On the Way to Paramedic in Northern VA
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Wednesday, June 27 2007
DTs! Now Chok-Full of Paramedic Goodness

"Relax," our instructor would say. "Once you're on scene, the emergency is over."

Now, that statement can be taken two ways. One way of reading it is, "By the time you arrive, all the bad things are finished happening" - the car has wrecked, the ground has broken the fall, the boiling water has scalded the arm and is growing tepid on the floor. Get busy with that assessment or that load-and-go.

The other way of reading it, the way most of us in class, I think, read it, was the Heroic way: Dun-dutdut-daahhhh! "Greetings, Citizen, it is I, MedicMan. State your troubles, for I am here. Get some vital signs for me, Basic Boy."

It is doubtful that our instructor intended us to believe the latter, but there it was, and it takes an awful long time it seems before we get it through our heads that, for all our knowledge, all our bleeping and blooping equipment, all the drugs in the drug box, our primary goal is still, 99.9% of the time, to just take the patient to the hospital.

That 0.1%? Usually a bolus of D50 for hypoglycemia and the admonition to the now-with-it patient to eat something, but even then we offer to take them to the hospital.

And yet, knowing this, the urge to "do something", in a medic kinda way, is still very strong; it is interesting therefore to come upon a situation where one could do medic stuff, but it's better to go, "Naaaaahhh," and just go.

We were called to an outpatient surgery center one evening for a BLS transport from the recovery room to a general observation floor of Big Hospital, which was only a few blocks away. The patient had just had minor abdominal surgery and had "slipped to the floor" when attempting to stand and leave. The nurses stated he had been assisted to a chair and did not actually flump onto the linoleum - no trauma.

Still in the chair, with a 500ml bag of D5W and a pulse oximeter on his finger. The patient we noted was responsive to voice. "He's been like that since the surgery," we were told, and I'm thinking: okay, perhaps a bit too much anesthetic or it's not yet worn off. Still, surgery ended four hours ago...

The pulse oximeter measures not only oxygen saturation (which was 100%), but also heart rate (by measuring a pulse in your finger) - which showed... 170?

"Oh, he was like that before the surgery," the nurse said. "He came in tachy."

"But 170 tachy?" we asked.

"Well, 100, 110," the nurse said.

Tachy, syncopal, lethargic... "Say, I see you have an IV going," I say

"Yes, he has a 20 gauge in his right hand,"

"Yeah, um, how much fluid has he had so far...?"

"Oh, this is just a 500 bag, he had four liters before this," the nurse said

"FOUR liters of saline? How much has he peed?" asks DTs

"He hasn't urinated for us," said the nurse.

On the outside, one says, "Hmmmm. We have to go. Now."

On the inside, one says, "Holy shit, MedicMan!"

This guy has been bleeding out into his abdomen (there was no blood pooling anywhere on the floor or chair) and has had 4 of his 6 liters of blood replaced with salt water, which does not have a lot of Red Blood Cell Goodness to carry oxygen and stuff. Indeed, his blood pressure was abysmal (70 or 80 something over gotta-go-now), which explained why his heart was beating so fast, trying to keep a pressure up with too little fluid in the pipes.

And this, Patient Reader, is where the bit about being a transporter first, hits home.

Could I have stayed on scene and done things to help this patient? Certainly! The 20-gauge needle in his hand was too small, for one thing. Dual 14-gauge needles, one in the crook of each arm was what he needed, for fast infusion of fluids. Get fluid in, raise the BP, which in turn will slow down the heart rate. Pump some pressors, constrict the blood vessels to raise the BP and maybe slow down the bleeding.

But DTs did none of these things, opting instead to manhandle the now-only-responsive-to-pain patient onto the cot and into the bambulance for a 60-second ride to the ER. Trendelenburg to put what little fluid he had into the core; throw a BP cuff around that little 500ml bag and inflate it to pressure infuse; voila, we're there at Big ER.

"DTs," you intone. "You are not using your newly-minted ParaPowers. What gives?"

Well, first, was I gonna stop the bleeding? Not without opening up the abdomen, and that be Surgeonstuff. And infusing fluids? Yeah, well, in the short-term perhaps, but he really needed blood, not more water, and that we don't carry - that be ERstuff.

But getting him to the surgeon and the ER?

"Relax," we told the nurse as we whisked him out the door. Dun-dutdut-dahhh!


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Posted Wednesday, August 08 2007 14:25  Site Meter