Catch and Release EMS

The time has finally come.  The long-awaited cruise with the family is only about 29 hrs away and we are all set.  The timing could not be better and I’m looking forward to warm sands and cold drinks.  Before I go, I wanted to get up a new post and check in with everyone.  

The past couple weeks have continued to be busy and I think it must be everybody.  The station renovation is almost done and can’t come soon enough.  Living in the trailers is really not that bad, but I think the prolonged time in the tight accommodations is starting to take a toll on the people here.  I’ve had to help deal with a number of cases of smart people doing silly things in the past month or so, some serious, some not, but taken as a whole, enough to be a little tiring over time.  Others are feeling some of it too.  That said, life and EMS have ways of righting your compass and keeping things in perspective.  In the past week(ish) I have been able to really help make the critical turn in two different patients on two different days.  Nothing amazing (Yes, I WILL post the big auto accident and extrication from a few weeks back eventually, but not this morning.).  Nothing that any of the people don’t do time and time again, but that’s the whole point.

Wayne and I were alone the first night.  Cat was working her career job, Tess’s son was on his last day home before deploying to Iraq, and another medic that was going to come ride for time had to back out last minute due to work.  We caught a couple of minor runs and were basically just having an easy, hot and humid, mid-summer shift.  The radio played loud between calls and I was just enjoying a nice smooth shift.  The call came out to our second due north for a 20 year old male having a “massive asthma attack”, history of same, at a bowling alley.  Additional was that he had forgotten his rescue inhaler and was having problems.  Sounds like a good run right from the start.  

Asthmatics, when they call 911, are often in pretty bad shape.  As a disease, it is mostly controllable on their own, so by the time they call for us, they have already tried most of the things that work for them and are in some serious trouble.  That a patient would call it a “massive attack”, be without meds, and coming from a smoky bowling alley on a humid night all told me that there were a lot of factors working against this guy.

I tell Wayne what I’m thinking as we rush up the road.  He’s with me on this line of thought and is working through traffic like he has somewhere to be.  I’m thinking of the number of things I may want to get done and briefly think that I’d like to have one more set of ALS hands to attack on several fronts if needed.  I know the guy is going to need a neb, we use albuterol first out, and possibly the solu-medrol (A steroid, methylprednisone).  Of course, one needs a neb set up, the other is IV or a deep muscle injection.  Not that big a deal, but if he is real bad, I’d like to be able to do both at once.  I hit Cat up on the Nextel to confirm that a shoulder should be deep enough for that med, and not just a thigh etc.  She hears the sirens in the background and confirms briefly that yeah, she does that all the time, and call her when I’m done.  (I’m a big fan of double checking things, even things you know, before you get yourself in a decision-making posture.  The response is a great time to double check a protocol or get a quick opinion.  This way, if things are bad when you get there, you know that you know that you know and you can focus, move aggressively and get the job done.)

We arrive at the bowling alley and I find the patient with the engine crew.  They have him on oxygen, but he doesn’t look great.  The guy is about 20, about 6 foot, 280 or so, a big guy, and while he is standing, he is sweaty, poorly colored and clutching the oxygen mask like he’s alone in the ocean clinging to a life-raft.  We get him into the back of the unit and I ask him a few short questions.  He answers them all basically as expected and confirms that this is like his other asthma attacks, only worse.  He is talking in partial sentences, only about 4-5 words between breaths.  I hear wheezes on both sides, but not real loud.  “Is your wheezing getting louder or softer?” I ask, and get  a slightly confused look.  “Could you hear your wheezing more before we got here?” this time I get a nod.  Damn. I’m thinking he is just starting to really clamp down.  In bad attacks, first they wheeze and it gets really loud, but when things are really starting to go over the edge for the worse, they get quiet.  It is NOT a good sign when wheezing stops sometimes.  We are near that edge and things are going to be decided in the next couple minutes.

We move him to our onboard O2 and Wayne helps me get out the nebulizer and the drug box.  I set up the neb and the patient is waiting for it.  “You know what to do here, right?” I ask.  He nods vigorously and starts inhaling deeply and trying to hold in the vapors.  Excellent.  We set up for better vitals and I move over to start a line.  I’ve decided that he is in a fair bit of distress, but since he has had NOTHING to try to fix this with, I’m hoping the neb will work for him.  Basically, I think, if he had not forgotten his puffer, he’d be good, so lets start there.   It will take a min or two to get the IV going.  In that time he’ll either get worse or he won’t.  If he does, then I’ll be all set to bring out the bigger meds, if not, then we are head of the beast and things will be looking good.  He has huge veins, much like my own, and I get a quick line going in his left hand.  He’s a good guy, and kinda embarrassed by having to call us.  He is a little chatty and I keep him engaged in conversation between pulls on the neb.  I’m using his ability to talk as a measure of how things are going.  

I’m pleased to hear him starting to talk in longer sentences and I see his body starting to relax some.  He’s feeling like things are working, and his labor of breathing is improving. It is decision time now.  I am all set to move up the ladder of meds now that the IV is set, but have to see if he needs it.  Often times, the use of the steroids means a longer stay at the hospital for observation, and if he is going to get better, I don’t want to put him through it.  On the other hand, we got to get him better.  He tells me that he is feeling everything open up, and it feels just like when his puffer works.  We’ve turned the corner.  His dad is on the way with his puffer I’m told about the time that dad arrives outside.  I start to pack things up for transport and have Wayne put away the drug box.  As I’m talking about getting going the patient asks if he really HAS to go to the hospital.  (wow, he must be doing better I think)  I see his oxygen level is at 100%, but he’s still getting oxygen, so that makes sense.  I tell him that I can’t force him to go, but that getting checked is always a good idea.  “But I don’t HAVE to?” he asks.  I explain that he does not HAVE to if he is really doing better.  He really doesn’t want to go and we work out a plan.  I take him off the oxygen and agree to watch him for a bit to make sure he’s doing okay.  His dad had been told to start for the hospital, and the patient makes a phone call to have him come back.  I see that he is totally relaxed, his lungs are clear and he’s speaking full sentences.  His O2 levels stay up on room air and all looks good.  A few minutes later, Dad is back, has the rescue inhaler if the patient needs it later and all is still well with his vitals.  I discontinue the IV, have the patient fill out a refusal of care and explain that he can call us back any time if he changes his mind.  He tells me that he never had to call 911 before, but that he’d never been that bad either.  I tell him he did the right thing, shake his hand and Dad’s as well and say goodbyes.  Wayne and I mount up and head back to the hospital to reload on supplies and replace the albuterol I used.  

This guy was only a couple of untreated minutes from having his airway slam shut and he knew it.  It never ceases to amaze me what a fine line between that sort of critically bad condition and a good enough condition to go back to everyday life there really is.  This guy was in a life-threatening state, and we were able to let him go home on his own.  That’s always nice, even if it was an easy, routine, every day type run.  “Catch and release EMS” I joke to Wayne and we share a chuckle as he turns up the radio and the tunes begin again.  Later that night we’d take two people with the flu to the hospital, so everyone that was just sick went to the ER, and the one guy in real trouble went home, figures.

Later that week, while enjoying the department picnic, a call goes out for an allergic reaction to a bee sting just up the road.  The on-duty basic unit is at the park with me and is dispatched with a medic from a second due.  I have my buggy with me and hop in to chase them the half mile up the road to the call.  The other medic hears that I’m going and waves off, so it is just us.  The basic actually has a nurse from the ER doing a ride-along that day.  She asked to get some street time to see what we do, and is going to ride with us in the future.  I’m all for that, and I really hope others will come out and play with us too.  It’s good for us to get some ER rotations in from time to time, and I think getting the nurses into the field will help us to understand the unique issues that we each face.  (Patients don’t appear on cots with IV’s already started in the wild for example).  

The patient is out front of her house on the porch.  She is 81 years old, and was stung on the hand by a bee.  She is allergic to this and the last sting messed her up pretty bad she says.  That was years ago, she tells me.  The EMT on the basic is one of my Lieutenants and I stay back a bit to observe at first.  She looks at the injection site and I see some swelling starting.  The patient says that her throat feels like it is getting tighter and I motion to the driver of the basic, who is also an ER Tech, that it is time to get going.  

In the back of the unit, I’m pretty well set.  I have an ER nurse, an EMT lieutenant who has taken her ALS classes and a driver whose day job is as an ER tech.  Considering that jumping a call with the buggy means that I get a crew at random, this is about as good as it gets.  We get vitals going, set up the ECG monitor and a line is started.  I’ve tossed my drug box keys to the nurse and by the time I look up, she has the benadryl drawn up and ready to go.  An IV is started and in goes the med.  I opt against using the epinephrine because I think we are ahead of things, and I really don’t want to drop a chemical stress test on an 80 year old heart.  (no Xopenex here yet).  I tell the nurse what I’m thinking, and she’s nodding along.  I see that our patient is still very nervous and as we get rolling to the ER, I rub her hand (not the one with the sting) and tell her, “I got you now, we got this licked, it’s all better from here.”  I’m rewarded with a smile and I can see her relaxing.  I warn her that she is going to be tired and thirsty and she understands.

The hospital transfer was enough to spoil a medic.  Scott, the tech and driver, gets her all set up in the room and the nurse goes over and does all the paperwork.  By the time that the patient’s nurse comes to the room everything is done and even the report is just a nod and a smile.  Now THAT is seemless patient care!  Ahh, the little things.  In short order, I’m back at the picnic eating burgers and dogs, and sharing stories with the guys.

Neither of these calls were remarkable for the action involved.  Neither were anything that any of the people reading this haven’t done time and time again themselves.  But they were the type of call where we really get a chance to make a difference for a patient and actually fix a problem ourselves.  It is calls like this that are important to remember after weeks of just hauling minor issues and flu patients to the hospital at 2am.  They are the bread and butter sort that are why we are all out there time and time again.  In a month of bogus administrative issues to deal with, and during a time that just kinda wears on you, these are the types of things that really bring back that perspective you need.  

So, this week I’ll be in the Caribbean, getting plenty of ETOH and Vitamin D, out of reach of cell phone and pager and generally trying to relax away a year of work.  In the back of my mind, I will know that around the world a million kindred spirits will be out there running the calls, and doing the myriad things that aren’t action-packed, aren’t glamorous, but make the difference for the millions of people they encounter in that time.  Cat and I will raise a toast to you all, and will come back with more stories to share in just over a week.

Have fun, Stay safe,
MedicChris

A clarification

To those of you who have been emailing and/or calling me wondering about my copious use of the third person, Cat was telling the story for the last post, The not so calm before the storm. She had a problem with the software we use to push the articles, and was logged in as me. While Chris is not immune to the Medic Ego, Chris has not reached the point where he must now refer to himself in the third person just yet. Grin. I was on the bench for the business end of that call, and it was Cat's story to tell. That group did a great job and I'm proud of them. -- Chris

Not-So-Calm Before the Storm, continued

The elation of saving a life was being tempered by hearing that our patient was deteriorating. We know we did our job and did it well; we cleared and secured the child’s airway and he was stable with good vitals upon turning him over to the ED staff. So what was happening? Respiratory had intubated the patient and had been suctioning secretions from the patient’s lungs. With airway trauma it is not unusual to see such secretions, however as time went by the secretions became thicker and darker – an ominous sign. The patient had most likely aspirated a piece of hot dog down into his lungs; the lungs react to such an irritant by producing secretions that the body tries to cough out, taking the irritant with it. However, these secretions can become thick and difficult to cough out, and patients who are unconscious (like our patient) cannot cough at all. Secretions in the lungs build up and block oxygen from getting into the blood, and can develop into pneumonia over time. Our patient needs to be in a pediatric ICU but our local community hospital doesn’t have one, hence the decision to fly the child out.

While the charge nurse was waiting to hear from the last med-evac service, we made the decision to wait for that call and be available to make the transport by ground if the helicopters can’t fly. By department policy we do not do interfacility transports. As an emergency service we have an obligation to our community, and therefore don’t like to take a unit out of service for the time it takes to transport a patient to a facility 30 minutes or more away (and that’s at response speed without bad traffic). In this case, however, we as a crew felt like this was still OUR patient to some extent and wanted to be a part of his continued care. Chris called our chief, made the arrangements, and made a new best friend when Chris relayed this information to the charge nurse. She knew her hospital wasn’t equipped to deal with this patient and was worried about how long it would take to get the child to an ICU if a helicopter wasn’t possible. By this point the rain had begun and shortly thereafter the call came that there would not be a helicopter coming; we were a go for ground transport.

An ED nurse was assigned to travel with the patient in our unit, an assignment she was less than pleased about. First of all, she was a half hour from the end of her shift and this transport was likely to take an hour and a half or more. Second, she had already made this run earlier in the day with another patient and another unit, an apparently the driver was new (actually, he was first day new) and got a little excited during the transport, throwing the crew in back (including the nurse) all over the place. She half jokingly asked Chris if this driver was new. Chris responded that as Captain he gets his pick of driver from anyone in the department, and he chose Wayne to driver for him. At this point Wayne walked into the room and pointed to the embroidery on his uniform shirt that said “Captain’s Driver”. The respiratory therapist got a chuckle out of that one. The nurse’s other concern was the level of training she would have helping her in case the patient crashed on the way. Chris grinned as he informed her of the credentials that would be traveling with her. Three nationally registered paramedics and one intermediate-paramedic, one of whom is an instructor, all of whom are PALS (pediatric advanced life support) and PEPP (pediatric education for prehospital professionals) certified. Combined we brought just under 40 years of EMS experience to the table. I believe that helped the nurse feel a bit more comfortable.

So for the next 10 minutes or so while the ED was preparing the patient for transport, we got our unit ready. Our patient was sedated and intubated, so we assembled every piece of airway equipment we might possibly use in the appropriate size for a 2 year old and set them out on the counter so they’d be immediately at hand if needed. BVM, suction and airway adjuncts were staged on the counter beside the cot, low oxygen bottles were replaced will full ones and the main onboard tank was checked. Monitor batteries were changed and Chris got the phone number for the PICU we were transporting to so we could give report en route. The nurse got orders from the ED physician for additional paralytics and sedatives (in case the meds wore off and the patient started to fight the ET tube), and collected the medications and syringes she would need. This can be dangerous because if a patient starts to wake up and strains against the ET tube it can become dislodged. This would require us to extubate and reintubate the patient during transport, a situation none of us wanted to be in. Meanwhile, we had been listening to radio traffic from the west end of the county that were reporting heavy rain and wind and numerous road closures due to flooding. This was the storm heading in our direction. No pressure.

The transport went smoothly, in part due to diligence in monitoring our patient and in part due to Wayne’s driving. He had to weave us through a massive construction zone at the junction of several major highways just south of Washington, D.C. (locals refer to the area as “the mixing bowl” due to all the exits, overpasses and signs concentrated in the area), which he navigated with precision and confidence. So you know, Wayne used to drive big rigs and now does mechanical work on fire apparatus so he really knows the unit inside and out and can maneuver it through traffic like no one else in our department. (Remember Chris hand-picked him to be his driver, and for good reason.) Anyway, despite one idiot driving a sports car who tried to whip around and cut us off on the highway (unsuccessfully, by the way, thanks to Wayne), the transport was smooth and uneventful. The patient’s oxygen level remained between 98% and 100% throughout with us bagging him, and we used capnography to help maintain proper breathing rate and ensure that the airway remained patent. Blood pressure and pulse were also stable. Arriving at the ED we were relieved that no problems arose while on the road. Enter Murphy. Just as we were sliding the cot out the back of the unit the patient started to wake up and fight the tube. Time for more meds, NOW. The nurse whipped out her “goodie bag” and gave additional doses of Versed (a sedative) and Vecuronium (a paralytic agent). That did the trick, and within seconds out patient was comfortably asleep again. A quick check confirmed that the breathing tube was still in place, whew. Ahhh, such wonderful drugs we have. It reminds me just how much we can really do for our patients in the field. As I like to put it – better living through chemistry. But I’m getting off track….

We found an employee to guide us to the PICU because only one of us (the nurse) had ever been there before. When we asked if she remembered the way, she said no and then told us that the only time she had been to the PICU was when her own child was being taken there, so she wasn’t exactly paying attention to the route; completely understandable. (Her child is fine, by the way, and has made a complete recovery.) So we make it to the PICU without any further changes or complications. We gave report to several pediatric nurses and an MD as we helped transfer the patient to the hospital bed. It felt good to be able give complete and accurate answers to every question the doc asked including drug dosages, tube size, CO2 levels, vitals (we had about 5 sets of complete vitals) and a complete history of the patient’s condition since the incident occurred. The doc asked about the hot dog the child had choked on and seemed pleasantly surprised as I said, “Here you go”, and whipped out a specimen jar from my pocket containing the hot dog and handed it to him. Now it really was job complete, time to relax.

As we left the hospital to return to our own area, the western sky was black and moving in our direction. We were exhausted and decided to make a coffee stop on the way back despite the approaching storm. I suppose someone up there decided to take pity on us because the rain held off until we had gotten our caffeine and made it back to our base hospital. Within minutes of pulling into the ambulance bay, however, the sky opened. It was quite a show; a very active storm with lots of lightning and swirling clouds. Kind of fitting I suppose, watching the storm release its pent up energy while we were decompressing from a very stressful call.

After the call while we were restocking the unit, Chris was pulled aside by the ED doc who treated the patient when we first brought him in. The doc praised our crew for a job well done and said that the call went perfectly, and that we had without a doubt saved the child’s life. He went on to suggest that the entire EMS crew and engine crew members (who had jumped on our unit to assist) should be commended, and offered to write a letter to that effect. It’s not often that we get to make such a significant and immediate impact on a patient’s life, and having the treating physician take time to give us such positive feedback really made us feel great. Calls like this are why we do this job.

(As of this posting we haven’t gotten any follow-up information about our patient from the secondary hospital. I’ll certainly post an update if and when I get any information.)
-MedicCat

No-So-Calm Before the Storm

Storm clouds were gathering that day, a typical occurrence for Virginia summers. The weather man was calling for possible severe storms. Doesn’t take a genius to figure that one out, just go outside and look up, duh. We were running a stacked medic unit that day, me, Wayne, Tess (who just passed her national registry paramedic exam!), and Scheila (a veteran medic and our department’s training coordinator who was getting some time on the unit with us). Notice Chris is not on the roster, and remember what happened last time he left me in charge of the unit? (See posting titled “Marines Rock!”) The call was for a choking. Typically the choking part is over by the time we get there and the patient just needs to be checked out. Not this time.

En route, we find out the patient is a 2 year old choking on a hot dog, and instructions were being given by phone on how to remove a foreign body from the airway. Now it’s time to change gears. Approaching the scene we see a large group of people in the area, apparently there was a barbecue going on in the neighborhood. A woman (the patient’s mom) rushes over with a limp, barely breathing child in her arms and hands him to one of the guys on the engine who promptly turns and rushes the child into the back of the ambulance while doing back blows to try and dislodge the hot dog. Unfortunately, while this was happening on one side of the unit, I had gotten out of the other side, grabbed bags and was headed towards the group. One of the medics I was working with that day yelled to me that the patient was coming to us, so I turned around, but not before 4 or 5 of the patient’s family members had gotten in front of me and were piling into the back of the ambulance. So while 3 members of the engine crew and the other 2 medics with me that day were beginning care for our patient, I was trying to remove all non-EMS personnel from my unit. Anyone who has run a serious call like this knows that you don’t need family in the back with you while you work on your patient. Family members don’t need to see what we need to do to save their loved one’s life, and in addition to being an emotional mess and therefore a distraction to us, sometimes family can interfere with patient care. It’s hard enough to focus on all the details of our work without a parent getting in the way or arguing with us about what we’re doing. So bottom line, tickets for the back of my unit are reserved for my crew and my patient only.

Once I was able to get into the unit I could see that the crew was busy; being aggressive in cases of airway compromise are key to being effective in our interventions. This poor kid was in a bad way. He was limp and listless, skin had taken on an ominous grayish color with blue creeping in around the lips. His breathing was coming in short, gasping breaths which were slowing down. The BVM was in place and we were ventilating, but could tell there was an obstruction. Out came the laryngoscope to get a better look. The airway was full of sputum and blood. Apparently the frightened mother had gotten a little carried away trying to do a finger sweep and remove the hot dog before we got there, and based on the amount of trauma in this kid’s mouth and throat I’m betting she had some serious finger nails. Suction cleared most of the blood and revealed a good sized chunk of hot dog almost completely blocking the child’s airway. The problem was compounded by the fact that it was lodged behind the epiglottis in the opening of the trachea. It was too big to fall completely into the trachea (thank God), but it was big enough to block the opening and the epiglottis was holding it firmly in place. That explains why the back blows we did were ineffective. Spontaneous breathing had all but stopped and the child’s oxygen level was in the low 80’s and falling. Scheila grabbed the Magill forceps and went after the hot dog. At first only a small piece broke off, but on the second try the rest came out. We immediately got O2 back on the patient and bagged aggressively. Then we heard one of the most wonderful sounds a medic can hear when dealing with a non-breathing child – crying. Yes! Crying means we’re moving air. Crying means breathing. “Wayne! Fast but smooth, GO!” I yelled through the window. Within a minute the gray color was being replaced by a pleasant pink and our patient was breathing on his own.

The low rumble of thunder was audible in the distance as we pulled onto the road and Wayne lit up the siren and stomped the gas. At this point I got on the horn to the ED to give them the heads up. Our patient was still breathing adequately, the crying was decreasing and he appeared sleepy which wasn’t too worrisome considering what he’d just been through, I’d be exhausted too! We roll into the ED a mere 7 minutes after marking on scene. Hey look, there’s Chris! He had been listening to the radio traffic and came up to the hospital POV to meet us. Chris had gotten there ahead of us and gave a heads-up to a nurse outside the ED. Upon hearing that we were rolling their way with a pediatric patient with an obstructed airway, the nurse sprang up and asked if we had called in to notify the ED yet. Chris assured her that we would if we hadn’t already, he was just trying to give them as much warning as possible. About that time our sirens could be heard approaching the hospital. The MD, respiratory therapist and nurses took over as we gave report. We also gave them the offending hot dog piece (.

A sigh of relief and high fives all around. There is no doubt that this child is alive today because of EMS. This was definitely one of those calls that reminds you why we do what we do. We all took a minute to decompress and then started cleaning and re-stocking. Life saved, job done. Well, not exactly…

The rumble in my tummy was second only to the thunder as I remembered that before this call we had been making dinner plans. The crew had decided to splurge tonight and order dinner from Outback Steakhouse, and Chris walked outside the ED so he could get a cell signal and call the station to start coordinating food orders. A staff member outside pointed to the lighted helipad and said to Chris, “They’re flying your kid.” “What?!? He was stable, what happened?” Chris asked. She told him that the patient had gone unconscious and his vitals were deteriorating, the ED charge nurse was waiting for a call from the helicopter service to see if they were flying. Chris looked up at the darkening skies and doubted that any helicopter could fly. As it turned out, the services to the north were experiencing a downpour and could not take off. One of the services to the south was pinned between two storms and couldn’t fly. The other service to the south had still not called back yet. The charge nurse was hopeful though, the pilots of this particular service are mostly retired military, specifically Vietnam combat chopper pilots who fly under most any conditions. Chris returned to the EMS room to give us the update.

And you thought the story was over…. stay tuned, there’s more to come.
- MedicCat