# Trainwreck #4



## usalsfyre (Oct 7, 2011)

So life has curb stomped my ability to post here lately, but I'll try to get back on track.

Your on a ground CCT unit in a metro area and are dispatched to a LTAC ICU for a 64 YOF post-arrest going to major-university hospital ICU across town. On arrival you find an unconscious, intubated patient who arrested 4 hours ago, had a ROSC and is now on a dopamine drip. 

Go...


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## fast65 (Oct 7, 2011)

First of all, what is LTAC?

Well lets start off with a little info:

Specs/Orders:
-Transport time?
-Crew?
-Vent settings?
-ETT depth?
-IV's, number/location?
-Dopamine dosage/drip rate?
-Other medications?

History:
-What is the patients medical history?
-Medications?
-Allergies?
-Cause of the arrest?

Vitals:
-HR, rhythm
-BP
-SpO2
-Temp
-LS
-Weight

Forgive all my questioning, I'm not real used to IFT's yet.


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## systemet (Oct 7, 2011)

usalsfyre said:


> So life has curb stomped my ability to post here lately, but I'll try to get back on track.
> 
> Your on a ground CCT unit in a metro area and are dispatched to a LTAC ICU for a 64 YOF post-arrest going to major-university hospital ICU across town. On arrival you find an unconscious, intubated patient who arrested 4 hours ago, had a ROSC and is now on a dopamine drip.
> 
> Go...



What's an LTAC ICU?

Is this an in-hospital or out-of-hospital event? What were the circumstances surrounding the arrest?  Was CPR performed, and for how long?  Do we have any trauma from the resuscitation attempt? How many defibrillations? What medications were given?  What pre-existing medical conditions does the patient have? What are their current medications? Do they have allergies to any meds?  

LOC: Patient GCS?  Are they paralysed?  Have they had sedation / analgesia?  When was their last sedation / analgesia dose? Last NMBA, if applicable?  Neuro exam?  

Airway: confirm tube placement?  A/E and capnograph, tube fogging, etc.  What size ETT? Is it appropriate for the patient?  Is it adequately secured?  How deep is it?  How does this compare to their documentation - has it moved?  Pilot balloon inflated?  Do they have CXR verifying placement depth?

Breathing: Is the patient manually or machine-ventilated?  What FiO2, what settings, what mode of ventilation, what settings?  SpO2?  Do they have an ABG?  Is the patient breathing spontaneously? Do we know anything about airway pressures? Are their lungs relatively compliant?

Circulation: HR, B/P, do they have an arterial line?  Any ECGs? If not, let's do one.  Is there a permanent or a transvenous pacemaker present?  Do they have peripheral or central IV access? How many sites, are they patent?  Are they catheterised?  Any urine output?

Meds:  What's the dopamine running at?  What sort of site is it running through, does it appear to be patent?

Do we have any labs, including a recent blood glucose?  Are any other medications running?  Does the patient have an NG tube? 

Physical exam? And such.  Code status?  No one has found a DNR since the arrest happened?

Basically, I'd like to know what went wrong, what they've done, and whether it appears to be working. Lots of questions!  I don't mean to sound pushy, thanks for putting up a scenario.


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## usalsfyre (Oct 7, 2011)

Sorry for the confusion, LTAC stands for Long Term Acute Care, a facility that can provide acute and intensive care for >90 days. It's sort of a mix between a hospital and a nursing home, but considered a hospital by the government.

The patient is admitted for care of stage IV decubitus on her sacrum and legs. She also has a history of diabetes, hypertension and ESRD which she receives hemodialysis for.The patient takes atenolol,and is on an insulin sliding scale. An hour after receiving dialysis she was witnessed slumping over and found to be in cardiac arrest. The patient received CPR and one round of epi for PEA before regaining a pulse, the systolic B/P was found to be in the 60s so the patient was started on dopamine which was titrated "quickly" to 20mcg/kg/min, in addition the patient had received in the neighborhood of 3 liters of NS. The only access you have is a single lumen IJ where the dopamine is running. The patient was intubated with a 7.5 ETT placed to a depth of 22cm at the lips, vent settings are assist control at a rate of 24, vT of 400mls, PEEP of 5, FIO2 of 1.0 and a 1 second I time. The nurse tells you the patients doctor diagnosed a perforated bowel via chest x-ray. The patient is airborne isolation for MRSA, C.Diff,  AND VRE (all the good stuff)

Physical exam shows a an unconscious intubated patient, GCS of 5 (E1, V1, M3).

 Head is intact, an NG tube is in place draining draining dark green (and has appx 3l of drainage today). No JVD is present, in fact the jugular veins can't be palpated on the 55kg patient. 

Breath sounds are equal, rhonchi is present in the right base, otherwise clear. No spontaneous respiratory effort seems to be present

Abdomen is non-distended, a colostomy and large surgical scar are present. A foley cath is in place, the patient has no UO today. 

Extremities are intact except for the frank, multiple decubitus present on the legs.

The current vitals are B/P 136/84 via NIBP, HR of 146, SpO2 of 100% and ETCO2 of 22 with a square waveform. No meds besides the epi or dopamine have been administered.
EKG:





No DNR, the family at beside is just saying "keep her alive, please". Transport time is 30 minutes, your partner is a medic but he has to drive, and is a graduate of a 10 week program and his only other EMS experience is as a non-transporting paramedic on a garbage truck .


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## usalsfyre (Oct 7, 2011)

Crap, forgot labs.

Na: 132
K+: 3.3
Cl: 97
HCO3: 24
BUN:28
Cr: 1.3

H&H: 10.2 & 28
WBC: 12.5


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## fast65 (Oct 7, 2011)

And did we have an ABG's?

I suppose all there is to do at this point is to get her ready for transport...and await the subsequent trainwreck


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## usalsfyre (Oct 7, 2011)

No ABGs. What can we do to optimize her for transport? There's a couple of adjustments to be made that will help.


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## fast65 (Oct 7, 2011)

Bear with me as I just got off shift, but the only thing I can think of at the moment is to decrease the ventilatory rate to try and bring the ETCO2 up to a more reasonable level. With the ESRD (which I suspect stands for _End Stage Renal Disease_) her body is going to be relying a lot more on her respiratory status to maintain the acid-base balance, so we'll need to manage that for her. I would also like to attempt to obtain another site for vascular access if possible.

I'm pretty sure that half my paragraph didn't make any sense, am I'm ok with that. h34r:


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## usalsfyre (Oct 7, 2011)

fast65 said:


> Bear with me as I just got off shift, but the only thing I can think of at the moment is to decrease the ventilatory rate to try and bring the ETCO2 up to a more reasonable level. I would also like to attempt to obtain another site for vascular access if possible.



Sounds great, you back the vent down to 16 with no ill effects, and manage to slide in a 20 ga for further access. Another thought is backing down the dopamine, a pressure of 136/84 is great, but not with a HR in the 140s. Her MAP is 101, back down on the dopa to keep a the MAP above 80 and get the HR down.  Finally the patient still seems dry (ultra flat jugulars) so a bit more fluid may be in order.

You do all of the above, the vitals improve (B/P of 106/74, HR of 108, SpO2 of 96% and ETCO2 of 37). and 10 minutes into the transport the sat suddenly drops into the 70s, the HR spikes to 130 and the pressure drops to 50 over ---.


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## systemet (Oct 7, 2011)

usalsfyre said:


> Sounds great, you back the vent down to 16 with no ill effects, and manage to slide in a 20 ga for further access. Another thought is backing down the dopamine, a pressure of 136/84 is great, but not with a HR in the 140s. Her MAP is 101, back down on the dopa to keep a the MAP above 80 and get the HR down.  Finally the patient still seems dry (ultra flat jugulars) so a bit more fluid may be in order.
> 
> You do all of the above, the vitals improve (B/P of 106/74, HR of 108, SpO2 of 96% and ETCO2 of 37). and 10 minutes into the transport the sat suddenly drops into the 70s, the HR spikes to 130 and the pressure drops to 50 over ---.



Wow.  This is moving quicker that I can keep up!  I was just typing a response to earlier!  Rhythm check?


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## fast65 (Oct 7, 2011)

Alright, well let's start by checking our vent and making sure nothing malfunctioned with it. I want to recheck my LS, tube depth, and look for secretions. Is there anything that I find that may have caused this rapid decline? Did she buck the tube?

Rhythm?

Lets give her a fluid bolus, pending our check of LS. With her being that "flat", and with those vitals, I'm suspecting there's some sort of hypovolemic shock going on here, so I'm a little hesitant about turning up the dopamine. Let's see how she handles the fluid, then we can start thinking more about turning the dopamine up.


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## usalsfyre (Oct 7, 2011)

Rhythm is now: 





Lung sounds are absent in the right, tube is still at 22cm. The chest seems to be rising unequally. All your equipment seems to be workig as before, except the vent is now alarming high PIPs and the monitor is screaming to "check patient".


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## systemet (Oct 7, 2011)

{Edit: ha ha... just posted this, then saw the post above!  Looks pretty funny)


Ok. So to the original condition:

* Seems reasonable that she's probably septic; decubitus bed sores are one possible culprit, perforated bowel is another, and the right basilar rhonchi are probably a secondary infection but are also suspcious.  She's also got leukocytosis.  Might be interesting to know her temp.

* Agree with changing the vent.  Although if she is alkalotic (and it seems reasonable that she is), I'm a little worried about what the K+ might do, as she's already hypokalemic.  Could also be a cause of the arrest.  [<----- Second edit: This is stupid, taking the pH down by reducing the minute volume will increase serum K+.  Sorry.]

* Would love to know how much they took off at dialysis, whether she's been normally compliant, and any previous problems.  Would be interesting to know about the previous abdo. surgery.  How is the colostomy site?  Another potential route of infection.

* ECG is difficult to interpret due to quality, as often happens in real life.  Sinus tachycardia, with left axis deviation, Sokolow-Lyon criteria for LVH.  Possible lateral strain / ischemia I / aVL, V5, V6.  Hard to measure the QT, but makes you wonder if it isn't a little long perhaps?  No clear infarct pattern.  Difficult to say if there's a hemiblock there.

* Agree that she may be volume depleted, wrt the jugulars, and the tachycardia, which seems quite significant for a 60 year old on beta-blockers.

* Assuming the glucose is normal?

* Would be nice to have an in-line filter on the ETT.


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## systemet (Oct 7, 2011)

usalsfyre said:


> Rhythm is now:
> 
> 
> 
> ...



Pulse?

Ok.  Run the mnemonic.  Tube's not displaced.  Let's fire a suction cath down the ETT to make sure there's not been some sort of mucus plug.  If the tube's clear, I think it's time to decompress the right side of the chest, and think about cardioversion / defibrillation, if decompression fails to resolve the arrhythmia.


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## fast65 (Oct 7, 2011)

Hmmm, well that is most certainly is a problem. Do we have a pulse? I'm going to say that the WCT is being caused by hypoxemia, and I suspect she may in fact have a pneumo. Let's go ahead and decompress her chest on the right side (2nd intercostal space, midclavicular). I imagine that will resolve the absent lung sounds, raise the SPO2 and cause the WCT to convert into a more stable rhythm (hopefully not asystole :rofl.


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## exodus (Oct 7, 2011)

fast65 said:


> Hmmm, well that is most certainly is a problem. Do we have a pulse? I'm going to say that the WCT is being caused by hypoxemia, *and I suspect she may in fact have a pneumo.* Let's go ahead and decompress her chest on the right side (2nd intercostal space, midclavicular). I imagine that will resolve the absent lung sounds, raise the SPO2 and cause the WCT to convert into a more stable rhythm (hopefully not asystole :rofl.



Could it be possible the tube went down too far somehow and is only in one lung?


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## fast65 (Oct 7, 2011)

exodus said:


> Could it be possible the tube went down too far somehow and is only in one lung?



Not likely, we initially had bilateral breath sounds when we left and the tube depth was noted at 22 cm, so it hasn't moved since we left.


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## exodus (Oct 7, 2011)

fast65 said:


> Not likely, we initially had bilateral breath sounds when we left and the tube depth was noted at 22 cm, so it hasn't moved since we left.



True, I missed the bi-lat breath sounds initially. There's some places around here that wouldn't surprise me if they had an improper placement.


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## abckidsmom (Oct 7, 2011)

fast65 said:


> Not likely, we initially had bilateral breath sounds when we left and the tube depth was noted at 22 cm, so it hasn't moved since we left.



And 22 at the lip struck me as slightly shallow anyway.  

We took her off the vent and are bagging her now, right?  Does she have any respiratory drive on her own?

Oh, and cardiovert or defibrillate, depending.

You sure know how to bring a train wreck.  IFT scenarios should be "Usals's EMTALA violations."


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## Handsome Robb (Oct 7, 2011)

I'm late to the party, like usual 

I'm definitely thinking sepsis/septic shock. I don't think it is hypovolemic in nature due to her receiving ~3L at the sending facility then us putting more onboard and the pt having no urine output. The ulcers and perforated bowel don't help her case either.

I agree with everyone's treatment on the current problem, check the tube, decompress the right side of her chest, cardiovert/defib as appropriate.

Kinda glad we don't do too many IFTs around here, cause this one is making me feel on the slow side.


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## NomadicMedic (Oct 7, 2011)

I agree with darting her chest and electricity.

Waiting to see what's next.


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## fast65 (Oct 7, 2011)

NVRob said:


> I'm late to the party, like usual
> 
> *I'm definitely thinking sepsis/septic shock. I don't think it is hypovolemic in nature due to her receiving ~3L at the sending facility then us putting more onboard and the pt having no urine output. The ulcers and perforated bowel don't help her case either.*
> 
> ...



I would agree, now that I've had a few cups of coffee, I can actually put it all together  I don't know why I said hypovolemic, the 3L of fluid is a big red flag.


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## abckidsmom (Oct 7, 2011)

NVRob said:


> I'm late to the party, like usual
> 
> I'm definitely thinking sepsis/septic shock. I don't think it is hypovolemic in nature due to her receiving ~3L at the sending facility then us putting more onboard and the pt having no urine output. The ulcers and perforated bowel don't help her case either.
> 
> ...



But at her baseline, did she have any urine output?  Plenty of people who have ongoing hemodialysis do not.

I am thinking that she was on the edge of sepsis, they did the standard HD plan, pulling off a couple of liters over a couple of hours, and that was too much for her.  Then they over reacted with the fluid, and she's back overtanked.

I bet once we fix that pneumo, we'll listen again and she'll be having fluid in those lungs.  Then what?  Let's flex these critical care muscles, huh?


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## fast65 (Oct 7, 2011)

abckidsmom said:


> But at her baseline, did she have any urine output?  Plenty of people who have ongoing hemodialysis do not.
> 
> I am thinking that she was on the edge of sepsis, they did the standard HD plan, pulling off a couple of liters over a couple of hours, and that was too much for her.  Then they over reacted with the fluid, and she's back overtanked.
> 
> I bet once we fix that pneumo, we'll listen again and she'll be having fluid in those lungs.  Then what?  Let's flex these critical care muscles, huh?



I suppose if that was the case we might be able to increase the PEEP?


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## abckidsmom (Oct 7, 2011)

fast65 said:


> I suppose if that was the case we might be able to increase the PEEP?



Only if you wanted another pneumo.  Blowing a lung like that so soon after transitioning to a transport vent screams vent malfunction or user error in setting the settings.

People who are stable on their settings don't typically all of the sudden develop a tension pneumo without some outside changes, even in a train wreck.  Well, maybe in a train wreck...


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## fast65 (Oct 7, 2011)

abckidsmom said:


> Only if you wanted another pneumo.  Blowing a lung like that so soon after transitioning to a transport vent screams vent malfunction or user error in setting the settings.
> 
> People who are stable on their settings don't typically all of the sudden develop a tension pneumo without some outside changes, even in a train wreck.  Well, maybe in a train wreck...



Dammit, you're right, I'm not sure what I was thinking :/ So let's say that after we decompress the pneumo we find a good amount of fluid in the lungs, what can we do? I mean going with diuretics isn't going to do much good, her kidneys aren't functioning well enough for them too; and PEEP is out because as you said, it would probably just cause another pneumo.


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## usalsfyre (Oct 7, 2011)

We dart the chest, the SpO2 improves to >90%, the B/P improves slightly to 70/30...but we're still in V-Tach. We do have a carotid and very weak peripheral pulses. 

So synchronized cardioversion? Or medication? 

Oh yeah, we're now stuck in traffic, and your 20 min ETE just turned into an hour, and you used a standard angiocath for the decompression...(ok, being slightly mean here )


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## fast65 (Oct 7, 2011)

Well, let's go with synchronized cardioversion and see where that gets us. How are our LS?


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## Handsome Robb (Oct 7, 2011)

abckidsmom said:


> But at her baseline, did she have any urine output?  Plenty of people who have ongoing hemodialysis do not.
> 
> I am thinking that she was on the edge of sepsis, they did the standard HD plan, pulling off a couple of liters over a couple of hours, and that was too much for her.  Then they over reacted with the fluid, and she's back overtanked.
> 
> I bet once we fix that pneumo, we'll listen again and she'll be having fluid in those lungs.  Then what?  Let's flex these critical care muscles, huh?



My critical care muscles are still itty bitty. 

Why would she have a foley cath in place with a baseline of no urine output though? Standard procedure by the care home possibly? Seems like an unnecessary risk to the patient when you consider the chance of UTI -> urosepsis. 

I'm kind of lost with this one, probably fluid in the longs but can't use peep otherwise risk another pnuemo. I have a thought but it might be a dumb one. We are on a CCT truck correct? Do we have hypertonic solutions available to us? Increase the osmotic pressure in the vascular space to draw fluid out of the alveoli and back into the vasculature thus reducing the fluid problem in the lungs, increasing oxygenation and volume/bp?

Be gentle please!!!


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## Handsome Robb (Oct 7, 2011)

fast65 said:


> Well, let's go with synchronized cardioversion and see where that gets us. How are our LS?



agreed.


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## usalsfyre (Oct 7, 2011)

Cardioversion a 100j, post cardioversion EKG resembles, however think more tachycardia:





(sorry couldn't find what I wanted).

The B/P improves to 110/74. 

Lung sounds are...crappy. Especially on the right.

We ARE on a CCT truck. What can we do that would allow us to use PEEP and go a long way towards helping the pneumo?


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## usalsfyre (Oct 7, 2011)

abckidsmom said:


> You sure know how to bring a train wreck.  IFT scenarios should be "Usals's EMTALA violations."


Nahhh, that's an upcoming L&D case that the truck I'm precepting on ran a couple of weeks ago. I've just got to figure out how to sufficiently change the details :unsure:.


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## usalsfyre (Oct 7, 2011)

NVRob said:


> I'm kind of lost with this one, probably fluid in the longs but can't use peep otherwise risk another pnuemo. I have a thought but it might be a dumb one. We are on a CCT truck correct? Do we have hypertonic solutions available to us? Increase the osmotic pressure in the vascular space to draw fluid out of the alveoli and back into the vasculature thus reducing the fluid problem in the lungs, increasing oxygenation and volume/bp?
> 
> Be gentle please!!!



Hypertonic saline is not a bad thought, but there's something else we can do while sitting in traffic.


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## usalsfyre (Oct 7, 2011)

More on hypertonic saline. So if the patient is volume overloaded, would pulling fluid into the vasculature be good? What's are some of the membranes most likely to allow fluid to deposit? 

Like I said, I understand the thought but there's better options. Hypertonic saline won't fix the fluid maldistribution problem. Your on the right road with PEEP, now how can we prevent the pneumo?


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## Handsome Robb (Oct 7, 2011)

usalsfyre said:


> More on hypertonic saline. So if the patient is volume overloaded, would pulling fluid into the vasculature be good? *What's are some of the membranes most likely to allow fluid to deposit?*
> 
> Like I said, I understand the thought but there's better options. Hypertonic saline won't fix the fluid maldistribution problem. Your on the right road with PEEP, now how can we prevent the pneumo?



That was my worry. It wouldn't be good but it would be better than having fluid build up in the lungs? Seems like I would have fixed one problem while building upon one that was already present :unsure:

In regards to what I bolded, can you go into a little more detail? I'm not sure I understand what your asking.

I'm pretty stuck on how to further prevent another pnuemo. I'm not keen on bagging this guy the entire time we are in traffic, can the vent be set to have no PEEP? I would think the lack of PEEP would help prevent another one from developing but then your not helping the wet lungs...


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## fast65 (Oct 7, 2011)

usalsfyre said:


> Cardioversion a 100j, post cardioversion EKG resembles, however think more tachycardia:
> 
> 
> 
> ...



Hmmmm, now that is a tough one, to be quite honest, I'm not sure how to handle that one. My initial thought was to increase PEEP, but decrease tidal volume, in my mind that might somehow work, but in reality I'm not so sure


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## Handsome Robb (Oct 7, 2011)

I have a thought and as usual I'm probably barking up the wrong tree but here it goes.

Could the pnuemo be caused by the patient having a spontaneous respiration against the vent causing a spike in intrathoracic pressure? Super long shot but it's about all I can come up with but if this is the case could paralyzing and sedating the patient reduce the risk of another pnuemo by removing the patients ability to breath spontaneously? In turn could the PEEP then be maintained or increased a bit to help with the displacement of fluid?

Ok back to my neurology paper.


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## usalsfyre (Oct 7, 2011)

One last hint. Since we're on a CCT truck, can we do something to _definitively_ treat the pneumo allowing us to use PEEP?


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## fast65 (Oct 7, 2011)

usalsfyre said:


> One last hint. Since we're on a CCT truck, can we do something to _definitively_ treat the pneumo allowing us to use PEEP?



Wait, we can't place a chest tube, right?

EDIT: the more I think about it, the more I'm second guessing it. A chest tube would only be for hemothrorax, correct?


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## Handsome Robb (Oct 7, 2011)

I know CCRNs can place chest tubes in many flight programs. Can a medic do that? Our flight medics can only monitor chest tubes last time I checked. Caveat being that I don't pay a ton of attention to their protocols. Thats about the only thing I can think of.

Chest tube is truly the only definitive treatment of a pnuemo unless you have some sort of trauma to the lung(s) that requires surgical intervention from what I have read.


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## abckidsmom (Oct 7, 2011)

usalsfyre said:


> One last hint. Since we're on a CCT truck, can we do something to _definitively_ treat the pneumo allowing us to use PEEP?



Right.  So we'll slip in a little chest tube.

Dude.  You need to give us a list beforehand, man!


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## usalsfyre (Oct 7, 2011)

NVRob said:


> I know CCRNs can place chest tubes in many flight programs. Can a medic do that? Our flight medics can only monitor chest tubes last time I checked. Caveat being that I don't pay a ton of attention to their protocols. Thats about the only thing I can think of.
> 
> Chest tube is truly the only definitive treatment of a pnuemo unless you have some sort of trauma to the lung(s) that requires surgical intervention from what I have read.



In Texas our medical director decides what we can and can't do .

Although it's not something that very often recommended or needed out-of-hospital, this is one of those times either tube or even just an open thoracostomy would be appropriate.


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## firetender (Oct 7, 2011)

*...then treat it like a train wreck!*

First of all, when you have a train wreck you organize patient treatment to handle the most viable; everyone else is left to personal consultation with his/her Maker.

Second of all, can you NOT see that this is a Buff and Turf, last ditch effort from what the OP reported?

Okay, then, let's get the facts straight, Sergeant Friday: No matter how you cut it, this patient was circling the drain.



> *From original post:* Your (sic) on a ground CCT unit in a metro area and are dispatched to a LTAC ICU for a 64 YOF post-arrest going to major-university hospital ICU across town. On arrival you find an unconscious, intubated patient who arrested 4 hours ago, had a ROSC and is now on a dopamine drip.


 
Okay, that's the general picture. What you have is what you have. Therein is your baseline of stability. Okay then, let's get a bit more detailed:



> The patient is admitted for care of stage IV decubitus on her sacrum and legs. She also has a history of diabetes, hypertension and ESRD which she receives hemodialysis for.The patient takes atenolol,and is on an insulin sliding scale. An hour after receiving dialysis she was witnessed slumping over and found to be in cardiac arrest. The patient received CPR and one round of epi for PEA before regaining a pulse, the systolic B/P was found to be in the 60s so the patient was started on dopamine which was titrated "quickly" to 20mcg/kg/min, in addition the patient had received in the neighborhood of 3 liters of NS. The only access you have is a single lumen IJ where the dopamine is running. The patient was intubated with a 7.5 ETT placed to a depth of 22cm at the lips, vent settings are assist control at a rate of 24, vT of 400mls, PEEP of 5, FIO2 of 1.0 and a 1 second I time. The nurse tells you the patients doctor diagnosed a perforated bowel via chest x-ray. The patient is airborne isolation for MRSA, C.Diff, AND VRE (all the good stuff)
> 
> Physical exam shows a an unconscious intubated patient, GCS of 5 (E1, V1, M3).



But now, the OP asks:



> What can we do to optimize her for transport?


 
There is NOTHING to optimize! The only option is to NOT mess with whatever delicate balance is present and PRAY NOTHING CHANGES. How more clear could that be?

*But then, all the juggling begins and it sounded pre-emptory to me.* Says one respondent to the OP:



> decrease the ventilatory rate to try and bring the ETCO2 up to a more reasonable level. With the ESRD (which I suspect stands for _End Stage Renal Disease_)


 
Could ESRD be another clue as to what you might choose to do, when, how and why?

...and bring her ETCO2 up to a more *REASONABLE* level? Sorry, but the fact that she's breathing at all is enough for me. I ain't gonna F with it in any way shape or form. Reasonable to whom?

Our OP now chimes in with more grist for the mill:



> You do all of the above, the vitals improve (B/P of 106/74, HR of 108, SpO2 of 96% and ETCO2 of 37). and 10 minutes into the transport the sat suddenly drops into the 70s, the HR spikes to 130 and the pressure drops to 50 over ---.


 
*You're goddamned right something else started going out of whack!* So at this time I can only ask, When do you decide that you accept WHAT you have in front of you? Must you mess with it?

Now, this woman has become a puzzle to work with -- a Rubic's Cube of trial and _*ALL* error because the basic stability you were presented with was compromised._

*Are any of you asking yourselves "What is stable FOR THIS PATIENT?"*

Now, I don't even need to go any further with the horrid details. Let's just put it this way. We've already established where the patient was at. Then, we decided we wanted to "optimize" her condition. So we start tweaking this and tweaking that. For every tweak, of course there is a related or unrelated response. But how the hell would we know if it has to do with her presenting condition or from what WE'VE done to her in our tweaking? 

*Do you see my point? This was an IFT, NOT an emergency intervention.*

So let me see where this goes. We tweak, something changes, we try and correct that and something related or unrelated changes so we mess with that.

Why in God's name would you treat symptom after symptom, in essence playing a juggling act with the physiology of an already compromised human being?

*Do you see my point? This was an IFT, NOT an emergency intervention.*

Blood pressure drops COULD BE hypovolemia. IF so, better push that bolus Heart rate goes up, better find something for that. Don't like that rhythm? cardiovert. 

By the time we get our sixth new contributer to the thread, here's where we are:



> I agree with darting her chest and electricity.



*WHOA, BABY!* We certainly had to get there from somewhere, and the somewhere didn't have anything to do with what we were loading up into the rig for a half-hour transfer. What has changed on its own?

No one will ever know because so many things were messed with it would be most impossible to determine. What's the goal here? Get her THERE alive.

Isn't Rule #1 "Don't upset the applecart?" Okay, maybe Hippocrates said it better.

Somewhere in there, she got a pneumothorax. But was it REALLY pushing her over the edge? *It doesn't matter. WHOOPIE! we have something new to treat!!! *From what I've been reading the urgency here is to get her to die in the ambulance rather than the hospital!

The patient is compensating left and right for the interventions you take to what? Assure stability? 

WHO ARE YOU KIDDING?

So, I have a point here that I will explore further still at my EMS Outside Agitator Blog. I'm not identifying this thread, or its posters -- just using the flow here as example, as long as that's okay with everyone.

I am in perfect agreement with exploring all the deep medical syndromes, playing with possibilities of treatment, their intended effects and what they actually did. I'm cool with exploring scenarios and "What If"ing them to death.

But *FIRST*, what I'd like to hear is that you 

#1) understand the call within the context of the Bigger Picture
#2) have an idea of the viability of your patient IN THE CONTEXT OF HOW MUCH TIME TO GET TO THE NEXT LEVEL OF APPROPRIATE CARE
#3) have spoken to the Dr. or other approprite authority to determine the limits and boundaries of your interventions
#4) have actually CONSIDERED the potential for the quality of life of YOUR patient

*There was none of that in this thread.*

Sure, it's a scenario, a fantasy (Jesus I HOPE!) and an exercise, but seriously, folks, at least START by posing the question like this"

* "IF we chose to aggresively treat a patient with this kind of condition, what do you think we'd do and how might the scenario develop/devolve?"*​ 
I want to hear how thinking paramedics act, not how acting paramedics administer.


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## fast65 (Oct 7, 2011)

usalsfyre said:


> In Texas our medical director decides what we can and can't do .
> 
> Although it's not something that very often recommended or needed out-of-hospital, this is one of those times either tube or even just an open thoracostomy would be appropriate.



Oh yeah, that's right, you guys have that nifty rule about your medical director determining your scope of practice


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## usalsfyre (Oct 7, 2011)

abckidsmom said:


> Right.  So we'll slip in a little chest tube.


We put one in, the lungs start to sound better, the transport is completed, your boss calls and offers you a $2/hr raise, for the single folks that cute nurse compliments you on being a ballsy clinician, ect, ect  .

That said, the patient expires two hours after arrival from multi-system failure.



abckidsmom said:


> Dude.  You need to give us a list beforehand, man!


I'll admit I was kinda pushing the limits with this one to see if anyone would go down that road. The patient this was based on didn't have the pneumo.


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## Handsome Robb (Oct 7, 2011)

usalsfyre said:


> In Texas our medical director decides what we can and can't do .
> 
> Although it's not something that very often recommended or needed out-of-hospital, this is one of those times either tube or even just an open thoracostomy would be appropriate.



Oy! Our MD decides what we can do. He just has to write a letter to the state requesting something outside of the state scope and the state has to approve it. 
He usually gets what he wants, except for I's getting Zofran due to the new prolonged QT study from the FDA. <_<

Every time a pt complains of nausea I'm telling the medic that I'm uncomfortable taking the pt  kidding */OT*

So the chest tube is in. Now what happens? We can resume ventilations with PEEP. I'd try to increase the PEEP a bit to hopefully move some fluid out of the alveoli if the current PEEP setting wasn't getting it done. Since we have established the patient is volume overloaded I'd tone down the fluids to TKO but keep the dopamine where it is set at and titrate up or down to effect.


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## firetender (Oct 7, 2011)

*I rest my case.*



usalsfyre said:


> That said, the patient expires two hours after arrival from multi-system failure.
> QUOTE]
> 
> And what was her last 2 1/2 hours of life like?
> ...


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## usalsfyre (Oct 7, 2011)

Firetender,  a big part of IFT at the critical care level is about optimizing mismanaged patients. This patient was mismanaged, not only in a way that probably led to her arrest in the first place, but definitely post arrest. The ungodly high ventilatory rate as set by the facility and the extreme tachycardia precipitated by the high dose of dopamine were unnecessary and likely harmful. Both of these needed to be adjusted immediately. Without exploring the fact that the whole thing was an exercise in futility from the start (which everyone there realized) the task we were given was to deliver a live patient with the greatest chance of survival. This means correcting mismanagement. It's not a reflection of arrogance, simply that the CCT personnel may have more experience managing this type of patient than many facilities. 

The days of taking a patient and running from facility to facility are over. Poor outcomes with these patients is why CCT evolved into a specialized arm of EMS.


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## usalsfyre (Oct 7, 2011)

firetender said:


> [
> And what was her last 2 1/2 hours of life like?
> 
> A receptacle for whatever looked fun to try.
> ...


Right, wrong or indifferent it's not our place to decide her fate. Family was at beside asking us to "do everything". As such, we're obligated to treat her to the best of our ability.


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## Shishkabob (Oct 7, 2011)

NVRob said:


> I know CCRNs can place chest tubes in many flight programs. Can a medic do that? Our flight medics can only monitor chest tubes last time I checked. Caveat being that I don't pay a ton of attention to their protocols. Thats about the only thing I can think of.



Sure as heck a Paramedic can place a chest tube.  My (now former) agency's flight service, flight medics and flight RNs had the same scope, and they could do chest tubes AND pericardiocentesis.


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## firetender (Oct 7, 2011)

usalsfyre said:


> Firetender, a big part of IFT at the critical care level is about optimizing mismanaged patients. QUOTE]
> 
> Were there something to optimize here, I'd say do the work. You're essentialy saying the discharging facility was incompetent, but were you the only judge of that? My point remains: there was nothing to optimize, only stabilize.
> 
> I hope you can see I was using this thread as a springboard to encourage more than technical reaction; it's called critical thinking.


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## abckidsmom (Oct 7, 2011)

usalsfyre said:


> Firetender,  a big part of IFT at the critical care level is about optimizing mismanaged patients. This patient was mismanaged, not only in a way that probably led to her arrest in the first place, but definitely post arrest. The ungodly high ventilatory rate as set by the facility and the extreme tachycardia precipitated by the high dose of dopamine were unnecessary and likely harmful. Both of these needed to be adjusted immediately. Without exploring the fact that the whole thing was an exercise in futility from the start (which everyone there realized) the task we were given was to deliver a live patient with the greatest chance of survival. This means correcting mismanagement. It's not a reflection of arrogance, simply that the CCT personnel may have more experience managing this type of patient than many facilities.
> 
> The days of taking a patient and running from facility to facility are over. Poor outcomes with these patients is why CCT evolved into a specialized arm of EMS.



This is what I was going to say. 

The scope of mismanagement is just astonishing.  For whatever reason, when I worked in the STICU, we seemed to have a run on gastic bypasses run amok.  I mean a.m.o.k.  They were all transferred in from outlying hospitals (teehee, like ours was the center of the universe, lol).  One was a 28 yo lady on Christmas break from college who had her GBP, was discharged home and THEN discovered the leak, but was not reopened, they just treated with antibiotics.  She died at Valentine's day.  Another lady had her surgery, and swirled a little afterward, needing a chest tube, which they inserted through the pleural space, through the diaphragm, perforating the stomach and then *not doing anything about it for 2 days!*

So to walk in on these situations and just scoop and scoot, you just can't do it.

In usalsfyre's scenario, the decision to treat the patient aggressively was made by the family.  These freestanding acute care facilities typically have good end-of-life care, but you can only do so much when the family is at the bedside demanding that everything be done.

Once the decision to treat was made, the staff ran amok with their treatment plan, and failed to reassess to find the balance.  No need to have her dopamine pegged, no need to have her panting on the vent.  No need for any of that, but there ya go.  Like you recognized, every treatment needed to be reacted to, and "our" treatment was merely a reaction to the staff's treatment, which helped us down this path.

Plus, in a train wreck scenario, it's going to move pretty quickly toward devastation, anyway.


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## Shishkabob (Oct 7, 2011)

It's not just CCT, either.  I've had more than my fair share of having to fix a sending facilities...err.. issues... doing 'just' a 911 truck.


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## firetender (Oct 7, 2011)

I really understand the counteracting mismanagement thing, but in this particular case, it seemed the odds of correcting ANYTHING were nil. My only concern would be to not risk making anything worse; therefore, inaction would be the only viable option. 

In her case, YES, I think she was stable enough for a half-hour ride to the next facility. If something went south enroute, well then you deal with it. But anything pre-emptive is just not appropriate in her case. What I read told me the actions you took exacerbated her downward spiral.

And did I hear the people who made the final call on whether or not you took aggressive action was the family's?

Something's missing.


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## usalsfyre (Oct 7, 2011)

Firetender, she was intubated by the facility. If she blew a lung on proper vent settings she sure as feces was going to blow one out on their overventilation, if she didn't have an MI that stopped her LV from working entirely because of the maxed out dopamine drip first. Yes, the family was at bedside, and asked the facility to "do everything to keep her alive". As such, at that point you become obligated to do the same, and that means fixing the problems you encounter. She was darn likely to crash enroute to the truck. I have seen patients that seemed "stable" crap out simply from moving to the EMS stretcher. If the patient's interventions are not where they should be they should be tweaked prior to initiating transport. The transport environment is harsher than an ICU bed. Talk to nurses who have done both and I doubt you'll find one that disagrees.

I'm not sure what your ethical issue here is. We weren't using her as a high-fidelity skills lab. We were doing what any prudent CCT team would.


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## firetender (Oct 8, 2011)

usalsfyre said:


> FI'm not sure what your ethical issue here is. We weren't using her as a high-fidelity skills lab. We were doing what any prudent CCT team would.


 
First of all I do not have an issue with YOUR ethics, nor am I critical of the actions you took which I have no doubt were appropriate in the given circumstances. I wasn't there. Maybe that's what got me asking my questions.

What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get. No one stepped back to question if furthering/continuing/initiating aggresive treatment was necessary. No one came to the conclusion that things were likely to get worse REGARDLESS of what was done.

To me, all that was obvious. That led me to my conclusion that the woman was stable ENOUGH for immediate transport. What I heard you relate was that AFTER you started adjusting the whatnots the woman began a fatal spiral. But honestly, it wouldn't have mattered if you did everything or nothing.

So it's not so much an ethical question as it is a moral dilemma. In a case like this, which is clearly end-of-life syndrome, when do you admit to yourself that it's a lost ship and all that's left to do is to make its passage as gentle as possible without neglecting your duties? 

This kind of stuff usually doesn't get considered in scenarios and it should be. We're the ones that have to live with the actions (or inactions!) we take and the choices we make. In the end we don't agonize about the fact that we lost them, what haunts us is how.


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## usalsfyre (Oct 8, 2011)

Firetender, I actually don't disagree with you. She honestly was going to crump shortly no matter what. Ideally the physicians and other staff at the sending should have had a very frank discussion about what was going on. Quite honestly, I think they did. But between belief in the "miracles of modern medicine" and the fact that this individual's social security probably provided a good part of the household income the family refused to acknowledge the obvious. At that point your hands become tied.


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## Handsome Robb (Oct 8, 2011)

Firetender. I respect you and acknowledge what you bring to the table but after your post in this thread you went down a notch in my book. I don't care if your a mod. You derailed the thread and its educational purpose.

Don't jump down our throats when the younger members, who are genuinely interested in furthering their knowledge in this field respond to a scenario presented to us. 

As a community leader your supposed to guide new/young members, not make them feel like morons.

I was enjoying this thread until you poked your head in here. I'm starting to agree with some of the people who have left that I remained in contact with about this forum.

Usalsfyre thank you for the scenario and the help you have provided me on a personal level. I hope that after you finish with taking care of yourself and your personal business you continue to post educational puzzles for us here.


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## Handsome Robb (Oct 8, 2011)

firetender said:


> What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get.



It's scenario based. You *may* be correct but thats not the point. Think about it from the point of view of a new provider who is excited and willing to learn from this scenario. Not a 'shes alive, transport her and we will treat her symptoms enroute in a bumpy cramped ambulance rather than stabilize her further in a controlled environment" point of view.
:unsure:

from the way *I* read it, your looking at it from an "if it aint broke don't fix it until it breaks" standpoint and the younger guys in here are looking at it from a prophylactic standpoint.


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## abckidsmom (Oct 8, 2011)

firetender said:


> What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get. No one stepped back to question if furthering/continuing/initiating aggresive treatment was necessary. No one came to the conclusion that things were likely to get worse REGARDLESS of what was done.
> 
> To me, all that was obvious. That led me to my conclusion that the woman was stable ENOUGH for immediate transport. What I heard you relate was that AFTER you started adjusting the whatnots the woman began a fatal spiral. But honestly, it wouldn't have mattered if you did everything or nothing.
> 
> ...





			
				Usalsfyre said:
			
		

> assist control at a rate of 24, vT of 400mls, PEEP of 5, FIO2 of 1.0 and a 1 second I time



If we did nothing, considered her "stable for transport" on these settings, and then she blew out a lung in traffic, we'd be held liable.  You can't leave a "stable" person on 100% oxygen, with itsy bitsy tidal volumes, with such a long part of the ventilatory cycle being spent on inspiration.  You just can't do it.

Regardless of whether she was stable for transport, those vent settings had to change.

Not to change them would be like, well, I can't even think of an analogy for what that would be like.  To show up with that patient at the receiving facility would be to become complicit in the ignorance.  

Also, leaving her on 100% leaves you backed into a corner, with nothing to increase should she need it, and how many times have we beat the "don't overuse oxygen" dead horse, anyway?

I love your mindset, firetender, and I tend to agree with you on many issues of the conscience, ethics, or whatever you call the touchy-feely side of things, but this lady was not our victim, not the victim of the medics scoring one more skill.  She was the victim of the healthcare system, our society's need to "do everything" even in the face of obvious futility.

This is a valuable conversation to have, and a very important bunny trail to make sure we go down every now and again, but I think the confrontational way you brought it into this thread sorta shut down productive conversation.


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## systemet (Oct 8, 2011)

firetender said:


> What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get. No one stepped back to question if furthering/continuing/initiating aggresive treatment was necessary.



I don't think we get to make the decision as to whether we continue aggressive care.  I think that's up to the patient, who has a choice to determine what's done in this situation by writing a DNR / personal directive.  

I think we have a moral and ethical responsibility to help here, to the best of our ability, and do whatever we can to increase any small chance of her recovering.

I accept fully that the "stability" here might be tenuous.  I agree that altering the dopamine and vent settings might undo this "stability".  Perhaps, in the best of all possible worlds, they're better made via consultation with an intensivist / EM guy at the receiving facility.

But if that's not available, then we have to make a judgment as what's in the best medical interest here.  It does sound like the dopamine is being ran too aggressively, and should be backed up, and that the ventilation strategy is overaggressive.  There's a sound argument not to give her a push if she's teeter-tottering on the brink of stability, as we don't not which direction she's going to move in.  

But I think the aggressive pressor usage is going to do terrible things to her afterload and cardiac oxygen demand, and may be worsening the situation.  As with the hyperventilation and potential pH issues.




> No one came to the conclusion that things were likely to get worse REGARDLESS of what was done.



I'm not sure that's true.  Several people identified that this patient was a "train wreck", which was actually the title of the thread.  




> To me, all that was obvious. That led me to my conclusion that the woman was stable ENOUGH for immediate transport. What I heard you relate was that AFTER you started adjusting the whatnots the woman began a fatal spiral. But honestly, it wouldn't have mattered if you did everything or nothing.



And of course you can't know whether it would matter if you did nothing, or if you intervened, because you have to do one or the other.  Doing nothing, and saying, "This is the best stability we're going to get", is also a choice that has consequences for the patient.



> So it's not so much an ethical question as it is a moral dilemma. In a case like this, which is clearly end-of-life syndrome, when do you admit to yourself that it's a lost ship and all that's left to do is to make its passage as gentle as possible without neglecting your duties?



Has the passage been made more rough here? The patient is anesthetised, and if we go by the logic that she's not going to recover whatever we do, then she's not regaining consciousness regardless.  She's sedated and has had analgesia.

We can make the argument that it might be easier for the family if she codes at the receiving facility instead (in this situation, partially hypothetical, she did).  Did our intervention really hasten the death?  And if it did, did it do it for minutes, hours, or days?  



> This kind of stuff usually doesn't get considered in scenarios and it should be. We're the ones that have to live with the actions (or inactions!) we take and the choices we make. In the end we don't agonize about the fact that we lost them, what haunts us is how.



I'll agree there's an element of ego in here.  And if you're suggesting that the medical field dehumanises the patient to enable them to cope psychologically, I'll happily agree with that.  But what's your alternate plan of action?

Would you leave the dopamine as it is?  Leave the ventilator settings as they are?  Will these actions result in the patient dying quicker, but with less sweat for the paramedics in the back?

Would you let the tension pneumothorax kill the patient?  Do you think it would be less likely to occur if she's being hyperventilated with a short I time?  Because I'm thinking that might increase the risk.

Would you refrain from cardioverting the VT?  Would you refrain from working the pulseless VT, or VF that resulted?

How would you justify this to the receiving facility, or to the patient's family?  

It's easy to say that she's not going to recover from this, and that she's beyond the help of modern medicine -- and I think it's likely that she is.  But how do you explain these decisions to the family or other medical staff?

I hate anecdotes with a passion, but I'll share one anyway.  I once saw an 80 year old woman pre-arrest in the CCU.  She was in the lowest priority monitored beds, waiting for the system to find somewhere for her to go, after having a relatively uneventful NTSEMI.  They found her right before shift change, as tends to happen in big hospitals.

Acute renal failure, K+ of 9.  Infarcted in the middle of the night.  I got to see them run the hyperkalemia protocol like you wouldn't believe.  Even the ventolin and kayexylate -- strangely they even pushed the furosemide.  Intubated her, stat angio, bunch of stents, and a balloon pump.  I remember thinking how terrible it was.  They could have just let her die, spared her all this indignity.

A week later I talked to her, and we had a conversation about the weather outside, after she'd been extubated and taken off the pump.

I agree that a lot of what we see is hopeless.  But every now and again there's something that's not.  How do you avoid losing that person in a cloud of cynicism?

All respect to you, I know you're a thinking guy.  I'm not trying to insult you.  I'm just trying to understand your thought process.  If you have something to teach, I'm happy to hear it.


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## BrushBunny91 (Oct 26, 2011)

Oxygen, vitals, and transport...


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## Handsome Robb (Oct 26, 2011)

BrushBunny91 said:


> Oxygen, vitals, and transport...



Not trying to call you out just pointing something out, this patient is intubated, has an NG tube placed, and is on a dopamine infusion. As a BLS provider you should refuse transport and request ALS. The interventions in place are out of your scope of practice, therefore putting you out of your scope of practice by accepting responsibility of the patient and transporting. 

Keep posting, you'll learn a lot around here, much more than your EMT class. However, testing for your class and NREMT cannot be based on answers or explanations you read here.


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## BrushBunny91 (Oct 26, 2011)

Thanks NVROB. I do understand my level of care and I would call for ALS.
I appreciate what this forum does to start up those critical thinking questions I might never be asked in class.


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