Wednesday, January 31, 2007

Tea, Earl Grey - Hot

The beverage of choice as I sit here writing. The mug is steeping and steaming on the desk next to me, and I will wait a little longer before I actually drink it. It's funny, with coffee I have to at least put milk or cream into the cup with the coffee as I don't like it black. Tea, however, is a different story. I learned to enjoy it without any additions, like milk or sugar, or even honey and lemon. I guess it was one of those tastes that I acquired over time and it stuck with me.

Yesterday was a tough day, at least to start out. Our first call was for a cardiac arrest. While we were on the way to the location of the call, Fire Alarm informed us and the engine company responding that the nature of the call was changed to an airway obstruction, which we both acknowledged. When we arrived on scene, we found this 64 year-old female appearing to be in distress. The firefighters were first on scene and they told us that they found her face down on the floor of her bedroom, unconscious. When the rolled her over to assess her, she regained consciousness, and they were able to sit her up, which they had done prior to our arrival. My primary impression was that she was in trouble - she was obtunded, but she would respond to questions, although somewhat slowly. She was pale, cool, and diaphoretic. One of the firefighters told us that he was able to get a systolic blood pressure of 130, but neither my partner or I believed that, as we couldn't find a radial pulse. She was also incontinent of stool, and continued to be while we were in transit with her. When she was able to talk to me, she had told me that she was nauseous and had had some dry heaves before we arrived.

Her history included a repair to an occlusion to her left brachial artery two weeks ago. The sutures were still in her bicep, looked fresh, and were dry with no redness or swelling. She also had a history of anxiety; before all of this started her husband, who I found out later is a pharmacist, gave her one of her prescription 1mg Ativan tablets. I was made aware of this as we were in the ambulance attempting to do the interventions we could at that time. She had no IV access, which made things more of a challenge. She was rather obese, which added another layer of complexity to all of the things going on at the time. Our attempts to oxygenate her were futile as she would keep tearing the non-rebreather mask we had put on her. Her heart rate started off at 64 BPM, and while we were en route in addition to her fighting with me, due to what I suspect was confusion brought on by increasing hypoxia, she began to brady down. When we arrived at the hospital, her heart rate was somewhere in the 40's and as we were wheeling her through the doors into the treatment room, she went unresponsive and became apneic. At that point it became the cardiac arrest that we were originally called for, albeit a witnessed one. The rest of the events went like clockwork; she was intubated immediately, and it took 4 of us to get IV access on her. My partner and I were looking for access in her feet, while two of the nurses (and I believe the shift's token Paramedic student) were looking on her arms. There was no access to her neck (she didn't have one), and the attending physician's attempts to put a central line were just as unsuccessful. We were finally able to get access in both of her feet and one of her arms, but it was a struggle.

The code was worked in the ED for approximately 45 minutes, and everything that could have been done was done: she got all of the resuscitory drugs (epinephrine, atropine, amiodarone, calcium chloride, and sodium bicarbonate, and probably others that I missed), she got paced, defibrillated at a couple of points, and I personally did most of the CPR. The attending had a doppler system that he was able to ultrasound her heart with, and at one point there was still activity but not enough to pump blood through this woman's body. So we kept at it until we were stopped.

In talking to the doc and a couple of the nurses afterward, the suspicion was that she may have had an underlying thrombus as a result of the surgery she had to repair the occlusion to her brachial artery. If that was indeed the case, there was nothing anyone but a surgeon could have done to keep her alive. At the point we were at with her, if this was indeed the case, it was too late.

We did 4 other calls yesterday, none as difficult as that one, thank God. One of them was for a 52 year-old female with chest pain. We arrived at the residence, and found that our patient was a non-english speaking Hispanic woman with a history of hypertension and of type 2 diabetes. For some reason my Spanish wasn't working, so I called the language line for help. We were able to determine that she wasn't having chest pain after all, but what she was able to describe as a "fluttering sensation" in her chest; she felt like her heart was racing and she wanted it to stop. Her vital signs were all within normal limits except for her pulse, which was approximately 180 BPM, confirmed with a pulse oximeter. We got her out of her apartment and into the ambulance; the first things we did were to get IV access (which we did), and get her on the cardiac monitor. The initial rhythm was Supra-Ventricular Tachycardia at 186, and I confirmed it with a 12-lead ECG. Because her BP was in normal limits I wasn't going to perform synchronized cardioversion; I figure that is reserved for when a patient in this condition is most unstable; clearly this woman was not there. So we started with 6mg of Adenosine rapid IVP followed with a rapid 20ml fluid bolus. It was the first time my partner had ever participated in this, I think; he was like a little kid. I thought it was kind of cool to see.... Anyway, we got the Adenosine on board and counted - at the count of 4 we watched the monitor go flat and the patient's eyes all of a sudden rolled back into her head. Then 2 seconds later she started to pick up a beat, which converted to a sinus tachycardia of 108. She started to cry, we (me, my partner, and the engine company who was there with us and wanted to watch) all started to clap. It was pretty awesome to see that a drug that's advertised to do this actually did it. I've seen it before - a few times, in fact - but it still blows me away to see it work.

The patient was stable all the way to the hospital, and by the time we got there I got some of my Spanish back and was able to talk with her a little. She felt better, but it was important for her to be observed to ensure that she didn't have a repeat occurrence.

The other calls included a possible hip fracture, an elderly male having weakness and dizziness and trouble keeping his oxygen saturation level stable (he was a nursing home resident and we got this from the nurse who gave us report), and a call that turned out to be miscommunication between our operations staff and the person who called. It turned out that he wanted one of our wheelchair vans - he is a very big man and travels with the help of a motorized wheelchair. Well, our operations "turfed" the call to Manchester Fire, for some reason. I think they thought that this patient could go by ambulance. When we arrived, it turned out not to be the case; the patient, who it turns out I know, was annoyed that we showed up. Not at us, but at whomever sent us. Well, we fixed the situation with a phone call to operations. We got the supervisor on the phone, and he tried his best to get us to take the call. We made it clear, with help from the patient, that we needed a chair van. First off, the patient weighs in at approxmately 600 lbs. There is no way that we could move him without help in any case. Second, the patient told us that this was not an emergency and he could wait the 30-45 minutes that it would take for a chair van to arrive at his residence. So he refused us, and waited for the chair van.

I only found out that operations had blown the call off when I obtained times for the call on the Fire Department's CAD system, and I saw that the requestor was one of our dispatchers. Not the first time it's happened, and probably not the last, either. But it was annoying to see that.

Today, in contrast, has been happily boring. I am off today, and I didn't get out of bed until noon. I'm doing household chores, and writing this. More to talk about later.

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