Aaa?

[MedicPrincess]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

also, there is no crying in ems or baseball.

 

[Guardian]

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]

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]

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]

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]

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]

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]

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]

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]

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.