Monday, January 01, 2007

It would take a miracle

Oops, so much for getting more blogging done over the holidays.  Things kinda snowballed on me instead of settling down for the year.  First, I was honored to be elected as the Rescue Chief for our department for 2007.  That starts in the first week of the year, but had me busy from the first of December.  Officers and crews had to be selected and assigned to stations and duty nights.  That is always a busy time of negotiations and trades, and then we had a bit of an emergency develop over getting our people updated with the new CPR protocols for the first of the year; that consumed just about every free minute for a couple weeks getting sorted out.  In the mean time, I actually did catch a couple of calls worth talking about and I intend to post them both here…with any luck over the next couple days even.

I’ve been taking it easy for a few days at my uncle’s place in the woods of east-central Tennessee.  A nice place here, enough to make you wish you were retired and living this life but it will have to remain something to work towards for now.  I almost bought the top of a mountain ridge, with views like something out of a postcard. A valley below, and the next range a few miles off in the distance.  Cat had already planned where the garden would go, and we were talking about how to lay out a down payment when we found out it was already sold.  Ah well, turns out there are other mountain tops, and other days coming.

We had duty on a Saturday shortly before Christmas.  I only have a few assigned shifts left before Chief-dom starts, and I’ve been really enjoying the last few days with “My Crew”.  Cat was leading for the shift, Wayne was driving as always, and I was reliving my EMS youth in the rear, with the gear.  We had breakfast with the Engine crew at a local deli place, good food and good company.  Afterwards, we were all standing outside the place chewing the fat while some of the guys had a smoke.  I joked that we looked like some sorry example of a new Fire and Rescue street gang. Someone from a neighboring department had Santa on a firetruck and since our radios were on scan, we could listen to them discussing how much candy to distribute and which streets to take first.  All in all a pretty low stress start to a really pretty day.  We had been back at the station for a little while when the call goes out a couple of dues away for a possible stroke.  The closest engine, from the neighboring department, was sent with us and was certain to get there well ahead of us.  

I am, as I said, in the back on the way and generally amusing my self with thoughts of riding as a rookie when I faintly hear the radio up front saying that the patient is unconscious and, oh yeah, CPR instructions are being given.  “Go ahead and add the third piece” I think to myself as the dispatcher announces that they are doing just that.  That means that we will arrive just after two fire engines from a different department on a code in progress.  Sounds like a crap shoot to me.  Cat yells back the news in case I didn’t hear, but I’m already starting to toss bags of supplies onto the cot.

As I mentioned before, the CPR protocols are set to change on the first of the year, and we are all rolling out the training to our people.  Of course that now means that in addition to showing up with two crews of people I don’t likely know, we also will have people of a mixed training background.  None of this is anything negative, just natural conditions of the state of transition.  I suggest to Cat that we assume nobody has the new information and run the ‘old’ rules, which are after all, still in effect.

It takes several minutes to get to the scene, pretty much in the center of our 4th due or so, and we hear that they are working the code well before we arrive.  I spend the time making sure we have everything we will need on the cot, ready to roll, and mentally reviewing the code protocols in my head.  We finally do come to a stop in front of the apartment building and I hop out to grab a backboard and the kit with the straps needed to use it.  I’m coming around the back of the unit to join up with Wayne and Cat as I am met by one of the firemen from the units on scene.  He tells me that they have gotten him (the patient) back after shocking him twice and he has agonal breaths.  They aren’t doing compressions anymore, and are assisting his respirations with the BVM.  “Wow, this stuff NEVER works” I tell him and grin.  I know that that is not true as I say it, but it does provide a small moment of levity while I mentally switch gears on the call.  I had no idea at the time just how many times I’d be doing that in the next 15 minutes.  

I have the board and the lifepack in my hands as we climb the stairs up to the apartment.  (upstairs again).  The crews from the engine are surrounding the patient.  He is in the lower 50’s, thin, and unconscious.  There is someone breathing for the patient with a BVM, and I note that it looks like he has a good seal on the mask and doesn’t appear to be having any issues…a good sign.  I’m a bit relieved to see that the engine officer apparently running the call as we arrive is the president of that department, and also a medic.  Good signs abound.  I mentally force myself to take it easy at first and get information and fight the urge to dive into the call.  We learn that he collapsed suddenly, there is a language barrier that is inhibiting communication for a history, he has been defibrillated twice, and that following the second shock, he showed signs of breathing.  All this comes to us in just under a minute.  Cat has swung around by the airway with the oxygen and the lifepack, and I’m working over to the patient’s side.  I’ve noted a scar on the patient’s chest and start asking about that, and I’m watching for signs that the patient is improving.  We learn that he had a heart valve replaced, and the guy working the BVM says he is breathing when the patient moves.  Cat has put on the 4-lead for the ECG and I’m starting at the beginning, feeling for a pulse.  The hairs on my neck twinge and I can’t place it…then I realize that while the patent’s chest is rising every time the bag is squeezed, it is no longer being led by his abdomen.  In other words, I don’t think the agonal breaths are still there, and I know that I’m not feeling a pulse.  I start to say something just as Cat has turned on the lifepak and is spinning around with the same news… Behind her I see two lines wiggling chaotically across the screen, V-Fib.  

Ventricular Fibrillation is what happens when the heart is stopping.  There is no organized pulse, and the heart quivers.  I have heard it said that if you could see the heart at that time, it would look like a bag of worms writhing.  I’ve always thought of it that way.  The bad news is that it means our guy is pulseless and apneic (not breathing)…dead by most standards.  The good news is that there is one thing to do..shock him.  That IS, after all, why it is called a defibrillator.  

Now, I know he has been shocked twice already, and that the electrical dose, in joules, increases for the first three shocks.  So, I think to myself, since the pads attached to the patient are still attached to the AED, and since that AED has already shocked him twice, it knows through its programming what dose to use.  “Hit him again” I say as I start to back away from the patient.  No need to tell ME to clear!  There was some talk at that point, but I didn’t hear it.  “He’s in V-fib. Shock him”.  I hear the AED talking and analyzing.  “Come on, come on” I think to myself as I’m checking to make sure everyone is clear.  “Shock advised” the AED says.  “No shit.” I think.  The Fire-Medic from the engine checks that everyone is clear as the system charges.  “Clear”…Thwump.  The patient flops quite a bit.  Good sign…really dead people take the shock without moving much.  I’m back on the patient just as fast as I can get there.  I look over at the monitor and I see that the rhythm is nearly flat.  “That looks about right” I say and start chest compressions.  “Well, there goes that save” I think, and I’m hearing someone say “30 and 2 right?”  Well, someone has the new training.  

We go into our compressions and respiration cycles and people are moving now.  I jokingly think to myself, “Hey, I’m the medic…I’m going to need to hand off these compressions to someone at some point here.”  Cat is getting set up to do the intubation, and the Fire-Medic starts looking for IV access on the guy’s arm.  There is not much there, no real surprise…he’s dead, so there is no pressure supporting his veins.  Cat confirms my compressions are showing on the monitor and I’m noting that the guy on the BVM is counting my compressions.  This actually helps because in the conversing about all that needs to go on, I’ve lost count….nice.  I hear him hit 30 and I stop so he can breath twice for the guy.  I tell him to keep counting, that I am losing count while looking for a vein in the guy’s arm etc. and I get a nod.  We are getting into our code groove when at the next pause for respirations I note that the monitor is showing some narrow complexes on the monitor….his heart is trying to get its act together.  “He has a pulse” I hear from in the room.  I’m already checking that with two fingers…but there is nothing there.  

We are briefly caught in a conversation about the fact that there are “beats” on the monitor, but that I’m certainly not feeling a pulse.  “Until I feel a pulse, It’s PEA, (Pulseless Electrical Activity…the signals are moving through the heart, but the muscle is not reacting in a beat) everyone okay?” I ask and end the conversation by restarting compressions.  I’m hoping that I wasn’t overly abrupt, but I also know that we are both facing a possible save (the heart is trying) but burning a clock too. “Get the Epi” I say and Wayne is on it.  A vein is found on the underside of his arm and we are almost in business there.  Cat is ready for the intubation at the next respirations.  The breaths go in and she gets the blade into his throat…and he gagged, or coughed around the blade.  Cat later said that she was visualizing the cords and saw them close.  I’m noticing, at the same time that there are more of the complexes on the monitor.  They are still too slow, about 30-40 per minute, but now I can feel a pulse with each complex on the monitor.  “Well, hot damn.  Welcome back.”  I think to myself.  “Okay, he’s Brady not PEA anymore.’ (told you…gear shifts).  “Lets get the line and atropine”.  Cat briefly suggests that the Epi is not in, but then shifts mental gears herself and agrees.  “Damn, this is more like a code in class than a ‘real’ one.” I start thinking.  

‘Mega-codes’ the practical tests we run in classes.  They usually jump at random from rhythm to rhythm to see if we can switch protocols on the fly.  ‘Real’ codes are done on living room floors like this one, involve a real, dead person, and proceed down a predictable line from “Mostly dead” (everyone think Princess Bride…okay, enough of that) to “Really dead”. Our guy has been in four rhythms in two minutes…Coarse V-fib, asystole or fine V-fib (I didn’t check which and didn’t care), PEA and now bradycardia.

The line is in place on the first try, (nice job to the fire-medic), and flowing well.  Wayne had the atropine out and opened the box, but now I’m noticing that the patient’s rate is up in the 70’s…not brady any more.  Hot Damn again.  Cat is suggesting we not go for the tube against his gag, and I’m not looking to sedate the dead guy we just got back, so I’m all for it.  And, oh yeah, we have great compliance and the airway is open and good oxygen is getting into his lungs etc etc etc.  The Atropine goes back into the drug box, I note that the oral airway is still in place and we are ready to move.  We get the backboard placed at the patient’s feet, and I suggest we just lift him up and slide the board under him.  We get that done in short order, have him strapped.  As we are getting ready to move, I hear that he has a oxygen saturation of 100% on the pulse ox.  (Okay, I’m fully alive, and I have a sat of 96-97% on a good day).  The guys get him moved to the cot and over to the unit pretty quick.  I tell the crews that it looks like we may have a save, that I want them to fax me a list of the names of the crew members there, and I’ll try really hard to not lose him on the way to the hospital.  

On the way, I am handling the respirations on the BVM and Cat and I reassess everything.  His rhythm is fairly stable, and we even get a Blood Pressure of 130ish over 50’s.  Well Merry Christmas to this dude.  We take the chance to double check doses and push a bolus of Lidocaine per our local protocol.  Honestly, I had never had someone come back on CPR and shocks alone and had to double check…but that is why we have that stuff on the unit.  We did get him on our end-tidal CO2 detector and find that he has a reading of 40-41.  That’s right in the middle of the idea range and a very good sign.

We get to the hospital before we hang the drip, but we can deal with that.  We get in and assist the ER staff in getting the patient transferred over to their equipment.  They confirm a pulse, and the blood pressure and even the O2 saturation.  He is put on a ventilator in short order and we give all the limited information we have to the doctor, along with a bag of all of his medications.  They are glad to hear about the lidocaine bolus and take over from there.  Our biggest miss was not getting a blood sugar level, and frankly we know better, but the number in the ER was over 130…more than fine.

I get into the report room where Cat and Wayne are already talking over the call.  I find out that they actually had had some trouble finding the place due to the ADC map showing two roads connecting that don’t.  (That is actually kinda common, but that’s another story).  In the end, I don’t know if he walked out of the hospital or not, but I know that we arrived on the scene of someone who was dead by any normal standard, and left a patient with a pulse, blood pressure, signs of great respiration, ventilation and perfusion.  He was taken to the ICU later in the day, and appeared to be stable whenever we checked in on him during the shift.  A nice way to start the season indeed.


At 8:06 PM, Blogger Doroshenk said...

Congrats on the Save, I still love hearing your stories, even from Idaho. To bad we're not billable when you tell them anymore:)

At 8:07 PM, Blogger Doroshenk said...

Congrats on the Save, I still love hearing your stories, even from Idaho. To bad we're not billable when you tell them anymore:)

At 8:03 AM, Anonymous Pete H said...

Lets get ahead of ourselves guys. Everyone on the scene did great. Any patient that arrives at ED with these signs are a possible 'Save'. Either way this patient has been given a top class level of care but wether they pull through is something different. I don't often find out about these patients because they often succumb to the cause of the initial cardiac arrest. For me it negates a lot of the hard work put in. For me it is about giving people the best possible chance no matter what.

Just on the new protocols. I back them 100%. But. A call I just did totally goes against the them. 84 yo,centrally cyanosed, agonal resps, HR16 unpalp.I was on a single response vehicle and just out of a deep sleep.I'm thinking a peri-arrest just about to lapse into a real one. I should of started CPR at the new rate. I didn't. I started rescue breathing. The patients HR came up, colour improved, palp pulse 130+ AFib, increased spont. resps. Rousable with pain when the crew arrived. She went on to revert to a NSR and GCS 15. One of those calls I think. Just shows that the new protocols are not the be all and end all. This took place on the 24th of December, so hopefully she could at least see Xmas in with her family. This job is never straight forward. Merry Xmas and New Year to all those at the sharp end, Pete H.

At 8:56 AM, Blogger MedicChris said...

Doroshenk -- Hey bud. I checked in on your site not long ago. Beautiful area you are in. Miss the "solve the world" talks. Hope all is well there.

Pete h -- Thanks for the kind words, and congratulations on your call as well. Nice when things work, even better when it was a "thinking medic" v. "cookbook medic" deal. Interesting line we walk too. On the one hand, the lawyer has your butt if you deviate at all from a standard of care, and on the other, the people setting the standard say that each step is "likely helpful" but unproven. I think, like anything else, we are moving forward one step at a time. I'm sure the new CPR will have a lot of benifits, and I'm also sure some part of it will be found to be "silly" in 10 years too.

At 1:01 PM, Anonymous Hank said...

The engine is about to go up for paramedic blogs and it will replace the static HTML links that are there now. We will go into beta in February and people can begin hosting their sites in the community.

What is the general term that you prefer to use today that covers paramedics,EMT, EMS, medics,tactical medical,firefighters, etc and everyone else who saves lives in this field? When I was younger, even paramedics were new so everyone was called a paramedic.

The site will have categories for each but it will be for rescue personnel and I don't want to sound too exclusive in the title.


At 5:34 PM, Anonymous ab said...

Ace, good save.

I live in the UK and i love these stories!!



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