Interesting Call

[Handsome Robb]

This morning signed in a couple minutes early to help out with a priority call that was just down the street.

Toned out for a priority 2 hemorrhage, at a local park, reported to be "under the bridge". Upgraded en route to priority 1. Arrive on scene to see the FD walking down a bike path with a frantic looking guy. Captain waits for us and says the guy stated his girlfriend wont wake up and that she's "all yellow". Also says she's about a mile down this path and that we probably can get the truck closer. So myself and the captain take the gurney and start walking while my partner hops in the rig and tries to get it closer. Takes about 12 minutes walking at a brisk pace down this path then about 100 yds through dead bushes down to the side of the river where we find a 55 year old female in a tent covered in dark red diarrhea, yellow as the smiley faces on this forum and moaning.

Responsive to painful stimuli, GCS of 9 (2/3/4), boyfriend denies any history, allergies or medications but states she uses "drugs" and drinks every day. States they drank a bottle of vodka last night then when he woke up this morning he found her like this.

We picked her up with a blanket mega-mover didn't make it onto the back of the gurney since we kinda rushed to get signed in, carry her through the bushes, put her on the gurney, pop her legs up, toss her on the monitor try to get a BP and SpO2% unsuccessfully, pop a non re-breather on her and start walking back towards the park. Partner comes up on the radio and says he can't get any closer to us and he's headed back to the park and I ask him to setup a couple start kits and bags and that we were "working".

Vitals:

Hr 70, sinus without ectopy, 12-lead unremarkable besides very flat T waves universally (did it later as we were leaving the scene).
BP unobtainable originally, 60/38 with her legs up and then became unobtainable again. No peripheral or radial pulses palpable, apical pulse matches the monitor
SpO25 unobtainable
RR 12 and uncomplicated
BGL 152

History - substance abuse "drugs" and ETOH, boyfriend denied anything else

Allergies - NKDA

Meds - None

Exam: severely jaundiced and beginning to become mottled in her extremities, cool, moist. PERRL but very sluggish at 6mm, absent peripheral and central pulses, apical pulse present, massive dark red diarrhea, urinary incontinence noted no signs of trauma.

Took another 10-12 minutes to boogie back to the truck, get in FF goes to one arm partner goes to the other and try for lines unsuccessfully while I place 12-lead stickers and capture it. I try an EJ with no dice and I toss my partner the IO kit. FF holds her leg, I held her arms and we get a patent IO in her left tibial plateau, I preloaded the lock with 20mg of lidocaine then chased it with a NS flush. Pushed the first 3 CCS slow then slammed the rest, tried an NPA which she started grabbing at and gagging so I removed it, and took off to the ER. Looking back should've taken a FF and their EMT student with me for the student's benefit and to ward off any demons. Took about 7 minutes code 3 to get to the hospital her boyfriend requested. I wanted to divert to the trauma center which was a little closer but her boyfriend was still at their campsite and we had no way of comminucating the change in destination to him. Guess I could've asked fire to run back and tell him but I don't think they would have liked that too much.

Hooked a liter bag with a BP cuff as a pressure infuser up to the IO and got about 750 CCs onboard during transport. Her GCS improved a little bit en route, up to an 11 (3/3/5) other than that, no other notable changes. By the time we were leaving the ER to go available she was intubated with a BP of 40/38

I'm wondering if I should've handled this differently. Had a few mixed opinions on the lidocaine flush of the IO in a peri arrest situation but my argument was 20 mg SIVP in a 100 KG patient isn't going to get anywhere near the therapeutic index for the cardiac effects and most of time we drill conscious/semi-conscious IOs is in those kind of situations.

My other question is I was told I should have done everything en route since she needs surgery lots of things, quickly, that I can't provide. I agree with this but I also have some issues with it. One is I need access and the hospital is going to need it as well, it was still actually their only point of access as I was leaving the ER about 45 minutes after we arrived. It took 3 of us to do that IO safely with how much she was moving around, wasn't a small lady either. Drilling it wasn't bad but flushing it wasn't pretty. We probably could've managed it with myself and a FF but bumping down the road doesn't make anything any easier. From the time we got back to the truck to the time we started transporting was 7 minutes. Should've tried for another point of access en route but I was busy messing with the NPA, calling report and securing the IO. Usually I don't bother securing them in arrests but she was moving around a lot and I didn't want her to dislodge it. I actually considered a second IO but by the time I got to it we were backing into the ambulance bay.

What are your thoughts? I flushed the IO with lidocaine for her comfort. There wasn't a whole lot I could do for this lady but that was one of the things I could at least try to make a little more tolerable. Thinking I should've started bagging her too, her respiratory rate was irregular and slowed down a little bit during transport but she still had a decent rate and tidal volume. I didn't notice any cyanosis but her color was so whacked I'm not sure I could have seen it anyways. After a couple minutes in the ER when the doc decided to RSI I helped out and bagged her since they were short on hands. I'm open to everything, positive and negative. I try to learn from every call and this was one of the sickest patients I've ever seen that still had a pulse.

Found out at the end of my shift that she died in the ICU soon after she got up there.

 

[Nova1300]

I suspect that you, my friend, just saw your first case of DIC. It can happen from a lot of things, especially in the patient you just presented (fulminant sepsis or hepatitis, massive GI bleed, lotsa other stuff, etc.) Airway control was probably a good thing, but she needed RSI and I don't know if you have the drugs or not. Fluids were a good move, pressors would be an option, but only to make her numbers look better. She was on her way out. You did good. And I don't think that lido bolus did squat.

 

[Handsome Robb]

I suspect that you, my friend, just saw your first case of DIC. It can happen from a lot of things, especially in the patient you just presented (fulminant sepsis or hepatitis, massive GI bleed, lotsa other stuff, etc.) Airway control was probably a good thing, but she needed RSI and I don't know if you have the drugs or not. Fluids were a good move, pressors would be an option, but only to make her numbers look better. She was on her way out. You did good. And I don't think that lido bolus did squat.

That's what I was thinking. Talking to a nurse later sounds like she coded and there was blood in the tube and basically everywhere else you think of.

Unfortunately no RSI here. Honestly it would have been a tough tube but doable. Mallampati 3, short, fat neck, obese. Took the ER a while to get it with a glidescope. I'm pretty confident I could have gotten it with a bougie though. One of the FFs was actually a per diem medic with the agency I work for so between the two of us we would have made it work.

Only pressor we carry is dopamine. Crossed my mind but I had other things to worried about. Really didn't get too far past ABCs with this lady. She never had a palpable pulse the entire time I was with her. It was all based on the fact that she was still moaning and auscultating for heart tones intermittently. ER was using a doppler on her femoral.

I was just boggled that she could have gone from walking, talking and partying last night to that so quickly but her boyfriend wasn't a great historian and was pretty distraught.

 

[Dwindlin]

I'll agree with those at the hospital, everything you did I think was appropriate, just should have been done enroute. I'll admit I am biased, in my own practice as a medic I have a pretty firm rule that the only thing I do on scene is a 12-lead (outside of an arrest of course), and even that I generally do in the truck.

I've said on here many times, I am a minimalist. "Stay and play" mentality needs to go away in my opinion. I don't care how stable the patient is, my unltimate goal is delivery to the ED if that is what the patient wants, so why delay?

 

[fast65]

I will agree that it would have been nice to RSI this lady, but I understand that you don't have that option. However, I would probably be a little hesitant to RSI her if she was my patient, considering that we only have Versed as an induction agent, and with a pressure of 60/38, I wouldn't be feeling to safe using.

That being said, I think you managed her pretty well. Like you said, another IO would have been ideal, but you were a little busy with other things, and that's understandable. Still, 750 cc is a decent amount of fluid to run through an IO over that short period of time. Next time though, bring a couple more hands along for the ride, like we discussed last night.

As far as pressors go, I would be a little wary about that. I'm highly suspicious that she's got some aspect of hemorrhagic shock going on as well, and pressors aren't particularly going to help that. But, I just woke up, so I could be wrong. Either way, nice job on a tough patient.

 

[Sublime]

I'm guessing she's in late stage shock secondary to acute liver failure.

Sounds like you handled it well. Unless you spent 10+ minutes in the box trying to get access, I think you can justify doing that on scene. I would of diverted intubation to the ER because she was managing her own airway at that time. Plus we don't have RSI.

 

[Veneficus]

you are just hell bent on raising BPs aren't you

 

[Handsome Robb]

you are just hell bent on raising BPs aren't you

:lol: said I thought about it, didn't really take it further than that I remember what you said.

I personally don't agree with doing everything en route but like you said, Dwindlin, every medic has their own style. I see no reason why 2 extra minutes on scene to get a patent point of access is unreasonable but that's just my point of view. Any particular reason why you do everything en route instead of on scene other than having the end goal of delivering them to the hospital?

 

[Dwindlin]

I personally don't agree with doing everything en route but like you said, Dwindlin, every medic has their own style. I see no reason why 2 extra minutes on scene to get a patent point of access is unreasonable but that's just my point of view. Any particular reason why you do everything en route instead of on scene other than having the end goal of delivering them to the hospital?

Nope. As I said above, I'm a minimalist, and I have reasonably short transport times (8 - 10 minutes). I'm the same way in the hospital as well, do I really need that central line/foley/a-line etc, etc, etc. Amazing how the further along in training you get the more you just want to leave the patients alone as much as possible. . .

There is a great book everyone tells medical students/residents to read called "House of God", it was much more relevant before work hour restrictions but the book lays out 13 laws of the house, one of them being "the delivery of good medical care is to do as much nothing as possible." One of truest statements ever made.

 

[Carlos Danger]

As sick as she was, it may not have been a bad idea to wait and get venous access enroute.

I don't see a problem with the lido. I don't think it helps a lot and probably isn't a priority in a patient this sick, but as little time as it takes, I don't think it's wrong either.

With that type of presentation I would have gone to the closest appropriate hospital.

Intubating her would have been wrong, IMO, with such a short transport time.

 

[Veneficus]

:lol: said I thought about it, didn't really take it further than that I remember what you said.

You are going to have to come and spend some time in the ICU. We can let you hang pressors and pressors until we get it out of your system

I would like to know who told you this lady needed surgery? Did they have a liver transplant waiting for her at the hospital or were they planning to correct varices post resuscitation?

I have only seen one save of a massively ruptured patient. The lady was in the inhospital dialysis unit just starting her dialysis when she basically vomited a fountain of blood as the chief of nephro and I were standing 5 feet away. That was a good day... Many things went right.

 

[RocketMedic]

I dont quite know a good way to manage this patient in the field. Saline doesnt help perfuse when the majority of a bodys blood supply is gone.

We're supposed to stay and play here for most medical. If they're sick, I cut it it to an absolute minimum.