1600 Joules

NO, we didn't super charge/over shock our pt on this call! That just happens to be the total amount of joules we used between all of the defibrillations that were administered. Crazy, huh? Yup. But lets go back to the beginning...
     So there we were, right. Working a 24 hour rescue shift in the usual location when we were dispatched to the neighboring city for "one unconscious". As my partner that day said, we "wee-wooed" all the way there. She is a trip and a lot of fun to work with. While enroute we hear that CPR is in progress. Great. It was kind of expected, but you always hope that it doesn't take that turn before you get there.
     However, upon our arrival the local FD was there doing their awesome BLS thing. They are always on top of it. They had already shocked this pt twice with the AED and dropped a King LT. If you don't know what that last thing is, google it. So really, half the work is already been done. Plus, the awesome autopulse (CPR machine) was called for and was being delivered shortly. We swap the pads over to our monitor to find very coarse VFIB and give our first shock at 200J. POW! And start more CPR. Things are being yelled out, needles are placed into veins and bones, and the pt is placed on the autopulse. This not only does better CPR, but it also frees up an extra set of hands to get things moving. It sounds funny, but it is a great machine.
     And speaking of the placement of needles, there were obviously a lot of people working on this pt and space was at a premium. I had to cut the pts pant leg to be able to place the IO. While doing this, my partner had to catch one of the FD guys from falling back on me. Good catch too! That could have resulted in disaster! I really didn't' feel like explaining to my superiors as to why one of the local FD personnel had an IO sticking in/out of his thigh.
    So anyways, we now have good vascular access and can start pharmacologic therapy. "FIRST EPI IN" as the autopulse squeaks away doing compression after compression.This made the act of carrying this pt down the stairs a bit odd. But the job was done. And just as we secured our squeaking life support device, pt, and all to the gurney, it was time for the next EPI. Then slam goes the doors, shock goes the defibrillator, and we are off like a shot! Priority one to the closest ER.
      While enroute another IV is started. More specifically, an EJ. This was perfect because it was just in time for some more medication. This time it is the antiarrythimic that is being given. It was easily pushed through the EJ and was flushed by the pressure bag in turnout gear. Shortly there after we not only see a spike in ETCO2 (look it up) but a decent rhythm on the monitor. Tada! We officially have ROSC! And, AND with a good pulse. However, this does not last very long. There ventricular ectopy started pouring into what was once a very pretty sinus tach. Then pulses were lost as the rhythm went from order to chaos or as those with an ACLS background like to call it, VFIB. But it's ok, we have the tools to hopefully correct this. Charging! CLEAR! And shock goes the monitor...NSR immediately with pulses. SWEET! Unfortunately we have to go through this process about 4 times before we get to the hospital. However, by that time we got the second dose of arrhythmic in and the ventricular ectopy calmed down to just an occasional PVC.
       Now that we have a pule, a blood pressure, a rhythm, and all that goodness it was time to take a closer look at what just happened and to organize a report that I can shout at the ER staff without them getting mad at me. What was the down time? What was the hx of the pt? Was it witnessed? Is that peridefib ST elevation or is this a true complicated STEMI? Oh btw, CLEAR! POW with another 200j of Detroit Edison that promptly converts VFIB back to ST.
     Upon arrival to the ER I shout out the report quick, fast, but not in too much of a hurry so it could be understood. The post arrest 12 lead was accomplished showing NO ST elevation but the pt was still sent up to the cath lab. Hopefully for some worthwhile intervention.
     As hectic and chaotic as the call was, it could have been much worse. It was actually one of the better calls where everything went right and all the pieces and players fell into place. Good job to everyone involved. We may never know what happened to this pt, but they certainly received a 150% effort on the part of everyone involved.


*I am sure all the defibs don't add up to 1600 in this little glimps of what is my professional life. However, the total number of defibs did equal that number. For the sake of time and ease of telling the story some details were left out and/or forgotten.*

Not just another fall

The thing I love and hate about EMS is that at any given time you may be called upon to utilize a skill or exercise some knowledge that you have not used in a long time or in the case of some people, ever. And these situations can come when you least expect it. That is why you never really know what you are getting until you get there. A call for a "fall" can be anything from fall down go boom from standing height to a cardiac arrest, or someone that fell off of a building after getting electrocuted.  The point is, you never really know. This call was no different.
     We were dispatched to a local rehab center for one that had fallen. At first thought, most would not think that this would be the most exciting call that probably wouldn't require more than a c-collar and a trip to the hospital. Don't assume anything because the mixture of the EMS brand of chaos coupled with Murphy's law tend to make for obscure and challenging situations. But I digress...
     When we get there, we find our LOL in obvious distress. She wasn't looking well and seemed very confused. OK, what could this be? Diabetic, hypotensive, a dementia patient that fell and just hasn't gotten up yet, or something else? Definitely something else.
      This pt had that glazed over look but was still breathing. The radial pulse was kind of weak and slow. Really slow! Like 20-24 beats a minute slow (normal is 60-100 a minute)! @#$%! MONITOR, GO! My partner slaps on the monitor leads and pads. The result of this action is a narrow (good) but very slow (not good) cardiac rhythm that is very symptomatic requiring immediate intervention.
     Now I am not sure why this phenomenon happens, but it seems as though when people are in dire straits and have super crappy vital signs, they seem to say very simple but very odd things. I once had a pt with a dissecting thoracic aorta with a horrible blood pressure and all she could tell me was "It hurts".  This Pt's only request was that she was hot and that we should take her pants off. Really? Really. We didn't take her pants off because it wasn't medically necessary. Anyway, back to the story.
      Flip the switch to the left and let's start pacing! Oh and we should probably start working on an IV or two as well. We start at a rate of 80 and are steadily increasing the mA (energy) until we get a good spike or capture. Unfortunately, this doesn't happen as easily as we would like. However, at this point we have an EJ in place and can try some pharm therapy! Since the pacer isn't really working at this point but isn't making things worse, we leave it on. Unfortunately, the pacer pads either got disconnected or someone turned down the energy because the pt went from a slow heart rate to no heart rate! I look at the monitor and am certain that everyone in the room could hear stream of profanities running through my head. Thankfully what came out of my mouth was much more politically correct. Something along the lines of "Crank it back up!" Thankfully we get a better paced rhythm this time. Not the best, but better. As soon as we get our pt on to the gurney and ready for transport, I take a better look at the monitor and decide to up the energy level on the pacer. Boom! Capture! We have a good pulse, a good BP, and now 2 IVs. Let's go!
      The ride was bumpy and loud, but we were able to get some fluid into the pt as well as make it to the hospital alive. Our pt would appear to pass out from time to time and just when we think we would have to start CPR and even more invasive with our treatments, she would wake up. We would have to yell her name or do a sternal rub but she was still alive. Oh and the fire department drove for us so we got there lickety split but I question their safe driving record from time to time. Although I always appreciate it when they drive for us.
     Once we get there and hand over care, the pt no longer requires TCP treatment and has a better blood pressure. Was this due to our treatments or was she just trying to make us look bad? Just kidding. Per the doc, it was probably a sick sinus syndrome, a heart block from an MI, or a bout of symptomatic bradycardia. Whatever the case may be, she will be getting a permanent pacemaker placed and hopefully will not have to deal with this issue again. Gotta love it when a call goes from blah to "PRIORITY 1" to a probable hospital discharge.  Good job everyone!