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.

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.

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.