CANMAN
Forum Asst. Chief
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Well, had a really crappy shift yesterday. First time in my career where I had a dislodgement of a therapeutic device while on transport, other then maybe 1-2 IV's over the span of about 14 years.
Shift started out awesome with a good shift brief first thing in the AM and I was working with a team of real A-game players. I also have an orientee with me who is currently in week 4 of his HEMS orientation and is coming along nicely, but didn't have any prior transport or HEMS experience. We were in a backup aircraft that although is the same type of airframe, is configured differently both medical interior and cockpit. (This is a point of contention with me because we have 5 aircraft, all of the EC135 variant, and none of them are exactly alike for items such as radios, location of stuff in the cockpit, etc) My orientee had yet to do a scene call and my partner (who is in my opinion one of the best nurses we have in the program) and I discussed our objectives for the shift and how things would roll. Myself and my orientee had previously discussed and practiced how a scene would normally run, just hadn't gotten a flight together yet, and then it came.....
We got alerted for a scene which would end up being a burn patient headed back to our facility which is the regional burn facility. My orientee was spot on with radio work and coordinates, and we preplanned on the way in. Down and secured and board the EMS unit to find a 169kg male patient with only history of CHF who ended up having 32.5% BSA partial and full thickness burns, mainly to the chest, neck, face, and arms. Alot of the full thickness area was upper chest, neck, and chin area with singed beard and nasal hairs. Patient reportedly "was sleeping" with a lit cigarette and awoke and he was on fire, although he smelled of accelerant and the fire marshals on the scene believed someone threw the accelerant on him and lit him off while inside his home. Patient had carbonaceous sputum, respiratory distress, and difficulty swallowing and controlling his secretions. We were all in agreement this guy took some significant heat and decided to RSI him. RSI although anticipated to be difficult went flawlessly without any issues at all using our new CMAC VL. My orientee did a great job with the airway and first pass without any hypoxia or resulting hemodynamic changes.
I departed to the aircraft with some of our gear to configure a bit and setup our ventilator (Hamilton T1) and a Propofol infusion for continued sedation. Naturally with 3 male flight crew in the back of a 135 with the third patient care seat dropped down, our drug bag, and Hamilton ventilator in the cabin, plus trying to cram a 169kg patient in we were going to be super tight. My other two team-mates packaged the patient with fire staff and brought to the aircraft. I hopped out to assist with the load, my orientee was operating the cot, and the fire guys were assisting. My nurse partner hopped into the aircraft to "receive" the patient during the load. My orientee moved the stretcher towards the clamshells at an angle that I knew was going to make loading difficult just due to inexperience but between myself and one of the firefighters we were able to get the cot moved more towards the left side of the wall/aircraft for loading. The patient was so large that we basically lost most of our visual around his body habitus as he was going to be entering the tunnel. BVM was disconnected, and upon loading the patients arms and shoulders were going to have a difficult time clearing the drop down seat. I focused in on this not wanting to injured his arms during the load, we encountered some resistance during the load as I was trying to push his girth inward to clear the seat, and at this moment the three firefighters gave a big unsolicited heave hoe push and in the patient went....
Unfortunately, so did our ETT, getting either caught up in BVM tubing or something and wedged in-between body habitus and the drop down portion of the tunnel in the 135. It got caught and completely dislodged ughhhhhh.... After the main portion of his body cleared the tunnel my saw my RN partner in the cabin cool, calm, and collected be like "F man our tube is out". I rushed around to the side, my orientee buttoning up the back not aware of what had happened, and started to assist my partner who started to mask the patient with BVM. Patient had copious secretions at this point and we attempted to suction, only to find out the onboard suction was not pulling vacuum. Troubleshooting failed and we quickly moved on to our portable backup, which was checked earlier that morning, to find that it too was also failing. It would not pull more than 50mmHG of suction and we were unable to clear alot of the secretions. Wiped the face off as best we could and patient is quickly becoming hypoxic. Got a slightly better seal but was still less than perfect with a two person BVM technique, OPA, and jaw thrust. We were able to ready our backup standard intubation gear and were able to pass another ETT successfully with a standard mac blade and bougie. At this point we secured, sedated, and vented and pulled pitch to lift the scene towards our destination.
Enroute had to make some vent changes for hypoxia and hypercarbia and the patient responded well. Dropped off at our center with ETCO2 less than 48mmHG and Spo2 hovering around 94-95% on 100% FiO2 and PEEP of 10. Attending anesthesiologist came over to myself and my partner as we were debriefing and was surprised that we even originally got the patient intubated, let alone were able to re-secure the tube after dislodgement in the aircraft with a bougie and said we did a "hell of a job". Unfortunately that did not make us feel any better about the situation.
Patient is currently admitted to our Burn ICU and ended up having a grade 3 inhalation injury and bought himself escharotomies of his neck, left arm, and chest last night due to increasing pressures. They are still having some issues with oxygenation and he is on 20 of PEEP when I went up to check on him. Labs and CXR today also show some mild CHF going on.
This has been really tough for me as I pride myself on being clinically strong and having excellent situational awareness. It was truly a swiss cheese model of so many holes lining up, and then some equipment failures just made things 10 times harder. I gave the analogy of imagine you are drowning and someone hands you a baby yesterday, because thats just how it felt. Haven't had that feeling in a very very long time.
Debriefing we all agreed we should have just shut the aircraft down and loaded cold due to his body habitus and difficult airway which would of given us ability to slow things down and communicate with everyone involved. I also struggle with the fact that I feel responsible because I was focused on the wrong stuff during the load, and question if I should have be the one loading in this situation vs. my orientee so I could have slowed the load down and called out some instructions to the fire guys and for my orientee to watch the airway....
Troubleshooting wise the motor in our portable suction unit indeed went bad and was found to be faulty by our biomed department. Aircraft suction was found to be working after some troubleshooting. This backup aircraft has an additional pilot controlled switch for "EMS Vac" that apparently is always in the on-position on our other aircraft and left that way, and during the pre-flight and call our pilot missed this was thrown to the OFF position rendering it in-op.
I am worried for the first time in my career of getting in trouble for an honest mistake in the setting of a difficult call. I am relatively new to this program, and the culture isn't that great. Historically they have disciplined and even fired certain staff members for calls gone sideways (most of those had other factors) but needless to say I am nervously anticipating our sit down.... No one is going to be harder on myself and my partner then we are just based off the type of provider's we are and how we hold ourselves to high standards. So I am hoping I am just overreacting. It's just really upsetting. Not something I ever wanted to have happen in my career, and certainly not something I wanted my orientee to have to see and be a part of this early on.
So, anyone else have S-show type calls they have been on?
Shift started out awesome with a good shift brief first thing in the AM and I was working with a team of real A-game players. I also have an orientee with me who is currently in week 4 of his HEMS orientation and is coming along nicely, but didn't have any prior transport or HEMS experience. We were in a backup aircraft that although is the same type of airframe, is configured differently both medical interior and cockpit. (This is a point of contention with me because we have 5 aircraft, all of the EC135 variant, and none of them are exactly alike for items such as radios, location of stuff in the cockpit, etc) My orientee had yet to do a scene call and my partner (who is in my opinion one of the best nurses we have in the program) and I discussed our objectives for the shift and how things would roll. Myself and my orientee had previously discussed and practiced how a scene would normally run, just hadn't gotten a flight together yet, and then it came.....
We got alerted for a scene which would end up being a burn patient headed back to our facility which is the regional burn facility. My orientee was spot on with radio work and coordinates, and we preplanned on the way in. Down and secured and board the EMS unit to find a 169kg male patient with only history of CHF who ended up having 32.5% BSA partial and full thickness burns, mainly to the chest, neck, face, and arms. Alot of the full thickness area was upper chest, neck, and chin area with singed beard and nasal hairs. Patient reportedly "was sleeping" with a lit cigarette and awoke and he was on fire, although he smelled of accelerant and the fire marshals on the scene believed someone threw the accelerant on him and lit him off while inside his home. Patient had carbonaceous sputum, respiratory distress, and difficulty swallowing and controlling his secretions. We were all in agreement this guy took some significant heat and decided to RSI him. RSI although anticipated to be difficult went flawlessly without any issues at all using our new CMAC VL. My orientee did a great job with the airway and first pass without any hypoxia or resulting hemodynamic changes.
I departed to the aircraft with some of our gear to configure a bit and setup our ventilator (Hamilton T1) and a Propofol infusion for continued sedation. Naturally with 3 male flight crew in the back of a 135 with the third patient care seat dropped down, our drug bag, and Hamilton ventilator in the cabin, plus trying to cram a 169kg patient in we were going to be super tight. My other two team-mates packaged the patient with fire staff and brought to the aircraft. I hopped out to assist with the load, my orientee was operating the cot, and the fire guys were assisting. My nurse partner hopped into the aircraft to "receive" the patient during the load. My orientee moved the stretcher towards the clamshells at an angle that I knew was going to make loading difficult just due to inexperience but between myself and one of the firefighters we were able to get the cot moved more towards the left side of the wall/aircraft for loading. The patient was so large that we basically lost most of our visual around his body habitus as he was going to be entering the tunnel. BVM was disconnected, and upon loading the patients arms and shoulders were going to have a difficult time clearing the drop down seat. I focused in on this not wanting to injured his arms during the load, we encountered some resistance during the load as I was trying to push his girth inward to clear the seat, and at this moment the three firefighters gave a big unsolicited heave hoe push and in the patient went....
Unfortunately, so did our ETT, getting either caught up in BVM tubing or something and wedged in-between body habitus and the drop down portion of the tunnel in the 135. It got caught and completely dislodged ughhhhhh.... After the main portion of his body cleared the tunnel my saw my RN partner in the cabin cool, calm, and collected be like "F man our tube is out". I rushed around to the side, my orientee buttoning up the back not aware of what had happened, and started to assist my partner who started to mask the patient with BVM. Patient had copious secretions at this point and we attempted to suction, only to find out the onboard suction was not pulling vacuum. Troubleshooting failed and we quickly moved on to our portable backup, which was checked earlier that morning, to find that it too was also failing. It would not pull more than 50mmHG of suction and we were unable to clear alot of the secretions. Wiped the face off as best we could and patient is quickly becoming hypoxic. Got a slightly better seal but was still less than perfect with a two person BVM technique, OPA, and jaw thrust. We were able to ready our backup standard intubation gear and were able to pass another ETT successfully with a standard mac blade and bougie. At this point we secured, sedated, and vented and pulled pitch to lift the scene towards our destination.
Enroute had to make some vent changes for hypoxia and hypercarbia and the patient responded well. Dropped off at our center with ETCO2 less than 48mmHG and Spo2 hovering around 94-95% on 100% FiO2 and PEEP of 10. Attending anesthesiologist came over to myself and my partner as we were debriefing and was surprised that we even originally got the patient intubated, let alone were able to re-secure the tube after dislodgement in the aircraft with a bougie and said we did a "hell of a job". Unfortunately that did not make us feel any better about the situation.
Patient is currently admitted to our Burn ICU and ended up having a grade 3 inhalation injury and bought himself escharotomies of his neck, left arm, and chest last night due to increasing pressures. They are still having some issues with oxygenation and he is on 20 of PEEP when I went up to check on him. Labs and CXR today also show some mild CHF going on.
This has been really tough for me as I pride myself on being clinically strong and having excellent situational awareness. It was truly a swiss cheese model of so many holes lining up, and then some equipment failures just made things 10 times harder. I gave the analogy of imagine you are drowning and someone hands you a baby yesterday, because thats just how it felt. Haven't had that feeling in a very very long time.
Debriefing we all agreed we should have just shut the aircraft down and loaded cold due to his body habitus and difficult airway which would of given us ability to slow things down and communicate with everyone involved. I also struggle with the fact that I feel responsible because I was focused on the wrong stuff during the load, and question if I should have be the one loading in this situation vs. my orientee so I could have slowed the load down and called out some instructions to the fire guys and for my orientee to watch the airway....
Troubleshooting wise the motor in our portable suction unit indeed went bad and was found to be faulty by our biomed department. Aircraft suction was found to be working after some troubleshooting. This backup aircraft has an additional pilot controlled switch for "EMS Vac" that apparently is always in the on-position on our other aircraft and left that way, and during the pre-flight and call our pilot missed this was thrown to the OFF position rendering it in-op.
I am worried for the first time in my career of getting in trouble for an honest mistake in the setting of a difficult call. I am relatively new to this program, and the culture isn't that great. Historically they have disciplined and even fired certain staff members for calls gone sideways (most of those had other factors) but needless to say I am nervously anticipating our sit down.... No one is going to be harder on myself and my partner then we are just based off the type of provider's we are and how we hold ourselves to high standards. So I am hoping I am just overreacting. It's just really upsetting. Not something I ever wanted to have happen in my career, and certainly not something I wanted my orientee to have to see and be a part of this early on.
So, anyone else have S-show type calls they have been on?
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It's certainly not the first CF by any stretch, but is the first CF I have been on where an ETT was yanked due to not paying attention. I appreciate the support guys. This call will most certainly stick with me and affect some decision making moving forward in these type of situations. In both my programs hot loads on scene with fire personnel is/was common practice and I have felt comfortable with that. I am 110% sure my current program wouldn't be open to the concept of cold loads if/when involving anyone else but flight crew, but I can certainly exercise that whenever I am flying and feel the need. Given this situation all over again it's the biggest decision I wish I would have executed. I am frequently a caller of cold off-loads at our primary facility for extremely sick and multiple intervention patients. When I first came here it was a frowned upon request, not from our pilots, but from the medical crew members because "this is the way they have always done it". We have to reposition from our primary to the secondary pad after patient drop off so it just became common practice here. It wasn't until I saw a crew trying to offload a balloon pump, vented, and 6 drips like idiots and I called for the pilot to cut it as I came out to assist that people got the concept of being able to communicate effectively with the big fan off. So I guess that's why I am just frustrated because I know better and failed to make that decision on the scene which could have prevented this. But like you guys said no one is infallible and what I do with the experience is what matters. Thanks again!