What could I have done better?

[weretiger13]

We got a call around 0500 the other morning, for a 57 M pt, Hx lung CA, c/o DIB. Like morons, we actually listened to directions dispatch gave us, causing us to take at least an extra 5 min to get on scene. Roads are absolutely horrible, pure ice sometimes covered by 3-4" snow.
We get there, MFRs have the pt on 8 L O2 via nasal cannula. Pt keeps saying "I just wanna breathe." The pt is coughing up blood, apparently ever since a biopsy 2 days ago, and has severe pedal edema. btw, pt is quite large, barely fits on the cot. We put the pt on 15 L NRB. As we are heading toward the ambulance, a mfr comes over and states pt wife wants no-code status. However, we have nothing in writing.
As we push the cot into the unit, the pt stops breathing. I commandeer a mfr to help me as my partner drives. Roads are horrible, so transport time will end up being 20-30 min. First thing, i have the mfr bag the pt. I tried to insert an OPA, but the pt's jaw was clenched. So, continue bagging, and I insert a NPA instead. Lung sounds barely present in upper lobes, absent everywhere else. Hook up the monitor, sinus tach. Pulse matches monitor.
I set up to start an IV, pt has very poor venous access. I tried twice to get an IV, failed both times. Look up at the monitor-crap. Idioventricular. Check pulse-no pulse. I begin CPR while the mfr continues to bag the pt. Frothy blood coming out of nose and mouth now.
My partner calls the ER, tells them the pt has coded, I'm doing CPR, and that we were told by a mfr that the wife wants no-code, but nothing in writing. ER told us continue bls. As we pull into the ER, the pt goes into asystole. (In the ER, they decided not to work the pt.)
My question is, what could I have done differently or better? I could not intubate due to the clenched jaw. I thought about starting an External Jug, which we are allowed to do, but to do that I would have had to sacrifice chest compressions. The pt was never in a shockable rhythm. I also though about trying to nasally intubate (which I've never had success with), but again, I would have had to sacrifice compressions. So again, I ask, what could I have done better? Any suggestions are welcome.

 

[MEDIC213]

If there were no spontaneous respirations, I don't see how you could have nasally intubated either. Maybe a trach, but if you're getting good ventilations with a BVM I would stick to it. As far as not being able to get a line, we're about to go to the EZ-IO's, so that takes care of that. Otherwise, you did what you could.

 

[Grady_emt]

Sometimes a BCLS code is the best thing to do in certain situations. Besides possibly taking an extra set of hands along with you (MFR), and given the circumstances, you did what you could which is what you should do for any patient.

 

[Evintos]

So I went to discuss your situation with a bunch of other EMTs, mostly EMT-B's, we came to the same conclusion that we would have used suction, keeping in mind ABC's as the frothy blood is compromising the 'A' and 'B' and CYA (code status and not having it written, although the ER complicated things a lot).

Not to sound like a broken record but "you did what you could." Obviously we weren't in the situation you were in and would not know how we would really respond to it if we were in your shoes. We can only give you these suggestions after rereading your scenario and thinking about it. CYA.

 

[firetender]

The time for you to do "better" is right now. That better is to let the call be what it was. The things you learned had nothing to do with technique and all have to do with finding pacing and rhythm. Trust that if you get into a similar situation, you'll do things a bit different because every situation IS different.

 

[Ridryder911]

On to top what Fire stated, you obviously want to learn off something.

It is easy to play arm chair quarterback, but I do not know your protocols but reviewing; here are some suggestions.

Maybe calling your Medical Director and advising the situation and getting a verbal DNR. Considering the history and situation. Possibly avoiding anymore treatment after aystole, altogether.

In regards to EJ, probably should had established it. Sorry, allow your MFR to perform 1 man CPR, stop for a few seconds start the line. It is not by the book in the real world. CPR can continue with an EJ attempt.

Carry Versed? Remember, versed can be administered intranasal, this would could have possibly allowed intubation. CPR and compressions are important, but again in a PEA situation, the airway maybe the cause... and if an airway is established, PEA maybe resolved (doubtful).

Again, you learn. You do the best you can do, that is all one can attempt. Don't beat yourself up.

R/r 911

 

[BossyCow]

Sometimes we do everything 'right' and the pt still dies. That's how we pay for those calls where everything that could go wrong did, and the pt lived.

 

[So. IL Medic]

Only thing I would add is to emphasize the IO route.

 

[weretiger13]

Thank you all for your comments. Hopefully next time I'll be able to apply some of the lessons I have learned from this call. One of the many things I love about this field is we never stop learning and, hopefully, improving.

Weretiger

 

[NRNCEMT]

Do you know if the bloody, frothy secretions came from a pneumo-thorax caused by the biopsy?

 

[medic5045]

Sounds like you did a good job. You can't beat yourself up over this kind of call, The patient sounds like he was in the late stages of lung CA. going with the EJ would have been a good idea stopping compressions to start an IV is ok and if the EZ-IO was available you said this patient was very large so that might not have worked EZ-IO'S are great we use them and i have come across times when the patient was overweight and unable to use it. Versed would have help with the intubation. Just remember we can't save them all but when we do save somebody don't it feel great!