29 December 2009

First Due Medic

Identifiable names, numbers, and locations and been changed to protect the identity of the ones who my not want to be identified

I decided to wait a while before I recounted a call I ran on 18 Dec, primarily so that I could possibly share a good outcome. Unfortunately, this is not going to be the case. It’s rather troubling to me that this call had the outcome that it did, this in part because the one reason I do this work is to ensure the best possible quality of life for the people that I come in contact with.

It is my assumption that every person that is subjected to my care should benefit in a positive way from our encounter. Now we all know that this is not going to be the case every time. Life happens in a weird way sometimes and death does most certainly happen. Maybe it’s my glorified view of our chivalrous actions that makes me want for all that is good; for whatever reason. However, I’d like to hope that it’s just something engrained in my genetics that make me strive for the best for my fellow man, be it neighbor or stranger.

I had only been home from work for an hour or so the morning of 18 Dec. As is my custom, I left my pager on so that I could be available to lend a hand in the county volunteer system. The career side of my job doesn’t afford a lot of opportunity for a lot of EMS work outside of inter-facility transports, so I sort of have to stay involved at whatever level I can to stay sharp.

I was reading some blogs that I follow when my pager went off.

“CCom to Station 25…possible heart attack…caller is stopped at The Quick Store on 585 South…caller advised her husband started shaking and then slumped over, not sure if he is breathing…. CCom first page at 0959.”

The first thing that registered in my mind was that the person dialing 911 had stopped at a convenience store that was right below my house. If it were not for the trees, I may be able to see the store from my front porch. It was close and I was already on my way out the door before the dispatch was over.

Unfortunately there was only one person at the station at that time and they were in the process of requesting an EMT or a driver for the call as I started my vehicle. This was wasting precious time as I waited for the request for additional personnel to finish paging out so I could mark up>

“CCom this is 172” I radioed backing out of the driveway.

“172”, dispatch replied.

“I’ll be responding POV, have Station 25 roll a truck and meet me on scene”, I advised.

“Station 25 did you copy 172?”

“10-4 CCom, we’ll have a truck in route momentarily” came the standard reply for acknowledging a call.

I couldn't’t help but think of all the possible heart attack calls that we get on a weekly basis in our county. A call that we take so seriously, dropping everything to rush to the scene to start definitive care, only to find somebody who would be better served by a cab company. To top it all off, how many unresponsive calls do we get that end up being a patient refusal of service when we get on scene? There had been a few recently and I couldn't’t help but think that this be just another one of those type of calls as I pulled into the parking lot of the store.

“CCom to 172”, dispatch called over the radio.


“Caller advised she’ll be standing by in a red cavalier”, I was told.

“10-4, I’m on scene…I’ll be making contact in a second”, I said as I got out of my vehicle.

I zipped my hi-vis jacket and holstered my portable radio while I made my way across the parking lot to the red vehicle parked cock-eyed in front of the store. It was about this time that I heard the truck signing enroute from the station, thankfully they were no more than five minutes away if it turned out to be something. There was an older lady standing inside the passenger side of the red car talking loudly to a man inside the car and shaking him trying to get a response. She was visibly upset and started recounting the events in an excited fashion leading to her calling 911 as I approached.

“Hi, my name is Gate, I’m a Medic here in Horry County….calm down and tell me again what happened…slowly”, I told her as I reached in to shake the gentleman who was slumped forward in the passenger seat of the car. He was held back only by the seat belt that ran across his chest.

“We was coming to Millville to see my grand-daughter…about the time we crossed the county line he started having trouble breathing and he told me he didn’t feel right”, she told me in as calm a voice as possible. I shook the man by his shoulder and got no response, so I did a light sternum rub; nothing. Placed my hand flat on his chest to chest for rise and fall; nothing.

“Then when we was coming through the curves back there, he just started shaking and just fell over against the window”, she continued.

I grabbed his right wrist to check for a radial pulse while checking for a carotid with my other hand; again, nothing. All the while during my assessment the lady who turned out to be his wife, continued on with her recounting of the events leading up to this point. For all the important information that she may have been giving at this point, I was not listening; I was zeroed in on the fact that this man was or had been clinically dead for less than five minutes by now.

“172 to 2510”, I said into my lapel mic.

“2510, go ahead”, the driver replied.

“Step it up, I need you here five minutes ago”, I said with some urgency in my voice.

“10-4, we’re about two minutes out”.

“CCom this is 172…this will be a working code blue”, I advised them.

Reaching inside the car and unhooking the seat belt, I worked my left arm in behind his back and then placed my right hand under his right armpit. With one swift motion I lifted and pulled at the same time pulling my now patient free from the car. It was then that I noticed a small crowd had gathered, some realizing that something was wrong. I placed the man on the cold asphalt parking lot and again quickly checked for any signs of breathing and a pulse; again, nothing.

I located my landmarks on the patient’s chest and placed the heel of my left hand on his sternum covered by my other hand. The guy had some drool coming out of the corner his mouth I noticed. It was then that the germaphobe in me welled up and called for passive air flow. I was really thankful for the knowledge that the body has about 15-20 minutes of oxygen in reserves at the cellular level and that inter-thoracic pressure would move enough air passively to sustain efforts for a few minutes. I started to compress the chest of the man who obviously was in cardio-pulmonary arrest. 1 & 2 & 3 & 4 &…….I counted out loud.

“OOOOOOOooooo NOOOOOOOOoooooo”, came a painful wail from behind me. I didn’t stop to look around, but I could only assume it came from his wife.
“Is something wrong with him?” an innocent and obviously uninformed bystander asked from beside me.

“Yeah… he’s kinda dead right now”, I said before I could catch myself. I’ve always had a problem with stupid questions, and this was certainly one that qualified as stupid, but the answer was purely instinctual.

I was really getting some good compressions in when I noticed the potential for some head trauma. Every time I would compress, his head would come up off the ground and then hit the ground when I released. Realizing this was not a good thing in general, I also realized that there were people watching. Amazingly enough though, not the first person stepped up and identified themselves as a CNA who works at the nursing home, nobody said “I know CPR, need some help”. They were all just watching the big guy lunging into the little guys’ chest….maybe they were transfixed by my high-vis jacket, I don’t know. Anyway, I went to one handed CPR so I could use my other hand to cradle his head and keep him from getting a subdural hematoma.

Enter our local volunteer heroes. The ambulance can be heard coming down the road for miles thanks to the piercing wail of a Wheelen siren through 200w speakers. As the truck entered the parking lot at mach II, siren still wailing and bumper smacking the ground, dragging on the way in; I wasn’t too sure how this was going to go from here on out.

The driver of the truck, an EMT that we’ll just call Fred, comes huffing over to where I am empty handed and asks, “What do you need?” Now I know we’re a long ways out from national standards of training yet, but BLS skills are pretty much the same world over. We’ve got a working code, common sense says that the next thing we are going to need is a BVM and ….. a monitor/defibrillator. Instead of wasting my time having to recite protocols and bring everyone up to speed, I just tell him to get me a stretcher, which he dutifully retrieves. Over the radio I now hear our radio hog who also serves as the band-aid purchasing agent for the rescue squad signing on scene. The next thing that puzzles me to this day is why the next thing out of his mouth is him advising dispatch that we have a working code and we’re going to need ALS. However, there are some things I try not to think about only because it hurts so much.

With the patient now on the stretcher and moving toward the truck, I run ahead and get the LifePak 12 and I.V. set up. With the stretcher now entering the truck, I apply the quick patches and switch the monitor on and set the leads. Now let me state this before continuing on any further; I absolutely despise the quick patches. I think every truck should have paddles on their monitors…I digress. With the monitor now I on and CPR stopped, I immediately recognise V-Fib. "Charging…all clear"…ZAP!...and CPR continues. I did finally take an opportunity to insert an OPA at this point, place a pillow under his shoulders and give a couple good breaths with the BVM w/ O2.

Now let’s talk about CPR for a minute here. Well, rather who is doing CPR. Fred is a 5’6” 350lb man who wears nothing but sweat pants and t-shirts at any given time of the year. He is also known as the guy who has more belly to cover up than T-shirt to accomplish the job. Now Fred is giving it all he can with CPR, more than once exclaiming how hard it is to do this. Needless to say, I’m not really concerned how tiring it is, just do it and do it right. Band-aid purchasing agent is standing at the side door in spectating mode just enjoying the show. I would have much rather had him in the back; not too bright a kid, but he was a former Army guy and he was fit. There would be no chance of him coding too from doing CPR; but Fred said he had this covered.

Checking the patients’ arms, I quickly realize he is going to be a tough stick, but I notice he’s got some nice jugs.

“Trendelenburg, Fred!”, I say

“Huh”, came his reply accompanied with a bewildered look befitting his appearance.

“Put his feet up…raise the foot of the stretcher”, I clarify

“Oh...O.K., that’s what I thought you meant”, he said refusing to concede he didn’t have a clue.

I inserted an 18 gauge needle in the right external jug getting immediate flash, following with a flush and starting a line of normal saline fluid. Turning to my left to grab the drug box I notice Band-Aid purchasing agent still standing there watching all the festivities.

“Code 3 please, no lights…no siren. Nice and smooth”, I tell him. He quickly slams the side door shut and runs to the front of the truck and jumps into the driver’s seat. In no time flat we lurch into motion as me and Fred continue our battle with death.

With 5cc’s of Epinephrine drawn up in a multi-dose syringe, I go ahead and push 1mg and flush the line. In between all this I’m trying my best to oxygenate the patient. Thankfully his neck being hyper extended was doing the trick. As I’m getting a pre-fill of Lidocaine I notice we are closing in on our second set of two minutes of CPR.

“Hold CPR” I say to the only person doing CPR. A quick glance at the monitor tells me it’s time to defibrillate again to knock out this V-Fib.

“Charging…ALL CLER"...ZAP!!..."continue CPR”, I say, and then give a few good breaths with the BVM. By this time we’re starting to get some gastric backflow and I decide to chance an intubation. I glance up at Fred and felt sorry for the poor guy. He looked like he could just lay down on the stretcher with the patient and die right there. He was now getting to the point where chest compressions were just intermittent and circulation and perfusion was just wishful thinking. The intubation was unsuccessful partially due to the crap I had spread around the head of the stretcher keeping me from getting all the way down to head level.

I needed to get a round of Ladocaine in and quick so I urged him, “Hard and fast there Fred, you’re his heart now!” Just as I had assembled the Ladocaine pre-fill in true Johnny Gage fashion, Fred was taking another break from doing CPR and I looked at the monitor and saw an organized rhythm. Shocked at this but pleased, I checked for pulses; none. PEA I can work with, so I psyched Fred up some more by telling him, “Keep at it Fred, you’re doing it ‘ol man…we’ve almost got him back…stay to it!”

Back to work Fred went pumping for all he was worth and sweating like a logging mule in July. I hit our pt with another 1mg of Epinephrine, continued to ventilate and suction the airway as best as I could manage all the while getting the Atropine ready. One milligram Atropine in and by this time we were about one minute from the ER pad. Just for good measure I gave another round of Epi as we were getting everything together to go into the ER.

Once inside I give my report to the attending physician and they continue resuscitative efforts. After about ten minutes of multiple drugs and one more shock, he is now intubated and on a ventilator; they bring out the doppler to listen for a pulse. First there is the loud screeching rubbing sound, the room fell silent, then the faint sound of blood perfusing and the artery expanding and contracting….music to our ears!!

“Get me a pressure”, the doc says.

After a minute, “167/95”, came the reply.

By golly we had done it!! I went out to the squad room to get started on my paperwork, which would take the next 45 minutes. That would be followed by exchanging the drug boxes at the pharmacy to get us back in service.

By the time we left, the patient was in the cath lab. I was so excited I could barely stand it. Everybody wants a save, but now came my real worries. What quality of life would he have past this point? Only time would tell. I decided then that I would follow his route to possible recovery. My hopes for his full recovery were bolstered even further later that day when I received a call from the hospital. My patient had been taken to ICU and was on a vent.

I went by to see him only once after that. The nurse in ICU told me that his diagnosis was alcohol induced myocardial myopathy, so I guess that explains the flask in his jacket pocket. They said he had very minimal neurological response and again only time would tell. Another factor not in his favor was the 5-10 percent cardiac ejection fraction.

Fast forward eleven days. I find out today that that he has been moved to a long term care facility where he will most likely live out his days in a vegetative state due to hypoxic brain damage. I now question myself over everything done during the call. Was everything done perfectly? No. Could we have done some things differently? Absolutely. This will be another learning experience where I will never again wait until I get to the truck to start care; care starts at contact and transport comes after stabilization.

I’ve been assured by the attending physician and trusted co-workers in the field that whatever damage he suffered started before I got there and my job was to keep it from becoming worse. I worked with what I had available. In a perfect world or even in the ER his chances may have only been marginally better.

With this being my first “save”, I am more frustrated than ever because of the outcome. I can’t help but feel that this guy and his family would be better off if he would have died; but I’m not the one that makes that call. I do my job because that’s who I am, and I work with what I’ve got.

1 comment:

  1. Never forget that the lack of 02 can do way more damage than we can imagine, and with this man having been under the influence, the body is much more relaxed. I'll never forget how little Mack was gray from lack of oxygen many hours after his accident.