Don't stick it out if you're not gonna use it

The last couple weeks have been eventful at the department from a Captain’s viewpoint, so I didn’t get the chance to write last weekend like I had hoped.  But, that is resolved, and life moves forward.  We actually had a relatively quiet week, and there is not much of interest to talk about from a call point of view from this week.

The renovation is coming along though.  The walls are painted, the floors are in, and things are looking better.  I can’t wait to get back in the house.  Maybe I will get some pics up when it is done.  Until then, Tuesday night duty means a single-wide trailer living room full of people on sofas, chairs and the floor watching Denis Leary and the rest of the guys from “Rescue Me” on the idiot box.  It was nice to see everyone drop what they were doing to get together and share comments.  It was even more nice of the Woodies (a term of affection for our local residents) to not call 911 long enough for us to watch it.

It was actually during the mandatory TV session that I was reminded of a call that we ran a few months ago that is of actual academic interest, besides just being odd.  Cat reminded me of it, which is ironic, as it occurred on a night she was at work.  Wayne was there, but I think Tess was gone working that night as well.  It had been a pretty normal night, a few runs, a few transports, nothing more than some O2-IV-Monitor runs as I recall.  (For those still in medic classes, here’s the secret.  Learn ALL of the cool  algorhythms, skills and odd cases…then know that 90% of your life is assess, History, O2, IV, ECG Monitor and transport. Hell, the other 10% is O2, IV, Monitor too, just add a cool step, then transport).  Anyway, call comes out as a possible allergic reaction one due to our north.  It’s the middle of the night and the patient is “adult female”.  

Medic rant of the week:  Dispatchers, “Adult Male” and “Adult Female” translates to “Not a kid, I didn’t care to ask”, at least in my head.  As responders, for many calls we really do care if the patient is 19 (a medical adult) or 99.  I’ll settle for “OLD like Yoda”, “Remembers Vietnam”, “Remembers Vanilla Ice” or “has a MySpace account” if you don’t want to get a number, but work with me some.

We are sent with the Engine from that station.  This crew has been with us for a couple years, and they have their stuff together.  They know their BLS skills and generally I get really good information on arrival.  In this case, we arrive on the scene and before I get to the door, I hear something about airway issue, or her tongue.  The lights are on in the front, and there are a few family-type bystanders.  They are staring inward, but not acting panicked…interesting.  As I get into the house, I see the patient.  She is indeed an adult female (“Yoda’s kid sister” age range..80’s as I recall), and I immediate get why we were sent for a “possible allergic reaction”.  The patient is calm, but a bit scared, has good color (more than a couple of the bystanders and firemen can say), is alert, oriented and has the biggest, most swollen tongue I have ever seen or heard of.  To paint a picture, she could not fully close her mouth, around the thing.  It protruded forward out of her mouth, and spilled on both sides.  Of course, what I noted first and foremost, is that it was THICK.  “Dear God, please don’t let her lose her airway” I think to myself.  I swing around in front of her, and get into my usual Catcher’s crouch in front of her.  As I’m looking at her scared eyes and huge tongue, I’m  thinking “Wow, I’m NEVER getting a tube past that…She gets her airway blocked….damn, what will I do.  Brief thoughts of things like cricothyrotomies (NOT in our protocols, and no real equipment for it either…okay, all of our medics reading this just thought about the scalpel in the OB kit and the suction unit…sickos.) and nasal intubations (Also not allowed, but I can probably do it, call the doc and get the okay to do it en route if I HAD to) flash through my head and I shake them off.  “Well, what happened here?” I ask.  “She can’t talk” I hear from the guys.  Not the best news.  She is trying to talk, but just making noises.  Better news, at least air is moving.  Her color told me that, but still, good to hear.  I notice that her tongue is so swollen it has been cut by her teeth and is bleeding ever so slightly.  Ouch.

Okay, time to fix this…kinda.  I get her on a Pulse Oxymeter to see how much oxygen is getting into her blood with the help of the fire guys and simultaneously start asking about meds…specifically new ones, new foods, new places, new pets etc.  I’m doing the full on, one man medic assessment drill.  I’m hearing that there is nothing new, her meds are all old.  I don’t recall specifics, but at the time I think things like “vitamin, vitamin, hormone, cardiac med, High blood pressure med…” as the names are read off.  Okay, some sort of cardiac issue, but nothing abnormal for her age.  No stokes, no MI’s etc in her past.  Her lungs are clear, and I notice that she is NOT scratching, her skin is NOT red, and there are NOT hives, there are NOT new things, NO allergies.  There is most certainly a sudden onset, wake you up, swollen tounge, and a real possibility of an airway nightmare that we do NOT want to consider.  Her vitals I don’t recall, but were about right for an 80-something woman who woke up, found her tongue so swollen she could not speak, got scared, got a house full of strangers and a (handsome, charming) medic in her grill telling her that it’s all going to be okay, while probably looking at her like the biggest puzzle of the month.  

I get the cot coming fast, and have her put on O2, just cause.  I’m thinking she’s either going to be totally okay, or she’ll suffocate in front of me.  I’m not ready to lay odds at this point either.  I know I need to be thinking allergic reaction protocol, but my inner voice is saying that is NOT what we have going on here.  If it IS an allergic reaction, this sort of airway issue gets Sub-Q epi (epinephrine under her skin), IV Benadryl, and Solu-medrol (a steroid).  Of course, Epi is better known as adrenaline, and does all the things that you are used to thinking of as an adrenaline rush…of course, that is not really good for an 80-something heart patient.  The O2 is just because that is what we do.  I mean, if her airway slams shut, it won’t get to her lungs, but in the event she gets less air, I want it to be all good stuff for her.

We whisk her off to the unit and I get going in the back.  One of the firemen is a pretty solid EMT from elsewhere, and they are all pretty good, so I have two of them hang out in the back with me for a minute.  I’m thinking that if she goes bad, she’s going to go REAL bad, so I want help on hand.  I fumble the first IV attempt..she has little old lady veins…and get the second.  The whole time I’m trying to watch her color, her demeanor, and everything else as I have an internal debate about the right move.  The cookbook part of me says, “you are saying allergic reaction…and there is an airway issue…pump her with meds”.  The wiser (I hope) part of me is saying “hang on now…this doesn’t smell like allergies, and do you really want to hit her with straight epinephrine and give her a chemical stress test to go with the bad tongue?”  By the time I get the line, I see that a bit of time has passed, she is getting more calm, and generally seems to be holding her own.  The voices settle on a compromise.  I give her the IV Benadryl only.  It is called for if an allergy, but if it is not that should just make her thirsty and tired.  (Medic students: ALL Drugs are Poisons, something to remember).  I have the epi out and ready to roll if she crashes, and I really hope I’m making the right call.  That it is not my life on the line with this one is not a comfort against the fact that it is entirely my call.

I get the med into the line and tell the Fire guys I got it from here.  She’s holding her own, and I’m thinking that if anything I should start seeing something soon.  Her vitals stay good, and she is breathing well.  I have Wayne haul freight, just in case, and I give my call to the ER.  I try to convey everything, and offer that I really am not positive on the allergy thing, and am really thinking it is something else.  They are cool with the treatments and patient status and I go back to watching.

Her tongue swelling does go down ever so slightly, and she starts to be able to talk some.  It is hard to understand, but it is an improvement.  That’s when the little cut to her tongue starts to bleed more.  It seems that she was so swollen, she was holding pressure on the wound with the tooth that cut it.  I say again, Ouch.

We get to the ER, and wheel her to a room.  The nurse is over quickly to get an idea of what’s up.  I give her report, tell her about the Benadryl, and the epi debate.  She’s someone I know pretty well there, and is cool with the line of thought.  I tell her that there is some improvement, and the patient says, “Doming Bemmer” which is swollen tongue for “doing better”.  Looking at her meds, she says, “Hey, this is an ACE-inhibitor”…referring to one of the cardiac/hypertension Meds.  (looking back I think it was Lisniopril, not that it matters).  “Yeah…” I say, wondering the significance.  The nurse has clearly had an Ah-ha moment.  She tells me that ACE inhibitors sometimes, rarely, have a side effect of sudden angioedema, even after years of use…Cool.  Well, for me, not her.  

I go back and write this one up carefully.  As I’m dropping off the report and such, I ask, “Hey, what’s the treatment?”  “Take her off the ACE inhibitors” I get back.  Gee thanks I think and chalk another one up to learning.  Interestingly, I have talked to several medics since then about this call and am zero for all of them in terms of anyone getting this one nailed before I tell them.  Good to know, and now we are all smarter.

Follow up:  This lady did fine and was released.  She is on a new hypertension med now of course.  Also, I looked into the right treatment online.  I’ll pass on the link, (I know it’s not exactly a text book, but it IS peer reviewed by definition) for others to see.  Turns out the ACE inhibitor is mentioned at the top, and had her airway slammed shut, the epi is the critical treatment.  Treatment generally is Epi and Antihistamines (Benadryl), so hitting her with everything would have been appropriate too.  I’m good with having done the ‘safer’ med (less likely to tax a risky heart) and standing by with, and planning to rapidly use, the epi at the FIRST sign that she was further losing her airway, but it was still a potentially risky move.  That’s the way it goes.  I can debate a decision either way, the point being to know enough to know that there are issues either way.  In the end, she’s better, I’m smarter, and now so are you.  That’s a good call, and a very good outcome.