RSV

[Chris EMT J]

How do you get over a near loss? We almost lost a kid and the intensity of the environment has left me wondering how do we do this job? How do we get over this?

We were dispatched to a 4month old difficulty Breathing and hpi includes recent diagnosis of RSV about 2days ago. Patient was sweating, in obvious respiratory distress, extremely diaphoretic. HR in 160s BP 89/55 O2 84% RR 60s temp 101.9f

I placed a IV gave a 1L of NS
Started a nebulizer treatment with a NRB 6lpm
The patient had congested breath sounds heard after neb and had some wheezing before the neb. Patients mother was so worried and the stress level associated was enough that after that call I needed a break. I took a few days off and am back but unsure how we do this job? The stress level should be enough to burn anyone out but my passion is with emergency medicine so how do you stop thinking about those stressful calls?

 

[E tank]

That a typo? A liter of IV fluid? That's for another thread....

The first thing to recognize is that 'we' do not 'lose' patients because we didn't get them hurt or sick. And in some cases, we didn't choose for them to live a couple of hours from reliable, predictable medical treatment.

There is a phenomenon among folks just getting their chops whereby they think they have more influence/responsibility in outcomes than they actually do. If you do your job correctly, you'll delay worsening of symptoms/processes until you get your patient to a place where definitive care is possible. Sometimes that is difficult or not possible and it isn't because of anything you did or did not do.

If you stay in this line of work long enough, you'll see this to be the case. In the mean time, talk to folks more experienced with you to validate and process your critical incident stress. It's a normal, very common stress reaction that you deal with by physical activity, sleep, meditation/prayer and avoiding recreational depressants for a day or two afterward.

 

[IsraelEMS]

@ChrisEMTA , you didn't lose the baby. You showed up to a parent's scariest moment (speaking from experience on both sides) and you took the mother seriously. You treated her baby and brought them to the hospital. You know that you helped the baby, but you will never understand the impact you had on the mother.

You did good. Is it stressful? Sure. Will we "win" every time? No. But that's not the goal. The goal is to help people. To treat them with dignity and calm their fears while taking care of them physically as much as we are capable of. Don't let yourself get caught in the what-ifs. Take every win you can and let go of the rest.

 

[NomadicMedic]

I decided to redact my comments.

 

[Chris EMT J]

I decided to redact my comments.

I saw it before you changed it. No we didn't give a whole 1L. My mistake on wording. We started as 1L and I cut it off after giving about 250ml. We were between back to back calls so the 1L were the only NS packs.

 

[E tank]

I saw it before you changed it. No we didn't give a whole 1L. My mistake on wording. We started as 1L and I cut it off after giving about 250ml. We were between back to back calls so the 1L were the only NS packs.

Nearly twice a 20cc/kg bolus in a four month old with a normal hr and bp? Why?

Odd that the hr was normal with a sat, rr and temp like that. I'd expect it to be over 200.

 

[Summit]

250ml is very roughly 35-40ml/kg for a 4mo. That's like giving 75kg adult a 3L bolus.

Tachypneic, low spO2, and febrile, but not hypotensive. This sounds like RSV with respiratory distress, sepsis alert, but not septic shock. Fluid overload and flash pulmonary edema are not going to help respiratory distress.

ABC. Suction and oxygen for RSV, then reevaluate.

I'm not sure what your protocols tell you to do, but normally that kid doesn't get a bolus in the field at all. The ER might consider 10-20ml/kg if the suction and O2 didn't improve things.

This is coming from someone who instinctually wants to run the other way from peds patients, they make me anxious, but go back to the basics and go from there.

 

[Summit]

Also, I'm guessing your protocol probably indicates nebs based on signs, but I don't feel like we are giving bronchodilators for RSV babies.

Moms of babies are almost always worked up if they are calling 911. You must bring the calm and don't let their stress transfer to you.

 

[Summit]

Also, do you have a pump or a buretrol? These are critical safety items when administering IV fluids to neonates, infants, and peds. It's too easy to mess up volumes with the little ones otherwise.

 

[Tigger]

Also, do you have a pump or a buretrol? These are critical safety items when administering IV fluids to neonates, infants, and peds. It's too easy to mess up volumes with the little ones otherwise.

If you're going to fluid bolus, avoid using a buretrol given that it's a 60gtt/ml set in nearly all cases. "Push-pull" using a three-way stopcock and a 20cc syringe is a great way to be accurate while also giving fluids at a reasonable rate.

 

[E tank]

250ml is very roughly 35-40ml/kg for a 4mo. That's like giving 75kg adult a 3L bolus.

I'd argue it's not. It's worse...a 4 month old doesn't possess the Starling contractility of an adult and can only cope with volume overload with increasing HR....if he/she has the reserve to do so...if not it's bradycardia leading to arrest...from 250 ml? Probably not but that is going to be one puffy baby the next day....

 

[Carlos Danger]

I'd argue it's not. It's worse...a 4 month old doesn't possess the Starling contractility of an adult and can only cope with volume overload with increasing HR....if he/she has the reserve to do so...if not it's bradycardia leading to arrest...from 250 ml? Probably not but that is going to be one puffy baby the next day....

But aren’t puffy babies the best babies?

 

[E tank]

But aren’t puffy babies the best babies?