens, horns, and bumping equipment to contend with. Should be interesting.*** At least no one was shooting at us.
So after our little bout of hypotension, we notice our pt needed the CBI bag changed. Doing so without getting fruit punch colored urine on your clothing is one thing. Doing the same thing down a highway that is in need of repair was nothing short of a miracle. Thankfully I will be able to wear that uniform again for another day. lol.
As we approach our destination, my partner calls report while trying to adjust a problem pump. He ended up putting the lab on speaker phone. I was monitoring the vent and the monitor at this point when suddenly under the chaos of traffic and the notice that is being put out by our ambulance, I hear crappy elevator hold music. The first thing that comes through my mind is "really?". I look at my partner and go "Are we really on hold right now?", to which he just rolls his eyes and hits end call. He gets the pump issue resolved and ends up calling report about 5 minutes out.
Upon our arrival to the facility, we move through the ER dodging IV poles, linen hampers, and the nursing staff. All that was said by all parties was "CATH LAB"! Once we get to the lab, my partner and I give report and get everything all transferred and swapped. Then I get the task of playing ventilator while we wait for respiratory to arrive. It only took about 10 minuets. It was probably a good thing. It gave me time to let my endogenous catecholamines wear off so I could return to my normal sinus brady.
Is it odd that I would rather have complicated MICU calls all day and loath boring (but easy) priority 3 transfers? The jury is still out on that one. lol.
Our patient decided to start having extreme difficulty breathing up there in ICU land and actually had to be intubated. He also decided to say "screw you guys, I'm going into cardiogenic shock"! I'm sure a few of you read that in Cartman's voice. lol. At any rate, this patient who had received a PVC challenge with out paralytics was fighting the tube and required both chemical and physical restraints. Good times.
As it turns out, this pt was having a rather large and complicated cardiac event that required pressors, vasodialators, sedation, pain management, continuous bladder irrigation (CBI), and ultimately a cardiac cath. It was a bit of an ordeal just getting this pt transferred to our equipment and gurney. So much in fact that we had to call for an extra set of hands to drive us priority one to the super hospital where the cath team was waiting.
As my partner starts swapping things over to our equipment, I start asking the friendly neighborhood RN what the story was with this pt. I get a jumbled and some what inadequate report and had to piece the rest together from the chart and the Doc. Oh and we are still trying to get everything swapped.
Just as we are finishing up getting pumps and vents set up and swapped over, our back up arrives. Oh good, we can go now! As we are getting the pt over to the gurney and swapping vents, our "Frankenstein vent" as my partner likes to call it, dies. Great. Not to worry though, the crew that showed up for man power also happened to be a MICU crew that had a vent. So we just borrowed theirs.
Now that we are out of the ICU and what felt like transfer purgatory, we still had a 35-40 minute drive to the cath lab at the super hospital. It's ok. It will just be a bit bumpy until we hit the interstate. Vitals q 5 min and watching the vent should be an easy task. After all, the transfer from the bed to the gurney was the hard part...right? Well I guess we were wrong on that one.
Remember how I said it was a complicated NSTEMI? Well the pt decides to dump their pressure enroute and brady down a bit. Not cool, intubated sick guy! The bradycardia was probably due to the A1 drug we had running but the hypotension wasn't. However, a fluid bolus did help get the pt back on track.Simple solutions for what seems like a complicated problem. Side note ***next time you listen to heart tones, try doing so with either a radio playing or someone yelling in your ear. Just to make it challenging. Because we had lights, sirens, horns, and bumping equipment to contend with. Should be interesting.*** At least no one was shooting at us.
So after our little bout of hypotension, we notice our pt needed the CBI bag changed. Doing so without getting fruit punch colored urine on your clothing is one thing. Doing the same thing down a highway that is in need of repair was nothing short of a miracle. Thankfully I will be able to wear that uniform again for another day. lol.
As we approach our destination, my partner calls report while trying to adjust a problem pump. He ended up putting the lab on speaker phone. I was monitoring the vent and the monitor at this point when suddenly under the chaos of traffic and the notice that is being put out by our ambulance, I hear crappy elevator hold music. The first thing that comes through my mind is "really?". I look at my partner and go "Are we really on hold right now?", to which he just rolls his eyes and hits end call. He gets the pump issue resolved and ends up calling report about 5 minutes out.
Upon our arrival to the facility, we move through the ER dodging IV poles, linen hampers, and the nursing staff. All that was said by all parties was "CATH LAB"! Once we get to the lab, my partner and I give report and get everything all transferred and swapped. Then I get the task of playing ventilator while we wait for respiratory to arrive. It only took about 10 minuets. It was probably a good thing. It gave me time to let my endogenous catecholamines wear off so I could return to my normal sinus brady.
Is it odd that I would rather have complicated MICU calls all day and loath boring (but easy) priority 3 transfers? The jury is still out on that one. lol.
Saturday, May 5, 2012
Stars of Life.
The past week has been very busy. However, it wasn't with sick or traumatized patients. It was with meetings and ceremonies. It's a bit out of character for me, I know. However, I was honored in D.C. at the annual AAA "Star's of Life". I will not go into the details of who the AAA is and what they do, but you can follow the link to find out more.
At any rate, it was a great experience. I was able to meet some of the best and brightest in the industry that were from all parts of the country and even the world. While I was there I not only got to tour the Nation's capitol (And run around it. Awesome!), but I was able to get a glimpse of how private EMS operates on the national level and even was part of a bit of lobbying. All in all, it was an interesting and enriching experience. Hopefully I will be able to return to D.C. again soon.
At any rate, it was a great experience. I was able to meet some of the best and brightest in the industry that were from all parts of the country and even the world. While I was there I not only got to tour the Nation's capitol (And run around it. Awesome!), but I was able to get a glimpse of how private EMS operates on the national level and even was part of a bit of lobbying. All in all, it was an interesting and enriching experience. Hopefully I will be able to return to D.C. again soon.
Saturday, April 28, 2012
Nothing exciting on the MICU, but...
Recently we really have not had anything too exciting or blog worthy on my truck. That's ok. It happens. I seems to be either feast or famine up here. I guess if people don't need saving, that is a good thing.
At any rate, tomorrow I will be fortunate enough to attend the "Stars of Life" event in D.C. starting tomorrow. It should be an interesting experience. I have not been to D.C. in about 15 years. I am looking forward to it. I will share any updates and/or new developments as they happen. Until then, it is the typical game of catch up that I am always playing. Bye for now.
At any rate, tomorrow I will be fortunate enough to attend the "Stars of Life" event in D.C. starting tomorrow. It should be an interesting experience. I have not been to D.C. in about 15 years. I am looking forward to it. I will share any updates and/or new developments as they happen. Until then, it is the typical game of catch up that I am always playing. Bye for now.
Thursday, April 12, 2012
Changes and general housekeeping
So I have received a few messages stating that my blog was hard to read thanks to the format and color scheme. Hopefully this helps.
Tuesday, April 10, 2012
That's one way to secure an airway...
Ok, so it’s 0100 in Afghanistan in the beginning of the spring. It’s a cool night with a waning moon with little cloud cover, so it’s clear but still pretty dark. So where do you think I am? You’re damn right, I’m sound asleep in bed. Well, I was until the lights get flipped on and my door is basically kicked down by one of the runners that was sent to get me. “Doc, you got patient!” is the first thing I remember. So as I am going from zombie to paramedic as I am putting my uniform on and getting my medic bag or aid bag as we called it, I am told that we have 4 patients and that they look pretty bad. Thanks new guy.
So we get over to the ANA or Afghan National Army TMC to find four pts ranging in severity. All four of them were victims of either shrapnel or small arms fire. Three out of the 4 are talking and basically complaining. The one that isn’t complaining is wrapped up like a mummy with ace wraps and kerlex bandages. This wasn’t just “blast concussion” weirdness, but something else was going on. As much as I hate to undo another medic’s bandage (ANA or US medic) we had to see what we were dealing with. So we start untangling this poor guy. It did take much to tell he was in bad shape. He was unresponsive to verbal stimuli, was breathing fast and irregular and then slow and irregular, and he had unequal pupils. I bet his blood pressure is all jacked too. Just a professional guess/opinion here. As we are getting the bandages off I check for a radial pulse and don’t find one. Great, he says sarcastically. So we move up to the brachial and its very weak and slow. Well, I guess this guy is very late down the shock time line.
So the bandages are off and we find a very neat linear and open gsw to the head. The bullet that hit this guy literally separated the two ventricles of the brain and was bleeding pretty badly. Oh and you could see the grey matter swelling. Well, that helped us to know what we are dealing with. The rest of the physical exam was pretty benign. He was “only” suffering from a GSW to the head with increased ICP even with his ballistically created vent.
Treatment and resus was going on while we were getting a good look at the entire picture of our sickest patient. However, since he was profoundly hypotensive (60/30), the other medics were unable to get in any peripheral access. I asked one of the corpsmen to pop in an IO. He attempted to get the FAST1 in place but he didn’t have any luck. I was standing at the head of the bed and gave it a shot and it popped right in. Now we were able to get his pressure up with some plasma volume expanders and hopefully able to reperfuse the squash a bit.
Mean while, the ANA PA was standing next to us and I tell him that this patient is loosing his respiratory drive. So what is his solution, you ask? He proceeds to the supply room and returns with a suture kit and 2-0 silk. What are you doing with that? I ask. He then proceeds to suture this poor guy’s tongue to his lower lip to prevent it from occluding the airway. 10 points for creativity, but I think a PVC challenge is in order here. I say thank you for your help and tell our interpreter to tell him to get out of the way. This guy needs an airway and he needs soon.
As this was all going down, our PA (US kind) asks me “Want me to go grab the RSI kit”? Please, sir. So he takes off in a full run. Mean while we start prepping this guy for the RSI. We get what meds we had on hand, and reassessed. Vitals were better than 60/30 but nothing super amazing. Our PA returns with the little black box that contained our RSI meds. I have to say I am not the biggest fan of Veccuronium, but it does the job. The 2 minute onset time seems like forever. Oh and don’t forget about that whole sutured tongue thing. You would think that it would have made for an easier intubation, but it actually did the exact opposite. It was a pain in the ass to say the least. So we get the drugs on board, our paralytic, the sedative, atropine, and some lidocaine for the ICP. As the drugs are taking effect, we assign jobs. You listen to lung sounds, you check BP continuously (doing that manually sucks, btw), and I’ll place the tube. I actually had to attempt the intubation twice thanks to Dr. Frankenstein’s suture job on the tongue. Ugh, that still makes me mad. Thankfully, the tube was placed on the second pass and we were able to get his sats up.
Now we reassess our situation, our patients, and our supplies. We are currently bagging an adult ANA soldier who has been sedated and paralyzed for transport due to airway control, we have 3 other patients, one who is an urgent surgical due to a GSW to his foot with loss of sensation and pulses to the extremity, and two other very minor patients that require nothing more than a bandage and some Motrin. Oh and “Dust Off” will be here in 45 minutes. Great. We just turned this little mud hut into an ICU. Hope we don’t get mortared tonight.
Thankfully no rockets or small arms fire bothered us that night. Unfortunately, our priority 1 patient wasn’t doing so well. His BP continued to fall and he was still bradying down even with fluids and pressor infusions. We kept him sedated and hopefully as pain free as possible before be died. But he didn’t make for the helos to take him to BAF for more definitive care. The other patient did and I am sure he was fine.
When we brought the other pt out to the HLZ to load our pts up into the helos, one of the medics asked me where the GSW to the head was. Sorry man, he didn’t make it. He just looked at me for a minute then he understood and took report on the other. The interesting thing about this portion of the event was that it was all done in almost complete darkness with just NVGs and good direction from the flight crew. As the birds take off and we could no longer hear them, I take off my NVGs and just look around. I was standing in the middle of the huge HLZ in the middle of the night with almost no sound. It was like being on the moon. A bit surreal to say the least.
We found out some interesting information from one of our “terps”. He said he was talking with the ANA medic who initially took care of the GSW to the head. Apparently he ran out under fire to grab the guy and pulled him to safety. He also made a second trip out there to pick up a rather large chunk of this guy’s brain that was on the ground and proceeded to stuff it back into the cranial vault. I know what you’re thinking. WTF? We were told he had to appreciate the small victories over there. I was just happy that he was serious about being a medic. After all, he did risk his life to pull him to safety.
The positive that came out of this experience was that it was my second successful intubation in country and more importantly that we worked well as a team to get the job done. Additionally, I was complemented by everyone on for my “trauma skills”. It made me feel good to hear that. No one likes to lose a patient, but you have to do the best you can for everyone and learn from your experiences. I think this was the situation at solidified my title as “Doc”. And the “Doc” vs rank is another story…
Saturday, April 7, 2012
It's that $#@! bird again!
So recently I was transporting an LOL in NAD complaining of back pain. For those of you who do not know that that is, Google it. And if you do not know what “googling” something is, how on earth did you get to this site? At any rate, my partner and I are dispatched to a private residence to transport this patient to a hospital that’s about 20 miles from her home. Going off of previous experience, I was assuming that this patient was going to be located up three flights of stairs in the messiest house and was going to weigh 300+ lbs. Thank goodness I can’t predict the future, because that would have been no bueno.
We arrive to find a tidy home with ample space to bring the gurney inside. This allowed us to move our LOL in NAD with minimal discomfort to her. She was very sweet and cooperative. As we start talking and getting her history, vitals, and whatnot, we ask her if she would like something for pain. She says “as long as you don’t have to start an IV. I’m a hard stick”. Now I am always one for a challenge, but I didn’t have a change to finish my coffee this morning so I respected her wishes and we took her priority 3 to the hospital.
Now since staring at one another would not only be uncomfortable, but also super rude, I ask her questions to fill in the gaps in my report. Turns out she is diabetic and did not check her sugar today. I offer to do so, since I didn’t poke her with a needle, I could at least do that for her. So she gives me her hand and says “which finger would you like”, and I reply “it doesn’t matter”. So she picks one, and wouldn’t you know it, it’s her middle finger. Normally that is not an issue. However, after I cleaned it and was ready to poke it with the lancet, it misfired and I had to get another one. It only took me 10 seconds to do so, but I turn back to my pt to find her with her middle finger still up facing the window and not realizing what she is was doing. I took the moment to let it sink it in and to hopefully see an interesting reaction from the many tailgaters we had that morning. Much to my dismay, no one other than myself noticed the bird flying around in the back of the ambulance. So I check her sugar and tell her she can “put that away”. This resulted in a confused look and the shrugging of some shoulders.
It was interesting to see someone of her age (think WWII vet) throwing up what would normally be seen as an obscene gesture. She didn’t notice and neither did the rest of the world. I guess that was one of those silver linings in an otherwise VERY priority 3 call.
We arrive to find a tidy home with ample space to bring the gurney inside. This allowed us to move our LOL in NAD with minimal discomfort to her. She was very sweet and cooperative. As we start talking and getting her history, vitals, and whatnot, we ask her if she would like something for pain. She says “as long as you don’t have to start an IV. I’m a hard stick”. Now I am always one for a challenge, but I didn’t have a change to finish my coffee this morning so I respected her wishes and we took her priority 3 to the hospital.
Now since staring at one another would not only be uncomfortable, but also super rude, I ask her questions to fill in the gaps in my report. Turns out she is diabetic and did not check her sugar today. I offer to do so, since I didn’t poke her with a needle, I could at least do that for her. So she gives me her hand and says “which finger would you like”, and I reply “it doesn’t matter”. So she picks one, and wouldn’t you know it, it’s her middle finger. Normally that is not an issue. However, after I cleaned it and was ready to poke it with the lancet, it misfired and I had to get another one. It only took me 10 seconds to do so, but I turn back to my pt to find her with her middle finger still up facing the window and not realizing what she is was doing. I took the moment to let it sink it in and to hopefully see an interesting reaction from the many tailgaters we had that morning. Much to my dismay, no one other than myself noticed the bird flying around in the back of the ambulance. So I check her sugar and tell her she can “put that away”. This resulted in a confused look and the shrugging of some shoulders.
It was interesting to see someone of her age (think WWII vet) throwing up what would normally be seen as an obscene gesture. She didn’t notice and neither did the rest of the world. I guess that was one of those silver linings in an otherwise VERY priority 3 call.
Thursday, March 29, 2012
It's not over, I promise!
I have been a bit busy the past few weeks. Work, school, and moving. Nothing easy, fun, or exciting in those three arenas. I do have a few more stories I am working on from my various adventures that I will be sharing soon. In the meantime, stay safe and pull to the right.
Thursday, March 8, 2012
A week of neuro badness
This week has been pretty busy, despite the fact that I am supposed to be on "spring break". Now although I don't have class this week, it just means that I worked a bit more. Additionally, all that work involved some very sick patients. One I even transported twice! Once to the hospital for a embolic cva and the second one for a subarachnoid hemorrhage. All of these calls required a lot of work.
It was all strokes, subdurals, and subacachnoid bleeds this week. Everyone hitting their heads, popping blood vessels, or throwing clots. Not to self, keep blood pressure under control and stay healthy. At any rate, our first bad neuro call of the week was in a hoarder house for a patient presenting with acute mental status changes. I am sure most people have seen the show on TV called "hoarders", so I will skip the description. However, the house was a mess to say the least. So we find our normally cantankerous pt sitting in a chair starring off into space. I know what you're thinking, "DIABETIC! Get the D50%!", however this was not the case. This pt had sudden changes in behavior and was flaccid on the right side. If it walks like a duck, talks like a duck, and has sudden right sided weakness, it is probably a duck...er...stroke. So extrication via the FD and IV, o2, monitor protocol applied and we were off like a shot to the friendly neighborhood ER where this pt immediately went to CT. I didn't see the CT, but they started TPA or clot busters asap because the onset was under 3 hours. This of course bought an ICU bed and a night or two in the hospital.
Then wouldn't you know it, two days later the same patient developed a subarachnoid bleed and could no longer be managed medically. Call the neurosurgeon! We need to get into the vault and stop the leak. The way to do that was to load this poor patient up and haul butt to the local super hospital for further treatment. But all that required from us was close monitoring and a large dose of diesel fuel.
The next one was an example of what could happen to someone if they do not take care of themselves at all. They presented via EMS to the local inner city ER with a BP of 300/160. No, that was not a type-o. I said 300 systolic. I am no doctor, but that should be managed a bit better. I'm surprised the patients' head didn't explode! However, their initial complaint was just a head ache which developed into another subarachnoid bleed. This patient required the works. Intubation with paralysis and continuous sedation with diprovan, and IV blood pressure control with Nicardipine. You know the BP is sky high if you need Nicardipine AND Diprovan. Just sayin'. So again, we take this patient priority 1 to the super hospital for neurosurgery. We were keeping those folks in the neuro ICU busy with this seemingly constant flow of critical patients.
I feel as though we had other critical patients with similar presentations this week. Let's be honest, this week has been a bit of blur. I like the constant flow and actually being utilized as a true MICU instead of slinging renal patients all day long. But everyday is different in the EMS world and you never know what is going to happen.
It was all strokes, subdurals, and subacachnoid bleeds this week. Everyone hitting their heads, popping blood vessels, or throwing clots. Not to self, keep blood pressure under control and stay healthy. At any rate, our first bad neuro call of the week was in a hoarder house for a patient presenting with acute mental status changes. I am sure most people have seen the show on TV called "hoarders", so I will skip the description. However, the house was a mess to say the least. So we find our normally cantankerous pt sitting in a chair starring off into space. I know what you're thinking, "DIABETIC! Get the D50%!", however this was not the case. This pt had sudden changes in behavior and was flaccid on the right side. If it walks like a duck, talks like a duck, and has sudden right sided weakness, it is probably a duck...er...stroke. So extrication via the FD and IV, o2, monitor protocol applied and we were off like a shot to the friendly neighborhood ER where this pt immediately went to CT. I didn't see the CT, but they started TPA or clot busters asap because the onset was under 3 hours. This of course bought an ICU bed and a night or two in the hospital.
Then wouldn't you know it, two days later the same patient developed a subarachnoid bleed and could no longer be managed medically. Call the neurosurgeon! We need to get into the vault and stop the leak. The way to do that was to load this poor patient up and haul butt to the local super hospital for further treatment. But all that required from us was close monitoring and a large dose of diesel fuel.
The next one was an example of what could happen to someone if they do not take care of themselves at all. They presented via EMS to the local inner city ER with a BP of 300/160. No, that was not a type-o. I said 300 systolic. I am no doctor, but that should be managed a bit better. I'm surprised the patients' head didn't explode! However, their initial complaint was just a head ache which developed into another subarachnoid bleed. This patient required the works. Intubation with paralysis and continuous sedation with diprovan, and IV blood pressure control with Nicardipine. You know the BP is sky high if you need Nicardipine AND Diprovan. Just sayin'. So again, we take this patient priority 1 to the super hospital for neurosurgery. We were keeping those folks in the neuro ICU busy with this seemingly constant flow of critical patients.
I feel as though we had other critical patients with similar presentations this week. Let's be honest, this week has been a bit of blur. I like the constant flow and actually being utilized as a true MICU instead of slinging renal patients all day long. But everyday is different in the EMS world and you never know what is going to happen.
Thursday, March 1, 2012
2%
Some times in this job you, or at least I get kind of jealous of calls that other crews have run and the treatments they had to perform on said call. It might sound kind of funny, this “medical envy” but I experience it from time to time as I am sure others do too. Well this crew brought in this patient that I could only describe as a “miracle of modern medicine”. Now let me paint you a better picture
This crew responded to an AARP member age group patient with a chief complaint of shortness of breath. Well this patient was short of breath because they were in V-Tach. No chest pain though which was surprising since there were more surgical scars from previous cardiac procedures on this patient than most people have teeth. At any rate, they do the IV, O2, monitor deal and start the rhythm management with the antiarrythmic flavor of the week. In this area, it happens to be Amio. They get about half way through it and the patient decides to arrest on them. Now this has happened to all of us in EMS before and will happen again. However, whenever it does happen, it is usually followed by a string of obscenities and good CPR. I am fairly certain that is what this crew did too. Thus only further perpetuating my little theory here.
Now this would be a routine cardiac arrest call. However, after about a minute or so of ACLS time, the patient wakes up. The patient then goes back into full arrest again about a minute later. Now I know what you’re thinking, and yes you are correct in thinking “WTF?”, I did it too when I heard the story. This cycle of ROSC, CPR, WTF, repeat continues at the hospital too. And don’t worry, there is plenty more “WTF” to go.
So obviously a bit surprised by the whole ordeal, the crew and the ER staff now have a pseudo-dead patient on their hands. And the game of “is it PEA or not” continues. In one of the instances of arrest, the patient is intubated by the ED doc and they start pushing all the fun ACLS drugs and start going down the protocol(s). But then, while good CPR is being done the patient starts to move all four extremities and even grimaces with each compression. Good thing they didn’t have the auto pulse. BTW, you probably don’t have to do CPR on a pt if you have to hold down their legs. Just sayin’. But this patient obviously did not have the greatest perfusion so it probably wasn’t the worst idea that was being thrown around in the room.
The battle between PEA and ROSC continued from the resus bay to the cath lab. On the way to the lab, multiple pressor agents were started due to the patient’s BP being “almost nothing over I want to go home”. And don’t think that because we made it to the cath lab that we in the clear. The fun had just begun at this point.
The first initial view thanks to the magic of fluro revealed more stents, grafts, staples, and sutures that I have ever seen in one x-ray. The cardiac silhouette was also the size of a small basketball and had about as much squeeze as a bean bag chair. The doc actually had to access through the mammary artery. Not exactly your traditional cath approach. Neo was also started on this patient too. For those keeping track, that is three pressor agents going. Holy alpha 1 agonists, Batman!
The cath showed multiple types of badness and that it was way beyond the scope of this hospital to handle. The reservations at the tertiary cardiac center has been made as well as a fast and loud way of getting there. Good thing they have a big truck, because they also decided to throw an IABP into this desperate patient to further complicate the clinical picture here. Not saying it was a bad idea, I am just saying it complicates things from both a medical and a logistical stand point. This was also when the staff discovered that the patients ejection fraction or EF was a whopping 2%. Just for comparative reason, the normal EF in a healthy person is about 60-67% depending on who you talk to. So an EF of basically nothing just further proves my point that this patient was and is a miracle of modern medicine. Additionally, No helicopter was called due to poor weather. However, I am not sure they would have been able to fit everything into the bird.
So let’s look at what is to be transferred with our poor patient here. Multiple vasoactive drips (4), ventilator since the patient was finally given RSI drugs, the monitor/defibrillator, and the IABP that is the size of your run of the mill desktop computer. That’s a lot of stuff to put in the back of an ambulance, let alone a helicopter. I think for once, the weather was a blessing and not a curse.
The patient was taken to the super hospital by their CCT team and promptly put on ECMO in hopes of either an LVAD or a completely new heart. Either way, the prognosis is not looking good.
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