# Trainwreck #6



## usalsfyre (Mar 4, 2012)

I know it's been a few months, but a recent case deserved a posting. 

CCT unit, dispatched at 0200 for a transfer from a smallish ICU to Big City Medical Center 20 minutes away. The only info you've got is the patient is "trached and on drips". 

On arrival you find a crowd of people with a "deer in the head lights" look standing at bedside of a 46 YOF three hours post-ROSC. The patient was 10 days post-CABG, had been extubated and was scheduled to go home the next day when she suffered a hyperkalemic arrest and required CPR, multiple defibrilations, calcium, bicarb, insulin and D50. The patient had multiple failed airway attempts and had been crich'ed with a 6.0 ETT. You see Levophed and Dopamine hanging, the nurse is telling you she's turning the midazolam drip off now that your here. 

The physician is at bedside telling you to "hurry up and get the hell out of here!" 

Go....


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## abckidsmom (Mar 4, 2012)

I'm so happy to see a train wreck!  Let's start with labs pre and post arrest, vitals and a description of her mental status. Add in anything remarkable from her physical exam and cxr. 

And keep the versed running while you type!  Omg don't turn that off!


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## NomadicMedic (Mar 4, 2012)

A set of vitals and vent settings too.


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## Maine iac (Mar 4, 2012)

usalsfyre said:


> On arrival you find a crowd of people with a "deer in the head lights" look standing at bedside of a 46 YOF three hours post-ROSC.
> 
> The patient was 10 days post-CABG, had been extubated and was scheduled to go home the next day when she suffered a hyperkalemic arrest and required CPR, multiple defibrilations, calcium, bicarb, insulin and D50.
> Did she have the CABG at this smaller hospital? Was she not extubated fairly soon after the operation? (all the CABGs that I've seen have been extubated within 6 hours of closure.) Just trying to figure out where the 10 days comes from.
> ...



Labs would be nice, blood gasses also. Any other history that we should know about. I assume the worst since it was a 46 yof getting a CABG....


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## Aidey (Mar 4, 2012)

Past history? Smoking status? Drug use? Weight? Family history? Why the heck did a 46yo require a CABG? Why not a stent? How many vessels were involved in the CABG? Did her K+ suddenly spike or had it been creeping up the last 10 days? 

Vitals? 
Labs - Specifically CBC, metabolic panel and ABGs. 

What is her K+ now? Does she have any of hyper K meds hanging? Because Glucose/insulin only help while they are being given. Calcium just masks the problem. Bicarb helps with the acidosis not the actual hyper K. And albuterol only gives you 2-4 hours before the K+ starts going back up again.*** Since her arrest was 3 hours ago, her K+ has the potential to be creeping back up again.

Why was she such a hard intubation? Was she that hard to intubate 10 days ago?



***All of that is _very _simplified for the sake of brevity.


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## usalsfyre (Mar 4, 2012)

abckidsmom said:


> I'm so happy to see a train wreck!  Let's start with labs pre and post arrest, vitals and a description of her mental status. Add in anything remarkable from her physical exam and cxr.


BMP around the time of arrest was
Na: 128 K+:8.3 CL: 104 HCO3: 30 BUN: 26 Cr: 2.1 BGL:132

Now it’s 
NA:132 K:+5.5 CL:108 HCO3:18 BUN:47 Cr: 3.3 BGL:108

Physical exam as follows

HEENT: Intact, pupils are constricted and non-responsive. A clear fluid of unknown orgin is seeping from the nostril, an NG tube putting out some coffee grounds is in place.  Airway is “secured” with the ETT in the throat, the physician, RT and nurse all tell you “it’s not really secured very well and if you pull it out she’s dead”, the ETT is full length and appears to have been tied with umbilical tape. There’s dried blood on the neck and a suction canister full of frank blood that came “from the cric (shrug)” at bedside. JVD is noted. 

Chest: The whole this feels like mush. Equal rise and fall is noted, breath sounds are diminished, esp on the left, where there is a chest tube hooked to a water seal putting out frank blood (200mls). The CABG scar is present over the sternum, it remains closed (thankfully). A dual lumen subclavian cath was placed during the code, connected to it are dopamine at 20mcg/kg/min, norepinephrine at 20mcg/min. The nurse mentions she was getting vasopressin at one point too, but they D/C’d that an hour ago

Abdomen& pelvis: Soft, but absent of any sounds. A foley is in place, there has been zero output since the arrest. A rectal tube it also present. 

Extremities are intact, radial pulses are VERY narrow but absolutely bounding. A 20ga is present in the R wrist. The patient is very pale, cool to the touch.



abckidsmom said:


> And keep the versed running while you type!  Omg don't turn that off!


Too late, its off and the patient does…..nothing. A couple of twitches, that’s it. The patient was 100% intact prior to the arrest. 



n7lxi said:


> A set of vitals and vent settings too.


HR of 136, B/P of 177/112, no resp effort outside the vent at 20, SpO2 of 99%, ETCO2 of 34

A/C at 20, vT of 550, 0 PEEP FiO2 of 80%



Maine iac said:


> Labs would be nice, blood gasses also. Any other history that we should know about. I assume the worst since it was a 46 yof getting a CABG....


The patient was extuabted prior to the code, and scheduled to go home with in the next 36 hours or so.

PaO2 of 204
PaCO2 of 34
HCO3 of  31
Elevated gap and base deficit (can’t remember what they were at the moment)

Morbidly obese with poorly controlled HTN and diabetes. 




Aidey said:


> Past history? Smoking status? Drug use? Weight? Family history? Why the heck did a 46yo require a CABG? Why not a stent? How many vessels were involved in the CABG? Did her K+ suddenly spike or had it been creeping up the last 10 days?


Smoker, family history. They were unable to stent a 100% blocked vessel, but only one vessel. No idea on how long about the K+, the staff is seriously wigging out and “can’t remember”



Aidey said:


> Labs - Specifically CBC, metabolic panel and ABGs.


CBC hasn’t been done post arrest (all other labs are off an iStat) pre-arrest it was a H&H of 10.1 and 42, can’t remember the white count. 



Aidey said:


> What is her K+ now? Does she have any of hyper K meds hanging? Because Glucose/insulin only help while they are being given. Calcium just masks the problem. Bicarb helps with the acidosis not the actual hyper K. And albuterol only gives you 2-4 hours before the K+ starts going back up again.*** Since her arrest was 3 hours ago, her K+ has the potential to be creeping back up again.


No meds other than the dopa and levo



Aidey said:


> Why was she such a hard intubation? Was she that hard to intubate 10 days ago?


“Well she was REALLY anterior….”


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## Aidey (Mar 4, 2012)

Did they just turn the drips up to maximum for the hell of it or is there a reason they made her hypertensive? The versed was the wrong drip to turn off...

PT/INR available?


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## triemal04 (Mar 4, 2012)

Get a better run down of what happened before/during the arrest, and what has been done in the last 3 hours, including when she was given the listed meds, and how much of each.
Why the chest tube?  At what point was it placed, and how long did it take to pull out 200cc of blood?
If possible get a better story than "from the crich" and where the canister of blood came from.  (by suction canister you mean one that holds 800cc?)
Get her med list; probably on blood thinners but find out which and what else.
Even with the near-discharge, find out how her recovery has been; any untoward events at all or completely uneventful?
How much fluid has been pulled from the NG tube?
Restart the flippin' versed (or use fentanyl if you prefer); she probably doesn't need it, but better to have running just in case.  Mind the BP as you start fixing the rest though.
Did they take an x-ray to confirm the tube placement?  Be nice to see and might also help you find out what is going on in her chest.
Have them start a CBC.  If you aren't still there for the results have them contact the recieving hospital and you while still enroute.

While you are finding all that out:
Ensure that the crich has not slipped into the R mainstem and that's what's causing the diminished left lung sounds.  Resuction the trachea; any current bleeding?
Secure it by your preferred method, but make sure it is secure.  Consider switching it out for a trach tube, or just cut the ET tube down so it isn't so long.  Make sure it's secure and in the right place...again.
The diminished lung sounds...any hint of rales?  Or does this appear due to the obesity and/or a misplaced tube?  Any tracheal deviation or signs of a pneumothorax?  The blood from the chest tube; is it still currently draining?
Adjust her tidal volume as needed based on her IBW and 8ml/kg of volume.  Drop the rate to 10 and increase the PEEP to 5.  A/C is fine on the off chance she starts breathing spontaneously (won't happen).  Drop the FiO2 to 0.5 and think about going lower, but 0.5 is probably fine.  Before leaving run an ABG again.
Back the dopamine to 10mcg/kg/min (IBW) and the levo to 4mcg/min.  Given the GI Bleed and large amount of blood loss it's going to go lower than that, but until you start volume replacement keep it running, but slower.  Start a fluid bolus and if you have it or they have it, start giving FFP and PRBC's.  If she is on coumadin (likely) start vit K.  Whole blood would be an option but that'd take longer.  Continue to titrate the pressors down as needed.  Volume replacement needs to be done; shoot for a MAP of about 60-65.
Start either another peripheral line (if you can get one to flow) or place/have the MD place another central line.
She's still got a slightly elevated K; could start a continous albuterol neb. 
This will have taken awhile; run her labs on the istat again.  As needed be ready with more Ca, bicarb, D50/insulin.  What is her Ca level anyway?


The patient's got a GI Bleed of some size or another; that's potentially what caused the renal failure when combined with her chronic HTN and diabetes, and between that and the acute blood loss from the resucitation she's hypovolemic.  With the constricted/unreactive pupils, HTN, pressors and (likely) blood thinners have to wonder if she also doesn't have a head bleed.  Also very likely that she's bleeding into her chest cavity.

Keep her sedated as needed with versed or a versed/fentanyl combo leaning more towards fentanyl.  Keep her MAP around 60-65, watch for any kind of urine output, and, just in case she does have a head bleed, signs of herniation.  Edit: should probably keep her ETCO2 right around 35mmHg or just a bit higher. Depending on the next set of labs, continue to give fluid/blood (anemic so probably more blood) and continue to titrate the pressors down as needed.

If there is an actual acute hemmorhage that's ongoing and the current hospital has the capabilities, it'd be better to get her into surgery there.

Leave for the next hospital.  Mention to the doctor that although I probably just helped kill her by screwing everything up, he should still talk to his malpractise carrier.


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## thisgirlisamedic (Mar 5, 2012)

Ok a few things kinda out order but where is the stack of strips from the code and I know the er did multiple 12 leads what's going on there? What was the rythm before arresting.  What changes if any after arrest.  The coffee grounds in the n/g may simply be from what went down her throat during this drs attempt at intubation, I guessed it wasn't on continous suction, one thing bothers me the most that is the cpr on the fresh cabg site, I wonder if it has caused trauma and worst case torn the to arteries, with this case I wouldn't be surprised to find a tear somewhere causing the chest tube out put and also the hemo. That made them put it in . I really think that b/p is not only med. Induced but a really big sign. That  I would puha cause its fixing to give out and be nothing. She is fixing to code again and i wouldnt want to be the one having to do cpr on her... I


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## Maine iac (Mar 5, 2012)

So... how did the transfer go?


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## abckidsmom (Mar 5, 2012)

usalsfyre said:


> BMP around the time of arrest was
> Na: 128 K+:8.3 CL: 104 HCO3: 30 BUN: 26 Cr: 2.1 BGL:132
> 
> Now it’s
> NA:132 K:+5.5 CL:108 HCO3:18 BUN:47 Cr: 3.3 BGL:108



K is down out of the sky, but still up, kidneys took a hit.  



> Physical exam as follows
> 
> HEENT: Intact, pupils are constricted and non-responsive. A clear fluid of unknown orgin is seeping from the nostril, an NG tube putting out some coffee grounds is in place.  Airway is “secured” with the ETT in the throat, the physician, RT and nurse all tell you “it’s not really secured very well and if you pull it out she’s dead”, the ETT is full length and appears to have been tied with umbilical tape. There’s dried blood on the neck and a suction canister full of frank blood that came “from the cric (shrug)” at bedside. JVD is noted.



Phyisician is going to secure the airway with sutures before the patient is moved.  



> Chest: The whole this feels like mush. Equal rise and fall is noted, breath sounds are diminished, esp on the left, where there is a chest tube hooked to a water seal putting out frank blood (200mls). The CABG scar is present over the sternum, it remains closed (thankfully). A dual lumen subclavian cath was placed during the code, connected to it are dopamine at 20mcg/kg/min, norepinephrine at 20mcg/min. The nurse mentions she was getting vasopressin at one point too, but they D/C’d that an hour ago
> 
> 
> > Scary stuff, this.  Was there a post-arrest 12 lead that may show evidence of the integrity or failure of the anastamosis?
> ...


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## usalsfyre (Mar 6, 2012)

*Got tied up in meeting yesterday....*

Sorry for the delay. 

Aidey, 
Pressors were started on the high end and quickly maxed. INR just came back as at 5.6.

Trimeal, 
Chest tube was placed in response to a pneumo, likely due to CPR. You can't get a straight answer on the blood, the physician is being somewhat evasive. Chest tube is draining, the 200mls has been over three hours. She's on Lovenox. The physician tells you she's not on PEEP because of the pneumo. 

thisgirlsisamedic,
EKG looked something like this immediately prearrrest: 





abckidsmom,
Post arrest 12 lead





Chest tube is new, post-ops were pulled day two per the normal procedure there uneventfully. 

CVP is 18. 

So, we back off on the FiO2 to 0.5, add a little PEEP and decide to start weaning the pressors a bit. 

As we turn the levo down from 20 to 15mcg/min, her pressure drops to 70/30 and we lose a radial.

Now what?


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## Aidey (Mar 6, 2012)

Packed RBCs and FFP. 

And just a radial or both? lol. What is the CVP now?


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## abckidsmom (Mar 6, 2012)

Dang. 

This facility has thoracic surgery And we are really going somewhere else?  Holy EMTALA violation, batman. 

Your train wrecks are always so morally complex!

Turn the the vasopressin back up to 18. Smaller steps. How much fluid has she had post arrest?  She's gonna exsanguinate through her LAD on the way to the other hospital. Maybe the sternum wires are responsible for her pneumo and her tamponade that's forming?


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## Melclin (Mar 6, 2012)

abckidsmom said:


> This facility has thoracic surgery And we are really going somewhere else?  Holy EMTALA violation, batman.



Yeah whats the go with that? What the cardiothoracic surgeons opinion on all of this? I'm no expert but it kinda seems like they're ganna need to open her up again. They can't do that there? Seems like she should have been in theatre already.


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## abckidsmom (Mar 6, 2012)

Melclin said:


> Yeah whats the go with that? What the cardiothoracic surgeons opinion on all of this? I'm no expert but it kinda seems like they're ganna need to open her up again. They can't do that there? Seems like she should have been in theatre already.



For real. I guess we, as the only people actively managing the patient, are going to need to do a pericardiocentesis.  (lol, autocorrect suggestion was pericardial entrails)

What does her heart sound like?


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## Veneficus (Mar 6, 2012)

abckidsmom said:


> Maybe the sternum wires are responsible for her pneumo and her tamponade that's forming?



If that is the case since the rough edges are usually bent towards the sternum I would probably want to go to another facility that deal with anymore care at this one.

Can't really complain about the emergent care, but it seems from the scenario the staff here was not prepared or experienced with this type of patient. 

The doc wanting to punt to somebody who can or at least more comfortable with is probably a very good decision.

C/T surgery generates money. Taking the easy cases and referring the troublesome ones is a business decision.


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## thisgirlisamedic (Mar 6, 2012)

This pts in icu and noone noticed lab.value changes, I know the last three labs drawn pre arrest were giving them clues to this it wasn't just a rapid onset it takes a while to get this out of wacky, I wonder what her sob panel shows dedimer


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## Veneficus (Mar 6, 2012)

thisgirlisamedic said:


> This pts in icu and noone noticed lab.value changes, I know the last three labs drawn pre arrest were giving them clues to this it wasn't just a rapid onset it takes a while to get this out of wacky, I wonder what her sob panel shows dedimer




It sounds like this patient was sent home and this event occured in the ED unless I understood it wrong.

Renal changes can take days or even a week before clinical symptoms appear. 

Prior to that, measurements of GFR and creatinine elevate usually 24 hours+ post insult. 

If this lady was bed confined, coagulation events like DVT converting to PE, as well as DVT expanding past the renal arteries are not only possible, but I have seen them.

It really sounds to me like a this very complex resuscitation somehow ended up at a place that doesn't deal with this kind of event. 

But I think it demonstrates that simple guidline based resucitation doesn't always work very well.

I also think it demonstrates very nicely the need and value of surgical intensivists.


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## thisgirlisamedic (Mar 6, 2012)

Elevated? Her coumadin kinda high but know she running a rib I wouldn't mess with the vitamin k besides its slow acting, when and what are her meds and last given, why have the not done a stat scan to look at what trauma they caused post arrest, moving her to risky I still think she has a tear in a major blood vessel and i wouldn't want to finish tearing it, I would really talk to staff about testing Murphy's law here......and i would at least like blood to be hanging to cause my fluids won't do anything but make her bleed pink, you can only maintain a b/ p with a drip for so long, I really wonder what was her urinary output pre arrest? Was she able to eat yet. Last meal and blood sugar insulin given, during this stay did she get a transfusion? Possible if there is already this level of incompetence that this onset was from a reaction to the transfusion or wrong meds given .  It still bothers me that they should be doing labs q 2 hrs or at least q 4 for sure I wonder what changes took place over the last 12 hours of labs? It would be nice to see here pre and post SOB panel and blood sugars and insulin given


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## thisgirlisamedic (Mar 6, 2012)

Sorry for errors my phone thinks its smarter then me but I'm sure u can figure out what should be there


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## Melclin (Mar 6, 2012)

This a pt for the adult retrieval team. If for some reason I was taking this pt, despite my protests, I'd be on the phone to the Adult Retrieval consultant for advice. 

Do you have systems for pt retrieval/retrieval co-ordinators/doctors/consultation hotlines etc, runs these things and whom you can consult with?


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## thisgirlisamedic (Mar 6, 2012)

Another thought her bun is going up showing more then likely that she is hypovelmic.  This still supports the bleeding due to trauma from cpr theory ?????


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## Veneficus (Mar 6, 2012)

thisgirlisamedic said:


> Elevated? Her coumadin kinda high but know she running a rib I wouldn't mess with the vitamin k besides its slow acting, when and what are her meds and last given, why have the not done a stat scan to look at what trauma they caused post arrest, moving her to risky I still think she has a tear in a major blood vessel and i wouldn't want to finish tearing it, I would really talk to staff about testing Murphy's law here......and i would at least like blood to be hanging to cause my fluids won't do anything but make her bleed pink, you can only maintain a b/ p with a drip for so long, I really wonder what was her urinary output pre arrest? Was she able to eat yet. Last meal and blood sugar insulin given, during this stay did she get a transfusion? Possible if there is already this level of incompetence that this onset was from a reaction to the transfusion or wrong meds given .  It still bothers me that they should be doing labs q 2 hrs or at least q 4 for sure I wonder what changes took place over the last 12 hours of labs? It would be nice to see here pre and post SOB panel and blood sugars and insulin given



Using pressors to maintain perfusion when volume replacement is needed is shown to increase mortality. The fact they are basing perfusion  on her systolic BP demonstrates clearly they are in over their head. 

The patient probably does need blood and maybe emergent surgery. 

A CT scan in a facility that is not going to do anything with the findings just delays the patient from getting to a facility that will. 

I wouldn't call a provider doing the best they can in a situation they do not regularly handle or are trained for incompetent.

Looking at just the CPR component, if you have no ability to open and close a chest, then performing CPR on a recent cardiac surgery patient over no emergency circulatory support is the lesser of 2 evils.

From what I read, it seems like too much focus was put on intubation vs. ventilation.

Did the cric go wrong? Sounds like it. But ask yourself, how often do you do one? How proficent are you at it? Would your best effort in a stressful situation be any better or worse?

How do you know the physician wasn't dealing with a variation in anatomy that he wasn't prepared for?

I never defend poor care, but as somebody who regularly deals with emergency room doctors and has to take a graduate exam in a few weeks on surgical critical care as part of my academic pursuits, if a person does not spend a lot of time on the topic, it is very easy to be overwhelmed.

Contrary to EMS belief, and not picking on you directly, ER docs, both EM trained and others, are not the masters of resuscitation or surgical pathology. They are not all knowing and all powerful by virtue of being a doctor in the ER. 

If they were, there would be no need for other specialists.      

This is a very complex patient and well outside of the realm of emergency medicine. The patient needs to go elsewhere. If she dies on the way or where she is at, she is still dies.

"Cut along the scar, clip the wires holding the sternum, spread the chest and reconnect vascular grafts or perform pulmonary endarterectomy as required, then expand the incision to the neck to explore iatrogenic bleeding from a cric" are not a part of any ED resuscitation guidline I have ever heard about.

The EMs who hang out on the forum please correct me if I am wrong on this.


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## thisgirlisamedic (Mar 6, 2012)

Incompetence wasn't just put on the Dr correct me if I'm wrong but don't most hospitals just use the er Dr for codes on floor, so I am sure he did everything he could and to the best of his ability, but the staff taking care of pt may have dropped ball on this one, I really think there is more to be seen that could have prevented her current state, I understand that they can only do what the pts Dr authorizes, but was the cardiologist that performed intial surgery available wouldn't be more practical and safer for him to open back up and stabalize prior to transport? If the original cabg was done on site why not go back in, I don't see a lot of receiving facilities being happy about accepting this pt?  I'm not saying don't transport I don't know the abilities of this facility vs. The receiving one... But it just doesn't seem to be logical to more someone this unstable, and yes you can use meds to keep pressure up but they only last as long as they have blood to move her bun really let's me know that's going downhill now grant it I work in the middle of no where I am two hours from nearest trauma center and have just a small hospital with not many services available so i do tend to look at things that aren't maybe going to happen in just mins. I tend to look long term and i do recall it only being 20 miles, so it is likely to get her to a better equiped. Facility, but i still wonder if it doesnt go against the do no more harm, one wrong bump and it could be well not good. Also one our units its just us two that's it so I would want a nurse or another medic along, just in case,


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## Aidey (Mar 6, 2012)

I'm sorry, I know you said you were on your phone but I simply can not follow what you are saying.


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## Anjel (Mar 6, 2012)

thisgirlisamedic said:


> Incompetence wasn't just put on the Dr correct me if I'm wrong but don't most hospitals just use the er Dr for codes on floor, so I am sure he did everything he could and to the best of his ability, but the staff taking care of pt may have dropped ball on this one, I really think there is more to be seen that could have prevented her current state, I understand that they can only do what the pts Dr authorizes, but was the cardiologist that performed intial surgery available wouldn't be more practical and safer for him to open back up and stabalize prior to transport? If the original cabg was done on site why not go back in, I don't see a lot of receiving facilities being happy about accepting this pt?  I'm not saying don't transport I don't know the abilities of this facility vs. The receiving one... But it just doesn't seem to be logical to more someone this unstable, and yes you can use meds to keep pressure up but they only last as long as they have blood to move her bun really let's me know that's going downhill now grant it I work in the middle of no where I am two hours from nearest trauma center and have just a small hospital with not many services available so i do tend to look at things that aren't maybe going to happen in just mins. I tend to look long term and i do recall it only being 20 miles, so it is likely to get her to a better equiped. Facility, but i still wonder if it doesnt go against the do no more harm, one wrong bump and it could be well not good. Also one our units its just us two that's it so I would want a nurse or another medic along, just in case,



Use periods for petes sake. And use the enter button and make periods. 

Please!


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## ffemt8978 (Mar 6, 2012)

Anjel1030 said:


> Use periods for petes sake. And use the enter button and make periods.
> 
> Please!



Agreed, but before this gets out of hand that will be the only grammar comment allowed in this thread.

Sent from my Android Tablet using Tapatalk


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## Farmer2DO (Mar 6, 2012)

usalsfyre said:


> Airway is “secured” with the ETT in the throat, the physician, RT and nurse all tell you “it’s not really secured very well and if you pull it out she’s dead”, the ETT is full length and appears to have been tied with umbilical tape.



Well, then, secure it better, or I'm not touching her.  Period.




> Morbidly obese with poorly controlled HTN and diabetes. Smoker, family history.





> C/T surgery generates money. Taking the easy cases and referring the troublesome ones is a business decision.



So, it sounds like this is a smaller facility that doesn't do a lot of complicated cases.  Who in the realm of Hades thought it would be a good idea to do a CABG on a 46 year old morbidly obese smoking female who's diabetes and hypertension are poorly controlled AND has a family cardiac history?  This is NOT an easy case, and should have been seen ahead of time as such.  Referring the troublesome cases AFTER they decompensate and are in extremis is also a bad business decision.



abckidsmom said:


> Dang.
> 
> This facility has thoracic surgery And we are really going somewhere else?  Holy EMTALA violation, batman.





Melclin said:


> Yeah whats the go with that? What the cardiothoracic surgeons opinion on all of this? I'm no expert but it kinda seems like they're ganna need to open her up again. They can't do that there? Seems like she should have been in theatre already.





Veneficus said:


> If that is the case since the rough edges are usually bent towards the sternum I would probably want to go to another facility that deal with anymore care at this one.



After she's stabilized.



> Can't really complain about the emergent care, but it seems from the scenario the staff here was not prepared or experienced with this type of patient.



Agreed.  Which is why they never should have done her in the first place.



> The doc wanting to punt to somebody who can or at least more comfortable with is probably a very good decision.



Here I disagree.  This is a dump job, and the exact type of case that EMTALA was meant to prevent.  She's obviously got some badness going on that likely needs surgical correction, and the sending facility has the surgical capabilities to deal with it.  The CT surgeon took her on; he needs to deal with the complications.  If this were a patient that couldn't come off pump (I've seen several times) and they wanted to send her somewhere that could place a VAD and evaluate her for a heart transplant, fine.  I have no problem with that.  But they created this problem, and it's a problem that is likely to worsen during transport, which then becomes my problem.



Melclin said:


> This a pt for the adult retrieval team. If for some reason I was taking this pt, despite my protests, I'd be on the phone to the Adult Retrieval consultant for advice.
> 
> Do you have systems for pt retrieval/retrieval co-ordinators/doctors/consultation hotlines etc, runs these things and whom you can consult with?



I work in a system where we have an adult transport team.  Usually a paramedic, RN, RT and perfusionist.  This is the only way this person should be going out of here.



Veneficus said:


> The fact they are basing perfusion  on her systolic BP demonstrates clearly they are in over their head.



Agreed. 



> The patient probably does need blood and maybe emergent surgery.



Also agreed.  By the surgeon that cut her in the first place.



> A CT scan in a facility that is not going to do anything with the findings just delays the patient from getting to a facility that will.



Agreed.



> I wouldn't call a provider doing the best they can in a situation they do not regularly handle or are trained for incompetent.



I understand where you are coming from, but there are 2 reasons I would seriously call in question the competence of the surgeon:  1) opening this patient up in the first place  2) not fixing his own mistakes.  Notice I didn't say for the patient decompensating in the first place.  Bad outcomes happen.  Fact of life.  But someone should have foreseen this and sent this woman to a larger center.




> Contrary to EMS belief, and not picking on you directly, ER docs, both EM trained and others, are not the masters of resuscitation or surgical pathology. They are not all knowing and all powerful by virtue of being a doctor in the ER.



My expeience has been that anesthesiologists, internists and surgeons with critical care training, and emergency physicians are generally pretty good at resuscitation.  I have worked around many, many internists and surgeons without critical care training, and it's obvious that it isn't their area of expertise.  



> This is a very complex patient and well outside of the realm of emergency medicine.



Agreed.  But he said she was in the ICU.  I don't really see where EM enters into this discussion at all. 



> The patient needs to go elsewhere.



Agreed.  The OR.  At the sending facility.




> "Cut along the scar, clip the wires holding the sternum, spread the chest and reconnect vascular grafts or perform pulmonary endarterectomy as required, then expand the incision to the neck to explore iatrogenic bleeding from a cric" are not a part of any ED resuscitation guidline I have ever heard about.



Again, this isn't an EM case.  It's solidly in the realm of CT surgery.  And the procedure you are describing can be done.  By a CT surgeon.  The same one who did the surgery in the first place.

I would be on the phone with my medical director about refusing to take this patient.  I have no problem taking patients that have a high chance of death during transport if I'm taking them somewhere for something that can't happen at the sending hospital.  I do it quite often.  I DO have a problem taking a patient that can be stabilized at the sending facility.  In fact, I believe it's required by law.


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## Veneficus (Mar 6, 2012)

Farmer2DO said:


> So, it sounds like this is a smaller facility that doesn't do a lot of complicated cases.  Who in the realm of Hades thought it would be a good idea to do a CABG on a 46 year old morbidly obese smoking female who's diabetes and hypertension are poorly controlled AND has a family cardiac history?  This is NOT an easy case, and should have been seen ahead of time as such.  Referring the troublesome cases AFTER they decompensate and are in extremis is also a bad business decision...



I agree without condition.

Now that is has happened though, the situation has to be resolved in the best interest of the patient. Punitively forcing an operation is not the solution.



Farmer2DO said:


> After she's stabilized..



You cannot stabilze somebody who needs surgery without it. No amount of medicine will do that. It is the whole basis for trauma systems. (I know this wasn't a trauma, but I think we agree this is still a surgical emergency)



Farmer2DO said:


> Here I disagree.  This is a dump job, and the exact type of case that EMTALA was meant to prevent.  She's obviously got some badness going on that likely needs surgical correction, and the sending facility has the surgical capabilities to deal with it.  The CT surgeon took her on; he needs to deal with the complications.  If this were a patient that couldn't come off pump (I've seen several times) and they wanted to send her somewhere that could place a VAD and evaluate her for a heart transplant, fine.  I have no problem with that.  But they created this problem, and it's a problem that is likely to worsen during transport, which then becomes my problem..



I am not saying this isn't a dump job. Likely it is. 

But how do we know sending this patient out is really sinister?

Is it possible that the surgeon thought it was a manageable case (either out of arrogance or ignorance) and then discovered afterword it was beyond his skill and now is hoping somebody better can fix it?



Farmer2DO said:


> I work in a system where we have an adult transport team.  Usually a paramedic, RN, RT and perfusionist.  This is the only way this person should be going out of here...



Sounds great



Farmer2DO said:


> Also agreed.  By the surgeon that cut her in the first place..



This I do not agree with. If said surgeon already knows this patient is beyond him, while it doesn't harm the statistics of said surgeon, in the interest of the patient, a superior provider is the right choice. 



Farmer2DO said:


> I understand where you are coming from, but there are 2 reasons I would seriously call in question the competence of the surgeon:  1) opening this patient up in the first place  2) not fixing his own mistakes.  Notice I didn't say for the patient decompensating in the first place.  Bad outcomes happen.  Fact of life.  But someone should have foreseen this and sent this woman to a larger center.



I am not saying this patient should not have been sent to a more capable center for the initial operation. Undoubtably she should have been.

But, I can tell you from experience that sometimes when you cut into somebody, what you find isn't always what you expect. (something I learned thinking I was draining a cyst, that ended up being a lipoma, but that is another story) 

Sometimes after a surgeon makes a mistake, it requires a better surgeon to correct it. I have been at the table for some very involved cardiac reoperations, and I am very glad I wasn't responsible for the outcome in any way as soon as I saw the mess once the chest was opened. In my experience reoperations often require extraordinarily skilled surgeons.



Farmer2DO said:


> My expeience has been that anesthesiologists, internists and surgeons with critical care training, and emergency physicians are generally pretty good at resuscitation.  I have worked around many, many internists and surgeons without critical care training, and it's obvious that it isn't their area of expertise.



I agree with this, but the trouble is when the patient has a surgical pathology, you cannot resuscitate successfully until that is fixed. 

Fooling around with medical treatments, intensive or otherwise just delays needed surgery.



Farmer2DO said:


> But he said she was in the ICU.  I don't really see where EM enters into this discussion at all.
> 
> Again, this isn't an EM case.  It's solidly in the realm of CT surgery.  And the procedure you are describing can be done.  By a CT surgeon.  The same one who did the surgery in the first place..



My mistake, when I read the scenario for some reason I thought this was an ED resuscitation and was addressing it for that, sorry.

And I made a mistake in my last post, I should have said thromboectomy, not endarterectomy. My fault.


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## Handsome Robb (Mar 6, 2012)

usals this one has me thoroughly confused. It's way over my head lol. 

It's pretty much been established that this pt needs surgery sooner then later. I'd rather not transport her while she is so unstable but I agree with vene, this original surgeon seems to have caused a much more severe problem and the fact that they are sending the pt out tells me that the surgeon is "admitting defeat" so to speak. 

The airway needs to be fixed. Don't risk losing it by pulling the original tube and swapping it for a trach tube, cut down the ETT as far as you can and like abckidsmom said, have an MD suture it into place. 

She's bleeding, the continuous drain from the chest tube along with the rest of the presentation seems to confirm this. Let's get some typed and crossed blood to the bedside if it isn't already there and hang it up. 

I second abckidsmom again on the heart tones. JVD + hypotension makes me think pericardial tamponade. If they are muffled get an MD in here and do a pericardiocentesis STAT. I'm probably totally wrong though. On the off chance I'm right does this help her BP at all?

I think the pressors need to come back up until we can do something about her hypovolemia and potentially low CO secondary to my presumed cardiac tamponade. Sticking with my idea once we do the pericardiocentesis lets try to ween the pressors a bit, one at a time, and see where this takes us.

I don't see a reason why we can't leave the PEEP at 5. Maybe even drop the FiO2 a tad bit more?

Another thought, the pt's heart was in bad shape to begin with and has now suffered further insult. Could we be dealing with a potential cardiogenic shock along with the presumed hypovolemic shock or am I now just trying to force more :censored::censored::censored::censored: on the pile? 

If we don't figure out how to fix the hypoperfusion pretty quick we are going to be stuck in a MODS situation that the pt may not be able to overcome if they aren't already there already.


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## Farmer2DO (Mar 7, 2012)

Veneficus said:


> You cannot stabilze somebody who needs surgery without it. No amount of medicine will do that. It is the whole basis for trauma systems. (I know this wasn't a trauma, but I think we agree this is still a surgical emergency)



I agree with your entire statement here.




> This I do not agree with. If said surgeon already knows this patient is beyond him, while it doesn't harm the statistics of said surgeon, in the interest of the patient, a superior provider is the right choice.



But this involves more than just saying "here is this trainwreck", and having her magically appear at the other end.  There is a whole lot that has to happen in between, including transfer of her to our gurney, transfer to our vent and IV pumps, continuous suction to chest tubes, cardiac monitor, art line and CVP (she'd better have those), and then we have to bounce her down the road to the other hospital and do all of the same stuff at the other end.  Interfacility ambulance transports are not benign.  One of the physicians I routinely do IFT for quoted a 10X increase in mortality for patients that are transferred between hospitals (I can't find that source; I'll have to ask him).  In her current condition, she is very likely to arrest between hospitals.  What's the answer?  Pull out my leatherman, snip the sternotomy wires and do open chest cardiac massage?  Cuz that's the only way she's going to get any decent perfusion.  This is more than punitive (although, patient care aside, I would force the idiot who started this mess to finish it if I could).  IMHO, taking her for a ride from a hospital that has CT surgery is wildly inappropriate; unethical even.  The person who did this may not be the best, but he CAN open the chest and try and correct it, making her more stable for transport.

If she dies during transport, there's going to be a big investigation, and one of the questions will be "Why did you transport this patient?".  I may or may not have blame legally, depending on the state, but that won't stop the family from suing me and my service.  Again, if she had been at a hospital that didn't have CT surgery (like if she didn't feel well after being discharged and went to a local hospital that didn't do her surgery) I would have no problem transporting her.  I try not to let legal concerns sway me from doing what I believe is best for the patient, but there's no getting around this: I want no part of this mess.

There is also the legal aspect.  From my understanding of EMTALA, you can't do this.  They have the capability, according to the law, of fixing their problem.




> I agree with this, but the trouble is when the patient has a surgical pathology, you cannot resuscitate successfully until that is fixed.
> 
> Fooling around with medical treatments, intensive or otherwise just delays needed surgery.



Agree again.

This lady already has many bad signs of having a bad outcome (death), like making no urine and no response to turning the versed off.  I think an ambulance ride would probably contribute to her downhill slide.  I respect your opinion and where you're coming from, I just don't agree with it.  

We may have to agree to disagree on this one.


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## Veneficus (Mar 7, 2012)

Farmer2DO said:


> This lady already has many bad signs of having a bad outcome (death), like making no urine and no response to turning the versed off.  I think an ambulance ride would probably contribute to her downhill slide.  I respect your opinion and where you're coming from, I just don't agree with it.
> 
> We may have to agree to disagree on this one.



You entire statemtn is very fair and balanced. I understand your concern about the patient dying in your care, that is a reasonable concern of any provider.

From my perspective which is neither right nor wrong. 

If I am convinced the patient cannot be helped by the surgical staff at this facility, dead is dead, and at the facility, in the ambulance, or at another facility is doesn't matter. In the effort to help, the patient stands the best chance moving up the system. 

It doesn't mean she will live, recover, or any other positive outcome. It is just a chance where there might be none otherwise.

On paper the sending facility should be able to help. BUt paper and the real world are different as I am sure you know.

You may not be convinced by my argument and that is cool, because different providers have different philosophical approaches.


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## abckidsmom (Mar 7, 2012)

Veneficus said:


> You entire statemtn is very fair and balanced. I understand your concern about the patient dying in your care, that is a reasonable concern of any provider.
> 
> From my perspective which is neither right nor wrong.
> 
> ...



So in the real world, practically speaking, how would you actually do this?  Take nursing staff with you for the ride?  She has a sketchy airway, multiple devices needing suction, some drips requiring maintenance, and looks ready to arrest again at any minute. 

The cct truck I was on only had one medic unless the info received from the facility looked like there was need for more. I can understand completely your rationale for transporting to the new hospital, could you imagine the sending facility sending staff along for the (super risky) ride?

And we are still not moving without that tube sutured in.


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## Farmer2DO (Mar 7, 2012)

I guess a fair compromise would be me providing the ambulance and the paramedic, and the surgeon is going with me.  He can bring whatever tools and drugs he wants; he can bring a nurse if he wants.  But he's responsible.  It's his patient.  He needs to ride this train wreck to its likely conclusion.  Don't wanna go?  That's fine.  Enjoy managing YOUR patient here.

And if we put up blood products, an RN, a mid-level, or a physician needs to go with me (in NYS, thank you very much, ENA).

And I agree with your comment about the airway.  Secure that sucker.

On a side note, in NYS, it's very clear legally:  the transferring physician is responsible for the patient until they arrive at the receiving facility.  I also think this would be the wisest course of action for the surgeon; show that he cares about the outcome and is doing everything in his power to correct it.  And dumping the patient on a CCT paramedic and his EMT partner is NOT everything.


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## Veneficus (Mar 7, 2012)

*In the real world*



abckidsmom said:


> So in the real world, practically speaking, how would you actually do this?  Take nursing staff with you for the ride?  She has a sketchy airway, multiple devices needing suction, some drips requiring maintenance, and looks ready to arrest again at any minute.
> 
> The cct truck I was on only had one medic unless the info received from the facility looked like there was need for more. I can understand completely your rationale for transporting to the new hospital, could you imagine the sending facility sending staff along for the (super risky) ride?
> 
> And we are still not moving without that tube sutured in.



I have this terrible problem with personal responsibility.

I believe in it...

If I messed up the patient, I would most certainly go with the crew personally. I would explain to the receiving physicians in person what I did and what went wrong, and I think it would be my responsibility to help provide to the best of my ability whatever the transporting crew required for the patient.

I think it would be extraordinarily unprofessional for a physician to hand a dying patient to a medic and simply wave good bye and wish them luck. Particularly if I was the physician who messed the person up.

Even if it was an unforseen complication, as far as I am concerned, my patient is my responsibility, and no event bad or good removes the person in charge from that responsibility. 

I certainly wouldn't try to turf that responsibility to a nurse or anyone else.

You have to figure, if this transport could not be carried out, the sending surgeon would be in the OR with this patient, so it is not like the ride to and back would prevent him from helping another patient.

Would it cost the facility some money? Sure it would, but mistakes are never free.

It is probably the least he could do.

If I was the medic on the truck, I would probably take the patient. BUt before I did, there would definately be a conference call between a medical director I answered to, the sending doctor, the receiving doctor, and it would be agreed upon that this was an act of compassionate care, not a standard transport that I would be soley responsible for.

I would also make sure the run report clearly stated the duress I was under to accept the patient.

and I would call my employer and request another crew for the extra hands. They could work out the billing with the sending facility.


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## exodus (Mar 7, 2012)

Just wondering, how long are you guys planning on spending on scene debating what to do or whether or not to go?  This patient doesn't need medications, this patient needs an OR.  If you have spent more than 30 or so minutes on scene and haven't done any procedures you can't do in the truck. It's too long. You could have been at the receiving already, sliding the patient to the prep gurney and been giving a report to the receiving surgeon.

I would do nothing with this patient other than bump the pressors up to maintain ~80 systolic with a blood infusion going. Then do a super fast transport to the receiving where they can do the surgery the patient requires to live.  If the patient hasn't coded in 3 hours, I would consider them stable for a 20 minute transport.


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## exodus (Mar 7, 2012)

abckidsmom said:


> So in the real world, practically speaking, how would you actually do this?  Take nursing staff with you for the ride?  She has a sketchy airway, multiple devices needing suction, some drips requiring maintenance, and looks ready to arrest again at any minute.



On all of our CCT transfer of care forms, there is a box that is checked "Patient is stable for transport." As well as: "Patient is unstable, but will benefit from the transport because: ________.".

If that capability is available there, have the MD write in the notes, that they refuse to provide those services due to whatever reasons.


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## Handsome Robb (Mar 8, 2012)

Alright. So we've established this is a bad situation and in the spirit of scenarios I'm going to go out on a limb and say that we probably aren't going to be getting the surgeon or any other staff members to ride with us. Personally I'd rather have another medic from my company, preferably a CCP along for the ride. If we are lucky maybe we can get a double medic car to respond and help with the transport for the simple fact that they are used to working in the back of a moving ambulance in the transport environment rather than taking staff from the sending facility that isn't trained or accustomed to transport medicine. 

Not trying to be the negative nancy. I'm just hoping that we can continue the progression of this thread rather than becoming stuck on the fact that the surgeon screwed up and it's his problem so he should ride with us. I agree with this viewpoint. It is, more likely than not, his fault and he needs to be the responsible party for this patient, whether that means opening her back up and fixing the problem our organizing a transport situation that will offer the patient the best chance at the best outcome. 

Also, I'd love some feedback on my post 



Aidey said:


> Packed RBCs and FFP.
> 
> And just a radial or both? lol. What is the CVP now?



Good point. Although it was a CABG is there some sort of peripheral damage to the thoracic aorta. Could we be dealing with a leaky dissecting aortic aneurysm which could be causing the presumed hemothorax or possible hemopnuemothorax? Is that even a possibility to have a slow leak from an aortic dissection with the pressure involved in the aortic arch? Although she is pretty profoundly hypotensive without the pressors. 

If I'm not mistaken aren't pressors contraindicated in the presence of hypovolemia? Thinking about this makes me revert back to my idea of the presence of a cardiac tamponade or cardiogenic shock rather than hypovolemic shock. 

Since the transport decision seems to be the hot topic why is this going by ground and not by air? I might have missed a weather report that eliminated this option. She's a high risk patient and since we are so worried about her coding en route why not work on getting her as "stable" as we can at the sending facility while we wait for the flight team to show up. We may be on scene for a little longer but in the end the actual transport time is going to be shorter. I also have limited understanding of flight physiology so I don't know if her current condition would contraindicate areomedical transport.

I know, I know. If you hear hoofbeats think horses before zebras


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## Veneficus (Mar 8, 2012)

NVRob said:


> The airway needs to be fixed. Don't risk losing it by pulling the original tube and swapping it for a trach tube, cut down the ETT as far as you can and like abckidsmom said, have an MD suture it into place.



I think it would be wise to start by confirming there is an airway and you are not ventilating the mediastinum.



NVRob said:


> She's bleeding, the continuous drain from the chest tube along with the rest of the presentation seems to confirm this. Let's get some typed and crossed blood to the bedside if it isn't already there and hang it up.



200ml from a chest drain is not much at all. But I agree there is likely a bleed. Where it is coming from and how severe could be debated. I think the most exediant way to determine this is by ultrasound. 

If blood is not already typed and matched or typed and crossed (which I hope it is by now, but you never know) then emergent use of O negative is a faster solution in the interest of moving right along.

The transthoracic, abd, and neck space, ultrasound should be nearly done by the time the blood is hung and running. 



NVRob said:


> I second abckidsmom again on the heart tones. JVD + hypotension makes me think pericardial tamponade. If they are muffled get an MD in here and do a pericardiocentesis STAT. I'm probably totally wrong though. On the off chance I'm right does this help her BP at all?.



If it is not a pneumo. But I wouldn't be overly eager to take a tamponade away from a bypass patient CPR was performed on. It might actually be controlling a very big problem like a partial graft malfunction.

During bypass, the pericardium is cut, I doubt it will heal in 10 days sufficent enough to be the major problem in this case.



NVRob said:


> I think the pressors need to come back up until we can do something about her hypovolemia and potentially low CO secondary to my presumed cardiac tamponade. Sticking with my idea once we do the pericardiocentesis lets try to ween the pressors a bit, one at a time, and see where this takes us.



If I was working on the problem being volume depletion, I would cut back pressors and institute blood products to a sbp of 80 or if transport is short 50.



NVRob said:


> I don't see a reason why we can't leave the PEEP at 5. Maybe even drop the FiO2 a tad bit more?.



possibly drop FIo2, but keeping intrathoracic pressure elevated collapses low pressure cardiac arteries. There is a chest tube in already so pneumo may not be an issue, but low pressure might be more optimal.



NVRob said:


> Another thought, the pt's heart was in bad shape to begin with and has now suffered further insult. Could we be dealing with a potential cardiogenic shock along with the presumed hypovolemic shock or am I now just trying to force more :censored::censored::censored::censored: on the pile?



I think you should forget all of those terms. This patient has an oxygen delivery problem. Once oxygen delivery to the heart falls below what it can compensate, it will fail. The cardiogenic shock is secondary to volume depletion. Once volume is fixed, surgically or medically, then you can worry about heart function. But since treatments of hypovolemic shock and cardiogenic shock can have competing effects, trying to fix both at once is rather futile.



NVRob said:


> If we don't figure out how to fix the hypoperfusion pretty quick we are going to be stuck in a MODS situation that the pt may not be able to overcome if they aren't already there already.



I think MODS in this patient is inevitable. The question being if it can be corrected. She might even life long enugh to get septic. 

But I think we are really dealing with organ donation now.


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## usalsfyre (Mar 8, 2012)

Sorry for the late reply, the last couple of days has been overrun. 

We ended up transporting after securing the airway with the "three ultra gorilla wraps of tape".  

We went immediately back up on the levo and started working the dopa down to work on the HR and increasing ventricular fill, we ended up weaning down to a pressure of 130/70ish on 10mcg of dopa and 20 of levo with a HR of 112. 

Chest drain stopped putting out after 200mls. 

No blood was administered (it wasn't available but I can't go into more detail than that in public). 

Patient was transported relatively uneventfully and expired within 12 hours. 

A surgeon was not available at the sending was the reason for transport. 

Overall it was an ugly case. Just wanted to share with what I see as a kick-@ss group of clinicians.


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## abckidsmom (Mar 8, 2012)

With no urine output and an already high K, being post arrest for the hyperkalemia, can anybody speak to the smarts of giving blood before starting CVVHD?  Seems like a robbing Peter to pay Paul kind of thing. 

Crazy situation.  Lots of issues to think about. Thank you for sharing. You really bump into a bunch of train wrecks in your world. I'm going to have to start a series of scenarios called Marginally Interesting Points to Ponder. It's about all I can drum up in my real life.


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## Veneficus (Mar 8, 2012)

abckidsmom said:


> With no urine output and an already high K, being post arrest for the hyperkalemia, can anybody speak to the smarts of giving blood before starting CVVHD?  Seems like a robbing Peter to pay Paul kind of thing.



For certain it is.

But in my experience of seeing people last days sometimes weeks with hyper K and minutes to hours when hemorrhaging, I'll take the hyper K.

Any word on if there was an ultrasound or where the blood was if they needed a surgeon and there was only 200 ml in the tube?


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## Farmer2DO (Mar 11, 2012)

Veneficus said:


> I have this terrible problem with personal responsibility.
> 
> I believe in it...



Me too.  I'm glad there are some providers that think this way.




> I think it would be extraordinarily unprofessional for a physician to hand a dying patient to a medic and simply wave good bye and wish them luck. Particularly if I was the physician who messed the person up.



Unfortunately, I see this ALL THE TIME.



> If I was the medic on the truck, I would probably take the patient. BUt before I did, there would definately be a conference call between a medical director I answered to, the sending doctor, the receiving doctor, and it would be agreed upon that this was an act of compassionate care, not a standard transport that I would be soley responsible for.
> 
> I would also make sure the run report clearly stated the duress I was under to accept the patient.
> 
> and I would call my employer and request another crew for the extra hands. They could work out the billing with the sending facility.



Excellent advice.



usalsfyre said:


> A surgeon was not available at the sending was the reason for transport.



This is probably the only reason I would consider this a legit transfer.  That being said, I'm sure they could find SOME surgeon around, even it it's not a CT surgeon, to go with me.  I mean, from what I've been taught, if a post-CABG patient arrests, they need their chest opened, because closed compressions just aren't going to do it.  A general surgeon, or even an OB/GYN would be better than nothing, because open chest cardiac massage just isn't in my scope of practice.  

But any other surgeon would probably pull the "I'm not a CT surgeon; this isn't my area."  Nor is it mine.....

I think you did the best you could with what you had.


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## Veneficus (Mar 11, 2012)

Farmer2DO said:


> I'm sure they could find SOME surgeon around, even it it's not a CT surgeon, to go with me.  I mean, from what I've been taught, if a post-CABG patient arrests, they need their chest opened, because closed compressions just aren't going to do it.  A general surgeon, or even an OB/GYN would be better than nothing, because open chest cardiac massage just isn't in my scope of practice..



Unfortunately, because of the way the system works, they probably couldn't find one. 

Too many problems with statistics,billing, and liability.  



Farmer2DO said:


> But any other surgeon would probably pull the "I'm not a CT surgeon; this isn't my area."  Nor is it mine.......



Unfortunately this a a problem in all of current surgical practice. General surgery is more or less the required training before a subspecialty now. Total body surgeons are almost nonexistant, replaced by hyperspecialists. This trend is likely to continue in the US.

Having said that, there is a growing need of the old school general surgeon. In areas where costs need to be contained, providers are in short supply, and for emergent patients.

Right now, only the surgical intensivist sort of fills this role. Which is an indemand specialty. Nobody wants to go into it though.  

At some level of hyperspecialty, costs exceed benefit and needed service no longer exists.  

I better stop now, before I really get going.


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## jjesusfreak01 (Mar 11, 2012)

NVRob said:


> Since the transport decision seems to be the hot topic why is this going by ground and not by air? I might have missed a weather report that eliminated this option. She's a high risk patient and since we are so worried about her coding en route why not work on getting her as "stable" as we can at the sending facility while we wait for the flight team to show up. We may be on scene for a little longer but in the end the actual transport time is going to be shorter. I also have limited understanding of flight physiology so I don't know if her current condition would contraindicate areomedical transport.



No room for all the equipment attached to the stretcher...


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