Wednesday, July 01, 2009

Beyond Our Control

It was bound to happen.

Called out at 0320 this morning for a person bleeding from a surgical site. Dispatched as a delta-level call – on the alpha/echo scale from MPDS (this stands for “Medical Priority Dispatch System”, which is how the state 911 system classifies medical calls) it is the second highest priority. Only echo-level calls (usually cardiac or respiratory arrest calls and other equally bad situations) are higher priority as a rule. And in hindsight this probably should have been dispatched out as an echo-level call.

We arrived at the location of the call to find 3 Goffstown police officers already on scene, plus there were a number of panicked, totally unhelpful family members running around and unable to answer my or Gretchen’s (she is my partner on the overnight) questions. There was an obscene amount of blood – it was everywhere. Patient was a 73 year-old female who’d had vascular grafting done approximately a month earlier. The incision site in her right groin had opened up, and it was bleeding profusely. She had a wound vac attached to the site, and the tubing was full. It looked like the vac sucked up a whole bunch of her blood volume, and the site was bleeding all around the vac dressing.

Patient was pale, cool, diaphoretic (I think to describe her as “shocky” is perhaps an understatement) and had an altered mental status. She was sitting on a commode in her bedroom, and she actually tried to stand up to get off when we got the stretcher into the house. There was no way, however, that we could even think of letting her do that. So I picked up the commode – with her on it – and pulled it out of her bedroom and into the living room so we could get her on the stretcher. In the midst of all this I got on the radio and requested help; the cops on scene certainly couldn’t get on the ambulance with us because of the position they were in. Hell, even if they could, I wouldn’t want them; of the three officers there, the only one without the “deer in the headlights” look was the patrol supervisor that showed up as we finished packing her up to go. The other two officers looked somewhat terrified. Thankfully, the engine company that we asked for arrived about a minute after that.

We got her out of the house, on to the ambulance, and on the road, arriving at the hospital about 6 minutes later. Total time from when we arrived on scene to when we arrived at the hospital was just about 20 minutes. In that time, we found the following:

  • She had no blood pressure to speak of. I think I picked up a systolic in the 60’s, but I couldn’t be sure
  • She kept pulling the non-rebreather mask we put on her off, ostensibly because of her mental status. This continued up until about a minute or so before she crashed in the trauma room
  • We could get no IV access; between Gretchen and me (I kidnapped one of the firefighters to drive so we could both work on her) we tried numerous times to find spots to put a line in with absolutely no success

The problem with access was no better in the hospital; the attending doc ended up putting a central line in because we had no peripheral access, and the nurses (and I; I continued to help in the trauma room) still could locate nothing; we looked in all of her peripheral extremities, and there was simply nothing to work with.

Probably 7-8 minutes after we arrived, her heart rate became markedly bradycardic, and within a few minutes, in spite of all the efforts to keep it from happening, she went into cardiac arrest. Became unresponsive, pulseless, and apeneic. She was intubated and CPR was started at that time. We continued for nearly an hour, with pulses returning and leaving multiple times. She got lots and lots of medication, including the maximum dose of Atropine prior and during the period of bradycardia. She got at least 8 doses of Epinephrine, possibly more, but I lost count after the sixth or seventh that I heard called out by the nurses. She also got 2 grams of Magnesium Sulfate as well as a significant dose of Amiodarone (300mg to start and 150mg more to follow), and the blood bank showed up with four units of O-Negative whole blood. Two units went in rather fast once it arrived. Plus we kept rotating around and around doing CPR.

We got to about 1 hour, and with no real changes, it was decision time for the attending doc. This was a difficult call; should we continue efforts or spare her any more suffering?

It became increasingly apparent that no matter what was done to intervene, nothing was going to help her. And I couldn’t help thinking that if her family had called even an hour earlier it might have saved her life.

Time of death was 0434 this morning.


Ellie said...

That's a rough call. How frustrating that you had so little time!
You guys (and the hospital too) don't have IO drills? Those things are golden. Not that even getting access would have even helped at that point.

Karen Brook Westhaver said...

So sorry, Walt. The further along in reading this post, the more I was afraid the ending would be as it was. Fast, creative and courageous work on your part! But I know it doesn't make this outcome any easier. Surely you know you, partner and crew (cool move "kidnapping" the fire dept. guy to drive so you + partner could continue to work with the pt)did more than everything you all could do. Prayers for you and the family. It doesn't make it any easier to know that no matter what, sometimes this is the outcome. Somehow, in reading this one, though, I kept having this feeling it was ultimately meant to be.....know what I mean? Still, hard.

Michael Morse said...

Sounds like an impossible situation. Nothing worse that a patient in desperate need of volume, and mostly because of that the IV is nearly impossible.

You did all you could, and gave her a chance. Sounds a bit hollow after the fact, but good job anyway.

Medic(three) said...

SOrry man. You done your job right though. All too often we are put in situations where we HAVE to do something even though we know that no matter what we do it won't do anything.

Godspeed, friend.

Medic(three) said...

ELLIE- IO drills are nice, however a standard Illinois IO needle will work all the same and provide access in 45 seconds or less. For about 18 bucks as opposed to 900.

I often think that we as medics forget about tools we have already.

Walt Trachim said...

Unfortunately, Ellie hit it right on the head. Whether or not I'd broken out our IO drill in the long run wouldn't have made very much difference because the one thing we needed - time - we simply didn't have.

I've thought about that since I posted and it occurs to me that the thing she needed most was a vascular surgeon to repair whatever had failed. Unfortunately, that was out of reach because of the high level of instability, not to mention the amount of blood lost prior to our arriving on scene.

I truly appreciate all of the kind words. They definitely help make it a little easier to process this one.

Capt. Schmoe said...

Tough call. Sometimes, it just doesn't make any difference what we do or try to do, the outcome seems the same. Whattayagonnado?

Thanks for the post.

Ckemtp said...

Great pivotal moment Walt. Losing the ones you shouldn't have to lose is tough... but we all know that and we've got to be there tomorrow to try and not do it again.

If the fates let us, that is...