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