# toughest call



## AnthonyTheEmt (Dec 4, 2009)

I started medic school back in september, and am currently working as an EMT. I was thinking back on a call my partner and I ran last year, and was trying to think about it from a medic standpoint about what I would have done. So here is the situation (this was the first real bad call I had run as an EMT, and kinda panicked): we get called out for a hypertension crisis. Patient is male in his mid-50's. My partner goes to talk to the nurse and find out the history on this guy. I walk into the patients room to find the guy on O2 via NC at about 2-3 LPM. Patient is unresponsive to deep painful stimuli. I take him off of the NC and immediately place him on a NRB at 15LPM (looking back on it, we probably should've started bagging him right there). I dont really recall what his lung sounds were. Here are his VS: 200/120, 135, 48, sating at about 75%. Nasty accessory muscle use, retractions, the whole shabangabang. I am thinking this guy is immediate transport. My partner walks in the room, and we consensually (sp?) that this guy needs to go now. According to the nurse, he was discharged from the hospital around 10am that day (it was about 8 or 9 at night at this point) in the exact same condition as he is now. She said "He's been like that all day". We load this guy up, and my partner gets a BP of 210/120. We get going and he is on high flow O2, and my partner says he is starting to go cyanotic, so he starts bagging him after dropping an OPA. We end up getting him to the hospital and they throw him on the monitor (dont know what the rythym was), his heart rate and BP had dropped into normal range. Never really found out what happened to him. I was thinking that as a medic, I could have hooked him up the monitor, and possibly intubated (he was deeply unresponsive, OPA was taken like a champ and airway compromise very likely). Also would have checked lung sounds. Please leave your feedback. I want to hear your take, and feel free to ask for any details that may have been left out.


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## MrBrown (Dec 4, 2009)

ABCs are about it unless you start carrying manitol and beta blockers or Derek Shepard becomes your medical director.

- How did his SPO2 look with OPA & bag mask? 
- Any evidence of aspiration? i.e. noticeable vomit, rhonchi etc

I mean you could certainly try to intubate him however my guess is he's going to be a biatch to intubate and it's not going to work.  

My money is on basic airway care, suctioning and a supraglottic adjunct.


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## mycrofft (Dec 4, 2009)

*"Supraglottic adjunct": I've been looking for that phrase for thirty years!*

1. Why was the pt discharged in that state? DNR?
2. Was this a private home or skilled nursing facility?
3. If airway was patent, no call for artificial airway.
4. Accesory muscle resps may indicate an airway embarassment, listen for lung sounds or sounds frmo larynx and trachea on down for point of restriction if enough air is moving to make a wheeze, stridor or whistle; point of diminuition may be enough. 
5. It may also indicate CNS affect from meds, circulatory or metabolic insult or deprivation. With high BP I assume you suspected CVA? Pupils?

Cutting to the chase, O2 airway and "Heigh-yo Silver, away". Follow any protocols applicable. ABC's then protocols.

I've had a few moribund geriatric pts who pinked up and improved from a litter ride from room to ambulance, much less room to ER., sometimes without O2.


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## zmedic (Dec 4, 2009)

Yeah, this is a patient who you really want to make sure you know their DNR status. Guy unresponsive to pain, from a nursing home who just was discharged and is going back? Likely this is a patient who has a poor long term prognosis, not someone you want to throw on a vent if they said they don't want one.


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## AnthonyTheEmt (Dec 4, 2009)

MrBrown said:


> ABCs are about it unless you start carrying manitol and beta blockers or Derek Shepard becomes your medical director.
> 
> - How did his SPO2 look with OPA & bag mask?
> - Any evidence of aspiration? i.e. noticeable vomit, rhonchi etc
> ...



No idea after O2. In CA, it is technically out of the EMT scope to use a pulse ox (stupid, I know), so I know have no idea what it went up to after O2. No evidence of aspiration. As mentioned, I do not recall what his lung sounds were.


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## AnthonyTheEmt (Dec 4, 2009)

mycrofft said:


> 1. Why was the pt discharged in that state? DNR?
> 2. Was this a private home or skilled nursing facility?
> 3. If airway was patent, no call for artificial airway.
> 4. Accesory muscle resps may indicate an airway embarassment, listen for lung sounds or sounds frmo larynx and trachea on down for point of restriction if enough air is moving to make a wheeze, stridor or whistle; point of diminuition may be enough.
> ...



I am not sure why this guy was discharged in that condition. But I do recall that he was a full code. It was out of a SNF, one that is notorious for waiting til the last minute to do anything. The reason an OPA was placed was because he was being ventilated with a BVM, tidal volume and respirations were inadequate. Not sure what meds he was on, I personally never saw the list. Dont recall pupils, meaning a CVA was entirely possible.


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