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So I posted some details of this in the directionless thread, was going to pm it to a select group of people then decided to make it available to the whole world rather than limiting myself.
It's ~1500 on a beautiful Thursday and you and your partner are returning from a somewhat long psych transfer out of town. Tones drop on you for a "priority 2 unknown problem man down, reported as a male in his early 20s laying in the grass in front of the movie theater" at the mall south of town that you just so happened to be coming up on. En route your call is reconfigured to a "priority 2 diabetic problem".
The mall parking lot is huge and there are a lot of little pieces of lawn around, after about 5 minutes meandering about the mall parking lot you find your patient. An ILS fire crew, mall security and the patient's father are already on scene.
Fire reports 19 yo male history of insulin-dependent diabetes was found laying on the grass "acting odd." Father states he was out with some friends but was "normal" at 0900 this morning.
Pt is a&ox0, responsive to loud verbal stimuli, GCS 11 (3/3/5) and mildly combative (think aimless, weak swats at hands and grabbing pant legs).
Initial vitals (per fire, there's my first mistake with this crew) of 110/70, pulse of 130 strong and regular at the radial, SpO2 78% on room air, respiratory rate 50 deep and regular. CBG "HI" with a ketone warning (>600 mg/dL on our glucometers.)
Physical exam shows no signs of trauma, skin is pink, hot and very dry, PERRL but sluggish at 4mm (outside in the 85 degree bluebird day) no JVD, trachea midline.
Chest is without signs of trauma, equal rise and fall bilaterally, clear to auscultation anteriorly and posteriorly, no retractions or accessory muscle usage noted.
Abdomen is soft, no palpable or pulsating masses noted, no guarding. Pelvis is stable, no urinary or bowel incontinence noted.
Lower extremities are unremarkable, upper extremities have a gazillion scars from what appear to be intravenous injections, other than that they're unremarkable, no peripheral edema noted.
History: IDDM and "psychiatric problems", father denied any previous suicide attempts, denies any knowledge of drug or ETOH abuse but states "it wouldn't surprise me."
No known allergies or drug allergies.
Medications: Insulin (father unable to be more specific), Prozac and guanfancine
I wanted to go to the closest facility but father was adamant about going downtown, second mistake. Should have put my foot down but at this point I didn't see anything that lead me to believe he'd take a dump on me like he did.
I will also add another mistake I made was letting dad **** around on the phone for ~5 minutes trying to find out allergies and the name of the patients medications, should've gone and gotten them from the ER.
What I did:
Non-rebreather at 15lpm, still semi-conscious at this point so tried an NPA that he fought viciously so I let him be since he was doing a decent job of protecting his airway. 4-lead, partner did repeat vitals while I worked on a line. This is where I realized this kid is in a much worse situation than I originally had thought but at this point I had already dismissed fire (third mistake before assuring the vitals they gave me were accurate. Some crews are awesome, this one not so much and I knew it but disregarded it.) I somehow managed to fight an 18g through the scar tissue in his right AC with a liter bag + pressure bag running wide open, partner botched the left AC.
Repeat vitals were
100/50
150 BPM, sinus tachycardia without ectopy. I didn't do a 12-lead...it wasn't high on my priority list, frankly it was at the bottom. I didn't see a reason but if I'm missing something please chime in.
87% on 15 LPM
RR 50 still deep and regular. Classic kussmaul respirations.
From this point it went downhill. We started transport routine and upgraded to code 3 soon after I took another set of vitals.
GCS reduced to 9 (2/2/5)
BP 74/p (NIBP gave 70/30, I couldn't hear it on our wonderful freeways so I palped it twice to be sure)
HR still 150 sinus without ectopy
SPo2 down to love 80s on 15 LPM
RR still 50/min, snoring but it was very obvious to me that he was tuckering out.
Lungs still clear from what I could hear, unfortunately the Master Cardiology is a little too good when the sirens are going and I couldn't get a great listen between them and the road nose.
Popped a NC wi 6lpm on, popped him supine, put a pillow behind him and did the most epic head-tilt chin-lift I've ever done and started bag assisting every 4-5 breaths which got him into the low 90s. Again tried an NPA that he fought violently so I again pulled it. Restrained upper extremities at this time because he was going after the only patent line we had and the only other option was an IO, his vasculature was totaled.
Transport was about 20 minutes. I didn't really get a whole lot done after I started bagging him. The ER tubed him straight away, started a CVC, and shipped him to the ICU. Unfortunately this was two days ago and I didn't make it to that ER today so I don't know any labs or an official Dx. Pop's wedding is mañana so I don't work again until Sunday.
I want the good the bad and the ugly. No holds barred. Criticisms, things to think about, "you're an idiot" or compliments are all welcome. I've had a few DKA patients, none that did anything like this. Only thing I could think of is potential Sepsis combined with DKA? We learned later he a discharged from the ICU within the last two weeks and had a foley, CVC, art line although was not on any antibiotics and the father stated he had not been complaining of anything.
Sparknotes of my mistakes:
1) Should have redone vitals as soon as we got to the pt even with fire already having done them.
2) didn't put my foot down with dad on transport destination and while he was cupcaking around on his cell phone.
3) dismissing the fire department prior to reevaluating vitals and getting a better picture.
4) he made it to the ER, I thought about diverting to the closer facility but they were on a CC divert so he'd have to be transfered out pretty quickly. With that said, I can disregard diverts if I deem necessary per protocol. Should I have diverted? it would have meant a physician with RSI capabilities. Sometimes in situations like this I'm told we can stop, they will control the airway while he's still on our gurney and arrange a rapid transfer to their main facility and we can just continue on our way. When I say rapid transfer though I mean in the range of 20 minutes or so to get through all the hoops they have to jump through.
5) we have nasotracheal intubation capabilities and a protocol to do it. With our 20/20 hindsight this patient probably needed it. Unfortunately, I do not feel comfortable with this procedure, have only been trained on it a handful of times and the general consensus I've gotten is that they're frowned upon by the ER and our QA/I. With that said I have no problem standing up for my actions and being a patient advocate but I felt it would be negligent for me to attempt a procedure I'm not comfortable with, without assistance, jamming down the highway with the disco lights going. Looking back had he gotten much worse or the transport been much longer I would have had to have done something.
Sorry for the novel and the spelling/grammar, iPad keyboards, a bumpy ambulance and a sleepy paramedic make for a fun read Ready, set, GO!
It's ~1500 on a beautiful Thursday and you and your partner are returning from a somewhat long psych transfer out of town. Tones drop on you for a "priority 2 unknown problem man down, reported as a male in his early 20s laying in the grass in front of the movie theater" at the mall south of town that you just so happened to be coming up on. En route your call is reconfigured to a "priority 2 diabetic problem".
The mall parking lot is huge and there are a lot of little pieces of lawn around, after about 5 minutes meandering about the mall parking lot you find your patient. An ILS fire crew, mall security and the patient's father are already on scene.
Fire reports 19 yo male history of insulin-dependent diabetes was found laying on the grass "acting odd." Father states he was out with some friends but was "normal" at 0900 this morning.
Pt is a&ox0, responsive to loud verbal stimuli, GCS 11 (3/3/5) and mildly combative (think aimless, weak swats at hands and grabbing pant legs).
Initial vitals (per fire, there's my first mistake with this crew) of 110/70, pulse of 130 strong and regular at the radial, SpO2 78% on room air, respiratory rate 50 deep and regular. CBG "HI" with a ketone warning (>600 mg/dL on our glucometers.)
Physical exam shows no signs of trauma, skin is pink, hot and very dry, PERRL but sluggish at 4mm (outside in the 85 degree bluebird day) no JVD, trachea midline.
Chest is without signs of trauma, equal rise and fall bilaterally, clear to auscultation anteriorly and posteriorly, no retractions or accessory muscle usage noted.
Abdomen is soft, no palpable or pulsating masses noted, no guarding. Pelvis is stable, no urinary or bowel incontinence noted.
Lower extremities are unremarkable, upper extremities have a gazillion scars from what appear to be intravenous injections, other than that they're unremarkable, no peripheral edema noted.
History: IDDM and "psychiatric problems", father denied any previous suicide attempts, denies any knowledge of drug or ETOH abuse but states "it wouldn't surprise me."
No known allergies or drug allergies.
Medications: Insulin (father unable to be more specific), Prozac and guanfancine
I wanted to go to the closest facility but father was adamant about going downtown, second mistake. Should have put my foot down but at this point I didn't see anything that lead me to believe he'd take a dump on me like he did.
I will also add another mistake I made was letting dad **** around on the phone for ~5 minutes trying to find out allergies and the name of the patients medications, should've gone and gotten them from the ER.
What I did:
Non-rebreather at 15lpm, still semi-conscious at this point so tried an NPA that he fought viciously so I let him be since he was doing a decent job of protecting his airway. 4-lead, partner did repeat vitals while I worked on a line. This is where I realized this kid is in a much worse situation than I originally had thought but at this point I had already dismissed fire (third mistake before assuring the vitals they gave me were accurate. Some crews are awesome, this one not so much and I knew it but disregarded it.) I somehow managed to fight an 18g through the scar tissue in his right AC with a liter bag + pressure bag running wide open, partner botched the left AC.
Repeat vitals were
100/50
150 BPM, sinus tachycardia without ectopy. I didn't do a 12-lead...it wasn't high on my priority list, frankly it was at the bottom. I didn't see a reason but if I'm missing something please chime in.
87% on 15 LPM
RR 50 still deep and regular. Classic kussmaul respirations.
From this point it went downhill. We started transport routine and upgraded to code 3 soon after I took another set of vitals.
GCS reduced to 9 (2/2/5)
BP 74/p (NIBP gave 70/30, I couldn't hear it on our wonderful freeways so I palped it twice to be sure)
HR still 150 sinus without ectopy
SPo2 down to love 80s on 15 LPM
RR still 50/min, snoring but it was very obvious to me that he was tuckering out.
Lungs still clear from what I could hear, unfortunately the Master Cardiology is a little too good when the sirens are going and I couldn't get a great listen between them and the road nose.
Popped a NC wi 6lpm on, popped him supine, put a pillow behind him and did the most epic head-tilt chin-lift I've ever done and started bag assisting every 4-5 breaths which got him into the low 90s. Again tried an NPA that he fought violently so I again pulled it. Restrained upper extremities at this time because he was going after the only patent line we had and the only other option was an IO, his vasculature was totaled.
Transport was about 20 minutes. I didn't really get a whole lot done after I started bagging him. The ER tubed him straight away, started a CVC, and shipped him to the ICU. Unfortunately this was two days ago and I didn't make it to that ER today so I don't know any labs or an official Dx. Pop's wedding is mañana so I don't work again until Sunday.
I want the good the bad and the ugly. No holds barred. Criticisms, things to think about, "you're an idiot" or compliments are all welcome. I've had a few DKA patients, none that did anything like this. Only thing I could think of is potential Sepsis combined with DKA? We learned later he a discharged from the ICU within the last two weeks and had a foley, CVC, art line although was not on any antibiotics and the father stated he had not been complaining of anything.
Sparknotes of my mistakes:
1) Should have redone vitals as soon as we got to the pt even with fire already having done them.
2) didn't put my foot down with dad on transport destination and while he was cupcaking around on his cell phone.
3) dismissing the fire department prior to reevaluating vitals and getting a better picture.
4) he made it to the ER, I thought about diverting to the closer facility but they were on a CC divert so he'd have to be transfered out pretty quickly. With that said, I can disregard diverts if I deem necessary per protocol. Should I have diverted? it would have meant a physician with RSI capabilities. Sometimes in situations like this I'm told we can stop, they will control the airway while he's still on our gurney and arrange a rapid transfer to their main facility and we can just continue on our way. When I say rapid transfer though I mean in the range of 20 minutes or so to get through all the hoops they have to jump through.
5) we have nasotracheal intubation capabilities and a protocol to do it. With our 20/20 hindsight this patient probably needed it. Unfortunately, I do not feel comfortable with this procedure, have only been trained on it a handful of times and the general consensus I've gotten is that they're frowned upon by the ER and our QA/I. With that said I have no problem standing up for my actions and being a patient advocate but I felt it would be negligent for me to attempt a procedure I'm not comfortable with, without assistance, jamming down the highway with the disco lights going. Looking back had he gotten much worse or the transport been much longer I would have had to have done something.
Sorry for the novel and the spelling/grammar, iPad keyboards, a bumpy ambulance and a sleepy paramedic make for a fun read Ready, set, GO!