# "You will kill the patient doing that!!!"



## Veneficus (Nov 15, 2010)

OK, 

I know at some point in our careers either in school or at work, most of us have been confronted with this piece of "wisdom."

I think it is time for a discussion.

I am sure not many are going to come forward and say "I killed my patient doing..." and I would expect anyone to.

But how many here have witnessed first hand an intervention that directly resulted in the death of a patient?

I don't mean "we had a really sick patient and in the treatment options we chose to do X and the patient died," or "we found a dying patient who we couldn't figure out what was wrong with him and the patient died." Not even "we probably should have done X but didn't."

I mean a certified confirmed kill. 

Now I am willing to bet a few people intubated an esophagus. But if you were intubating, was RSI performed, or was the patient so far gone that the patient could be intubated without pharm aid?

Defib something other than v-fib or pulseless v-tach?

Push a lethal med dose or an absolute contraindicated med?

How soon after did the patient die? 

What was done to fix it? 

Who noticed?

Did anyone find out/ get disciplined/sued etc?

Finally what have you been told would result in you killing a patient?


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## Gymchick (Nov 15, 2010)

Well, as I mentioned in my other thread...I was told that if I put a BP cuff on the arm where a patient had a renal dialysis shunt...it would have killed him.


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## Veneficus (Nov 15, 2010)

Gymchick said:


> Well, as I mentioned in my other thread...I was told that if I put a BP cuff on the arm where a patient had a renal dialysis shunt...it would have killed him.



yea, that is what spawned this thread.


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## 46Young (Nov 15, 2010)

I'm not quite sure what you're asking. Are we supposed to speak about a med, neglect, or intervention error that resulted in a fatality (llike maybe giving atropine for cx pain, morphine for a Sz, etc.), or having a somewhat stable pt die from a proper intervention?

Personally, I haven't killed anyone due to clinical error. When I was a medic student, my preceptor and I killed a 26 y/o male by cardioverting unstable SVT into asystole. I also rendered a 56 y/o male unconscious and in a slow idioventricular PEA after a Sz following ntg admin (got him back and also relieved his cx pain LOL), but I don't think these two examples cases are what you were asking for.


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## usalsfyre (Nov 15, 2010)

I've been told all sorts of crap will kill a patient, or take away a physicians assesment ability, ect, ect, ect. Mostly when you dig a little your intervention being described that way is inconvient/scary/not what the staff at a recieving facility is used to.

My one confirmed kill was an adult CF Pt in respiratory failure, sats in the 70s and ETCO2s in the 90s while being BVM'd with 10 of PEEP and an FI pretty dang close to 1.0. Yet due to his long history with the disease process he was still conscious. Attempted intubation with just Etomidate, resulted in trismus. Pushed Rocc and ended up with the pt deterorating into PEA in the 25 sec it took to place the tube. Worked for 20min, called on ED arrival. Reported immediately to the clinical department. We had a call review, during which it was decided the only other course that would have been a cric when the trismus was observed. The whole thing was chalked up as an educational issue.


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## Smash (Nov 15, 2010)

I've been told that "that will kill the patient!" so many times about various things, I've lost count.  Funnily enough, it never has!

I think in hindsight I have done a lot of damage to patients in the pre permissive hypotension era, squeezing as much crystalloid and colloid into patients as I can to get to a "normal" blood pressure. 

My only justification is that it was the accepted standard of the day


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## 46Young (Nov 16, 2010)

Long ago, I heard that giving a COPD pt supplemental O2 would kill them by knocking out their respiratory drive, pretty much right away. J/K. Please don't anyone go off on a  32 post hypoxic drive tangent, as there are several previous threads addressing that topic. 

I've also heard that if you don't board and collar everyone that c/o traumatic neck/back pain, even if it was a parking lot MVA w/ only paint transfer, they could turn to look at something, sever their spinal cord, collapse and die. It matters not if the spinal motion restriction process causes more damage. We're saving lives, damn it!

Seriously, I was once told that all medications have the potential to kill. That might be a bit of exaggeration, but the point is to not empty your box of wonder drugs just because you can, according to the cookbook. I can think of more than several examples where relatively benign drugs such as dextrose, oxygen, and NS can potentially cause great harm or kill the pt.

I've been told that giving ntg without a line to the pt w/ inferior changes, unless the V4R checks out, can kill them.

I've been told that failure to suppress multifocal PVC's can leave the pt at risk of R on T, sending them into V-Fib, if the myocardium is sufficiently stimulated during the relative refractory period. It's why we cardiovert rather than defib SVT/ V-Tach w/pulse.


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## 46Young (Nov 16, 2010)

Smash said:


> I've been told that "that will kill the patient!" so many times about various things, I've lost count.  Funnily enough, it never has!
> 
> I think in hindsight I have done a lot of damage to patients in the pre permissive hypotension era, squeezing as much crystalloid and colloid into patients as I can to get to a "normal" blood pressure.
> 
> My only justification is that it was the accepted standard of the day



Yeah, we used to dump in up to 6 liters of NS. Matter of fact, I just looked up the NYC REMSCO ALS Non-Cardiogenic Shock protocol (515), and it hasn't changed. Give 3 L, and call for 3 more if no change.

http://www.nycremsco.org/images/articlesserver/ALS_Protocols_January_2010_v01012010d.pdf


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## beandip4all (Nov 16, 2010)

laying a chf'er flat ---> flash edema--> resp failure?

that's always the trotted out example about why it's so important to check lung sounds on every single pt... 

:shrug:


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## MrBrown (Nov 16, 2010)

That NYC Protocol book *will* kill you! Seriously, up to six litres of fluid for shock and a KVO rate of IV fluid for pulmonary edema? OMG!


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## RUGBY66X (Nov 16, 2010)

46Young said:


> Yeah, we used to dump in up to 6 liters of NS. Matter of fact, I just looked up the NYC REMSCO ALS Non-Cardiogenic Shock protocol (515), and it hasn't changed. Give 3 L, and call for 3 more if no change.
> 
> http://www.nycremsco.org/images/articlesserver/ALS_Protocols_January_2010_v01012010d.pdf



wow...we don't even have near that much fluid on the trucks. if we run a 500 bag wide open and we don't make it to the ER before its gone somethings wrong. I think theres about 20 hospitals within 15 min of where im sitting right now and the areas i work in were only about 5-10 min max of 3-4 of them with 2 of those being level 1 trauma centers.


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## MediMike (Nov 16, 2010)

I have yet to play reaper (that I know of ) But have seen it "firsthand".  We had a 60 y/o code, initially PEA --> Asys -->VFib began transport, got him to the hospital with pulses intact.  Pt. deteriorated again after central line was placed at ED.  VTach with pulses, doc ordered a shock, I observed the RN setting the monitor up for a shock, and against my objections proceeded to DEFIB the pt. twice at 200J.  No sync...pt. snapped right back to asystole.  Nothin' pisses me of quite as much as workin a pt. and then having them lost due an a stupid negligent error.


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## reaper (Nov 16, 2010)

Well, what can I say! I'm working on 2 billion served!


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## Gymchick (Nov 16, 2010)

I've been told the COPD one too - never lay them flat, and be very careful about giving them oxygen because of the hypoxic drive.  

Also, don't suction more then 10 seconds or the patient will suffocate because you've sucked all of their oxygen out. (That one is from class.)

Also, don't look in the mirror and say "Candyman" three times in a row.


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## 46Young (Nov 16, 2010)

MrBrown said:


> That NYC Protocol book *will* kill you! Seriously, up to six litres of fluid for shock and a KVO rate of IV fluid for pulmonary edema? OMG!



The protocol is for non cardiogenic shock, but still....


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## 46Young (Nov 16, 2010)

RUGBY66X said:


> wow...we don't even have near that much fluid on the trucks. if we run a 500 bag wide open and we don't make it to the ER before its gone somethings wrong. I think theres about 20 hospitals within 15 min of where im sitting right now and the areas i work in were only about 5-10 min max of 3-4 of them with 2 of those being level 1 trauma centers.



We're only permitted to give two 500cc boluses in general, and we also have the 70/90 Sys. permissive hypotension guidelines as well.


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## abckidsmom (Nov 16, 2010)

Quite a while back, we were nosing around in the monitor's archives and found a code summary from a cardiac arrest.  The patient was in a sinus rhythm, and the provider defibrillated him 3 cute little times.  He was dead after that.

I've heard of a lot of stupid mistakes that only increased morbidity, but not actually killed the patient.  

In my personal experience, we had a close encounter with disaster when I had a preceptee who had drawn up 2 mLs of Dopamine instead of Ativan for a seizing patient.  I should have been checking the vial behind her, but I didn't...the only reason we caught it is because we talked about how thick the Ativan was and how difficult it is to pull up into the syringe.  The preceptee said, "No it isn't, it was easy."  So we checked the vial and it was dopa.  That's when I almost died.  She had the syringe in the IV line about to push it when we figured it out.


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## lampnyter (Nov 16, 2010)

you will kill the patient if you dont take that NRB off while switching to the main oxygen!11!!!11!


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## Smash (Nov 16, 2010)

46Young said:


> The protocol is for non cardiogenic shock, but still....



Non cardiogenic shock as in septic shock, for example, as opposed to "I have a knife in my belly" shock? It doesn't sound unreasonable for the first, somewhat horrific for the second!


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## JJR512 (Nov 16, 2010)

Gymchick said:


> ...Also, don't look in the mirror and say "Candyman" three times in a row.



Three times in a row is fine...it's the fifth time you have to watch out for.


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## EMSLaw (Nov 16, 2010)

Gymchick said:


> Also, don't suction more then 10 seconds or the patient will suffocate because you've sucked all of their oxygen out. (That one is from class.)



The Intermediate/Paramedic equivalent is this:  

You must preoxygenate your patient for two minutes before you intubate.  You then have EXACTLY THIRTY SECONDS to successfully tube the patient.  If you don't do it in thirty seconds, reoxygenate for another two minutes OR YOUR PATIENT WILL SUFFOCATE AND DIE A HORRIBLE DEATH AT YOUR HANDS.


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## 46Young (Nov 16, 2010)

Smash said:


> Non cardiogenic shock as in septic shock, for example, as opposed to "I have a knife in my belly" shock? It doesn't sound unreasonable for the first, somewhat horrific for the second!



The Cardiogenic Shock protocol allows for a modest fluid bolus for presumed rt sided failure, to increase preload. Non Cardiogenic Shock covers basically any other condition that presents with symptomatic hypotension, such as sepsis, the inbleed, multitrauma, dehydration, neurogenic, etc. Vasovagal syncope usually self corrects, so fluids would be unwise in that situation. Obviously, the 3&3 is intended for the trauma pt. N.C.S. is a catch-all for all non-cardiac causes of hypotension.


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## 46Young (Nov 16, 2010)

EMSLaw said:


> The Intermediate/Paramedic equivalent is this:
> 
> You must preoxygenate your patient for two minutes before you intubate.  You then have EXACTLY THIRTY SECONDS to successfully tube the patient.  If you don't do it in thirty seconds, reoxygenate for another two minutes OR YOUR PATIENT WILL SUFFOCATE AND DIE A HORRIBLE DEATH AT YOUR HANDS.



It's been proven that w/ a healthy adult in their 30's give or take, that they can knock out their respiratory drive, and then wait for several minutes or more before they de-sat. The elderly peri-arrest pt with limited physiological reserve will de-sat much quicker, but certainly not to a great degree in those magical thirty seconds, especially if they were pre-oxygenated either w/ ETI, a King, or good BVM w/cric pressure. IIRC, the oxygen dissociation curve begins to gain momentum below 80% or so, and is more or less a freefall below 60%.

Edit: Found it!

http://www.ccmtutorials.com/rs/oxygen/page06.htm


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## EMSLaw (Nov 16, 2010)

46Young said:


> It's been proven that w/ a healthy adult in their 30's give or take, that they can knock out their respiratory drive, and then wait for several minutes or more before they de-sat. The elderly peri-arrest pt with limited physiological reserve will de-sat much quicker, but certainly not to a great degree in those magical thirty seconds, especially if they were pre-oxygenated either w/ ETI, a King, or good BVM w/cric pressure. IIRC, the oxygen dissociation curve begins to gain momentum below 80% or so, and is more or less a freefall below 60%.
> 
> Edit: Found it!
> 
> http://www.ccmtutorials.com/rs/oxygen/page06.htm



We discussed that in class.  Here's a simple test.  Put a pulse-ox on your finger.  Hold your breath for as long as you can.  See how much the number changes. 

Still, the National Registry says thirty seconds or else.


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## usalsfyre (Nov 16, 2010)

46Young said:


> The Cardiogenic Shock protocol allows for a modest fluid bolus for presumed rt sided failure, to increase preload. Non Cardiogenic Shock covers basically any other condition that presents with symptomatic hypotension, such as sepsis, the inbleed, multitrauma, dehydration, neurogenic, etc. Vasovagal syncope usually self corrects, so fluids would be unwise in that situation. Obviously, the 3&3 is intended for the trauma pt. N.C.S. is a catch-all for all non-cardiac causes of hypotension.



A blanket 3 liters for would be unwise for hemorrhagic issues. That said, it's probably not a bad deal for neurogenic, sepsis ect. 

Titrating fluid to target goals (pulses, LOC) is the current thinking, and that may well require 3 liters.


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## usalsfyre (Nov 16, 2010)

46Young said:


> It's been proven that w/ a healthy adult in their 30's give or take, that they can knock out their respiratory drive, and then wait for several minutes or more before they de-sat. The elderly peri-arrest pt with limited physiological reserve will de-sat much quicker, but certainly not to a great degree in those magical thirty seconds, especially if they were pre-oxygenated either w/ ETI, a King, or good BVM w/cric pressure. IIRC, the oxygen dissociation curve begins to gain momentum below 80% or so, and is more or less a freefall below 60%.
> 
> Edit: Found it!
> 
> http://www.ccmtutorials.com/rs/oxygen/page06.htm



Agreed limiting your ETI attempts based on physiologic signs (SpO2 and HR primarily) makes FAR more sense than an arbitrary 30 seconds. Who's to say you don't start to get hypoxia prior to 30 seconds? Also HOW you preoxygenate a patient makes a difference. Best is an anesthesia bag, however allowing a patient to breathe through a BVM actually works fairly well, they're simply able to entrain some room air in addition to the O2.


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## 46Young (Nov 16, 2010)

usalsfyre said:


> A blanket 3 liters for would be unwise for hemorrhagic issues. That said, it's probably not a bad deal for neurogenic, sepsis ect.
> 
> Titrating fluid to target goals (pulses, LOC) is the current thinking, and that may well require 3 liters.



I know, the protocol says "up to two liters."


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## usalsfyre (Nov 16, 2010)

46Young said:


> I know, the protocol says "up to two liters."



Got ya, that makes sense.


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## zmedic (Nov 16, 2010)

I'd like to remind everyone of the hemoglobin dissociation curve, ie by the time that the patient has de-saturated you're pretty far down in PO2. So the goal shouldn't be "try intubating till the sats drop" because then that's pretty late. 

Sure 30 seconds is a bit random, but you need to build a safety factor into what is being taught because there will always be those people who when aiming for 30 seconds take a minute. If everyone thinks they can really go 2 minutes, some will take 3 etc. 

Speaking of killing patients, intubating Aspirin overdoses is a good way to kill your patient.


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## Foxbat (Nov 16, 2010)

zmedic said:


> Speaking of killing patients, intubating Aspirin overdoses is a good way to kill your patient.


Just curious, why? Hemorrhage from injuries due to intubation?


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## usalsfyre (Nov 16, 2010)

zmedic said:


> I'd like to remind everyone of the hemoglobin dissociation curve, ie by the time that the patient has de-saturated you're pretty far down in PO2. So the goal shouldn't be "try intubating till the sats drop" because then that's pretty late.
> 
> Sure 30 seconds is a bit random, but you need to build a safety factor into what is being taught because there will always be those people who when aiming for 30 seconds take a minute. If everyone thinks they can really go 2 minutes, some will take 3 etc.
> 
> Speaking of killing patients, intubating Aspirin overdoses is a good way to kill your patient.



The problem is the curve is so individualized to a patient there's no way to apply it in the clinical setting. I've had patients desat as soon as I stuck the blade in their mouth (far less than 30 seconds) and some that never moved off 100% through a 2+ minute intubation. The rest if medicine uses 92% as a cut off, which equates to VERY mild, reversible hypoxemia. Your safe as long as your using this.

Intubating ASA overdoses is not what kills them. SIMV at a rate of 10, tidal volume of 500mls and thinking an EtCO2 of 40 is hunky dory is what kills them.


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## 46Young (Nov 16, 2010)

zmedic said:


> I'd like to remind everyone of the hemoglobin dissociation curve, ie by the time that the patient has de-saturated you're pretty far down in PO2. So the goal shouldn't be "try intubating till the sats drop" because then that's pretty late.
> 
> Sure 30 seconds is a bit random, but you need to build a safety factor into what is being taught because there will always be those people who when aiming for 30 seconds take a minute. If everyone thinks they can really go 2 minutes, some will take 3 etc.
> 
> Speaking of killing patients, intubating Aspirin overdoses is a good way to kill your patient.



I would hope that it would be understood that a pt w/ a low sat, or no reading if down for a while would necessitate some pre-oxygenation and a quick tube. The reason I brought up the curve was to show that when you get below 90, and definitely below 80, you're behind the 8-ball and shouldn't be tooling around. This goes for any sick pt, not just someone needing intubation. I've had a COPD pt go from 82% to the 50's in the half a minute or so I took to drop the tube, confirm it, etc. The junctional braycardia didn't help matters either.


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## iamjeff171 (Nov 17, 2010)

picked up a CHF'er at a local SNF the other day, lungs were real wet. the RN said their pt had flash pulm edema and their BIPAP wasnt workin. i told her we were going to put the pt on our CPAP, at which time the RN informed me that CPAP wouldnt do anything for the pt, and i HAD to intubate her right now! and according to her i was wasting my time with SL nitro 

mind you this pt was currently sitting up, self supporting in bed (they didnt have the forethought to raise the head of the bed), CAOx4, and while in resp distress, able to answer all questions appropriatly. oh, she was also had an SPO2 of 97% on the NRB they had her on.

if i had done everything that nurse wanted me to do, that pt probably would be dead.


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## iamjeff171 (Nov 17, 2010)

picked up a CHF'er at a local SNF the other day, lungs were real wet. the RN said their pt had flash pulm edema and their BIPAP wasnt workin. i told her we were going to put the pt on our CPAP, at which time the RN informed me that CPAP wouldnt do anything for the pt, and i HAD to intubate her right now! and according to her i was wasting my time with SL nitro 

mind you this pt was currently sitting up, self supporting in bed (they didnt have the forethought to raise the head of the bed), CAOx4, and while in resp distress, able to answer all questions appropriatly. oh, she was also had an SPO2 of 97% on the NRB they had her on.

if i had done everything that nurse wanted me to do, that pt probably would be dead.


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## zmedic (Nov 17, 2010)

The issue with aspirin OD is the patient will be breathing fast and deep to compensate for their metabolic acidosis. The problem with intubation isn't just that people don't set the vent right (though that doesn't help). It is that:

1: We can't use positive pressure to ventilate for these patients as well as they are doing for themselves, if you matched tidal volumes and rates with what they are doing in these cases you'd be doing quite a bit of barrotrauma. 

2: Even the brief amount of time the patient is apenic during the intubation will increase their CO2 to a level that can be quite dangerous. 

(The pathophys is that ASA is in the uncharged form more at lower PH, and thereby able to diffuse through cell membranes into the cells from the blood where they are doing the most damage. Keeping the patient alkalotic helps prevent this)

So what I've been hearing on my tox month at the poison control center is for ASA OD is:

1: Avoid intubation if at all possible.
2: Consider awake intubation, ideally using local anesthetic. 
3: Don't paralyze the patient (part of number 2)
4: Pre-treat with massive doses of Na bicarb (think 8-10 amps)
5: Consider something like ketamine which will cause less respiratory supression.

Now this is the thinking for tox trained ED physicians, most of these you won't be able to do in the field. But the lesson is that people shouldn't be thinking "it's fine to intubate these patients, I just need to set my vent fast enough." You can still kill people even if you do that.


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## usalsfyre (Nov 17, 2010)

zmedic said:


> So what I've been hearing on my tox month at the poison control center is for ASA OD is:
> 1: Avoid intubation if at all possible.



I agree with this point. However, these patients will get intubated and placed on PPV, as they can not sustain the level of respiration we're talking about without failure becoming imminent at some point. Depending on where in the clinical course we contact them determines whether they get intubated by EMS or not. 

It is entirely possible to ventilate these patient appropriately and not cause barrotrauma, but perhaps not on most vents EMS has access to.


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## Bullets (Nov 17, 2010)

My patient, not my actions. called for UR, Not breathing, CPR going, Arrive, do our medical thing, get pt into the truck, drive to hospital, about 5m out we successfully capture and pace the pt all the way into the code room. As we are giving the report to the RN, a tech walks over and yanks the leads off the pt, asystole, worked him for 4 more minutes, pronounced. 

We worked that guy for almost 30m and everyone, ALS, BLS, PD and Fire did a damn good job. I thought the cop was going to tear the techs head off and shove it you know where


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## Veneficus (Nov 17, 2010)

Bullets said:


> My patient, not my actions. called for UR, Not breathing, CPR going, Arrive, do our medical thing, get pt into the truck, drive to hospital, about 5m out we successfully capture and pace the pt all the way into the code room. As we are giving the report to the RN, a tech walks over and yanks the leads off the pt, asystole, worked him for 4 more minutes, pronounced.
> 
> We worked that guy for almost 30m and everyone, ALS, BLS, PD and Fire did a damn good job. I thought the cop was going to tear the techs head off and shove it you know where



I am not sure how this ties in to the post, but if you worked a guy for 30 minutes, and there was no response, were you expecting a different outcome?


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## HappyParamedicRN (Dec 22, 2010)

In my personal experience, we had a close encounter with disaster when I had a preceptee who had drawn up 2 mLs of Dopamine instead of Ativan for a seizing patient.  I should have been checking the vial behind her, but I didn't...the only reason we caught it is because we talked about how thick the Ativan was and how difficult it is to pull up into the syringe.  The preceptee said, "No it isn't, it was easy."  So we checked the vial and it was dopa.  That's when I almost died.  She had the syringe in the IV line about to push it when we figured it out.[/QUOTE]


:0    Just think of all the blood pressure that patient would have had....just before he coded!    wow


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## exodus (Dec 23, 2010)

Bullets said:


> My patient, not my actions. called for UR, Not breathing, CPR going, Arrive, do our medical thing, get pt into the truck, drive to hospital, about 5m out we successfully capture and pace the pt all the way into the code room. As we are giving the report to the RN, a tech walks over and yanks the leads off the pt, asystole, worked him for 4 more minutes, pronounced.
> 
> We worked that guy for almost 30m and everyone, ALS, BLS, PD and Fire did a damn good job. I thought the cop was going to tear the techs head off and shove it you know where



Wait... He pulled the leads off? So? Do you mean the pads off? How the hell does someone pull pacer pads off while it's pacing?


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## rhan101277 (Dec 23, 2010)

EMSLaw said:


> We discussed that in class.  Here's a simple test.  Put a pulse-ox on your finger.  Hold your breath for as long as you can.  See how much the number changes.
> 
> Still, the National Registry says thirty seconds or else.



Yeah it takes a few minutes for pulse-ox to change.  That is why with any pt. with a respiratory component I used end-tidal CO2 so I can tell immediately that they are not breathing.


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## thegreypilgrim (Dec 23, 2010)

Haven't been indoctrinated with too many ZOMG!! You'll Kill The Patient!! type deals other than the COPD hypoxic drive thing that everyone seems to get. Although a lot of people around here seem to believe that narcan is the antidote to benzo OD...yeah.

And this is the only kill story I've got.

Back when I was an EMT I watched an OCFA medic kill someone with lidocaine. I didn't understand what was happening at the time, and the only reason it sticks out in my memory was because my partner at the time was in paramedic school and sort of questioned what the OCFA guy was doing and was quickly shut down with a level of belittling derision that only OCFA FF's are capable of. Thinking back on it now, I think I know what happened. I think the patient was in some kind of ideoventricular rhythm, and the medic OCFA Protocol Droid decided to give them a bolus of lido...patient coded right after.


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## SerumK (Dec 23, 2010)

I kill patients all the time. Laughter heals everything except a broken rib.


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## jroyster06 (Dec 24, 2010)

The Biggest one.

IF YOU ARE IN HOLLYWOOD:
your pt collapses, check for a pulse, yell GET THE CRASH CART, start Hollywood CPR, at a rate of 20 compressions to 3 breaths, shock asystole and push 7cc of adrenaline, then say we got them back, wait 30 seconds your pt will wake up and you and him can walk down to the cafeteria together and grab a cup of coffee.


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