On the Way to Paramedic in Northern VA

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Friday, August 29 2008
FDGB, or Worse

We're taking a patient from non-trauma ER to Big Hospital. On arrival for pickup I step into the room, as usual. This gives me the opportunity to a) introduce me self and partner(s), b) let the patient know that their long wait for transport is almost over, and c) gather an overall patient impression, eg skin tone, warm and dry, level of consciousness, etc. My tendency is to do this even before seeking the RN for report, as sometimes a nurse's opinion can color one's thinking.

My patient is a homeless woman wearing a c-collar, who has been in the ED for 12 hours, c/o neck pain. She suffered an ETOH related fall three days ago and has just now been seen - lo and behold, a C5 fracture. I stand where she can see me, introduce self and partner. She seems okay, CAOx3, O2 at 2L NC. Her boyfriend is seated next to the bed, looking worried. The patient is on a heart monitor, for some reason, and I notice that the BP on the monitor is... 240/180. Hmmmmm. These things have been known to be wrong.

"I need to speak with the nurse for a few minutes, get some paperwork and all that, so I'll see you shortly," says DTs.

The nurse was a perky, newly-minted RN, with a tendency to disappear. No worries, I get most of my info from the H&P in the chart while she's off getting a set of transfer VS. My partner steps up.

"Um, hey. The nurse, she just put the patient on an NRB at 15L."

"Really? Well, okay. I don't guess it'll hurt anything." I suspect she was told in class that Bambulance Folk put all their patients on oxygen, non-rebreather, at 15L.

The nurse returns and gives report. Her VS include a new BP of 248/198. "So, do I need to sign anything?"

"Say, that's, uh... really, really high for a blood pressure. Could you please run this by the doc and see if he wants to treat this?"

The RN returns after a few minutes to say no, the doctor doesn't see this as a problem. Did you show the doctor the actual numbers, or just say, "Hey doc, the ambulance guy asked if you wanted to give the patient medicine before they left." No, he looked at the vital signs and shrugged.

"Show him again, please. Make sure he knows what the BP is, and please, ask if he wants to give some Labetalol or something."

RN returns: No, doc says everything's fine. And he just stepped away. Perhaps something to attend, perhaps to avoid further bother from the uppity and bothersome bambulance guy.

Wonderful. No help here whatsoever, next best thing is to do the Ambulance Thing - take the patient to a hospital. Ideally, I should have refused the patient as unstable. Next time, yes, "Live and Learn".

"Okay," says DTs to Partner, "Let's just go - it's 20 minutes to Big Hospital. I want to go lights and sirens, starting here in the parking lot."

Annoying fact: Most of the hospitals in this area are using the same computer network. Good thing is, all the CT, MRI and XRay info is available at any hospital. Bad thing is, the hospitals no longer print same. I haven't seen the XRay of this patient's c-spine, or a head CT. I did a quick neuro check after introduction and All Seemed Well, but we board the patient as a precaution.

Boyfriend wants to come along. "Well, I'll tell you," says DTs in his Just An Old Country Medic persona. "I fooled around so long gettin' the paperwork and all, I wasted a lot of time. To make up for it, we're gonna go lights and sirens and push all the traffic out of the way. You can come along, but you need to ride up front with the driver, and wear a seat belt." Medic Sense was more than just tingling, but no reason to alarm anyone.

We load the patient, hit the lights, and pull onto the street. Huzzah. I attempt to contact my medical control to resolve my dilemma.

Dilemma, DTs?

Why yes. Hearken back to School Daze. High BP - really high, 248/198 BP - is M-O-O-N, that spells Bad. However, a really high intra-cranial pressure or ICP - caused by an internal head bleed as the result of a head trauma, like a fall - causes the BP to rise so that blood flow to the brain isn't compromised. If the pressure in the skull is high, one needs a high BP to maintain perfusion.

The patient had a neck trauma from a fall - there is the possibility of a head trauma, even without external signs, such as a laceration or contusion. I didn't have any CT or XRay on hand to see if there was a brain bleed. Nurse didn't mention it, but she was new. Doctor... 'nuff said. Certain signs are usual with high ICP, most notably changes in pupillary response, but these can sometimes be subtle and can be missed in the back of a bouncing bambulance. Should I treat the absurdly high blood pressure? Or leave it, seeing as how we were minutes from the hospital? I wanted advice.

I contact our dispatch to be patched through to med control, and am put on hold. The Muzak version of "New York, New York"... DUH, Duh, duh-duh-duh, DUH, Duh, duh-duh-duh... flashback to the Blues Brothers in the elevator. Meanwhile I'm watching the pulse-oximeter enter Launch Mode.

What is Launch Mode? It goes, "100... 99... 98... 97... 96... 95..."

"Hey, DTs, we got a CCM here, you wanna talk to him?"

Why yes, that'll do nicely, thanks. I explain the problem as I check the pulse-ox. Still on the patient's finger... pulses good in that arm... "88... 87... 86... 85". Interestingly, the heart rate is steady.

"Actually, never mind the BP," says DTs, "Patient isn't breathing right now I gotta go ok? thanks bye," Oh shit oh dear.

Chuck the NRB and start BVM on O2. We're already going L&S, so that's taken care of. Get on speaker phone and call the ED while pulling the ET kit out and checking the tube integrity. BVM. Give Destination ED the story, "Gonna tube now, gotta go bye." Such Drama! Whee!

Destination is alerted, good. BVM. DTs looks at the patient and tosses the ET stuff aside. BVM. There's no way to reposition the head with that collar on. It can be done, but not bouncing around like this... go for a Combitube. Damn thing won't go in. The patient is not clenching - just, won't go in. BVM. Phooey. At least get a OPA. Hell, even THAT doesn't want to go in. This is ridiculous. BVM. Try a smaller OPA. Okay, finally. Sort of. 95... 96... 97...

We get to Big Hospital, and now DTs thinks, "Oh Shit." Boyfriend is in the front. We've gone from "Bye honey see you there" to back-from-the-commercial-break "ER" crash-cart drama.

So there it is - patient crashed. It was humiliating to not get the tube. I almost didn't want to go in yet. Try again?- a nanosecond of pause until Self, It Ain't About You kicked in.

I felt much better about the tube business after the staff at Big Hospital tried. Respiratory couldn't get it. Anasthesia came to the ED and THEY couldn't get it. The patient finally had a surgical cricothyrotomy. Which, had the transport been any longer, was in the back of my mind anyway - we have that in our protocols.

It is an interesting point of human nature, or at least mine, to note that I felt better about failing to get the tube after others failed also. That is some BS I'm working to eradicate... another subject entirely,

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Posted Sunday, November 16 2008 18:27  Site Meter