The next couple of days are going to be radically busy, just in terms of where I have to go and what I have to do. I’ll have to simply power myself through them.
Tomorrow I’m working as an evaluator in Concord for the monthly ALS practical. That’s becoming a regular thing for me to do, but I still have to remember that it’s on the calendar and to sort of prepare myself for it. The other is on Monday I’m going to Greenfield, Massachusetts to take the practical part of my medic refresher. It’s a long way to drive, but it’s better than sitting in a classroom for 48 hours. Having done the refresher on-line has been an excellent experience. I’ve gotten quite a bit out of it, and sometime today I’ll take the written final exam.
A couple of posts ago I talked about how ridiculous things can be when I’m dealing with some of the facilities in Boston that I go to. That level of stupidity (and what I believe to be incompetence) ramped up early Friday morning, and I have been incredibly angry about it since. Although I’ve settled down and have been able to look at things somewhat more objectively, for a while I was absolutely beside myself. I was angry to the point where I couldn’t put two words together without stuttering, and I am still contemplating whether or not I should voice a complaint about a situation I got placed in.
Early yesterday (Friday) morning – just about 4:00AM – we were dispatched to the nursing facility we’re contracted with for a person with an altered mental status. It was dispatched as a priority one call as most of our calls over there are, so we went there straight away.
We were sent to what is known as the “MACU” or Medical Acute Care Unit. It is a loose facsimile to a hospital intensive care unit, both in its layout and its attempts at providing care. When we arrived, a Physician Assistant who I’ve dealt with before met us as we got off of the elevators. He told us that we were going to be transporting a 40 year-old female to the Boston Medical Center. She was a dialysis patient who had what appeared to him to be a mass just below her fistula site. It was about the size of a golf ball. In addition, she had a temperature of just over 102 degrees F. She was unusually compliant; normally she is rather agitated and not terribly cooperative, which apparently is baseline for this person. He didn’t give up her chart (usually we’re able to get it to have a look at history, etc.), and didn’t give us much more information about her history, other than a history of a Traumatic Brain Injury. The envelope that he was sending with us had a summary of this incident; nothing more or less.
As he was talking to us, I had a really bad feeling about it, and I had no idea why that was. I asked him if she was stable enough to go to the BMC, and he assured me she was. He also made it a point to say that it wasn’t necessary to take her to a closer hospital; later on I would remember that with a bit of irony. And Paul, my partner, asked her if she had a Do Not Resuscitate order or not. The PA didn’t answer him; he walked away as if he didn’t hear the question.
We got to where the patient was, and we found her sitting in a chair across the hall from the entrance into her room. Tall and slender with a very vacant look on her face. Visibly diaphoretic, she wasn’t alert or responding to commands or questions appropriately. She did get up at one point and walked into her room with the two staff members trying to get her dressed to go with us following (she was wearing only a t-shirt when we arrived), and she laid on her bed, talking about having to “pay someone.”
After much persuasion, we were able to get her on the stretcher and out of the building. Once we loaded her on the ambulance, however, things changed – not in our favor.
As soon as we locked the stretcher into the frame, I watcher our patient sigh – and take her last breath. My partner, Paul, and I just looked at each other for a second – we each had the same thought: “did we just see what we thought we saw?” So he started checking her level of responsiveness with both verbal and painful stimuli (this consisted of screaming into her ear while digging his knuckles rather forcefully across her sternum) while I grabbed an ambu-bag and got it connected to Oxygen. She was already on the cardiac monitor – it showed no activity except for an occasional complex. CPR was initiated – I was doing compressions while he was breathing for her and calling for another ambulance. The BLS unit that was also on the overnight happened to be leaving the hospital across the street, so they showed up within about a minute. One of the guys, Jesse, jumped in and took over compressions from me. As Paul was intubating her I drilled her left leg with an IO needle. I got a 1000ml bag of Saline attached and under pressure as quickly as my hands would move. Over the next 5-6 minutes we got 2 rounds of Epi and Atropine into her while continuing CPR. No changes to her rhythm – she still showed asystole on the monitor. To complicate things further, we had to suction the ET tube multiple times because she had junk coming up into it while she was being ventilated.
We brought her over to the hospital – they knew we were coming as in the middle of compressions and pushing meds I called in and let them know what we had. We walked through the doors and into the resuscitation room and immediately got her onto their stretcher. I started talking to the attending doc, telling her what we had and what was done before getting there. The team in the room took over from us, and they got her back. They had pulses about 15 minutes later.
Now this was all good, but one of the nurses came out and asked us if this patient had a DNR order. As we never got an answer from the PA and there wasn’t a copy of a Comfort Care/DNR order in the packet of documentation we were given at the nursing home, we couldn’t be certain whether she had one or not. Regardless, because we didn’t have one in our possession we were obligated to make the effort to resuscitate her. However, they made phone calls while we were there – they talked to whoever was working on the MACU. That person informed them this she was listed in their computer system as having a DNR although they could find no record of the hard copy anywhere.
Later on, I found out more about our patient that the PA didn’t think was necessary to inform us about. First, our patient had not only the TBI, but she also had a seizure history, and she’d been resuscitated once before, resulting in further anoxic brain injury. Plus she’d been an IV drug user for an extensive period of time, which likely was the catalyst for much of what she had for problems.
I had to talk with the attending about this situation. She wanted to hear what happened from the beginning; it was a little difficult to do that when we were bringing her in because of all of the activity going on. So I told her what happened, and as I was doing this one of the nurses asked us if we’d gotten a blood glucose level while we were working her. I answered that we hadn’t, and she immediately started bitching at us about it. My response was rather curt: I told her in no uncertain terms that our having to secure her airway and breathe for her and do compressions and push drugs that were necessary for her survival had a little more priority at that time than checking a blood glucose. As I was saying this, however, I did kick myself because it is something I usually always check on a cardiac arrest patient. This time was different because it happened right in front of us, and I had other things in mind. In hindsight, though, it makes sense that we should have checked it; with the fever, she probably was metabolizing her glycogen stores faster than normal. And she had a glucose level of 33 in the ED.
The doc actually understood where we were coming from, but the nurse was pretty nasty. She glared at me as we were leaving. And I glared back.
Nothing like being put in the middle of a crummy situation. Especially so close to the end of shift…
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