RocketMedic
Californian, Lost in Texas
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So, I recently had a patient suffering from severe cardiogenic shock as a result of a massive left-sided infarct. Respiratory collapse and failure on arrival, hypotensive, etc. Diagnosis was pretty quick, but here's where I have second thoughts.
In San Antonio or CA or EMSA or a lot of other "regressive" areas without RSI, I'd have scooped and ran to the closest appropriate facility, perhaps ten minutes away. This patient could have been manually ventilated with a BVM + adjunct, albeit with developing gastric distension and a less-than-optimal airway/ventilation scenario. A King or iGel would have likely been successful as well. Initial airway-management techniques were of moderate effectiveness but did not improve perfusion or oxygenation (SpO2 persistently <90% despite moderately-good ventilation with 100% oxygen, EtCO2 <20, and the Brady/hypo Spiral of Doom)
Instead of this, though, we slowed down, obtained a more-comprehensive set of vitals (confirming our initial diagnosis), established vascular access and intubated the patient with an RSI procedure, which allowed us to more-properly stabilize the airway and ventilate the patient more appropriately. Yes, it was medically indicated and necessary, but I do question the mentality behind it- were we RSIing because we could or because it was really in the patient's best interest? On the one hand, respiratory failure with persistent hypoxia is a death sentence left untreated, but correcting those problems doesn't clear blocked arteries or repair infarcts. Pressors, oxygenation and pacing help numbers, but this patient probably needed a cath lab, and I suspect we slowed that down (although on the flipside, the patient was probably too unstable to go to the cath lab without ED stabilization, which was essentially what we were doing).
I think that the biggest "change" in our tempo came with the arrival of our supervisor, but I do think that our agency expectations played a part, in that we pride ourselves on doing as much as we can for our patients (in contrast to other agencies that are transport-first). The supervisor and expectations aren't wrong, but I am unsure if they are were the most correct for our patient's situation. Sure, we went deep into the toolkit and got "better" numbers, but it was also time-consuming, and minutes matter. Did we fall into the protocol trap? Overall, our time difference was approximately 20 minutes, and in all honesty, could have been cut down with some workflow improvements and better time management on our part as EMS.
The patient did not survive the event, going into arrest approximately 30 minutes after arrival at hospital (1 hour after initial call), ROSC x3 but then a refractory v-fib arrest that was eventually terminated. Comorbidities and situation made survival unlikely, but I do feel that we could have done better.
In San Antonio or CA or EMSA or a lot of other "regressive" areas without RSI, I'd have scooped and ran to the closest appropriate facility, perhaps ten minutes away. This patient could have been manually ventilated with a BVM + adjunct, albeit with developing gastric distension and a less-than-optimal airway/ventilation scenario. A King or iGel would have likely been successful as well. Initial airway-management techniques were of moderate effectiveness but did not improve perfusion or oxygenation (SpO2 persistently <90% despite moderately-good ventilation with 100% oxygen, EtCO2 <20, and the Brady/hypo Spiral of Doom)
Instead of this, though, we slowed down, obtained a more-comprehensive set of vitals (confirming our initial diagnosis), established vascular access and intubated the patient with an RSI procedure, which allowed us to more-properly stabilize the airway and ventilate the patient more appropriately. Yes, it was medically indicated and necessary, but I do question the mentality behind it- were we RSIing because we could or because it was really in the patient's best interest? On the one hand, respiratory failure with persistent hypoxia is a death sentence left untreated, but correcting those problems doesn't clear blocked arteries or repair infarcts. Pressors, oxygenation and pacing help numbers, but this patient probably needed a cath lab, and I suspect we slowed that down (although on the flipside, the patient was probably too unstable to go to the cath lab without ED stabilization, which was essentially what we were doing).
I think that the biggest "change" in our tempo came with the arrival of our supervisor, but I do think that our agency expectations played a part, in that we pride ourselves on doing as much as we can for our patients (in contrast to other agencies that are transport-first). The supervisor and expectations aren't wrong, but I am unsure if they are were the most correct for our patient's situation. Sure, we went deep into the toolkit and got "better" numbers, but it was also time-consuming, and minutes matter. Did we fall into the protocol trap? Overall, our time difference was approximately 20 minutes, and in all honesty, could have been cut down with some workflow improvements and better time management on our part as EMS.
The patient did not survive the event, going into arrest approximately 30 minutes after arrival at hospital (1 hour after initial call), ROSC x3 but then a refractory v-fib arrest that was eventually terminated. Comorbidities and situation made survival unlikely, but I do feel that we could have done better.
