Trainwreck #6

[thisgirlisamedic]

Sorry for errors my phone thinks its smarter then me but I'm sure u can figure out what should be there

 

[Melclin]

This a pt for the adult retrieval team. If for some reason I was taking this pt, despite my protests, I'd be on the phone to the Adult Retrieval consultant for advice.

Do you have systems for pt retrieval/retrieval co-ordinators/doctors/consultation hotlines etc, runs these things and whom you can consult with?

 

[thisgirlisamedic]

Another thought her bun is going up showing more then likely that she is hypovelmic. This still supports the bleeding due to trauma from cpr theory ?????

 

[Veneficus]

Elevated? Her coumadin kinda high but know she running a rib I wouldn't mess with the vitamin k besides its slow acting, when and what are her meds and last given, why have the not done a stat scan to look at what trauma they caused post arrest, moving her to risky I still think she has a tear in a major blood vessel and i wouldn't want to finish tearing it, I would really talk to staff about testing Murphy's law here......and i would at least like blood to be hanging to cause my fluids won't do anything but make her bleed pink, you can only maintain a b/ p with a drip for so long, I really wonder what was her urinary output pre arrest? Was she able to eat yet. Last meal and blood sugar insulin given, during this stay did she get a transfusion? Possible if there is already this level of incompetence that this onset was from a reaction to the transfusion or wrong meds given . It still bothers me that they should be doing labs q 2 hrs or at least q 4 for sure I wonder what changes took place over the last 12 hours of labs? It would be nice to see here pre and post SOB panel and blood sugars and insulin given

Using pressors to maintain perfusion when volume replacement is needed is shown to increase mortality. The fact they are basing perfusion on her systolic BP demonstrates clearly they are in over their head.

The patient probably does need blood and maybe emergent surgery.

A CT scan in a facility that is not going to do anything with the findings just delays the patient from getting to a facility that will.

I wouldn't call a provider doing the best they can in a situation they do not regularly handle or are trained for incompetent.

Looking at just the CPR component, if you have no ability to open and close a chest, then performing CPR on a recent cardiac surgery patient over no emergency circulatory support is the lesser of 2 evils.

From what I read, it seems like too much focus was put on intubation vs. ventilation.

Did the cric go wrong? Sounds like it. But ask yourself, how often do you do one? How proficent are you at it? Would your best effort in a stressful situation be any better or worse?

How do you know the physician wasn't dealing with a variation in anatomy that he wasn't prepared for?

I never defend poor care, but as somebody who regularly deals with emergency room doctors and has to take a graduate exam in a few weeks on surgical critical care as part of my academic pursuits, if a person does not spend a lot of time on the topic, it is very easy to be overwhelmed.

Contrary to EMS belief, and not picking on you directly, ER docs, both EM trained and others, are not the masters of resuscitation or surgical pathology. They are not all knowing and all powerful by virtue of being a doctor in the ER.

If they were, there would be no need for other specialists.

This is a very complex patient and well outside of the realm of emergency medicine. The patient needs to go elsewhere. If she dies on the way or where she is at, she is still dies.

"Cut along the scar, clip the wires holding the sternum, spread the chest and reconnect vascular grafts or perform pulmonary endarterectomy as required, then expand the incision to the neck to explore iatrogenic bleeding from a cric" are not a part of any ED resuscitation guidline I have ever heard about.

The EMs who hang out on the forum please correct me if I am wrong on this.

 

[thisgirlisamedic]

Incompetence wasn't just put on the Dr correct me if I'm wrong but don't most hospitals just use the er Dr for codes on floor, so I am sure he did everything he could and to the best of his ability, but the staff taking care of pt may have dropped ball on this one, I really think there is more to be seen that could have prevented her current state, I understand that they can only do what the pts Dr authorizes, but was the cardiologist that performed intial surgery available wouldn't be more practical and safer for him to open back up and stabalize prior to transport? If the original cabg was done on site why not go back in, I don't see a lot of receiving facilities being happy about accepting this pt? I'm not saying don't transport I don't know the abilities of this facility vs. The receiving one... But it just doesn't seem to be logical to more someone this unstable, and yes you can use meds to keep pressure up but they only last as long as they have blood to move her bun really let's me know that's going downhill now grant it I work in the middle of no where I am two hours from nearest trauma center and have just a small hospital with not many services available so i do tend to look at things that aren't maybe going to happen in just mins. I tend to look long term and i do recall it only being 20 miles, so it is likely to get her to a better equiped. Facility, but i still wonder if it doesnt go against the do no more harm, one wrong bump and it could be well not good. Also one our units its just us two that's it so I would want a nurse or another medic along, just in case,

 

[Aidey]

I'm sorry, I know you said you were on your phone but I simply can not follow what you are saying.

 

[Anjel]

Incompetence wasn't just put on the Dr correct me if I'm wrong but don't most hospitals just use the er Dr for codes on floor, so I am sure he did everything he could and to the best of his ability, but the staff taking care of pt may have dropped ball on this one, I really think there is more to be seen that could have prevented her current state, I understand that they can only do what the pts Dr authorizes, but was the cardiologist that performed intial surgery available wouldn't be more practical and safer for him to open back up and stabalize prior to transport? If the original cabg was done on site why not go back in, I don't see a lot of receiving facilities being happy about accepting this pt? I'm not saying don't transport I don't know the abilities of this facility vs. The receiving one... But it just doesn't seem to be logical to more someone this unstable, and yes you can use meds to keep pressure up but they only last as long as they have blood to move her bun really let's me know that's going downhill now grant it I work in the middle of no where I am two hours from nearest trauma center and have just a small hospital with not many services available so i do tend to look at things that aren't maybe going to happen in just mins. I tend to look long term and i do recall it only being 20 miles, so it is likely to get her to a better equiped. Facility, but i still wonder if it doesnt go against the do no more harm, one wrong bump and it could be well not good. Also one our units its just us two that's it so I would want a nurse or another medic along, just in case,

Use periods for petes sake. And use the enter button and make periods.

Please!

 

[ffemt8978]

Use periods for petes sake. And use the enter button and make periods.

Please!

Agreed, but before this gets out of hand that will be the only grammar comment allowed in this thread.

Sent from my Android Tablet using Tapatalk

 

[Farmer2DO]

Airway is “secured” with the ETT in the throat, the physician, RT and nurse all tell you “it’s not really secured very well and if you pull it out she’s dead”, the ETT is full length and appears to have been tied with umbilical tape.

Well, then, secure it better, or I'm not touching her. Period.

Morbidly obese with poorly controlled HTN and diabetes. Smoker, family history.

C/T surgery generates money. Taking the easy cases and referring the troublesome ones is a business decision.

So, it sounds like this is a smaller facility that doesn't do a lot of complicated cases. Who in the realm of Hades thought it would be a good idea to do a CABG on a 46 year old morbidly obese smoking female who's diabetes and hypertension are poorly controlled AND has a family cardiac history? This is NOT an easy case, and should have been seen ahead of time as such. Referring the troublesome cases AFTER they decompensate and are in extremis is also a bad business decision.

Dang.

This facility has thoracic surgery And we are really going somewhere else? Holy EMTALA violation, batman.

Yeah whats the go with that? What the cardiothoracic surgeons opinion on all of this? I'm no expert but it kinda seems like they're ganna need to open her up again. They can't do that there? Seems like she should have been in theatre already.

If that is the case since the rough edges are usually bent towards the sternum I would probably want to go to another facility that deal with anymore care at this one.

After she's stabilized.

Can't really complain about the emergent care, but it seems from the scenario the staff here was not prepared or experienced with this type of patient.

Agreed. Which is why they never should have done her in the first place.

The doc wanting to punt to somebody who can or at least more comfortable with is probably a very good decision.

Here I disagree. This is a dump job, and the exact type of case that EMTALA was meant to prevent. She's obviously got some badness going on that likely needs surgical correction, and the sending facility has the surgical capabilities to deal with it. The CT surgeon took her on; he needs to deal with the complications. If this were a patient that couldn't come off pump (I've seen several times) and they wanted to send her somewhere that could place a VAD and evaluate her for a heart transplant, fine. I have no problem with that. But they created this problem, and it's a problem that is likely to worsen during transport, which then becomes my problem.

This a pt for the adult retrieval team. If for some reason I was taking this pt, despite my protests, I'd be on the phone to the Adult Retrieval consultant for advice.

Do you have systems for pt retrieval/retrieval co-ordinators/doctors/consultation hotlines etc, runs these things and whom you can consult with?

I work in a system where we have an adult transport team. Usually a paramedic, RN, RT and perfusionist. This is the only way this person should be going out of here.

The fact they are basing perfusion on her systolic BP demonstrates clearly they are in over their head.

Agreed.

The patient probably does need blood and maybe emergent surgery.

Also agreed. By the surgeon that cut her in the first place.

A CT scan in a facility that is not going to do anything with the findings just delays the patient from getting to a facility that will.

Agreed.

I wouldn't call a provider doing the best they can in a situation they do not regularly handle or are trained for incompetent.

I understand where you are coming from, but there are 2 reasons I would seriously call in question the competence of the surgeon: 1) opening this patient up in the first place 2) not fixing his own mistakes. Notice I didn't say for the patient decompensating in the first place. Bad outcomes happen. Fact of life. But someone should have foreseen this and sent this woman to a larger center.

Contrary to EMS belief, and not picking on you directly, ER docs, both EM trained and others, are not the masters of resuscitation or surgical pathology. They are not all knowing and all powerful by virtue of being a doctor in the ER.

My expeience has been that anesthesiologists, internists and surgeons with critical care training, and emergency physicians are generally pretty good at resuscitation. I have worked around many, many internists and surgeons without critical care training, and it's obvious that it isn't their area of expertise.

This is a very complex patient and well outside of the realm of emergency medicine.

Agreed. But he said she was in the ICU. I don't really see where EM enters into this discussion at all.

The patient needs to go elsewhere.

Agreed. The OR. At the sending facility.

"Cut along the scar, clip the wires holding the sternum, spread the chest and reconnect vascular grafts or perform pulmonary endarterectomy as required, then expand the incision to the neck to explore iatrogenic bleeding from a cric" are not a part of any ED resuscitation guidline I have ever heard about.

Again, this isn't an EM case. It's solidly in the realm of CT surgery. And the procedure you are describing can be done. By a CT surgeon. The same one who did the surgery in the first place.

I would be on the phone with my medical director about refusing to take this patient. I have no problem taking patients that have a high chance of death during transport if I'm taking them somewhere for something that can't happen at the sending hospital. I do it quite often. I DO have a problem taking a patient that can be stabilized at the sending facility. In fact, I believe it's required by law.

 

[Veneficus]

So, it sounds like this is a smaller facility that doesn't do a lot of complicated cases. Who in the realm of Hades thought it would be a good idea to do a CABG on a 46 year old morbidly obese smoking female who's diabetes and hypertension are poorly controlled AND has a family cardiac history? This is NOT an easy case, and should have been seen ahead of time as such. Referring the troublesome cases AFTER they decompensate and are in extremis is also a bad business decision...

I agree without condition.

Now that is has happened though, the situation has to be resolved in the best interest of the patient. Punitively forcing an operation is not the solution.

After she's stabilized..

You cannot stabilze somebody who needs surgery without it. No amount of medicine will do that. It is the whole basis for trauma systems. (I know this wasn't a trauma, but I think we agree this is still a surgical emergency)

Here I disagree. This is a dump job, and the exact type of case that EMTALA was meant to prevent. She's obviously got some badness going on that likely needs surgical correction, and the sending facility has the surgical capabilities to deal with it. The CT surgeon took her on; he needs to deal with the complications. If this were a patient that couldn't come off pump (I've seen several times) and they wanted to send her somewhere that could place a VAD and evaluate her for a heart transplant, fine. I have no problem with that. But they created this problem, and it's a problem that is likely to worsen during transport, which then becomes my problem..

I am not saying this isn't a dump job. Likely it is.

But how do we know sending this patient out is really sinister?

Is it possible that the surgeon thought it was a manageable case (either out of arrogance or ignorance) and then discovered afterword it was beyond his skill and now is hoping somebody better can fix it?

I work in a system where we have an adult transport team. Usually a paramedic, RN, RT and perfusionist. This is the only way this person should be going out of here...

Sounds great

Also agreed. By the surgeon that cut her in the first place..

This I do not agree with. If said surgeon already knows this patient is beyond him, while it doesn't harm the statistics of said surgeon, in the interest of the patient, a superior provider is the right choice.

I understand where you are coming from, but there are 2 reasons I would seriously call in question the competence of the surgeon: 1) opening this patient up in the first place 2) not fixing his own mistakes. Notice I didn't say for the patient decompensating in the first place. Bad outcomes happen. Fact of life. But someone should have foreseen this and sent this woman to a larger center.

I am not saying this patient should not have been sent to a more capable center for the initial operation. Undoubtably she should have been.

But, I can tell you from experience that sometimes when you cut into somebody, what you find isn't always what you expect. (something I learned thinking I was draining a cyst, that ended up being a lipoma, but that is another story)

Sometimes after a surgeon makes a mistake, it requires a better surgeon to correct it. I have been at the table for some very involved cardiac reoperations, and I am very glad I wasn't responsible for the outcome in any way as soon as I saw the mess once the chest was opened. In my experience reoperations often require extraordinarily skilled surgeons.

My expeience has been that anesthesiologists, internists and surgeons with critical care training, and emergency physicians are generally pretty good at resuscitation. I have worked around many, many internists and surgeons without critical care training, and it's obvious that it isn't their area of expertise.

I agree with this, but the trouble is when the patient has a surgical pathology, you cannot resuscitate successfully until that is fixed.

Fooling around with medical treatments, intensive or otherwise just delays needed surgery.

But he said she was in the ICU. I don't really see where EM enters into this discussion at all.

Again, this isn't an EM case. It's solidly in the realm of CT surgery. And the procedure you are describing can be done. By a CT surgeon. The same one who did the surgery in the first place..

My mistake, when I read the scenario for some reason I thought this was an ED resuscitation and was addressing it for that, sorry.

And I made a mistake in my last post, I should have said thromboectomy, not endarterectomy. My fault.

 

[Handsome Robb]

usals this one has me thoroughly confused. It's way over my head lol.

It's pretty much been established that this pt needs surgery sooner then later. I'd rather not transport her while she is so unstable but I agree with vene, this original surgeon seems to have caused a much more severe problem and the fact that they are sending the pt out tells me that the surgeon is "admitting defeat" so to speak.

The airway needs to be fixed. Don't risk losing it by pulling the original tube and swapping it for a trach tube, cut down the ETT as far as you can and like abckidsmom said, have an MD suture it into place.

She's bleeding, the continuous drain from the chest tube along with the rest of the presentation seems to confirm this. Let's get some typed and crossed blood to the bedside if it isn't already there and hang it up.

I second abckidsmom again on the heart tones. JVD + hypotension makes me think pericardial tamponade. If they are muffled get an MD in here and do a pericardiocentesis STAT. I'm probably totally wrong though. On the off chance I'm right does this help her BP at all?

I think the pressors need to come back up until we can do something about her hypovolemia and potentially low CO secondary to my presumed cardiac tamponade. Sticking with my idea once we do the pericardiocentesis lets try to ween the pressors a bit, one at a time, and see where this takes us.

I don't see a reason why we can't leave the PEEP at 5. Maybe even drop the FiO2 a tad bit more?

Another thought, the pt's heart was in bad shape to begin with and has now suffered further insult. Could we be dealing with a potential cardiogenic shock along with the presumed hypovolemic shock or am I now just trying to force more :censored::censored::censored::censored: on the pile?

If we don't figure out how to fix the hypoperfusion pretty quick we are going to be stuck in a MODS situation that the pt may not be able to overcome if they aren't already there already.

 

[Farmer2DO]

You cannot stabilze somebody who needs surgery without it. No amount of medicine will do that. It is the whole basis for trauma systems. (I know this wasn't a trauma, but I think we agree this is still a surgical emergency)

I agree with your entire statement here.

This I do not agree with. If said surgeon already knows this patient is beyond him, while it doesn't harm the statistics of said surgeon, in the interest of the patient, a superior provider is the right choice.

But this involves more than just saying "here is this trainwreck", and having her magically appear at the other end. There is a whole lot that has to happen in between, including transfer of her to our gurney, transfer to our vent and IV pumps, continuous suction to chest tubes, cardiac monitor, art line and CVP (she'd better have those), and then we have to bounce her down the road to the other hospital and do all of the same stuff at the other end. Interfacility ambulance transports are not benign. One of the physicians I routinely do IFT for quoted a 10X increase in mortality for patients that are transferred between hospitals (I can't find that source; I'll have to ask him). In her current condition, she is very likely to arrest between hospitals. What's the answer? Pull out my leatherman, snip the sternotomy wires and do open chest cardiac massage? Cuz that's the only way she's going to get any decent perfusion. This is more than punitive (although, patient care aside, I would force the idiot who started this mess to finish it if I could). IMHO, taking her for a ride from a hospital that has CT surgery is wildly inappropriate; unethical even. The person who did this may not be the best, but he CAN open the chest and try and correct it, making her more stable for transport.

If she dies during transport, there's going to be a big investigation, and one of the questions will be "Why did you transport this patient?". I may or may not have blame legally, depending on the state, but that won't stop the family from suing me and my service. Again, if she had been at a hospital that didn't have CT surgery (like if she didn't feel well after being discharged and went to a local hospital that didn't do her surgery) I would have no problem transporting her. I try not to let legal concerns sway me from doing what I believe is best for the patient, but there's no getting around this: I want no part of this mess.

There is also the legal aspect. From my understanding of EMTALA, you can't do this. They have the capability, according to the law, of fixing their problem.

I agree with this, but the trouble is when the patient has a surgical pathology, you cannot resuscitate successfully until that is fixed.

Fooling around with medical treatments, intensive or otherwise just delays needed surgery.

Agree again.

This lady already has many bad signs of having a bad outcome (death), like making no urine and no response to turning the versed off. I think an ambulance ride would probably contribute to her downhill slide. I respect your opinion and where you're coming from, I just don't agree with it.

We may have to agree to disagree on this one.

 

[Veneficus]

This lady already has many bad signs of having a bad outcome (death), like making no urine and no response to turning the versed off. I think an ambulance ride would probably contribute to her downhill slide. I respect your opinion and where you're coming from, I just don't agree with it.

We may have to agree to disagree on this one.

You entire statemtn is very fair and balanced. I understand your concern about the patient dying in your care, that is a reasonable concern of any provider.

From my perspective which is neither right nor wrong.

If I am convinced the patient cannot be helped by the surgical staff at this facility, dead is dead, and at the facility, in the ambulance, or at another facility is doesn't matter. In the effort to help, the patient stands the best chance moving up the system.

It doesn't mean she will live, recover, or any other positive outcome. It is just a chance where there might be none otherwise.

On paper the sending facility should be able to help. BUt paper and the real world are different as I am sure you know.

You may not be convinced by my argument and that is cool, because different providers have different philosophical approaches.

 

[abckidsmom]

You entire statemtn is very fair and balanced. I understand your concern about the patient dying in your care, that is a reasonable concern of any provider.

From my perspective which is neither right nor wrong.

If I am convinced the patient cannot be helped by the surgical staff at this facility, dead is dead, and at the facility, in the ambulance, or at another facility is doesn't matter. In the effort to help, the patient stands the best chance moving up the system.

It doesn't mean she will live, recover, or any other positive outcome. It is just a chance where there might be none otherwise.

On paper the sending facility should be able to help. BUt paper and the real world are different as I am sure you know.

You may not be convinced by my argument and that is cool, because different providers have different philosophical approaches.

So in the real world, practically speaking, how would you actually do this? Take nursing staff with you for the ride? She has a sketchy airway, multiple devices needing suction, some drips requiring maintenance, and looks ready to arrest again at any minute.

The cct truck I was on only had one medic unless the info received from the facility looked like there was need for more. I can understand completely your rationale for transporting to the new hospital, could you imagine the sending facility sending staff along for the (super risky) ride?

And we are still not moving without that tube sutured in.

 

[Farmer2DO]

I guess a fair compromise would be me providing the ambulance and the paramedic, and the surgeon is going with me. He can bring whatever tools and drugs he wants; he can bring a nurse if he wants. But he's responsible. It's his patient. He needs to ride this train wreck to its likely conclusion. Don't wanna go? That's fine. Enjoy managing YOUR patient here.

And if we put up blood products, an RN, a mid-level, or a physician needs to go with me (in NYS, thank you very much, ENA).

And I agree with your comment about the airway. Secure that sucker.

On a side note, in NYS, it's very clear legally: the transferring physician is responsible for the patient until they arrive at the receiving facility. I also think this would be the wisest course of action for the surgeon; show that he cares about the outcome and is doing everything in his power to correct it. And dumping the patient on a CCT paramedic and his EMT partner is NOT everything.

 

[Veneficus]

In the real world

So in the real world, practically speaking, how would you actually do this? Take nursing staff with you for the ride? She has a sketchy airway, multiple devices needing suction, some drips requiring maintenance, and looks ready to arrest again at any minute.

The cct truck I was on only had one medic unless the info received from the facility looked like there was need for more. I can understand completely your rationale for transporting to the new hospital, could you imagine the sending facility sending staff along for the (super risky) ride?

And we are still not moving without that tube sutured in.

I have this terrible problem with personal responsibility.

I believe in it...

If I messed up the patient, I would most certainly go with the crew personally. I would explain to the receiving physicians in person what I did and what went wrong, and I think it would be my responsibility to help provide to the best of my ability whatever the transporting crew required for the patient.

I think it would be extraordinarily unprofessional for a physician to hand a dying patient to a medic and simply wave good bye and wish them luck. Particularly if I was the physician who messed the person up.

Even if it was an unforseen complication, as far as I am concerned, my patient is my responsibility, and no event bad or good removes the person in charge from that responsibility.

I certainly wouldn't try to turf that responsibility to a nurse or anyone else.

You have to figure, if this transport could not be carried out, the sending surgeon would be in the OR with this patient, so it is not like the ride to and back would prevent him from helping another patient.

Would it cost the facility some money? Sure it would, but mistakes are never free.

It is probably the least he could do.

If I was the medic on the truck, I would probably take the patient. BUt before I did, there would definately be a conference call between a medical director I answered to, the sending doctor, the receiving doctor, and it would be agreed upon that this was an act of compassionate care, not a standard transport that I would be soley responsible for.

I would also make sure the run report clearly stated the duress I was under to accept the patient.

and I would call my employer and request another crew for the extra hands. They could work out the billing with the sending facility.

 

[exodus]

Just wondering, how long are you guys planning on spending on scene debating what to do or whether or not to go? This patient doesn't need medications, this patient needs an OR. If you have spent more than 30 or so minutes on scene and haven't done any procedures you can't do in the truck. It's too long. You could have been at the receiving already, sliding the patient to the prep gurney and been giving a report to the receiving surgeon.

I would do nothing with this patient other than bump the pressors up to maintain ~80 systolic with a blood infusion going. Then do a super fast transport to the receiving where they can do the surgery the patient requires to live. If the patient hasn't coded in 3 hours, I would consider them stable for a 20 minute transport.

 

[exodus]

So in the real world, practically speaking, how would you actually do this? Take nursing staff with you for the ride? She has a sketchy airway, multiple devices needing suction, some drips requiring maintenance, and looks ready to arrest again at any minute.

On all of our CCT transfer of care forms, there is a box that is checked "Patient is stable for transport." As well as: "Patient is unstable, but will benefit from the transport because: ________.".

If that capability is available there, have the MD write in the notes, that they refuse to provide those services due to whatever reasons.

 

[Handsome Robb]

Alright. So we've established this is a bad situation and in the spirit of scenarios I'm going to go out on a limb and say that we probably aren't going to be getting the surgeon or any other staff members to ride with us. Personally I'd rather have another medic from my company, preferably a CCP along for the ride. If we are lucky maybe we can get a double medic car to respond and help with the transport for the simple fact that they are used to working in the back of a moving ambulance in the transport environment rather than taking staff from the sending facility that isn't trained or accustomed to transport medicine.

Not trying to be the negative nancy. I'm just hoping that we can continue the progression of this thread rather than becoming stuck on the fact that the surgeon screwed up and it's his problem so he should ride with us. I agree with this viewpoint. It is, more likely than not, his fault and he needs to be the responsible party for this patient, whether that means opening her back up and fixing the problem our organizing a transport situation that will offer the patient the best chance at the best outcome.

Also, I'd love some feedback on my post

Packed RBCs and FFP.

And just a radial or both? lol. What is the CVP now?

Good point. Although it was a CABG is there some sort of peripheral damage to the thoracic aorta. Could we be dealing with a leaky dissecting aortic aneurysm which could be causing the presumed hemothorax or possible hemopnuemothorax? Is that even a possibility to have a slow leak from an aortic dissection with the pressure involved in the aortic arch? Although she is pretty profoundly hypotensive without the pressors.

If I'm not mistaken aren't pressors contraindicated in the presence of hypovolemia? Thinking about this makes me revert back to my idea of the presence of a cardiac tamponade or cardiogenic shock rather than hypovolemic shock.

Since the transport decision seems to be the hot topic why is this going by ground and not by air? I might have missed a weather report that eliminated this option. She's a high risk patient and since we are so worried about her coding en route why not work on getting her as "stable" as we can at the sending facility while we wait for the flight team to show up. We may be on scene for a little longer but in the end the actual transport time is going to be shorter. I also have limited understanding of flight physiology so I don't know if her current condition would contraindicate areomedical transport.

I know, I know. If you hear hoofbeats think horses before zebras

 

[Veneficus]

The airway needs to be fixed. Don't risk losing it by pulling the original tube and swapping it for a trach tube, cut down the ETT as far as you can and like abckidsmom said, have an MD suture it into place.

I think it would be wise to start by confirming there is an airway and you are not ventilating the mediastinum.

She's bleeding, the continuous drain from the chest tube along with the rest of the presentation seems to confirm this. Let's get some typed and crossed blood to the bedside if it isn't already there and hang it up.

200ml from a chest drain is not much at all. But I agree there is likely a bleed. Where it is coming from and how severe could be debated. I think the most exediant way to determine this is by ultrasound.

If blood is not already typed and matched or typed and crossed (which I hope it is by now, but you never know) then emergent use of O negative is a faster solution in the interest of moving right along.

The transthoracic, abd, and neck space, ultrasound should be nearly done by the time the blood is hung and running.

I second abckidsmom again on the heart tones. JVD + hypotension makes me think pericardial tamponade. If they are muffled get an MD in here and do a pericardiocentesis STAT. I'm probably totally wrong though. On the off chance I'm right does this help her BP at all?.

If it is not a pneumo. But I wouldn't be overly eager to take a tamponade away from a bypass patient CPR was performed on. It might actually be controlling a very big problem like a partial graft malfunction.

During bypass, the pericardium is cut, I doubt it will heal in 10 days sufficent enough to be the major problem in this case.

I think the pressors need to come back up until we can do something about her hypovolemia and potentially low CO secondary to my presumed cardiac tamponade. Sticking with my idea once we do the pericardiocentesis lets try to ween the pressors a bit, one at a time, and see where this takes us.

If I was working on the problem being volume depletion, I would cut back pressors and institute blood products to a sbp of 80 or if transport is short 50.

I don't see a reason why we can't leave the PEEP at 5. Maybe even drop the FiO2 a tad bit more?.

possibly drop FIo2, but keeping intrathoracic pressure elevated collapses low pressure cardiac arteries. There is a chest tube in already so pneumo may not be an issue, but low pressure might be more optimal.

Another thought, the pt's heart was in bad shape to begin with and has now suffered further insult. Could we be dealing with a potential cardiogenic shock along with the presumed hypovolemic shock or am I now just trying to force more :censored::censored::censored::censored: on the pile?

I think you should forget all of those terms. This patient has an oxygen delivery problem. Once oxygen delivery to the heart falls below what it can compensate, it will fail. The cardiogenic shock is secondary to volume depletion. Once volume is fixed, surgically or medically, then you can worry about heart function. But since treatments of hypovolemic shock and cardiogenic shock can have competing effects, trying to fix both at once is rather futile.

If we don't figure out how to fix the hypoperfusion pretty quick we are going to be stuck in a MODS situation that the pt may not be able to overcome if they aren't already there already.

I think MODS in this patient is inevitable. The question being if it can be corrected. She might even life long enugh to get septic.

But I think we are really dealing with organ donation now.