Trainwreck #4

[abckidsmom]

One last hint. Since we're on a CCT truck, can we do something to definitively treat the pneumo allowing us to use PEEP?

Right. So we'll slip in a little chest tube.

Dude. You need to give us a list beforehand, man!

 

[usalsfyre]

I know CCRNs can place chest tubes in many flight programs. Can a medic do that? Our flight medics can only monitor chest tubes last time I checked. Caveat being that I don't pay a ton of attention to their protocols. Thats about the only thing I can think of.

Chest tube is truly the only definitive treatment of a pnuemo unless you have some sort of trauma to the lung(s) that requires surgical intervention from what I have read.

In Texas our medical director decides what we can and can't do .

Although it's not something that very often recommended or needed out-of-hospital, this is one of those times either tube or even just an open thoracostomy would be appropriate.

 

[firetender]

...then treat it like a train wreck!

First of all, when you have a train wreck you organize patient treatment to handle the most viable; everyone else is left to personal consultation with his/her Maker.

Second of all, can you NOT see that this is a Buff and Turf, last ditch effort from what the OP reported?

Okay, then, let's get the facts straight, Sergeant Friday: No matter how you cut it, this patient was circling the drain.

From original post: Your (sic) on a ground CCT unit in a metro area and are dispatched to a LTAC ICU for a 64 YOF post-arrest going to major-university hospital ICU across town. On arrival you find an unconscious, intubated patient who arrested 4 hours ago, had a ROSC and is now on a dopamine drip.

Okay, that's the general picture. What you have is what you have. Therein is your baseline of stability. Okay then, let's get a bit more detailed:

The patient is admitted for care of stage IV decubitus on her sacrum and legs. She also has a history of diabetes, hypertension and ESRD which she receives hemodialysis for.The patient takes atenolol,and is on an insulin sliding scale. An hour after receiving dialysis she was witnessed slumping over and found to be in cardiac arrest. The patient received CPR and one round of epi for PEA before regaining a pulse, the systolic B/P was found to be in the 60s so the patient was started on dopamine which was titrated "quickly" to 20mcg/kg/min, in addition the patient had received in the neighborhood of 3 liters of NS. The only access you have is a single lumen IJ where the dopamine is running. The patient was intubated with a 7.5 ETT placed to a depth of 22cm at the lips, vent settings are assist control at a rate of 24, vT of 400mls, PEEP of 5, FIO2 of 1.0 and a 1 second I time. The nurse tells you the patients doctor diagnosed a perforated bowel via chest x-ray. The patient is airborne isolation for MRSA, C.Diff, AND VRE (all the good stuff)

Physical exam shows a an unconscious intubated patient, GCS of 5 (E1, V1, M3).

But now, the OP asks:

What can we do to optimize her for transport?

There is NOTHING to optimize! The only option is to NOT mess with whatever delicate balance is present and PRAY NOTHING CHANGES. How more clear could that be?

But then, all the juggling begins and it sounded pre-emptory to me. Says one respondent to the OP:

decrease the ventilatory rate to try and bring the ETCO2 up to a more reasonable level. With the ESRD (which I suspect stands for End Stage Renal Disease)

Could ESRD be another clue as to what you might choose to do, when, how and why?

...and bring her ETCO2 up to a more REASONABLE level? Sorry, but the fact that she's breathing at all is enough for me. I ain't gonna F with it in any way shape or form. Reasonable to whom?

Our OP now chimes in with more grist for the mill:

You do all of the above, the vitals improve (B/P of 106/74, HR of 108, SpO2 of 96% and ETCO2 of 37). and 10 minutes into the transport the sat suddenly drops into the 70s, the HR spikes to 130 and the pressure drops to 50 over ---.

You're goddamned right something else started going out of whack! So at this time I can only ask, When do you decide that you accept WHAT you have in front of you? Must you mess with it?

Now, this woman has become a puzzle to work with -- a Rubic's Cube of trial and ALL error because the basic stability you were presented with was compromised.

Are any of you asking yourselves "What is stable FOR THIS PATIENT?"

Now, I don't even need to go any further with the horrid details. Let's just put it this way. We've already established where the patient was at. Then, we decided we wanted to "optimize" her condition. So we start tweaking this and tweaking that. For every tweak, of course there is a related or unrelated response. But how the hell would we know if it has to do with her presenting condition or from what WE'VE done to her in our tweaking?

Do you see my point? This was an IFT, NOT an emergency intervention.

So let me see where this goes. We tweak, something changes, we try and correct that and something related or unrelated changes so we mess with that.

Why in God's name would you treat symptom after symptom, in essence playing a juggling act with the physiology of an already compromised human being?

Do you see my point? This was an IFT, NOT an emergency intervention.

Blood pressure drops COULD BE hypovolemia. IF so, better push that bolus Heart rate goes up, better find something for that. Don't like that rhythm? cardiovert.

By the time we get our sixth new contributer to the thread, here's where we are:

I agree with darting her chest and electricity.

WHOA, BABY! We certainly had to get there from somewhere, and the somewhere didn't have anything to do with what we were loading up into the rig for a half-hour transfer. What has changed on its own?

No one will ever know because so many things were messed with it would be most impossible to determine. What's the goal here? Get her THERE alive.

Isn't Rule #1 "Don't upset the applecart?" Okay, maybe Hippocrates said it better.

Somewhere in there, she got a pneumothorax. But was it REALLY pushing her over the edge? It doesn't matter. WHOOPIE! we have something new to treat!!! From what I've been reading the urgency here is to get her to die in the ambulance rather than the hospital!

The patient is compensating left and right for the interventions you take to what? Assure stability?

WHO ARE YOU KIDDING?

So, I have a point here that I will explore further still at my EMS Outside Agitator Blog. I'm not identifying this thread, or its posters -- just using the flow here as example, as long as that's okay with everyone.

I am in perfect agreement with exploring all the deep medical syndromes, playing with possibilities of treatment, their intended effects and what they actually did. I'm cool with exploring scenarios and "What If"ing them to death.

But FIRST, what I'd like to hear is that you

#1) understand the call within the context of the Bigger Picture
#2) have an idea of the viability of your patient IN THE CONTEXT OF HOW MUCH TIME TO GET TO THE NEXT LEVEL OF APPROPRIATE CARE
#3) have spoken to the Dr. or other approprite authority to determine the limits and boundaries of your interventions
#4) have actually CONSIDERED the potential for the quality of life of YOUR patient

There was none of that in this thread.

Sure, it's a scenario, a fantasy (Jesus I HOPE!) and an exercise, but seriously, folks, at least START by posing the question like this"

"IF we chose to aggresively treat a patient with this kind of condition, what do you think we'd do and how might the scenario develop/devolve?"​

I want to hear how thinking paramedics act, not how acting paramedics administer.

 

[fast65]

In Texas our medical director decides what we can and can't do .

Although it's not something that very often recommended or needed out-of-hospital, this is one of those times either tube or even just an open thoracostomy would be appropriate.

Oh yeah, that's right, you guys have that nifty rule about your medical director determining your scope of practice

 

[usalsfyre]

Right. So we'll slip in a little chest tube.

We put one in, the lungs start to sound better, the transport is completed, your boss calls and offers you a $2/hr raise, for the single folks that cute nurse compliments you on being a ballsy clinician, ect, ect .

That said, the patient expires two hours after arrival from multi-system failure.

Dude. You need to give us a list beforehand, man!

I'll admit I was kinda pushing the limits with this one to see if anyone would go down that road. The patient this was based on didn't have the pneumo.

 

[Handsome Robb]

In Texas our medical director decides what we can and can't do .

Although it's not something that very often recommended or needed out-of-hospital, this is one of those times either tube or even just an open thoracostomy would be appropriate.

Oy! Our MD decides what we can do. He just has to write a letter to the state requesting something outside of the state scope and the state has to approve it.
He usually gets what he wants, except for I's getting Zofran due to the new prolonged QT study from the FDA. <_<

Every time a pt complains of nausea I'm telling the medic that I'm uncomfortable taking the pt kidding /OT

So the chest tube is in. Now what happens? We can resume ventilations with PEEP. I'd try to increase the PEEP a bit to hopefully move some fluid out of the alveoli if the current PEEP setting wasn't getting it done. Since we have established the patient is volume overloaded I'd tone down the fluids to TKO but keep the dopamine where it is set at and titrate up or down to effect.

 

[firetender]

I rest my case.

That said, the patient expires two hours after arrival from multi-system failure.
QUOTE]

And what was her last 2 1/2 hours of life like?

A receptacle for whatever looked fun to try.

Someday soon I hope we get to treat more people and less patients.

 

[usalsfyre]

Firetender, a big part of IFT at the critical care level is about optimizing mismanaged patients. This patient was mismanaged, not only in a way that probably led to her arrest in the first place, but definitely post arrest. The ungodly high ventilatory rate as set by the facility and the extreme tachycardia precipitated by the high dose of dopamine were unnecessary and likely harmful. Both of these needed to be adjusted immediately. Without exploring the fact that the whole thing was an exercise in futility from the start (which everyone there realized) the task we were given was to deliver a live patient with the greatest chance of survival. This means correcting mismanagement. It's not a reflection of arrogance, simply that the CCT personnel may have more experience managing this type of patient than many facilities.

The days of taking a patient and running from facility to facility are over. Poor outcomes with these patients is why CCT evolved into a specialized arm of EMS.

 

[usalsfyre]

[
And what was her last 2 1/2 hours of life like?

A receptacle for whatever looked fun to try.

Someday soon I hope we get to treat more people and less patients.

Right, wrong or indifferent it's not our place to decide her fate. Family was at beside asking us to "do everything". As such, we're obligated to treat her to the best of our ability.

 

[Shishkabob]

I know CCRNs can place chest tubes in many flight programs. Can a medic do that? Our flight medics can only monitor chest tubes last time I checked. Caveat being that I don't pay a ton of attention to their protocols. Thats about the only thing I can think of.

Sure as heck a Paramedic can place a chest tube. My (now former) agency's flight service, flight medics and flight RNs had the same scope, and they could do chest tubes AND pericardiocentesis.

 

[firetender]

Firetender, a big part of IFT at the critical care level is about optimizing mismanaged patients. QUOTE]

Were there something to optimize here, I'd say do the work. You're essentialy saying the discharging facility was incompetent, but were you the only judge of that? My point remains: there was nothing to optimize, only stabilize.

I hope you can see I was using this thread as a springboard to encourage more than technical reaction; it's called critical thinking.

 

[abckidsmom]

Firetender, a big part of IFT at the critical care level is about optimizing mismanaged patients. This patient was mismanaged, not only in a way that probably led to her arrest in the first place, but definitely post arrest. The ungodly high ventilatory rate as set by the facility and the extreme tachycardia precipitated by the high dose of dopamine were unnecessary and likely harmful. Both of these needed to be adjusted immediately. Without exploring the fact that the whole thing was an exercise in futility from the start (which everyone there realized) the task we were given was to deliver a live patient with the greatest chance of survival. This means correcting mismanagement. It's not a reflection of arrogance, simply that the CCT personnel may have more experience managing this type of patient than many facilities.

The days of taking a patient and running from facility to facility are over. Poor outcomes with these patients is why CCT evolved into a specialized arm of EMS.

This is what I was going to say.

The scope of mismanagement is just astonishing. For whatever reason, when I worked in the STICU, we seemed to have a run on gastic bypasses run amok. I mean a.m.o.k. They were all transferred in from outlying hospitals (teehee, like ours was the center of the universe, lol). One was a 28 yo lady on Christmas break from college who had her GBP, was discharged home and THEN discovered the leak, but was not reopened, they just treated with antibiotics. She died at Valentine's day. Another lady had her surgery, and swirled a little afterward, needing a chest tube, which they inserted through the pleural space, through the diaphragm, perforating the stomach and then *not doing anything about it for 2 days!*

So to walk in on these situations and just scoop and scoot, you just can't do it.

In usalsfyre's scenario, the decision to treat the patient aggressively was made by the family. These freestanding acute care facilities typically have good end-of-life care, but you can only do so much when the family is at the bedside demanding that everything be done.

Once the decision to treat was made, the staff ran amok with their treatment plan, and failed to reassess to find the balance. No need to have her dopamine pegged, no need to have her panting on the vent. No need for any of that, but there ya go. Like you recognized, every treatment needed to be reacted to, and "our" treatment was merely a reaction to the staff's treatment, which helped us down this path.

Plus, in a train wreck scenario, it's going to move pretty quickly toward devastation, anyway.

 

[Shishkabob]

It's not just CCT, either. I've had more than my fair share of having to fix a sending facilities...err.. issues... doing 'just' a 911 truck.

 

[firetender]

I really understand the counteracting mismanagement thing, but in this particular case, it seemed the odds of correcting ANYTHING were nil. My only concern would be to not risk making anything worse; therefore, inaction would be the only viable option.

In her case, YES, I think she was stable enough for a half-hour ride to the next facility. If something went south enroute, well then you deal with it. But anything pre-emptive is just not appropriate in her case. What I read told me the actions you took exacerbated her downward spiral.

And did I hear the people who made the final call on whether or not you took aggressive action was the family's?

Something's missing.

 

[usalsfyre]

Firetender, she was intubated by the facility. If she blew a lung on proper vent settings she sure as feces was going to blow one out on their overventilation, if she didn't have an MI that stopped her LV from working entirely because of the maxed out dopamine drip first. Yes, the family was at bedside, and asked the facility to "do everything to keep her alive". As such, at that point you become obligated to do the same, and that means fixing the problems you encounter. She was darn likely to crash enroute to the truck. I have seen patients that seemed "stable" crap out simply from moving to the EMS stretcher. If the patient's interventions are not where they should be they should be tweaked prior to initiating transport. The transport environment is harsher than an ICU bed. Talk to nurses who have done both and I doubt you'll find one that disagrees.

I'm not sure what your ethical issue here is. We weren't using her as a high-fidelity skills lab. We were doing what any prudent CCT team would.

 

[firetender]

FI'm not sure what your ethical issue here is. We weren't using her as a high-fidelity skills lab. We were doing what any prudent CCT team would.

First of all I do not have an issue with YOUR ethics, nor am I critical of the actions you took which I have no doubt were appropriate in the given circumstances. I wasn't there. Maybe that's what got me asking my questions.

What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get. No one stepped back to question if furthering/continuing/initiating aggresive treatment was necessary. No one came to the conclusion that things were likely to get worse REGARDLESS of what was done.

To me, all that was obvious. That led me to my conclusion that the woman was stable ENOUGH for immediate transport. What I heard you relate was that AFTER you started adjusting the whatnots the woman began a fatal spiral. But honestly, it wouldn't have mattered if you did everything or nothing.

So it's not so much an ethical question as it is a moral dilemma. In a case like this, which is clearly end-of-life syndrome, when do you admit to yourself that it's a lost ship and all that's left to do is to make its passage as gentle as possible without neglecting your duties?

This kind of stuff usually doesn't get considered in scenarios and it should be. We're the ones that have to live with the actions (or inactions!) we take and the choices we make. In the end we don't agonize about the fact that we lost them, what haunts us is how.

 

[usalsfyre]

Firetender, I actually don't disagree with you. She honestly was going to crump shortly no matter what. Ideally the physicians and other staff at the sending should have had a very frank discussion about what was going on. Quite honestly, I think they did. But between belief in the "miracles of modern medicine" and the fact that this individual's social security probably provided a good part of the household income the family refused to acknowledge the obvious. At that point your hands become tied.

 

[Handsome Robb]

Firetender. I respect you and acknowledge what you bring to the table but after your post in this thread you went down a notch in my book. I don't care if your a mod. You derailed the thread and its educational purpose.

Don't jump down our throats when the younger members, who are genuinely interested in furthering their knowledge in this field respond to a scenario presented to us.

As a community leader your supposed to guide new/young members, not make them feel like morons.

I was enjoying this thread until you poked your head in here. I'm starting to agree with some of the people who have left that I remained in contact with about this forum.

Usalsfyre thank you for the scenario and the help you have provided me on a personal level. I hope that after you finish with taking care of yourself and your personal business you continue to post educational puzzles for us here.

 

[Handsome Robb]

What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get.

It's scenario based. You may be correct but thats not the point. Think about it from the point of view of a new provider who is excited and willing to learn from this scenario. Not a 'shes alive, transport her and we will treat her symptoms enroute in a bumpy cramped ambulance rather than stabilize her further in a controlled environment" point of view.
:unsure:

from the way I read it, your looking at it from an "if it aint broke don't fix it until it breaks" standpoint and the younger guys in here are looking at it from a prophylactic standpoint.

 

[abckidsmom]

What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get. No one stepped back to question if furthering/continuing/initiating aggresive treatment was necessary. No one came to the conclusion that things were likely to get worse REGARDLESS of what was done.

To me, all that was obvious. That led me to my conclusion that the woman was stable ENOUGH for immediate transport. What I heard you relate was that AFTER you started adjusting the whatnots the woman began a fatal spiral. But honestly, it wouldn't have mattered if you did everything or nothing.

So it's not so much an ethical question as it is a moral dilemma. In a case like this, which is clearly end-of-life syndrome, when do you admit to yourself that it's a lost ship and all that's left to do is to make its passage as gentle as possible without neglecting your duties?

This kind of stuff usually doesn't get considered in scenarios and it should be. We're the ones that have to live with the actions (or inactions!) we take and the choices we make. In the end we don't agonize about the fact that we lost them, what haunts us is how.

assist control at a rate of 24, vT of 400mls, PEEP of 5, FIO2 of 1.0 and a 1 second I time

If we did nothing, considered her "stable for transport" on these settings, and then she blew out a lung in traffic, we'd be held liable. You can't leave a "stable" person on 100% oxygen, with itsy bitsy tidal volumes, with such a long part of the ventilatory cycle being spent on inspiration. You just can't do it.

Regardless of whether she was stable for transport, those vent settings had to change.

Not to change them would be like, well, I can't even think of an analogy for what that would be like. To show up with that patient at the receiving facility would be to become complicit in the ignorance.

Also, leaving her on 100% leaves you backed into a corner, with nothing to increase should she need it, and how many times have we beat the "don't overuse oxygen" dead horse, anyway?

I love your mindset, firetender, and I tend to agree with you on many issues of the conscience, ethics, or whatever you call the touchy-feely side of things, but this lady was not our victim, not the victim of the medics scoring one more skill. She was the victim of the healthcare system, our society's need to "do everything" even in the face of obvious futility.

This is a valuable conversation to have, and a very important bunny trail to make sure we go down every now and again, but I think the confrontational way you brought it into this thread sorta shut down productive conversation.