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.
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