Trainwreck #6

[usalsfyre]

Sorry for the late reply, the last couple of days has been overrun.

We ended up transporting after securing the airway with the "three ultra gorilla wraps of tape".

We went immediately back up on the levo and started working the dopa down to work on the HR and increasing ventricular fill, we ended up weaning down to a pressure of 130/70ish on 10mcg of dopa and 20 of levo with a HR of 112.

Chest drain stopped putting out after 200mls.

No blood was administered (it wasn't available but I can't go into more detail than that in public).

Patient was transported relatively uneventfully and expired within 12 hours.

A surgeon was not available at the sending was the reason for transport.

Overall it was an ugly case. Just wanted to share with what I see as a kick-@ss group of clinicians.

 

[abckidsmom]

With no urine output and an already high K, being post arrest for the hyperkalemia, can anybody speak to the smarts of giving blood before starting CVVHD? Seems like a robbing Peter to pay Paul kind of thing.

Crazy situation. Lots of issues to think about. Thank you for sharing. You really bump into a bunch of train wrecks in your world. I'm going to have to start a series of scenarios called Marginally Interesting Points to Ponder. It's about all I can drum up in my real life.

 

[Veneficus]

With no urine output and an already high K, being post arrest for the hyperkalemia, can anybody speak to the smarts of giving blood before starting CVVHD? Seems like a robbing Peter to pay Paul kind of thing.

For certain it is.

But in my experience of seeing people last days sometimes weeks with hyper K and minutes to hours when hemorrhaging, I'll take the hyper K.

Any word on if there was an ultrasound or where the blood was if they needed a surgeon and there was only 200 ml in the tube?

 

[Farmer2DO]

I have this terrible problem with personal responsibility.

I believe in it...

Me too. I'm glad there are some providers that think this way.

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.

Unfortunately, I see this ALL THE TIME.

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.

Excellent advice.

A surgeon was not available at the sending was the reason for transport.

This is probably the only reason I would consider this a legit transfer. That being said, I'm sure they could find SOME surgeon around, even it it's not a CT surgeon, to go with me. I mean, from what I've been taught, if a post-CABG patient arrests, they need their chest opened, because closed compressions just aren't going to do it. A general surgeon, or even an OB/GYN would be better than nothing, because open chest cardiac massage just isn't in my scope of practice.

But any other surgeon would probably pull the "I'm not a CT surgeon; this isn't my area." Nor is it mine.....

I think you did the best you could with what you had.

 

[Veneficus]

I'm sure they could find SOME surgeon around, even it it's not a CT surgeon, to go with me. I mean, from what I've been taught, if a post-CABG patient arrests, they need their chest opened, because closed compressions just aren't going to do it. A general surgeon, or even an OB/GYN would be better than nothing, because open chest cardiac massage just isn't in my scope of practice..

Unfortunately, because of the way the system works, they probably couldn't find one.

Too many problems with statistics,billing, and liability.

But any other surgeon would probably pull the "I'm not a CT surgeon; this isn't my area." Nor is it mine.......

Unfortunately this a a problem in all of current surgical practice. General surgery is more or less the required training before a subspecialty now. Total body surgeons are almost nonexistant, replaced by hyperspecialists. This trend is likely to continue in the US.

Having said that, there is a growing need of the old school general surgeon. In areas where costs need to be contained, providers are in short supply, and for emergent patients.

Right now, only the surgical intensivist sort of fills this role. Which is an indemand specialty. Nobody wants to go into it though.

At some level of hyperspecialty, costs exceed benefit and needed service no longer exists.

I better stop now, before I really get going.

 

[jjesusfreak01]

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.

No room for all the equipment attached to the stretcher...