# I don't even know where to start



## Anjel (Jan 26, 2011)

Ok so since you guys are usually pretty helpful. Take a whack at this one.

On my clinical last night a 81yr old man is brought in by ALS. CC difficulty breathing. The medic that brought him in has only been able to get a line in his index finger? I think. One of the fingers anyway. 

The only thing the medic had was the papers from the nursing home and told us he thought the pt has "some kind of clotty thing going on. His one leg is bigger than the other"

SOOO..... upon assessing and figuring out whats going on this is what we get.

Pulse 67 at the lowest 112 at the highest

Resp. 40 shallow. He was intubated and sedated once the doctors saw this.

GCS= 9

BP- 168/132

HX- Patient has a "controlled brain bleed" and just got over bacteria pneumonia.

Course rales are present with diminished breath sounds in the lower lobes.

CT scan shows MULTIPLE PE'S bilaterally. 

Patient couldnt have clot buster because of brain bleed. But if he didn't get the clot buster he would die from that too. On top of all this the Ct showed he had an ischemic stroke.

Also we could no longer keep him sedated, because his BP would bottom out so we had continuous suction as he was gagging.

How in the world is this man still alive??? And I'm sorry I think the medics that brought him in did a very poor job. I don't know if they could of intubated him because he has a gag reflex, and I'm not sure if they have the ability to sedate someone like that. But as a basic I think I would of at least bagged him? Maybe I'm wrong. But wow that was absolutely the most screwed up person I've seen.


----------



## usafmedic45 (Jan 26, 2011)

> How in the world is this man still alive???



The ability of the human body to keep going after it should be dead is pretty amazing at times.  Usually it's inversely proportionate to the likelihood of the patient having any meaningful recovery.


----------



## vquintessence (Jan 26, 2011)

usaf gave you the best answer.

From your perspective of the medics report (which I think has been grossly paraphrased) it is easy to make the assumption they were subpar providers, and perhaps they were.  However when you get to deal with your first PE who is severely hypoxic & significantly obtunded, let us know how well it went.


----------



## Anjel (Jan 26, 2011)

I swear to God that what I put in quotes came from the medics mouth during his report. There's about ten people who will attest to the poor report he gave. But besides that... My question was.... What should or could they have done. 

From my standpoint as a basic. I would of assisted ventilation with the bvm. Because the man had no prior history of a PE so I really am not sure what should of happened. 

That's why I am coming to the wonderful resource of the ParaGods(kidding!)  here on emt life.


----------



## Aidey (Jan 26, 2011)

This man was sick, and there was likely nothing the medics who brought him in could do. Not all places are able to sedate and intubate people, and even in areas that are he may not have met the criteria to do it prehospital. What was his SpO2? His Co2? Just becuase his respirations were 40 and shallow does not mean bagging him was indicated, or would have helped. 

My guess is that this was a patient who was normally on blood thinners, who was taken off of them after the intracranial bleed started, and is now developing clots because he is stuck in bed at a SNF and is off his meds. He probably has multiple underlying conditions exacerbating the situation and adding to how difficult he is to manage medically. On top of that he is 81 years old, which doesn't help. 

It is hard for me to judge what I would have done since I don't have a full set of vitals, so I don't have a good idea of the patients exact presentation. He would have gotten an EKG, IV, blood sugar check, capnography and whatever O2 therapy was indicated based off of his Co2 and SpO2 and lung sounds. If he just had pneumonia, it is entirely possible he has it again. 

I am willing to bet good money this man is never going to come off of that vent, and if he does, it will be as an end of life decision.


----------



## vquintessence (Jan 26, 2011)

Anjel1030 said:


> I swear to God that what I put in quotes came from the medics mouth during his report. There's about ten people who will attest to the poor report he gave. But besides that... My question was.... What should or could they have done.
> 
> From my standpoint as a basic. I would of assisted ventilation with the bvm. Because the man had no prior history of a PE so I really am not sure what should of happened.
> 
> That's why I am coming to the wonderful resource of the ParaGods(kidding!)  here on emt life.



Perhaps he had no known prior hx of PE, however his presentation and social factors (for lack of better word) scream for the strong consideration of PE.  He is extremely tachypneic. Has had a recent cva (suggesting preexisting coagulopathies) as well as backing off potentially prescribed "blood thinners".  Is presumably bed ridden following the above mentioned insults to his brain.  The medics mentioning of "one leg bigger than the other", suggests poor peripheral ciruclation and presumably DVT.

Irrespective of the above, the most pertinent differentials coming to my simplified ambulance brain would be:

PE
CHF
AMI
COPD exacerbation
sepsis
PNA re-emerging


Your strong urge to use a BVM on the pt doesn't go against your training, and without knowing the specifics Aidey has mentioned, you bagging the poor gentleman would have been your best attempt to stabilize.

Ultimately the _clot busters_ you mention are what could "save his life" while ironically sending him to the grave through another etiology.  It's cruel this man is full code and not in hospice :sad:


----------



## Anjel (Jan 26, 2011)

vquintessence said:


> Ultimately the _clot busters_ you mention are what could "save his life" while ironically sending him to the grave through another etiology.  It's cruel this man is full code and not in hospice :sad:



This exactly the conversation everyone involved in the case had with one another. The doctor threw his hands up and said "I don't know what to do."

To address another question his spo2 was 79% when he got there and 100% after intubation. That was why my strong urge was to bag. Because something needed to be done and that's all I could think of. 

You guys know a lot lol from the info I gave you, you came up with every conclusion that the docs and nurses at the hospital did. I love it and wanna be able to be at that level one day too. ^_^


----------



## abckidsmom (Jan 26, 2011)

Anjel1030 said:


> This exactly the conversation everyone involved in the case had with one another. The doctor threw his hands up and said "I don't know what to do."
> 
> To address another question his spo2 was 79% when he got there and 100% after intubation. That was why my strong urge was to bag. Because something needed to be done and that's all I could think of.
> 
> You guys know a lot lol from the info I gave you, you came up with every conclusion that the docs and nurses at the hospital did. I love it and wanna be able to be at that level one day too. ^_^



So you see that a group of pretty good medics and the physicians who had their eyes on the patient both arrived pretty quickly at "You're damned if you do, and damned if you don't."

This guy had a couple of fatal etiliogies working, and you're criticizing the medic because he didn't ventilate the patient with a bag valve mask?  Sounds like he had to work pretty hard for that IV he got, and spent a good amount of time on his physical exam and extracting the story from the paperwork so that he could clue the ER staff into what the problem is.

Sometimes ER staff like it when medics do not "diagnose" the patient, rather, dance around the issue and paint a picture for them.  Something about egos, and cooperative treatment and all that.

Here's you're take home:  it's more complicated than anything you learn in EMT class.   In 98% of your calls, you're going to be guessing, not fully educated about the medical condition your patient has, or providing a taxi service.  There are going to be around 50 calls in your career as an EMT where you're going to look back and see that you provided more than a comfortable ride and a good assessment, and that's assuming you keep learning and ride in a busy system.

Keep learning.  Ask questions, but be careful how you phrase them, so as not to push people's buttons.


----------



## Anjel (Jan 26, 2011)

abckidsmom said:


> Keep learning.  Ask questions, but be careful how you phrase them, so as not to push people's buttons.



I definitely should of phrased that different. And if I offended anyone I am sorry.

I wasn't trying to imply he didn't do his job. Except with the poor report giving skills. Because that I was criticizing. He didn't even leave a run sheet. 

I just wanted to know what should of been done.


----------



## exodus (Jan 27, 2011)

If I was the doc, I may have been inclined to trach him and keep him on a vent that way so he can spent the rest of his time being awake with his family and not sedated...


----------



## Veneficus (Jan 27, 2011)

Anjel1030 said:


> This exactly the conversation everyone involved in the case had with one another. The doctor threw his hands up and said "I don't know what to do."




That's an easy answer:

Punt on first down!

The pt is contraindicated for thrombolytic therapy, most likely contraindicated or not helped by heparin, the only other options for removing the PE are intravascular or surgery which he is unlikely to survive. So call surgery, have them exclude, call vascular have them exclude, call pathology and let him know that you will be transferring the patient to their service in a few minutes.


----------



## EMS49393 (Jan 27, 2011)

Anjel1030 said:


> I definitely should of phrased that different. And if I offended anyone I am sorry.
> 
> I wasn't trying to imply he didn't do his job. Except with the poor report giving skills. Because that I was criticizing. He didn't even leave a run sheet.
> 
> I just wanted to know what should of been done.



Likely, nothing more could or should have been done then what the medic did.  "Bagging" a person is not as easy as you think when they are still somewhat conscious and have their own respiratory drive.  You could possibly do more harm than good in that instance.

As for his report, did you stop to think that he might have been overwhelmed by this man's ability to still be alive despite many fatal etiologies?  I'm overwhelmed thinking that man in his 80's with that many problems is still alive.  He likely did all he could and may have been completely flustered because he could do no more.  Come on, you said your self that the doctor even threw up his hands and didn't know what to do.

I know you want to do things and make everyone better, but with some patients you are better off not doing anything but a good assessment and transport.   Sometimes when they are compensating just enough to stay alive, you have to let them compensate until you can get them to an ER.  If they crash, you deal with that if and when it happens.  Working on this particular patient in an arrest situation is probably a hell of a lot easier then working on him in his present condition.  

In the words of my brilliant paramedic instructor:  "Don't be a homeostatic jacker."


----------



## cstiltzcook2 (Jan 27, 2011)

EMS49393 said:


> "Don't be a homeostatic jacker."


  that is awesome. I won't forget this one.


----------

