Tuesday, September 07, 2010

Break From The Books

I had to step away from the Chemistry textbook for a while. I’ve been at it for the past 4 hours and while it’s only the beginning of the course I feel like it is incredibly tedious already. I hope when the next classes meet it gets more interesting.

In addition, I’m trying to get some other things done. Like the rest of my Critical Care continuing education. That is also a challenge because of the amount of time it is taking. But I’m hopeful that I can finish that up soon.

As it happens I can talk about something that I’d originally done a lot of in this blog, although lately it hasn’t been as much as I would like. The subject? EMS, of course! There’s been precious little to talk about recently, but over the past week I’ve been on a couple of calls that have really infuriated me. Both of the calls originated from nursing facilities, and both patients were in cardiac arrest.

The first one was last Thursday originating from a nursing home that I’d only been to a few times but was entirely unimpressed each time I went there. This call was no different. In fact, when we were done I was pretty incensed because of the total ineptitude shown by the facility staff when it came down to the patient. A 66 year-old female who easily looked 20 years older, Oxygen saturation levels started dropping approximately 90 minutes prior to our being called the facility. For me to describe the scene that awaited us when we arrived would both be inadequate and inappropriate, but the nurse who gave us report (and wanted this patient out of their facility as quickly as possible) was really clueless. The patient was still breathing when we arrived – at about four times per minute – but as we were extricating her from the building she arrested. All stop. Asystole was showing on the monitor, she was pulseless, and she was apneic. And CPR was started immediately. We got her loaded aboard the ambulance and did all of the appropriate things: intubation, medication, and unfortunately, no defibrillation as there was no change in her rhythm. We did a rapid transport to the closest hospital (I think our on-scene time was maybe 12 minutes and our transport time was about 4 minutes) where they got pulses back for maybe 60 seconds. They lost pulses and she was pronounced shortly thereafter.

What really stoked the flames with this call was that the facility handed us a stack of paper that I didn’t look at until we were at the hospital. Included in this stack were admission notes on 6 other patients and no information on the patient we transported except for a notice of a 30 day bed hold with our patient’s name on it.

Needless to say, I was not happy.

The second call was on Saturday. My old Boston truck got sent to what is still my Favorite Nursing Home for what was dispatched as an unknown medical. That said, however, anytime a crew goes there for an unknown it usually is for a cardiac arrest. This time was no different, but what we walked into was.

I have to preface what I saw with a little background on this particular facility. It is an incredibly large place with a lot of people, both residents and staff. One of the features of this place is an acute medical care unit that is supposed to provide care close to that of any hospital. Unfortunately, my experience has always been that they fall woefully short by a long way. This time was no different than any other that I’d been to, either. We arrived to find a cast of maybe 7 people in the room working on this poor patient, an 81 year-old male with a history of esophageal cancer. One of the people in the room was the floor’s attending physician who was attempting to intubate this patient for the second time and failing miserably. I saw a suction canister that had nearly 500 ml of blood in it – I found out later that this is what was suctioned out of the patient after the first attempt at intubation by the doc. This patient had a port in his chest for access, which the team working him had used. He’d gotten two doses of Epinephrine but no doses of Atropine. All three of us who were medics that were present picked up on that immediately – who in their right mind, supposedly following algorithms for working an asystolic arrest does not give Atropine?

As soon as they would let us, we got into the room – there was a considerable amount of blood on the floor as well as on the bed – and moved the patient on to our stretcher. We got him out of there as quickly as possible and onto the ambulance so that we could attempt to at least undo some of the damage that had been done in the facility. A secure airway, an IO cannula placed in the patient’s tibia, and more medication, including Atropine. We all knew, however, that it was not going to work due to how far things had gone before we arrived. We took the patient to the closest hospital and when we arrived and brought him into the treatment room, the first question we were asked was where we were coming from. When we answered, the response by all parties present was a mix of groans, shaken heads, and anger from the attending doc – not at us but at the facility. This sort of thing happens often, and it is unfortunate because with a little bit of guidance much of this could certainly be avoided.

It turned out that I had transported this patient myself on a number of occasions prior to my becoming a supervisor. I remembered that I liked him and that he was a really nice man with a sense of humor that was present in spite of his illness.

Later on, I found that the day after this happened two more similar calls came out of the facility over that 24 hour period.

I only have one word for it: maddening.


TOTWTYTR said...

We don't go to many of these calls, but they are incredibly frustrating. As you do, we try to get the patient out of the facility as quickly as possible to minimize the damage. The referrals from these facilities are beyond useless most of the time.

Anonymous said...

You know you can report these places and their incompetencies! I do. They add up after a while and spell trouble for those places. I report them to th AG's office as well as not performing adequste humane care. Just a thought.