Call review 54 yom syncopal.

[Righteous]

New medic here just wanted a call review.

So I'm sitting in the unit *****ing about how bored I am.....

We get a call dropped on us for 54 yom pt down, changing colors.

Takes about 15 minutes to get on scene. I get on scene and climb some giant stairway that reminds me of the temple of doom. After huffing it about 5 minutes up we get to the house. Once inside the house we got up 3 floors (more stairs) to find the PT.

On arrival 54 yom found supine next to bed in obvious distress. Fire and wife are present. Fire has a blood sugar and a 4 lead on the patient. Hes breathing about 30 times a minute, looks panicked and he looks super, super pale. He keeps saying "Im going to die" Radial is thready.

I glance over at the monitor and I cant even remember what the rhythm was now that I think about it. I think it was some form of sinus tach. The wife starts giving me a run down and fire is getting a line.

Wife basically says: Pt had some kind of extreme bowel movement, and then began vomiting. The only history she gives me is "Kidney stones". Wife points out his obviously distended belly and advises that this is not normal. Its super distended more on the right side if you can imagine that. Not rigid. Fire comes back with a BP 110/60. Not sure on a time frame as she came over because she was called after pt woke up on the floor.

I look back over to the monitor and fire has pulled it off already in anticipation of moving him. Firefighter moves behind pt to lift him up. Eyes immediately roll back. Pt is placed supine and consciousness returns. We sheet carry him down. He keeps flailing his arms and saying hes about to die but remains conscious. Secure em to the stretcher and move to rig.

No IV has been started. He gets an 18 to the AC enroute, 1000ml wide open. I look up and I have no rider. Pads are placed on patient and he keeps flailing his arms almost removes his line twice and knocks off my glasses. Pt stops moving, hes in V-fib now. Shock @ 200. He comes back around. Still in V-tach. Flails arms harder.

This cycle happens again about 2 more times. Patient never leaves V-tach. Pt is taken inside of hospital. We move em over to the hospital bed and he moves his arm one more time before he stops moving.

All said and done the patient dies. Doc cant find anything with his ultrasound. They work the patient a while.

This was my first really serious call, feel like it shoulda went a lot better, more uniform.

Feel free to critique, don't pull any punches.

Thanks.

 

[NomadicMedic]

With your utter lack of any real details, there's no way to "critique" this call.

I'm sure the white knights will jump in and say I'm being a tool and "ah, everybody loses one brah" But it seems like you clearly had no idea what was going on, nor did you ever control the scene until you were in the truck and heading down the road. At that point, you were nothing more than a person unlucky enough to be in the truck. That you shocked him seems more luck than anything else.

Give us some details and answer the hard questions.

History? meds? What was that BM all about? Blood? What were the vitals YOU took? Did you ever take any vitals? What was the original rhythm? Did you capture a 12 lead? Did you do anything other than shock him?

Did you just walk into the ED and say "here you go Doc"

What do you think the cause of his arrest was?
Why didn't you have a rider? How are you going to manage your calls differently in the future? It's your job to not only treat the patient correctly, but you need to be able to effectively convey the full situation to the ED on handover.

 

[Righteous]

Hx Is got was "kidney stones" thats it. The bowel movement was just described as large. There was no blood in the vomit. No one visualized the BM as it was in a different area of the house. On scene I took the fires BP of 110/60 as fact. I palpated an irregular pulse in the 80s. Respiration's were in the 30s.

No 12 lead was captured. I just didn't get to it. I assumed he was having a triple A or something/ bleeding into the stomach for some reason and he needed a surgeon. I went back to inquire about the 12 lead about 2 hours later. They never printed one at the hospital either.

My vitals were 110 palp inside the unit and and 104/ 40ish on arrival to ER. Transport time was 8 minutes. Vitals were only taken on scene by me on scene arrival, at truck, and pulling into hospital

There is no pulse Ox. We don't have one but he looked bad and his CRT >3s. Auto cuffs suck and pt keeps moving so manual the above BP manual is all I could get.

Respiration sporadic.

No rider was my fault. Guess I was in too much of a rush to look up and ask for one. I suppose in future calls 12 lead on scene, more focus on vitals. Hx was the wife and all she had for us was kidney stones. Pt doesnt really answer questions. Maybe less haste on scene? Full report was given to the Doc and I stuck around for 30 minutes to answer the rest of his questions. I pretty much relayed everything to him.

I'm not looking for an oh well or good job. Im looking to improve.

Thanks for the input. Gotta go to work. ask more questions Ill answer later.

 

[SeeNoMore]

It certainly seems like staying more organized is a good goal. The very fact that you can't remember his initial rhythm shows you need to learn to calm down on calls. Not trying to be harsh, most of us have lost our cool at some point especially when new. That being said, if I had a patient who I suspected of suffering life threatening internal bleeding I would also attempt to expedite transport. I would certainly not advocate staying on scene longer to "focus" on v/s. I would have taken note of the rhythm and taken my own b/p. You describe a fairly lengthy extrication from the house so a 12 lead and IV access prior to leaving might be wise. Again, I would really focus on accomplishing as much of this as possible without delaying transport. If you have plenty of hands v/s, a 12 lead and a line should not take much time. I would have brought along help of some kind en route. Given it's also essential to gather as much information as possible, it might have been wise to have the family members gather meds / other info as you are treating / packaging the patient and bring them along if appropriate. Good luck.

 

[CANMAN]

With your utter lack of any real details, there's no way to "critique" this call.

I'm sure the white knights will jump in and say I'm being a tool and "ah, everybody loses one brah" But it seems like you clearly had no idea what was going on, nor did you ever control the scene until you were in the truck and heading down the road. At that point, you were nothing more than a person unlucky enough to be in the truck. That you shocked him seems more luck than anything else.

Give us some details and answer the hard questions.

History? meds? What was that BM all about? Blood? What were the vitals YOU took? Did you ever take any vitals? What was the original rhythm? Did you capture a 12 lead? Did you do anything other than shock him?

Did you just walk into the ED and say "here you go Doc"

What do you think the cause of his arrest was?
Why didn't you have a rider? How are you going to manage your calls differently in the future? It's your job to not only treat the patient correctly, but you need to be able to effectively convey the full situation to the ED on handover.

Agree with all of this. Also in my experience when a patient tells you "I am going to die" versus asking "am I going to die" they generally do in fact die, with the quickness, of something normally we can do little about..... Something to be said for that impending sense of doom. Although your organizational skills seem like they need some work, you're new and that will get easier with time and experience.

 

[Tigger]

Do others think it would be appropriate to start an IV as soon as it becomes clear that the patient can't tolerate sitting up? Or do you see that as a reason to leave quickly?

I've had two people arrest on me as I sat them up in their bed in the last year, and I was certainly glad to have started an IV before moving them.

 

[NomadicMedic]

Do others think it would be appropriate to start an IV as soon as it becomes clear that the patient can't tolerate sitting up? Or do you see that as a reason to leave quickly?

I've had two people arrest on me as I sat them up in their bed in the last year, and I was certainly glad to have started an IV before moving them.

Yes. I certainly would have had a big line started, but I would have had a much better baseline assessment. A set of vitals that I took, a 12 lead, a bag full of medications from the bathroom and an extra set of hands that I trusted.

The lesson to be learned from this call is: build yourself a safety net. It's easier to start a line in the house before the arrest. It's better to take a few minutes to get a good assessment than to be rushed out of the house by fire. The medic that's transporting calls the shots and if you even think you might need extra hands, take them.

Scene management can be difficult if you're not assertive. The key is being assertive without being a d-bag.

 

[Brandon O]

Sounds like a tough call. I would say this: there is a point for everyone where you stop trying to figure out what's going on, say "screw it," and basically punt. (Whatever that means -- usually supportive care and driving fast.) While this is never a great thing and you should always be trying to figure out what's up, you may reach a juncture where it's unlikely to matter, because you're at least in the right ballpark. (For instance, SVT vs. VT? Who cares, zap it.)

In this case, you may have gotten off that train too early. Without even knowing what chapter you're reading from -- is it cardiac? peritonitis? aortic catastrophe? -- you don't even really know how to punt. Stay and play? Drive fast, but to where? What resources should you activate? And so on.

Of course, trying to stay on that train when it gets this rocky is tough, requiring both enough knowledge to keep following it down the rabbit hole, and the equanimity not to get rattled and yell uncle before you've reached an adequate cognitive save point. It's hard to stroke your Dr. House beard when there's VT on the monitor.

(Can anyone tell me how many metaphors I've mixed in this post?)

 

[highglyder]

You have some pretty solid advice here. I'm glad to see that we're not playing the "you messed up, you're an idiot" or "you have a knowledge gap, you're incompetent" game.

Some things that I would have liked to know are:
- Any recent complaints or expressions of not feeling well?
- Any change in behaviour?
- When was the last time he looked well/normal?
- Any chance of recent trauma?
- Any alcohol or drug (Rx or illicit) use?
- What happened between the BM and the bed?
- How has his urine output been within the last 24-48 hours?
- Is hematuria present? What about colour and clots?
- What was the BG value and temperature?

Clearly he is no longer able to compensate for whatever is causing the hemodynamic instability. I'm at a loss as well with the details you've provided, but my first hunch would be sepsis. A 12-lead would be handy, but probably not a game changer.

You're a new medic and what happened to you is, although not desirable, relatively common. Time, experience, and exposure are your best friends. Discussion and self-review are essential. Take your time because I for one don't care how you compare to the clock, but rather in terms of quality of the care and investigative skills.

 

[Jason]

You have gotten some pretty good feed back... hard... honest... straight forward.
I agree with Highglyder: "You're a new medic and what happened to you is, although not desirable, relatively common. Time, experience, and exposure are your best friends. Discussion and self-review are essential. Take your time because I for one don't care how you compare to the clock, but rather in terms of quality of the care and investigative skills."
And also with DEmedic: "The lesson to be learned from this call is: build yourself a safety net. It's easier to start a line in the house before the arrest. It's better to take a few minutes to get a good assessment than to be rushed out of the house by fire. The medic that's transporting calls the shots and if you even think you might need extra hands, take them.
Scene management can be difficult if you're not assertive. The key is being assertive without being a d-bag."
Scene management can also mean your safety and your crew's safety.
Keep reviewing, keep learning, make decisions, execute, learn, and improve.
Your a Medic -- in addition to adapt and overcome -- learn and improve.

 

[NTXFF]

Do others think it would be appropriate to start an IV as soon as it becomes clear that the patient can't tolerate sitting up? Or do you see that as a reason to leave quickly?

I've had two people arrest on me as I sat them up in their bed in the last year, and I was certainly glad to have started an IV before moving them.

^^^^This! If we get in a hurry or lose our focus there isn't a 912 to back us up. Everything comes with time and no matter how much time you have we would all be liars if we said that something like this couldn't happen to anyone on this forum. I've seen a 31 year guy catch himself getting worked up.