# PNB



## Phridae (Feb 2, 2005)

Well I just got back from a long and exhausing code, PNB, whatever you want to call it. We were toned out at 2301. The last time someone had see this person alive was 2200. Police were on scen with their AED at 2306.  One of our EMTs was there before the officer and had begun CPR. Mind you, this call came in as difficulty breathing. So the officer gets there, sees the EMT doing CPR, and states we have a code blue. We get on scene at 2308. I go in with the monitor and the med bag. He didnt look like he'd been down that long. He wasnt very pale or anything quite yet. Anyways, we get the monitor on him and it shows asystole. We end up with 3 medics and two EMTS on scene total. Which, for Delavan is surprising. When we have a code, people come out of the woodwork. Well, I'm spiking IV bags and putting the end title CO2 detector on the BVM while one of the medics is going for the tube. Another medic is going for the line. We end up getting 2 lines, and the tube. 3 Epi and 2 Atro are pused while we're still in the house. We get him on a backboard and on the cot, then to the rig. Get him hooked up to our vent. And hey, this guy's got a pulse. And and nice looking rhythm. Tachy at about 120. No radial pulses though. Not with a pressure of 50/30-ish. This guy has a history of drugs and whatnot. The medic who tubed him said that she was confused, because she was looking for the white of his vocal cords, but they werent white. They were more a dark brown color. Anyways. Some BiCard is given, along with 4 of Narcan. Then, we're looking like mad for our narc box. We have things all seperated. The narc box as the morphine, versed, and what not in it. We're looking for this incase this is just an overdose and he does come out of it all mad and thrashing.  We thought we left it in the house. The house that smelled of dope. But  we found it. Anyways. The narcan does nothing. His pupils are fixed, but not dialated. We get him to the ED without any other delay. This ED we went to is just that. Its just an ED. Its not a hospital. Anyone that needs to be admitted gets shipped out.  Its the only ED around her like it. And I love it. Well, this guy is obviously not going to be walking out of this place. So, they get a chest xray, tubes in good position. They start a d-drip. Turns out this guy had a right sided infarction.  We end up taking him to a hospital 30 miles away. Gave 40 a vaso on the way there, and just took bp's. I manned the clipboard. He made it there okay. One of the medics who we dropped off at the station on the way to the hopsital was surprised the guy didnt code on us again. His pressue never got about 60 on the way to the hospital. But up in the ICU they said it was 110. Then they put in an art-line. Wish they had done that at the ED. So much easier. They dont think he's going to make it. I dont know. No one knows how long he was down.

But it was fun. (fun? I mean...sad and unfortunate) 
Now I'm tired. Time for sleep.


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## Jon (Feb 2, 2005)

> _Originally posted by Phridae_@Feb 2 2005, 05:03 AM
> * Well I just got back from a long and exhausing code, PNB, whatever you want to call it. We were toned out at 2301. The last time someone had see this person alive was 2200. Police were on scen with their AED at 2306.  One of our EMTs was there before the officer and had begun CPR. Mind you, this call came in as difficulty breathing. So the officer gets there, sees the EMT doing CPR, and states we have a code blue. We get on scene at 2308. I go in with the monitor and the med bag. He didnt look like he'd been down that long. He wasnt very pale or anything quite yet. Anyways, we get the monitor on him and it shows asystole. We end up with 3 medics and two EMTS on scene total. Which, for Delavan is surprising. When we have a code, people come out of the woodwork. Well, I'm spiking IV bags and putting the end title CO2 detector on the BVM while one of the medics is going for the tube. Another medic is going for the line. We end up getting 2 lines, and the tube. 3 Epi and 2 Atro are pused while we're still in the house. We get him on a backboard and on the cot, then to the rig. Get him hooked up to our vent. And hey, this guy's got a pulse. And and nice looking rhythm. Tachy at about 120. No radial pulses though. Not with a pressure of 50/30-ish. This guy has a history of drugs and whatnot. The medic who tubed him said that she was confused, because she was looking for the white of his vocal cords, but they werent white. They were more a dark brown color. Anyways. Some BiCard is given, along with 4 of Narcan. Then, we're looking like mad for our narc box. We have things all seperated. The narc box as the morphine, versed, and what not in it. We're looking for this incase this is just an overdose and he does come out of it all mad and thrashing.  We thought we left it in the house. The house that smelled of dope. But  we found it. Anyways. The narcan does nothing. His pupils are fixed, but not dialated. We get him to the ED without any other delay. This ED we went to is just that. Its just an ED. Its not a hospital. Anyone that needs to be admitted gets shipped out.  Its the only ED around her like it. And I love it. Well, this guy is obviously not going to be walking out of this place. So, they get a chest xray, tubes in good position. They start a d-drip. Turns out this guy had a right sided infarction.  We end up taking him to a hospital 30 miles away. Gave 40 a vaso on the way there, and just took bp's. I manned the clipboard. He made it there okay. One of the medics who we dropped off at the station on the way to the hopsital was surprised the guy didnt code on us again. His pressue never got about 60 on the way to the hospital. But up in the ICU they said it was 110. Then they put in an art-line. Wish they had done that at the ED. So much easier. They dont think he's going to make it. I dont know. No one knows how long he was down.
> 
> But it was fun. (fun? I mean...sad and unfortunate)
> Now I'm tired. Time for sleep. *


 all of my codes involved patients who, upon arrivial to ED were VERY STABLE (Read aysystolic in 3 leads). I've never had a "save" either in clinical or on the street. Kinda depressing   - at least you guys did EVERYTHING YOU COULD and got the Pt. to the ED fast, with a pulse and rythym (both are VERY GOOD THINGS - DUH!)

you win some, you lose some..


Jon


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## Chimpie (Feb 2, 2005)

Good job.  Whether or not he makes it, good job.  It sounds like you all worked together doing the best you could for him.


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## ffemt8978 (Feb 2, 2005)

At least you gave the guy's family a chance to say goodbye to him at the hospital.

Sometimes, you just gotta take your victories where ever you can find them.

I've personally done CPR over a dozen times, and have never had a patient live longer than 24 hours afterwards.


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## Phridae (Feb 2, 2005)

> _Originally posted by ffemt8978_@Feb 2 2005, 01:50 PM
> * At least you gave the guy's family a chance to say goodbye to him at the hospital.
> 
> Sometimes, you just gotta take your victories where ever you can find them.
> ...


 I've done CPR once. On my chiefs mother in law.  :blink: 

We had another code about a month ago. Maybe longer. I wasnt on it. But it was some guy who was driving his car or something. (what I know is sketchy, sorry) But someone saw this guy slumped over in his car and got out to see if he was okay. Apparently this somebody was a medic.  Some other people stopped to. They pulled this guy to the ground and performed CPR in the middle of Hwy 50. Right in fron of McDonalds. Another EMT who was there said by the time they were putting the cot in the back, the guy was asking if he could sit up. Crazy.


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## Phridae (Feb 2, 2005)

> _Originally posted by Chimpie_@Feb 2 2005, 11:52 AM
> * Good job.  Whether or not he makes it, good job.  It sounds like you all worked together doing the best you could for him. *


 We all did work together nicely. I was surprised. Usually we have so many people on these calls that 10 people are doing the same thing it seems. This time it was just 5 of us. There was no frantic looking for anything, no running back to the rig because something important was forgotten. We got everything done in a nice order. I have to say this was the best code we've ran in a long time. Considering we have a code about once every 2 months or something.


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## rescuecpt (Feb 2, 2005)

In response to Jon's post about bringing in stable patients (asystole) - I actually had one recently that started as asystole, we got him into a perfusing rhythm (but not breathing on his own), and the ED staff made him stable again (asystole).  Man was I pissed.   :angry:


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## Phridae (Feb 3, 2005)

I also forgot to mention that when we got to the ED, the whole garage smelled of burning breaks. Why? Because the driver drove with the parking break on the entire time.  It was a nice laugh.


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## PArescueEMT (Feb 5, 2005)

> _Originally posted by Phridae_@Feb 3 2005, 01:23 AM
> * I also forgot to mention that when we got to the ED, the whole garage smelled of burning breaks. Why? Because the driver drove with the parking break on the entire time.  It was a nice laugh.  *


 OOPS... i've never done that one


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## PArescueEMT (Feb 5, 2005)

> _Originally posted by rescuecpt_@Feb 2 2005, 10:30 PM
> * In response to Jon's post about bringing in stable patients (asystole) - I actually had one recently that started as asystole, we got him into a perfusing rhythm (but not breathing on his own), and the ED staff made him stable again (asystole).  Man was I pissed.   :angry: *


 Would that DWEDA??


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## rescuecpt (Feb 5, 2005)

> _Originally posted by PArescueEMT+Feb 5 2005, 03:01 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (PArescueEMT @ Feb 5 2005, 03:01 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-rescuecpt_@Feb 2 2005, 10:30 PM
> * In response to Jon's post about bringing in stable patients (asystole) - I actually had one recently that started as asystole, we got him into a perfusing rhythm (but not breathing on his own), and the ED staff made him stable again (asystole). Man was I pissed.  :angry: *


Would that DWEDA?? [/b][/quote]
 huh?


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## ffemt8978 (Feb 5, 2005)

DWEDA = Dead With Emergency Department Assistance


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## Jon (Feb 5, 2005)

> _Originally posted by PArescueEMT+Feb 5 2005, 03:00 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (PArescueEMT @ Feb 5 2005, 03:00 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-Phridae_@Feb 3 2005, 01:23 AM
> * I also forgot to mention that when we got to the ED, the whole garage smelled of burning breaks. Why? Because the driver drove with the parking break on the entire time. It was a nice laugh.  *


OOPS... i've never done that oneC   [/b][/quote]
 yeah...then again, one of our trucks had no brake....

and it wasn't just once................ :lol:    

Jon


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## Jon (Feb 5, 2005)

> _Originally posted by rescuecpt+Feb 5 2005, 08:44 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (rescuecpt @ Feb 5 2005, 08:44 AM)</td></tr><tr><td id='QUOTE'>
> 
> 
> 
> ...


huh? [/b][/quote]
 The Great Goddess Does not know about Dying with ED asstiance????


OMG  

What to do, what to do......

I guess she can no longer be RescueCapt....


Now must be FNG, or PHDNA (person who don't know abbreaviatons, DUH!) 


Jon


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## SafetyPro2 (Feb 5, 2005)

I went to bed last night with a premonition that I'd be doing CPR before the sun came up. Sure enough, at 0530 the tones go off for a "Person Not Breathing" about a block from my house (and yes, I had the ambulance). One of the other guys lives in the same are and had the Utility last night, so we both got on-scene at the same time. Grab our gear and go in, and PDs in there talking to the wife (first red flag...they're usually doing CPR). PD Sgt. says "He's down the hall." As we head down, overhear wife saying "I don't need an ambulance" in a resigned voice (second red flag). We go down and have to step over the O2 lines running out of the closet (third red flag). PT is lying on his back in bed with an NC on and obviously in full arrest. Pale, but not overly cyanotic. PD Sgt. comes in and says "He's dead." We begin to realize this is a terminal PT, so we do a quick check. Trunk is warm to touch. I ask PD if we know the down time and get a negative. I ask if we have a DNR...again negative. We roll the PT and check for signs of post-mortem lividity on the back...none. Move the limbs...no sign of rigor. Again, do we have a DNR? Nope. Third FF/EMT arrives at that time, and we look at each other and all say "We gotta work him". 

As BLS, we're only allowed to "determine" death based on a few obvious factors, including PM lividity and rigor, and he didn't have any of the criteria. And barring any legal DNR/Advanced Medical Directive, we can't NOT start resuscitative efforts. So, we start CPR and hook up the AED. AED shows asystole. We continue with another cycle and again, asystole, so we package and go. Get him to the ER and they work him for a couple minutes before calling him.

Turns out he's an old family friend of one of our FFs, who got on scene and then followed us down to the ER. Terminal with pulmonary fibrosis, and was supposed to sign his DNR today. 

And to top it all off, both PD and the ER staff got pissed at us for following the County protocol. PD expected us to come in and make a field determination for them, but he didn't meet any of the signs. ER staff got pissed because we brought in an unsavable PT (one doc kept asking us if the wife told us to not resuscitate...doesn't matter if she did, we can only follow a written order). At least during our crew meeting this morning, everyone (including the Captains and BC) reiterated that we did exactly what we should have, and the Chief will be having a conversation with the PD Chief over his Sgt's behavior on-scene (apparently some inappropriate comments about our personnel were made in front of the PT's family.)

So, that's how my day's been going.


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## Wingnut (Feb 5, 2005)

Well I'm sorry you got such a negative response, but you did the right thing. And consequently covered your ***...I've heard too many horror stories about EMS personnel doing exactly what that Sgt & Dr wanted you to do and it rarely ends well.  



*Golf clap for SafteyPro*


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## PArescueEMT (Feb 5, 2005)

See Below


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## PArescueEMT (Feb 5, 2005)

For Safety Pro:


.......A
....E....P
..S........P
....U....L
.......A


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## ffemt8978 (Feb 6, 2005)

> _Originally posted by PArescueEMT_@Feb 5 2005, 07:47 PM
> * See Below *


 That's a cheap way to increase your post count!


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## PArescueEMT (Feb 6, 2005)

it was an accidental double post. I had to change 1 of them. Would you rather have a "see above"?


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## Phridae (Feb 6, 2005)

> _Originally posted by PArescueEMT_@Feb 5 2005, 09:49 PM
> * For Safety Pro:
> 
> 
> ...


 I don't understand that.


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## Chimpie (Feb 6, 2005)

> _Originally posted by Phridae+Feb 6 2005, 07:21 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (Phridae @ Feb 6 2005, 07:21 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-PArescueEMT_@Feb 5 2005, 09:49 PM
> * For Safety Pro:
> 
> 
> ...


I don't understand that. [/b][/quote]
 Round of applause.


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## Jon (Feb 6, 2005)

> _Originally posted by Chimpie+Feb 6 2005, 10:31 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (Chimpie @ Feb 6 2005, 10:31 AM)</td></tr><tr><td id='QUOTE'>
> 
> 
> 
> ...


Round of applause. [/b][/quote]
 Wa Whaaaa.....


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## Jon (Feb 6, 2005)

> _Originally posted by SafetyPro_@Feb 5 2005, 07:02 PM
> * As BLS, we're only allowed to "determine" death based on a few obvious factors, including PM lividity and rigor, and he didn't have any of the criteria. And barring any legal DNR/Advanced Medical Directive, we can't NOT start resuscitative efforts. So, we start CPR and hook up the AED. AED shows asystole. We continue with another cycle and again, asystole, so we package and go. Get him to the ER and they work him for a couple minutes before calling him.
> *


 are you allowed to call Command and elevate the decision above your head?

In PA for DNR's you call command anyway - the doc has the final say.

Sounds like you could have given the command doc the brief heads up and had him speak to the wife, explain the situtation, and let the doc decide, then the ED can't complain when you get there.


Hindsight is always 20/20

Jon


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## PArescueEMT (Feb 6, 2005)

> _Originally posted by MedicStudentJon+Feb 6 2005, 12:36 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (MedicStudentJon @ Feb 6 2005, 12:36 PM)</td></tr><tr><td id='QUOTE'>
> 
> 
> 
> ...


Wa Whaaaa..... [/b][/quote]
 you would have done it if I hadn't and you know it.


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## PArescueEMT (Feb 6, 2005)

Plus... it was a good idea.


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## Jon (Feb 6, 2005)

> _Originally posted by PArescueEMT+Feb 6 2005, 05:42 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (PArescueEMT @ Feb 6 2005, 05:42 PM)</td></tr><tr><td id='QUOTE'>
> 
> 
> 
> ...


you would have done it if I hadn't and you know it. [/b][/quote]
 it all depends on the meaing of the word "It"  but probably yes


Jon


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## Phridae (Feb 6, 2005)

Anyways....I just found out that the guy died on friday. Darn. Was hoping to chalk another one up for our walking codes.


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## SafetyPro2 (Feb 7, 2005)

> _Originally posted by MedicStudentJon_@Feb 6 2005, 09:39 AM
> * are you allowed to call Command and elevate the decision above your head?
> 
> In PA for DNR's you call command anyway - the doc has the final say.
> ...


Nope, only Paramedics get to make base station contact here. EMTs just get to provide treatment based on our scope, which in this case is AED, CPR and high-flow diesel. Our rigs aren't even equipped with the radio system to make base station contact. All we do is call the ER on the cell phone once we're in route to give them a heads up of what we're bringing, and that's strictly a courtesy thing.

Now, had we had ALS on-scene for this call, then yes, they probably would have made base station contact, explained the situation and the base station staff would have made a field pronouncement. Since we're only BLS though, we're stuck with our protocol. We couldn't even call for ALS at that time because our transport time to the hospital is shorter than the response time for an ALS unit, and we're not allowed to wait on-scene for ALS to arrive. Long story, but we don't get an automatic ALS dispatch here...we're currently working on a way to provide ALS through out department.

If we have a valid DNR (state form or an advanced healthcare directive), we don't start (or if its in progress, discontinue) resuscitative efforts and hand off "custody" to the police until the Coroner arrives. However, any familiy member on-scene can override a valid DNR. In other words, if the wife says "Help my husband." we have to start resuscitative efforts even if he has advanced directives to the contrary. 

We can "determine" a few specific obvious signs of death. Is a patient is pulseless and apneic and has one of these conditions, we don't start resuscitative efforts. Most of them are pretty obvious (decapitation, incineration, decomp, evisceration of heart, lung or brain tissue). The trickier ones are post-mortem lividity and rigor. In those cases, we have to auscultate breath sounds for 60 seconds, auscultate an apical pulse for 30 seconds and check for neuro-motor response (usually pupils).


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## SafetyPro2 (Feb 8, 2005)

Just got home from my second pulseless and apneic, terminal PT in 3 days. 180 degrees from the last one. This PT had a valid DNR and had the signs of death for a field determination. And the cop on-scene couldn't have been nicer (this one's one of the senior guys and head of their union).

Almost was three PNB calls...call earlier tonight for a seizure almost went bad. Just as I was walking in, the Capt. came out and told me "He stopped breathing...go assist with CPR." I rushed in, but he had spontaneously re-started, so we loaded him and transported.

God I'll be glad when this shift ends.


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## Jon (Feb 8, 2005)

> _Originally posted by SafetyPro_@Feb 8 2005, 06:00 AM
> * Just got home from my second pulseless and apneic, terminal PT in 3 days. 180 degrees from the last one. This PT had a valid DNR and had the signs of death for a field determination. And the cop on-scene couldn't have been nicer (this one's one of the senior guys and head of their union).
> 
> Almost was three PNB calls...call earlier tonight for a seizure almost went bad. Just as I was walking in, the Capt. came out and told me "He stopped breathing...go assist with CPR." I rushed in, but he had spontaneously re-started, so we loaded him and transported.
> ...


 I had one yesterday in clinical. The Doc's didn't answere the command phone, so EMS showed up with a "VERIFIED POA states Pt. DNR" - POA couldn't find DNR papers. if the Doc hand answered the phone, we probably wouldn't have gotten the patient.

I got to do CPR for the first time in 5 months - forgot how sore you are later....  

Jon


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