# Aaa?



## MedicPrincess (Mar 3, 2007)

Okay seasoned people....tell me what you think...critique the call if you wish too...

Dispatched for an unknown age female, sitting behind the wheel of her car at a busy intersection, appears unconscious.  On scene with FD and PD the decision is quickly made to break a window as she "looks sick" and is not responding to banging on the windows (the doors are all locked).

45 yo F, pale, extremely cool, very diaphoretic, barely palpable radial pulse, weak carotid, shallow breathing.  Pulled from her car, straight onto stretcher, load into ambulance, loud groan with sternal rub.  FD medic throws the 4 lead on - shows a SR with very peaked T-waves (I have the 6 second strip if you want I can scan them and post them), my medic grabs her IV stuff, I get the Accu-Check.  Its 155.  A FD EMT tries for manuel BP.  Grab NRB as I go to put it on her she has turned purple from about the second intercostal space up and appears to not be breathing.  Another sternal rub, a little harder this time, and she takes like a gasping breath and begins to become a little combative.  NRB in place.  

My medic is telling me to start looking in her other arm b/c she didn't get any flash but then the IV flushed fine.  Quick look at the monitor and her SR has now turned to ST with runs of ectopy (5-9 PVC's at a time).  I get the 12 lead, hand it to the FD Medic, tell my medic we need to get going now, I think she needs to intubate this patient, asked the FD medic to stay, and got out to drive.  Our entire onscene time was 6 minutes from the time we pulled up and called on scene to the time I called responding.

Enroute, a 12 showed ST with ectopy.  Patient contiuned to alternate between unresponsive and combative, screaming that her back hurt. That was all they had time to do as my response time was about 2 minutes.  We were never able to obtain a BP.

In the ER, she screamed about her back hurting when we transferred her from our stretcher to theirs.  She then coded.  40 minutes later she was cool to the touch, purple from the second intercostal space up, mottled from there down and the ER DR called it, time of death 2242.

They pushed 8mg Epi, 3mg Atropine, 1amp Sodium Bicarb, 40units Vasopressin, and hung a Dopamine Drip.  DR intubated with 7.5 ET tube one first attempt.  They were never able to get a BP either.

Now during the code they tried repeatedly to get blood for labs.  The DR did a femoral stick and was unable to get any blood initially.  I took over compressions from the nurse and he was able to get 10cc of blood as long as I was doing compressions.  Thats it.  The site he stuck her for the femoral blood did not ever have any blood come out of it after that.

What do you think?  I initially thought perhaps a PE due to her color, however after talking with the DR he is saying if she threw a PE she wouldn't have come around.  He is theorizing a dissected thoracic aneurism.  Probably started leaking and as she became combative it caused it to rupture totally.

My partner was pretty upset by this call.  She likes to deliver our patients to the ER all nice and pretty with everything done.  We didn't stay on scene long enough for her to get the bag spiked and hung, the lidocaine pushed for the ectopy,  and the patient intubated.  She was pretty upset that she didn't get it all done, the patient died, and she felt like I didn't care because I wasn't bawling my eyes out like she was.

I felt, and still feel like, we had no business sitting on scene with this patient.  If we'd have delayed another 2-3 minutes, we'd have been working that code in the middle of that busy intersection.  Not the best place, IMHO.  This seems like a patient that no matter what we did, she was dead anyway, it was just a matter of a few minutes as to where she died....in our truck or in the ER.


----------



## Airwaygoddess (Mar 3, 2007)

that sounded like a pretty rough call, sounds like multi system failure, I think the doc is right, aortic aneurysm.  The patient also sounded like she was a diabetic.  Sometimes no matter how fast you can move, death moves even faster.


----------



## davis513 (Mar 3, 2007)

I'm not experienced enough or qualified enough to render an opinion or a critique but I did want to say that I think you wrote a great review of the call. 

Reading such reviews/self-evaluations helps me tremendously in mentally in preparing for "my next call" by learbning how others have responded.

Thanks for sharing!


----------



## Ridryder911 (Mar 4, 2007)

Many possibilities but it appears to be a underlying Aortic Aneurysm. Patient had bled out inside and whenever some tamponade did occur she complained of back pain, which is typical symptamology. As well as the intermittent level of LOC, because of positioning causes a temporary tamponade. 

The classic "purple" line from nipple caudally is seen in those with aortic tears and sometimes pulmonary embolisms (which is a possibility as well, but usually do not have BP changes). The elevated T wave was associated myocardial ischemia because coronary circulation is compromised as well poor peripheral circulation because again it is pumping out into the chest cavity.

These patients die ... no matter what you do.  

The other possibility is a classic transmural infarct AMI.. no ejection fraction left and thus no pump. Again, same results.. dead. 

Your partner needs to get over her self.. she should had realized the symptoms and realize there is nothing your going to do that will change outcome. If they can't handle calls thsy need to sek another profession. People die.. we do the best we can and being upset is not going to help your next patient. 

R/r 911


----------



## Firechic (Mar 5, 2007)

Well..... Damn. 
Can we not have a little compassion for one of our own? 
Does she have a pattern of bawling her eyes out everytime? If yes, then she should look into another field. If not, then talk to her or tell her to talk to someone else if it bothered her that much for whatever her reason is. 

Sounds like it was a very interesting call, thanks for sharing.


----------



## Ridryder911 (Mar 5, 2007)

She should be the one in control of when it is time to leave or not. Was there not assistants that could "spike" a bag and assist her ? As well, lidocaine etc.. can be adminstered enroute. If this had been a different type of diagnosis then I would be upset that the scene time was so short. There is no way proper assessment and stabilization could have had occured just within 6 minutes. 

After thinking about it; it appears she might be more upset that she lost "control" of her scene than the patient lost itself.

If she was the medic, she and her alone should be the only one to decide when it is time to start transporting.

R/r 911


----------



## MedicPrincess (Mar 6, 2007)

Ridryder911 said:


> After thinking about it; it appears she might be more upset that she lost "control" of her scene than the patient lost itself.


 
Thats what I am thinking.  She said she "never doesn't get everything done."  She very much likes to get everything done before we get enroute.  IV all nice and pretty, blood drawn, 12-lead, vitals, O2 on.  Deliver the patient to the ER all nice and pretty, ready to go.   And never do I rush her.  We just get it all done, albeit with a little longer scene times than necessary, IMO.  

But this was different.  This patient looked like death.  That last thing I wanted to do is have her code right there, less then 2 miles from the ER when we could very well get moving down the road.  She was clearly "load and go."

Our shift commander and medical director talked to us about this patient yesterday.  They agree, the right thing was done.  The ER was not at all upset that we PUHA with this lady.  The ER Dr actually said, "Finally, someone did the right thing with a sick patient."


----------



## Jon (Mar 6, 2007)

Princess... 
I have the same problem If I do a swoop and scoop when working 911... I feel like a dunce when I don't have a "perfect" report for the hospital because I didn't have time to do a full assessment or get a good PMH. But you know what? I did my job - I delivered the patient quickly and efficiantly to definitive care.

Another Example... when I'm working an event, if I'm called for a "medical emergency" I at least have a moment while I'm responding to get myself in the mindset to provide medical care... if someone walks into the first aid room and I turn off my DVD player and they say they have chest pain... it throws my rythym off... the call often ends up being a C*F because my mind hasn't caught up with me.


PS - as for the call.. the "blue from the nipple line up" is a halmark of a PE, as I was taught... but from what it sounded like, it could have been a AAA or a PE... either way, as Rid said... once the heart is deprived of blood for too long, there aint anything we can do about it. I hope you can find out what it was... I'm sure they'll do an autopsy.


----------



## Guardian (Mar 6, 2007)

so let me get this right, if a pt is really sick, we should load and go.  The whole reason ems was created was to stop that method.  Real ALS ems is simply taking the ED to the pt.  We are trained to work cardiac arrests for a reason.

Scenario 1:

Sick person gets loaded and transported quickly to the ED.  Due to bouncy ride, pt doesn't get IV or other critical intervention.  Pt arrives at ED and goes into arrest.  The nurses at ED then have to start IV and do other basic stuff before drugs and other advanced stuff can be done.

Scenario 2:

Same sick person gets proper treatment on scene (IV, ETT if necessary, etc) and is transported 3 mins later than person in scenario 1.  While in route, two minutes from hospital, pt goes into arrest.  Pt is automatically given proper meds, defib, etc and hospital is notified.  When ambulance pulls up, first round of drugs have been given, all the basic crap is taken care of and pt is transfered to ED staff who immediately consider other options.

Which pt was better off?  Which pt got the critical treatment faster?  Which pt will get advanced hospital treatment faster?  The answer to all three is the pt in scenario 2.


There are of course exceptions.  If you suspect a problem that can only be fixed with surgery, then you need to transport sooner than later (this wasn't the case in your example).  But for god's sake, don't abandon all your training the minute you get a patient who actually needs a paramedic and not just a ride or a quick ride to the hospital.


----------



## Jon (Mar 6, 2007)

Guardian... the patient already has an apparently patent IV line, and a cardiogram...

Yeah... they weren't intubated... but patients don't NEED to be intubated... they can usually be managed by a BLS airway and BVM. Yes, the ALS provider, with assistance from others, should have been able to spike a bag and push lidocaine during the transport... Ambulances are designed to allow the crew to treat a patient while moving... otherwise we'd still be in Caddilacs with both of us riding up front


----------



## Guardian (Mar 6, 2007)

also, there is no crying in ems or baseball.


----------



## Guardian (Mar 6, 2007)

Jon said:


> Guardian... the patient already has an apparently patent IV line, and a cardiogram...
> 
> Yeah... they weren't intubated... but patients don't NEED to be intubated... they can usually be managed by a BLS airway and BVM. Yes, the ALS provider, with assistance from others, should have been able to spike a bag and push lidocaine during the transport... Ambulances are designed to allow the crew to treat a patient while moving... otherwise we'd still be in Caddilacs with both of us riding up front



I never said the pt didn't have a line.  The debate is over scene time.  Princess says scene time was too long, and I say no.  pts do need to be intubated.  Ambulances are not designed to allow paramedic to perform ETT or IV while moving, they are designed to carry equipment.


----------



## Jon (Mar 6, 2007)

Guardian said:


> I never said the pt didn't have a line.  The debate is over scene time.  Princess says scene time was too long, and I say no.  pts do need to be intubated.  Ambulances are not designed to allow paramedic to perform ETT or IV while moving, they are designed to carry equipment.


Good point, Guardian... but to press the issue... have you seen the studies that ALS leads to longer scene times? Yes, ALS brings SOME of the hospital with us... but we still are not difinitive care... we don't have a cath lab in the rig with us, nor do we have an OR... for some patients, the best treatment is high-flow diesel, and the good EMT or medic recognizes that.

I do agree, though, that perhaps Princess rushed her partner... the AIC/Crew Chief/ Seinior Provider really is the person who makes the call as to when, and how, to transport.


----------



## MedicPrincess (Mar 6, 2007)

Guardian said:


> Princess says scene time was too long, and I say no. pts do need to be intubated.


 
Never said scene time was too long.  

I said if we'd have stqyed any longer we'd have started working that code in the middle of the intersection, which when faced with the option of working it there or getting her to the ER in a more "ideal" setting for a code, I choose the ER.

As for crying...my parnter cries at least once a week.  She's a crier, I'm not.  I was just pissed b/c she made it seem like I don't give a rats butt b/c I don't cry.

Oh...for the record, there's also no crying in firefighting!


----------



## Guardian (Mar 6, 2007)

Jon said:


> Good point, Guardian... but to press the issue... have you seen the studies that ALS leads to longer scene times? Yes, ALS brings SOME of the hospital with us... but we still are not difinitive care... we don't have a cath lab in the rig with us, nor do we have an OR... for some patients, the best treatment is high-flow diesel, and the good EMT or medic recognizes that.
> 
> I do agree, though, that perhaps Princess rushed her partner... the AIC/Crew Chief/ Seinior Provider really is the person who makes the call as to when, and how, to transport.



Ok, I understand and respect your point of view but as long as we are pressing the issue...intubation and defib and ALS meds are definitive care.  Critical interventions=definitive care.  ALS does lead to longer scene times but if done properly, can shorten overall treatment times as demonstrated in my 2 scenarios.  Do we carry a cath lab, no, but we do carry a 12 lead which can greatly shorten the time from chest pn to cath lab.  Try doing a 12 lead in the back of a moving ambulance and let me know how that works out for you.  I do agree with you on the issue of scene time and surgery though.


----------



## Guardian (Mar 6, 2007)

EMTPrincess said:


> Never said scene time was too long.
> 
> I said if we'd have stqyed any longer we'd have started working that code in the middle of the intersection, which when faced with the option of working it there or getting her to the ER in a more "ideal" setting for a code, I choose the ER.



Fair enough.  My only point was that staying a couple more mins on scene and working a code in an ambulance can actually be better for pt survival.  If you felt unsafe in an intersection then the fire department isn't doing their job (parking big red piece of metal behind ambulance) and I would understand leaving for the hospital early or preferably just moving out of harms way.


----------



## Anomalous (Mar 8, 2007)

Guardian said:


> Ambulances are not designed to allow paramedic to perform ETT or IV while moving, they are designed to carry equipment.




That's where we do most of ours.


----------



## Pablo the Pirate (Mar 9, 2007)

theres a couple of things here i think should be brought up.  First of all yes Intubating is a definative and and in the long run best airway.  But why should you waste time intubating when an airway can be very well maintianed bls, esspecially when there are other "definative" things that need to be done. I dont think that you should waste time on a scene intubating unless absolutely nessecary. ie RSI or already working code. All the new guidelines coming out are moving away from intubating in the field.  who knows you may find that in the future medics dont ETT in the field.  secondly I rarely rarely start an IV sitting on scene! bouncing down the road is where I start them.  If you cant start an IV bouncing down the road and have to waste time on scene to start an IV on pt that needed to be in the OR 10 mins ago how good are you to your pt. at that point.  I dont mean to be putting anyone down or bashing anyone but as a medic you should be able to start an IV and do all your other advanced skills in less than desirable circumstances. Just my humble opinion


----------



## Ridryder911 (Mar 9, 2007)

The main point is to use good and wise clinical judgement. Sometimes I start a line and intubate on the way, sometimes I give up to the second line or third line than transport. It all depends on the situation. 

Sorry, intubation is being slammed by bias studies, and the danger is 98% of EMS health care workers can NOT read a scientific study accurately if their life dependent on it. For example Wang's studies is full of flaws and biases, but .. we all are up in arms about it. If you think an airway can be secured by solely BLS maneuvers in the field, you are foolish and have little experience. 
Show me a full tummy and a little air into the belly and I will show you chemical aspiration pneumonia. .. The same reason, they intubate you while you are in surgery.. & just think you have been NPO 12 hours prior as well...

Again, most of what we is never black& white, that is why many "tasks' achievers never make it, one can not write enough protocols to cover everything. That again, is why formal and thorough education is important...

R/r 911


----------



## Guardian (Mar 11, 2007)

umm, yep, what rid said.

Pablo, you rarely start IVs on scene?  I only start about 98% of mine on scene.  Why would you start IVs while bouncing down the road.  Is that how you get your kicks?  I'm not trying to be an ***, it just doesn't make any sense to me.  Sure, there are some situations where you have to start a line while moving but they are few.

bls airways SUCK.  I'm not sure I can make that any clearer.  bls airway is like playing russian roulette.  The bls airway is better than not breathing, but other than that, is sucks.  98% of the time, what's the first thing hospitals do for seriously ill/injured patients?  They intubate them.  That should tell you something right there.


----------



## Guardian (Mar 11, 2007)

another thing, lets not confuse why the new cardiac arrest guidelines are putting less emphasis (lower in the protocol list) on intubation.  It's not because they are suddenly discovering intubation to be less effective than they once thought.  It's because we suck at it so much and thus are taking too much time trying to intubate while neglecting other essential stuff.  If educators were doing their job, I wouldn't be writing this right now.


----------



## medx69 (Mar 12, 2007)

always remeber BLS before ALS yeah if your pt is not getting better by just ventilating move to et tube, did the fire medic ride in also if so two medics on board 1 for iv 1 for et dont ever worry about b/p cant feel radial most likely not going to get a b/p airway should have been first concern with ivs en route to hosp and or et tube placement en route also I always do codes with bvm monitor and backboard till loaded, because you can ventilate compressions and defib if necessary why drag drop bag and drug box out and have more to carry back to the truck, ivs meds and et tubes can be done en route, and i agree pt's that arrive in er with ivs and or ets benefit, while it does take more time for er to reassess problem and begin their tx, that call seemed to be handle well and everyone of us would have done it differently.


----------



## Ridryder911 (Mar 12, 2007)

Wow ! That was one long sentence. 

First our job is to stabilize the patient for transport. I have found much easier to establish an IV and intubate in a large room than going down a bumpy road. Why the hurry on a full arrest?.. their dead, they can't get worse! Again it depends on the situation, but stabilize enough to be able to provide care enroute. 

What good is a monitor, if you don't have an IV line to push med through? Even ACLS recommends 1-2 minutes of CPR before defibrillating on a unwitnessed arrest, surely you can establish a line and intubate if someone is able to perform CPR. Like Guardian stated, intubation has not been removed it is just emphasized not to stop compressions very long to perform an airway. I agree,  the reason they no longer push intubation is because many medics suck at it.. because they were trained at lower levels and received inadequate education, poor TQI and no proficiency intubation requirements. Airway devices such as LMA does not prevent aspiration which occurs very frequently in cardiac arrest and has a near fatal outcome. 

Sometimes, I won't even respond back with L & S .. if it is a short distance....why ?  Many services are now responding back without such.

The reason ER may "take longer" is because the physician is now responsible and has to make another assessment. Treatment should not be any different except possibly checking with U/S for mechanical movement of the heart in a , determining tamponade, etc.. in a PEA situation.


----------



## Pablo the Pirate (Mar 13, 2007)

please understand that i was by no means sayin we shouldnt intubate.  i was just repeating what the new guidelines are saying.  I do think we should intubate! there are too many reasons why we should.  as for why i rarely start IV's on scene there is a very good reason behind it. Namely longer transport times.  It's not uncomman to have 15 to 20 min in the back of the truck.  I just dont think sitting on scene to start an IV is a good idea when i can do it bouncing down the road.


----------



## Ridryder911 (Mar 13, 2007)

!5 -20 minutes is not a bad return response time.. try 1 hour +.. Again, it is one of those situtaion and scenarios, I do not believe should be written in stone. Like all protocols, they should be left under the discretion of the medic.. and used as general guidelines.. not thou shall or not.. 

R/r 911


----------



## firemedic1563 (Mar 26, 2007)

OK, maybe it is just me, but I have to disagree with Guardian that this one should not have been a load and go. AAA or not, she presented as being in some sort of shock. She was pale, cool, had no peripheral circulation, probably had a sudden onset as she was found in a busy intersection. Sounds like she is bleeding out somewhere. What are we going to do in the field to save her? Nothing. A rapid load, quick IV, get her on monitor and go!

Manage her airway enroute, and intubate if necessary. She needed surgery and needed it fast. Chances are in this particular case, she would not have made it to the OR regardless, but we can't determine that in the field. Ever hear of the golden hour? It applies to more than trauma. We are not definitive care. Sometimes we can be, but overall we have neither the equipment nor the training of a Hospital. We cannot treat this patients underlying problem. We can manage some problems from it, and provide advanced life "support". But only surgery can correct the condition and treat her.


----------



## Guardian (Mar 26, 2007)

Firemedic1563, I believe in taking a systematic approach to pt assessment.  If you don't learn to do this, you will jump to conclusions (diagnosis) and kill people.  There are many many many types of disease, illness, and trauma that will present with the symptoms that were given in the first post.  When I see a 45 y/o middle aged women with "pale, cool, had no peripheral circulation", I don't jump to conclusions and decide she is having a AAA.

Let me give you a hypothetical example of why good paramedics don't jump to conclusions, stay calm, and do what they are trained to do.  Same scenario, 45 y/o women in an intersection with the same s/s that were given in first post.  Firemedic1563 pulls up on scene and prematurely decides she's having a AAA.  They load and go with the pt.  Halfway to the hospital, the pt vomits and aspirates and the abdomen is now distended because firemedic1563 couldn't get the tube on the bumpy road.  No IV was attained either.  Nevertheless, firemedic is proud of her/himself for at least getting the pt to the hospital fast because time is critical in AAA.  Then the doctor comes over and asks firemedic why he/she didn't secure a proper airway, give medications, and do a 12 lead and alert the surgical team that a major MI was coming in.  It now takes an extra 45 mins for the pt to get to surgery.  Because of this, the pt dies.


----------



## Ridryder911 (Mar 26, 2007)

firemedic1563 said:


> Ever hear of the golden hour?



Ever hear how the "golden hour" is Bull Sh*t ? Read a little more than the novel of R.A. Conley (inventor of shock trauma) Trauma Center, where he declared the _Golden Hour _.. yes, myth! 

There has been no scientific findings after years and years of research that proves there has ever or ever will be such things. The same as the magical 8 minute response time.. all made up stuff, that has been handed down for generation and generations without any substance to it. 

Trauma Surgeons as Dr. Don Trunkey, etc.. all original shock trauma surgeons will agree delayed care is not good, but in reality there is little we can do in the field and with the extent of injuries, really not much can be done at all. Many die after 2-3 days with complications of shock syndrome with organ failures. This is those that you blame on the ICU or hospital for "letting them die", in reality most medics know *very little * about shock, even though we should be the best educated in it. Since that is job !

I was fortunate to meet Dr. Trunkey and he definitely will tell you they way it truly is !.. 

For more information on this look in this months _ JEMS_ in which Dr. Bledsoe has written an article _ Have We Set the Bar Too High?_ .. I suggested to him, maybe we need a "Myth Busters for EMS"...

One needs to understand cellular level of lactic acid and metabolism as well deluge of acidotic blood kept in the capillary system when released causes major problem (diluted down version). 

Ever wondered why person become pale in shock state? Where did all the blood supply feeding tissue go ? 

So yes, we need to be concerned with delayed scene times, but we need to perform a thorough assessment and history. 

R/r 911


----------



## Guardian (Mar 26, 2007)

firemedic1563, In most cases, and a 12 lead, IV, ETT could be done in 10 mins.  I'm not talking about taking my good old time.  Heck, I usually shoot for a less than 15 min cardiac arrest scene time.

"definitive care" doesn't mean crap if the pt's dead because something critical like intubation wasn't done.  The term "definitive care" could be argued but all I know is most if not all of what we do is just as important as "definitive care" and sometimes more so.


----------



## Guardian (Mar 26, 2007)

typo...RA Cowley


----------



## firemedic1563 (Mar 27, 2007)

Good points and all well taken. I am not arguing that we need to diagnose anything, rather that a quick, yet thorough assesment be done and the need for rapid transport be decided based on the finding of the need for critical interventions that we cannot perform. I have seen firsthand patients saved via surgical and/or invasive procedures in the very trauma center named after R. A Cowley. Many of them would not had survived a few more minutes.

I do agree that an arrest is workable in the field, and the few minutes should be taken to intubate, and attempt to get a line. But problems arise, and transport should not be delayed. if you are having problems with a line, either try enroute, or maybe start thinking IO if there are no other options. On that note, do any of you use the IO guns?


----------

