Where does THIS plug go?

It has been really busy since the last post, personally starting a Master’s program, and at the station as well.  The department ran one of those truly difficult calls that you know is out there somewhere.  I was only peripherally involved in the call itself, as I was busy on a taxi run when the call went out.  I’m going to write up the call, and my understanding of the great job our entire department really did on it…but not tonight.  CD’s comment on the last posting (and by the way, I’m choosing to assume that the scary part of the post was the Doc not believing us and sitting the guy up again) reminded me of another call, one that abruptly ended upon arrival at the ER.  

In our first due, there is a place we all know as The Fossil Farm.  This place is the poster child for every bad story you’ve ever seen under the title “Nursing Home”.   This place makes you want to die young as opposed to risk going there.  I have to follow it with the fact that it IS better than it has been in the past, thanks to law suits and state interventions I understand, but it smells of urine and Funk, the staff is minimally trained, and on the whole doesn’t seem to give a rip about the people inside it.  The patients are generally in pretty bad shape, with med lists and previous conditions as long as your arm, and don’t have the insurance to go somewhere else.  You can see them most days sitting in wheelchairs at odd angles in the hall staring at you as you pass with your cot and gear.  We all know the place, and we all know it well.  So well that we all start to groan as soon as we hear the box 12-01 on the dispatch.  There are few things they do well, but recognizing dead is one of them.  (Okay, sometimes it takes an hour or two, but that is another blog).  

Anyway, when the call goes out for a “Stoppage of breathing” at this place, and we all head over knowing two things: One, someone is dead and two, they probably stink.  The response is a short one, and Cat loaded the cot with all the bags, the lifepak and the drug box as we roll.  We arrive just ahead of the engine, and start to glove up as we ride the elevator to the ‘second’ floor.  (The main entrance to this place is on the lowest floor, but there is a hill to one side, and there is a door from the ‘second’ floor out to the side parking lot at the end of the hall…this comes into play later.)  We exit on the second floor, and turn left towards the dispatched room number.  There is some staff standing around outside a door down the hall.  “No need to be in doing anything, just look from the hall” I think as we head that way.  There were also a few people around who were not staff, possibly family, which struck me as odd.  

Of course odd is relative, pun intended, and when I turned to enter the room, the sight made me forget about the strange non-staff in the hall.  On the floor of the room is a large, apparently dead, man who is on the receiving end of some spirited CPR compressions.  That’s a real plus all things considered, but while he is laying on a board, presumably to give a solid base for compressions and to move him to the floor from the bed, it is laying across him, not along him.  Oh, his head is UNDER the bed, and compressions are being given by a (normally) slight lady who looks a full 40 weeks pregnant while a fairly built guy is struggling with a nonrebreather mask and oxygen tank….maybe they were just ahead of the curve on the “compressions only” CPR trend.

A LOT of things went through my head here…none of them complementary.  The reader’s digest version is something like, “Well, they are doing compressions at least….Holy Cow is she pregnant…If she goes into labor, I’m quitting…Where’s the dude’s head…How did they get his head under THERE?...So much for an airway…Nice guy – lets HER do compression while he tries to put an oxygen mask on a guy who isn’t breathing….Well, let’s do this.”  

Orders get issued pretty quick and we go to work.  We slide the patient out from under the bed, and Cat gets down on the floor to drop a tube into his airway.  The compression job is taken off the soon-to-be-mom’s hands, and I get the lifepak connected quickly to take a look at what we have.  Cat gets the tube in the first pass and now we can breathe for him.  Compressions are paused and the ECG shows an asystolic ‘rhythm’, but also a couple agonal ‘beats’.  If you’ve run for a while, you know the funny looking, wide, ugly wiggles that are the final throes of a heart that I’m talking about.  Well, thank God for combi-pads on the lifepaks, because we were able to get pacing started really quickly.  

Protocols say to do something silly like start with low milliamps and work your way up in intervals until you achieve mechanical capture and then increase it by 10% at a rate of 80 beats per min etc, etc, etc.  Well, technically that’s what I did.  It just looked to the untrained observer like I looked at the 320lbs or so dead guy, hit pace and spun the dial until it stopped.  Hey, I hit every increment!  As Bob Page would say, “Set it and forget it”.    The patient is moving a bit with each beat, and the monitor shows electrical capture.  Cool.  “Hey, do we have a pulse with that?” I ask.  Cat and I check are checking for a pulse, but it is hard to tell at the carotid because of the way the guy moves with each beat.  We check further down the arm and find a faint, but palpable pulse.  He’s still not breathing, but hey, we can do that for him.  

I used to call pacing a patient, “Summoning the invisible elf”.  When you do it, the patient twitches at the chest as the pads deliver smallish shocks to the patient, causing the heart to beat.  If you stand back and look at the patient, they look like there is some little invisible elf kicking them in the ribs about 80 times a minute.  

Well, woo-hoo, check this out, he’s not out of the woods at all, but hey, we’ve been here just a few minutes and we have gone from dead under the bed to a pulse, albeit thanks to our pacing, and that is more than you get most times by far.  The guy is moved to our backboard and cot and we start to head for the unit.  The fire guys have moved the unit around to the side of the building, so we can use the exit at the end of the hall and don’t have to go into the elevator again.  Nice thinking on their part.

An IV is started in the unit and we go for some vitals.  There was a good flash in the chamber when we got the line, a good sign for a blood pressure, but not conclusive.  We have him by a thread, and I really, really, really don’t want to lose that.  His eyes looked bad, in the I-was-just-dead way, and we noted that his nose started to bleed.  “Hey, he’s bleeding!” I think, and probably for the first time that it was good news.  Bleeding from the nose in this case means not just a pulse, but a pressure.  Cool.  Now yes, gravity can do that too, but he was flat on the floor before and not bleeding, and he was on the cot, somewhat less flat, and blood does NOT flow uphill.  As we take off for the short response to the hospital, maybe two miles away, the BP machine beeps with the news….90/30 or so, not much, but I’ll take it.  

The call goes out to the hospital to say we are coming, and preliminary report is given.  At the ER, I’m pretty much floating out of the unit.  This isn’t a save, and it probably results in no brain activity at best, but I’ve done my part in this one, and we are “Not Dead”.  Not Dead is good on a code, and it happens rarely enough, so it’s good enough for now.  We get into the waiting cardiac/trauma bay where the code team awaits.  They quickly hop into action as we walk in, and I start spouting a report.  The IV bag is on the guy’s chest, and the tube has blood in it, gravity does that too, but a pulse helps.  I see them setting up their machines, and the Doc comes over to inspect things.  

I’m telling him that we got a BP en route, pulses to match the pacing and mechanical respirations, and wondering “What the HELL is that whining, buzzing, ringing noise?”  I look back at the LifePak and am greeted with three parallel, horizontal dashed lines, and a flashing indicator telling me to connect leads.  “What the…”  I scan the patient, and my pads and leads are still on.  Then I see that the wires from the pads end at the connector, and the connector is loose on the cot…Someone disconnected my pacer.  “You have GOT to be kidding me!” I think so loud I almost yell it.  “No pulse” says a nurse next to Cat.  “The Patient has no pulse…in PEA on arrival” I hear the Doctor say to the report taker.  “LIKE HELL!” I think…I’m livid.  (To those now lost, the doctor just said that the patient never had a pulse at the hospital, that I was shocking him, but that it was not causing the heart to beat.  Pulseless Electrical Activity.  It also means he’s saying that I just ran an entire code without doing CPR on someone with no pulse.  My ass I did!)  I hold up the disconnected lead from the paddles towards the Doc, “No shit…Y’all pulled the pads!”  I don’t recall his response, but it didn’t matter.  I go to the nurse taking report and make sure she has all the background on the call and storm out to the report room.

There, for the first time in my life, I actually throw things.  Just pens, sure, but I’m as pissed off as I’ve ever been.  I’m pacing, cannot sit down, and sure can’t write the report.  Cat and Wayne gathered our stuff and were headed back to the unit.  Now, I wasn’t about to let the report stand saying that there was no pulse on arrival.  They boned this one and I was not rolling over.  I stick my head into the curtain, and see that they did not regain capture, and that the code is going poorly.  Frankly, a lot of this time is a bit of a rage-filled blur.

I must have been visibly pissed off, because Doctor Dave, universally liked and respected by everyone I know came over to talk.  “What’s up?” he asked.  I told him what I had, that I got a measured B/P, two providers felt a pulse, and we had active bleeding.  Before I get to the end, he puts his hand on my shoulder, looks me in the eye and says, “We disconnected your pacer didn’t we?”  And THAT is why he is liked and respected.  “Yeah, and the doc said we came in here in PEA, and no compressions.  That’s crap, and I’m pissed.”  He talks me down and assures me that he’ll be talking to the doctor and the team.  I feel better, and I trust him to follow up on that.  Of course, my report is both accurate and complete, and clearly states that we had capture, a blood pressure, and the pacer was disconnected upon arrival.  

I get back to the station, still fuming a bit and the guys ask me how it turned out.  The patient died and I explain what happened.  They empathize and have a story of their own to share.  You see, among the many patient care issues at the Fossil Farm, the staff had been repeated told that they had a serious fire hazard.  The door we left from, the one on the second floor, for years had opened inward, not outward.  This is bad.  If that place burns, heaven forbid, then when people rush the door, it would not open, they’d have to pull it into themselves to get out...that’s not code, and they have been told to change it many times.  It seems that my fire crew, ornery and helpful bunch that they are went to open those doors for us while we worked, and found that they couldn’t push them open.  Well, not ones to be stopped by mere hinge structures, they pushed on the doors until they DID open outward.  I’m sure that did nothing good to the hinges.  They told the staff that they’d have to look at having that fixed, but make sure the next time they came that it still opened outward.  I love those guys.

Well, a good chuckle was had by all, and my anger away quickly.  Nothing makes you get over a bad one like the guys back at the house.  I love this place.