It so rarely happens

.... to actually have a "save."

The setting: The second day of my 72hr shift that I recently finished.

My partner: She has a paramedic patch on her arm, but she's really better used for my general entertainment and in general just annoys the piss out of me. I don't think she actually realizes how annoying she is or that when somebody walks away from her and doesn't say "walk with me" or "I'm still listening" then it means that they don't want to hear her. Earlier on this particular morning, she'd tried to follow me in to the bathroom at the station. It's a regular bathroom, it's not like there are stalls or anything. I'd actually had to tell her to leave the bathroom and then she stood outside the door and kept talking even after I had turned on the fan to give her the hint to go away. So, she will now be referred to as SS. Oh, she also has the similar first name as mine. This becomes important during the call. She thinks it's really funny and entertaining also. I do not.

Our first call of the day didn't come out until about 1600 that afternoon for an unconscious. Enroute, we are told that bystanders have started CPR. Now, keep in mind that the majority of the time "bystanders are doing CPR" either
a) they are actually running around the person and aren't doing shit to help or
b) they ARE doing compressions on an unconscious diabetic patient who ends up with a bruised or broken sternum and they just needed some D50 or
c) the "unconscious" person is actually flailing around and trying to get them to stop doing compressions.

So, FD gets on scene and calls out that CPR is in progress and they are getting ready to be shocking the patient with the AED. Now, THIS is a great thing! It means we might actually have something to work with.

So, we're looking for our nice big red blinking GPS locator dot. Hmmmm..... it's not where they said it was and we can't find it. I call on the Fire channel to ask where they are. The captain says "We're by the building. Just park behind us." Great! Which building???? From the opposite direction down this street comes our supervisor The Great One, as she likes to think of herself. SS says "OH! LOOK! LOOK! There's TGO! She knows where we're going. Follow her!" I tell SS "No. She's following us now. She's also looking for the fire department." So, we find out that this guy is actually on a dock, so TGO tells me to cut down a road that is actually a good block off of the address. After we get back to the docks, we actually can see the big red dot. I LOVE having a GPS locator like that!

On our way there, I had told SS that I'll handle airway if she can work on getting a line. The implied part of this, of course, is that since she will be closest to the patient's torso, that she'd also stick him on the monitor. I admit, I forgot that the implied part is only if I'm with somebody with a half a brain. Give me a good basic or intermediate any day! At least they know that the patient needs to be on the monitor during a code.

So, we pull up on scene and SS goes to walk off trying to carry the airway bag, monitor, and drug bag. That's nice and all, but it's not like this is going to be a refusal or something. So I toss a backboard on the stretcher as the fire capt is pulling it out and grab the portable suction (I have heard that this is kinda important for that whole airway thing). We have to walk around the building, through some construction stuff and down a ramp to get to the back of the building where the patient is. I tell SS to put some of the equipment on the stretcher. She started to argue with me that she had it (which is quite stupid when she's standing there with a good 70lbs of equipment hanging off her and can't walk right). So, I just took the airway bag and the monitor from her and put them on the stretcher. (I figure if she drops the drug bag, it's not nearly as bad as dropping the monitor.)

So, we walk around the back and yup, FD is doing compressions and bagging the patient. The guy was apparently walking around working and just suddenly fell over and wasn't breathing. The FD paramedic tells us that they already shocked him twice with the AED and haven't pushed analyze again within the past few minutes because they could hear us pulling up. Okay, that works for me.

I go to the head and start getting everything ready for intubating the patient. SS kneels down at the pt's left side and puts a tourniquet on him. The monitor is behind her at the pt's hip. I tell her "Before you stick him, let's put him on the monitor and see what we got." SS says "He's on the AED." I tell her "I want him on the monitor." SS: "But he's on the AED." DG: "I know that but I don't know what rhythm he's in. Put him on the monitor and put our pads on him." SS: "He's got their AED pads on him."

At this point, TGO is telling the two firefighters doing CPR that they need to do 2 breaths to every 30 compressions instead of just reaching over and putting the patient on the monitor. TGO obviously just recently watched the video to renew her ACLS. The FF that was bagging was looking at me like "WTF?" I told him he was doing fine and to just keep bagging like they had been (which was at 8 a minute, so it wasn't a problem anyway) until I had everything ready to intubate. The paramedic with FD reached around SS and grabbed our leads and started putting them on the pt while I pulled the AED pads off. I'm glad one of the FFs reminded me to turn the damn thing off also. That would be MY luck, to manage to defib myself with an AED.

So, put him on the monitor and see that we are in PEA at a rate of 34. Okay, NOW get the line since we can actually see what we have to work with. FF keeps doing compressions until I'm ready to intubate. I tell the FF to stop doing compressions and stick the blade in the patient's mouth. Another of the FFs is giving cricoid pressure (I tell ya, I LOVE THOSE GUYS!) and asking what else I need. Just as I see the epiglottis, I hear TGO tell the FF that was doing compressions "Hey. Keep doing compressions. Don't stop. Do 30 compressions to every 2 breaths. Allow for total recoil of the chest." I'm going "CRAP!" in my head. I said "No. NO. Don't start compressions. I'm trying to intubate him TGO." The FF paramedic by my head actually turns around and tells her again because she starts to tell the FF to keep doing compressions. I don't get this. She can clearly see that I'm intubating the patient. Maybe she missed that part of the video. Either way, he's tubed and all's good in that area. The FF starts compressions again after we confirm placement and start to secure the tube.

During this time, SS has gotten an IV started and is giving NS. I look up at the monitor and tell the FF doing compressions to hold so we can check the rhythm and for a pulse. The pt is in sinus tach with a strong carotid!!! YAY!! He even has good radial pulses. I'm looking at the monitor from the head and can see the ST elevation. TGO calls for a helo to transport the pt to the closest hospital that has cardiac capabilities. (She'd wanted to send him to the smallest closer hospital that I wouldn't even take my sick dog to and I'd told her that we needed to send him further up the road to a higher level of care.)

I now look over at SS and see her starting to push an amp of something. I yelled "STOP! WHAT ARE YOU DOING? WE HAVE A PULSE!" SS looks up with this total blank look and says "Oh we do?" Seriously, I don't understand how the hell she missed all of us celebrating the fact that we actually got a pulse back, she'd even CHECKED for a pulse (supposedly, unless she just randomly wanted to grab the guy's wrist for the hell of it). So, the patient ended up getting 0.5mg of Epi. I was just sitting there wanting the smack the shit out of her and praying that we didn't screw up what we'd just accomplished.

TGO is asking me "DP, do you want to give a Lidocaine bolus or just hand a drip?" SS looks up and goes "Oh. I don't know. Ummmm maybe?" I looked at TGO and said "Let's give a bolus then hang a drip for maintenance." TGO asked me "Do you want to give 1 or 1.5 mg/kg?" I said "Lets just go with 1mg/kg because of his age (we were guessing around 70 years old)." TGO: "Okay. How much do you think he weighs?" I'm looking at the guy and tell her probably about 200-210lbs. Now, here's the thing, you can just give the whole amp if he's about 220lbs and doing 1mg/kg. Its just easier that way. So, what does TGO administer? 55mg. I have NO friggin clue how she got 55mg. None at all. She tells me this after we get him c-collared and backboarded. I asked her about it later, and she got this blank look on her face, followed shortly by a "oh shit" look. I figured out later that if we did 1.5mg/kg and then halved it because of his age, it was at least close enough to not look like we totally suck at math. By this point, the patient is breathing on his own, irregular and shallow and at about 10 breaths per minute.

So, we get him loaded up and get to the LZ and hang the maintenance drip for the Lido. The patient starts gagging and is starting to hyperventilate and chew on the tube. I gave him 3mg of Versed because I can only hope that somebody would do the same for me in that situation. So, he stops breathing on his own, which is fine since we already have that handled, and stops biting and gagging. SS says "he's in wide complex tachycardia!" I didn't point out that he had been the whole time and he has a matching pulse rate. SS says "Maybe it's v-tach!" I tell her "No. It's not v-tach. That looks nothing like v-tach. It's just wide. Just like he still has the same ST elevation that he's had the whole time. He also still has p waves. It looks really good considering everything he's been through." SS: "But what should we do?" DP: "Nothing. We already have a lido drip hanging and his pressure is good (It was like 150/100 at this point). Don't mess with what isn't broken."

I mentioned to TGO and SS that we should do a 12-lead since we have time and since it is a true medical reason for the code. So, SS then dances around in her seat. It looked like she was trying to chase her own tail but couldn't turn completely. No, it wasn't that she was excited that we were doing a 12-lead, it was because she probably thought this would make her look busy (she told me later that she didn't know where to put the stickers for the 12 lead). TGO is telling me "DP, you'll have to show this dinosaur how to do it." Okay, she's not a friggin "dinosaur" in EMS. We have some that could be considered "dinosaurs" and they know how to do 12-leads and interpret them. Also, when she said "DP," SS had this "aw shit" look on her face until she realized that TGO wasn't talking to her.

So, we do the 12 lead and TGO is going "it says there's artifact interference! now we don't know what it is!" See, this is why I HATE when people rely on machines to do their job for them. I don't like the fact that on most 12-lead EKGs that are done now have the machine's interpretation on them. So, TGO looks at the lead II line and says "Yep! It's a bundle branch block. I knew it! I knew I saw rabbit ears." *sigh* There weren't any "rabbit ears" on any of the leads. There was a significant elevation in leads V3 and V4, in addition to lead II and lead III.

So, the flight crew gets there. The flight paramedic used to work for us and is a "dinosaur." He's also taken quite a few patients from me lately. He also remembers TGO from when she started here as a basic and has made her way up the chain. They step in the back and I start to give report. Then TGO and SS start talking over me. I just stopped because it wasn't doing a damn bit of good to try to talk over them. Keep in mind, all we had was a name and an approximate age, everything else was unknown. I hand the 12 lead strip over to the flight paramedic and he looks at it and goes "Ahh. You chose the right hospital to ask us to take him to." TGO is pointing at the strip in the flight medic's hand and saying "SEE! I knew it was a bundle branch block! See! It's a bundle branch block! That's what happened!" The flight medic just looked at her and said "Ummm yeah okay." Of course, then I had to ask for my 12-lead back since he wanted to take it with him and I needed it for my report.

So, the patient got a nice helicopter ride and was taken to the Cath lab and kept intubated and actually had to have a Fentanyl drip for continued sedation. YAY!

It's a call like that for why I stay in this business where I'm rarely ever appreciated.

Oh yeah, when we got back from the station, SS backed into another ambulance. I had the great pleasure of telling TGO "You know those days when things just seem to go right?" TGO: "Yeah...." DP: "You know... those days that things go right... and then somebody backs into another ambulance with their ambulance?" TGO: "UGH! I take it you weren't driving?" DP: "Nope. SS did it." More on this the next post.