Tuesday, February 19, 2008

Another Student Installment

Yesterday was one of those days where it was a sort of mixed bag of stuff, all of it a bit of a challenge, and none of it boring or dull.

First off, I have another Paramedic student. His name is Keith, and he is an active duty member of the United States Army where he serves as a flight medic. A note about that: you do not have to be a Paramedic to be a flight medic in the military, although it is helpful to have the certifications, from what I am told. The Army Health-Care field's training is such where 68W's (I believe that is the new MOS for Army Medics - I know it used to be 91W) are initially trained up to the level of a Nationally Registered EMT-Basic and given further training beyond that which is Army-specific. I also know that the only Army-qualified Nationally Registered Paramedics are those serving in special operations-type capacities, i.e., Special Forces, Rangers, and others. Air Force Pararescue jumpers are also trained up as Nationally Registered Paramedics, as are Navy SEALs whose initial MOS is that of a hospital corpsman. Both PJ's and SEALs, as well as SF and Ranger medics, get a boat load of additional training beyond the National certification. I have copies of their protocols, and what they can do outstrips anything I can do in the field by a long shot.

Back to my student. He is in the same Paramedic program that I went through, and he has finished all of his classroom and most of his hospital rotations. He's started his field rotation with me, and I'm going to give him the best I have to get him to where I believe he needs to be. And with that, yesterday was a sort of "baptism by fire" for him. Our first call of the day was for a person who had fallen. An engine company was sent along with us, and when we got the dispatch sheet off of the Fire Alarm printer, it was because our patient was a combative 600 pound male. Hell of a way to start.... Well, we got on scene and found this patient: 45 years old, 6'6", and very, very large. He was sitting on his sofa being attended to by the firefighters. He was alert and oriented, color wasn't great but he didn't look really bad, either. The fire guys had him on a non-rebreather at 15 liters/minute of Oxygen, and when I started asking questions I found out that this man had a history of Congestive Heart Failure and was also a non-insulin dependent diabetic. The patient's main complaint was a bruise on the inside of his right elbow; his problem is that he'd been having trouble with circulation of late, and his primary care physician wanted him to have it evaluated.

By all accounts, he was not combative; he actually was a really nice guy who just happened to be extremely large, so much so that he needed to be transported on our bariatric stretcher.... So we made the call to have our bari stretcher and the unit who transports with it brought to the scene. At that point we released the engine, thinking we would be able to handle him with the 5 of us that would ultimately be there.

So while we were waiting, we got some further history from his son and his ex-wife who happened to be there. In addition to what he told us, he also had a history of coronary artery disease with a prior heart attack, to which our patient said, "it was a minor one." He also had been having episodes of slurred speech and he had passed out at one point, which the patient denied - pretty emphatically, in fact. We got vitals except for a blood pressure as we didn't have a cuff big enough anywhere. We also checked his blood glucose, which was 409 - pretty high. At that point the patient told us his doctor had been working with him on adjusting his medication doses as what he'd been on wasn't working on his sugar levels. He denied chest pain, denied any real difficulty in breathing, wasn't dizzy, didn't have any nausea or vomiting. We took him off of the Oxygen and checked his saturation level a few minutes later, and it was 98% on room air. His heart rate was a little quick, just over 100. We considered putting him back on Oxygen to try to help his heart rate come down, but he didn't want it.

By this time the transfer unit with the big stretcher arrived. When the crew on that truck tried to get the stretcher into the apartment, we found it wouldn't fit through the doors, nor would it fit through the slider on his ground floor deck, so we had to walk him - slowly, at his own pace - out to where the stretcher was, approximately 10-12 feet away from the slider, probably a total distance of 15-18 feet. It took a few minutes to do this, but we were able to get him out to the bari stretcher and get him seated on it. We had the head of the stretcher all the way into a 90 degree angle and he used up every inch of the space on it. Once we got him on the stretcher, we got it raised as high as it would go and moved him to the ambulance to load him on. It was tricky because there were a couple of stairs, but we got him successfully loaded aboard. Then the trouble started.

As soon as we locked the stretcher into the frame, he started to gasp. We checked him, and we discovered that he had gone unresponsive - he'd been talking to us while he was being loaded aboard, less than a minute before. Two of us pushed him into a higher sitting position, thinking that perhaps he'd lost his airway. He'd gagged a couple of times while Keith, my student, was trying to talk him through breathing. At that point, the patient stopped. Everything happened at once - he went this really dark shade of purple then ashen gray, he'd stopped breathing, he'd lost his pulse, and we got him on the monitor immediately and discovered he was in asystole. All in a span of maybe 15-20 seconds. So we started resuscitation on him - CPR right away, he had no airway to speak of and myself and J, the medic from the other truck, tried to intubate him but had nothing to work with just because of his size. He got a combi-tube instead. We got an IO into his right tibia with patent flow, and he immediately got a round of drugs. After 4-5 minutes of CPR we re-checked to see if we had anything to work with. Nothing - no change in rhythm. We got underway (Space, J's partner, drove like the wind) and got a second round of drugs into him. After 3-4 minutes we re-checked and found we had V-Fib on the monitor - we got a shock in. That pushed the patient back into Asystole, so we continued CPR. Got to the hospital, the two docs and a number of nurses and others came out to the truck. The doc, KZ, asked us what we had and what we'd gotten done. We told her what happened, the patient's history, and what was done for efforts, and when she saw the patient she called it right then and there.

The family showed up about 10 seconds after that - I took matters into my own hands and intercepted them, brought them into the family room inside the ED, and told them what had happened. The patient's ex-wife was saddened as you'd expect, but his 21 year-old son took it really hard. He believed it was his fault that his father died. I sat them down and talked with them both - I'm glad his mother was with him - and explained that there was noting that he did to cause his father's dying. I told him that because of his father's size and medical problems, there was nothing that he did that pushed his father over. His mother then said that I was right and that it was only a matter of time before it happened.... They were both grateful for all of our efforts. A few minutes later, Dr. Z went into talk with them, and from what I was told she basically said the same thing that I did.

A tough situation, but a good learning experience for my medic student, all things considered. And they don't get much more difficult or complicated than this one did, and he handled it both appropriately and rather well. I was impressed.

The other notable call was for a "sick person." We found this 69 year-old male who has what I suspect is either leukemia or possibly one of the lymphomas - I'm not sure. Fever and chills going on for 2 days after having received 2 units of whole blood and a unit of platelets. Made me think transfusion reaction initially, but there are a couple of nasty viruses out there with symptoms like this, including the strains of influenza.... No nausea or vomiting, but he had a temperature of 103.9 degrees F. He also had a foley catheter in place for problems with BPH (an enlarged prostate), and he had a PICC line (Peripherally Inserted Central Catheter) in his right arm. He'd been taking both Tylenol and Motrin for the fever with no breaks. Very warm and dry, pale, and shaking almost uncontrollably. His sister was there - she was the caller - and she told us about the blood transfusion and gave us what medical history she could. We took him up to the hospital after we assessed and packaged him, and he ended up in an isolation room due, I suspect, to his immune system being vulnerable. He got IV fluids and more drugs to work on the infection that he was likely harboring. We didn't give him fluids on the way, and the only reason is that I didn't want to play with the PICC line; it's not that I couldn't, but considering his condition I figured it would be best if he were dealt with in the setting that he ended up in. That ended up being a wise choice.

Keith will be back next Monday. Hopefully I won't show him such a good time....

1 comment:

Ellie said...

Interesting call with the bariactic arrest. It was cool to read your version and the version that Space wrote.
Hope all is well with you in ManchVegas!