ROSC

My white cloud gave out on the last four-day rotation. We had four cardiac arrest patients in two rotations, 8 days (and an apartment fire with a total of five patients, but I'll save that story for later). Surprisingly enough, we got return of spontaneous circulation (ROSC) on all four, and three have survived past the 24-hour mark.

I was planning to write up three, and then we had the fourth, and the stories are just too long to tell. I'll try and summarize briefly.

* * *

Patient #1 was an unwitnessed arrest in a parking lot, very brady on arrival, v-fib soon after, transported immediately (work a code in a mud puddle in a parking lot? no thanks), tubed and everything enroute, shocked three times, the third shock at the hospital driveway ended up getting pulses back. He was very sick, however -- a primary respiratory arrest -- and died 20 hours later in ICU.

* * *

Patient #2 was a witnessed arrest at home, v-fib on arrival. Fire shocked him once, put in an EZ-IO, and had started CPR when we arrived. We worked him for 20 minutes onscene, going from fib to asystole to fib to v-tach to ugly sinus tach with pulses. He got lots of drugs, including early bicarb and amiodarone after pulses were back to try and get things working a bit better.

We did a 12-lead in the driveway -- massive STEMI. Code 3 to a cath lab hospital, transmitted the 12-lead. He started to have some spontaneous breaths, and then coughed the balloon of the tube out. Crap. We pulled over, got him reintubated.

He went up to the cath lab soon after we arrived, and after a successful cath went to the ICU, where at last report he remained in critical condition.

* * *

Patient #3 was a witnessed arrest in a bar on Christmas day. Complained of acid reflux and just plain dropped. Bystander CPR in progress. We start CPR, get him on the monitor. V-fib. Shock once. Converts. Get him tubed.

He has a perfusing rhythm and blood pressure almost immediately. Do a 12-lead right there on the bar floor. I should scan the strips, but the monitor reads "Inferior-posterior infarct" and "anterior infarct" on one shot, and then told us "septal infarct," "anterolateral injury pattern," and "inferior injury pattern" a few minutes later. I thought it just looked all bad.

Transmitted the strip -- I actually called the inital report from the bar, bagging with one hand. STEMI activation. We gave him an antiarrythmic -- I honestly can't remember if it was amio or lidocaine, I was on the airway -- and some versed because he was bucking the tube, and transported.

He coded again in the ED. Shocked 4 or 5 times. More drugs. Taken up to the cath lab. 100% occlusion of the LAD. Ballooned, stented. Called the ICU the next day. He'd been shocked twice more there, probably reperfusion ischemia. Then we had four days off.

Come back on New Year's Eve. Call the ICU. Not there. Dead, or to a floor, I wonder. To a floor would be cool. Call registration to check. Not in the hospital, they say.

Discharged, they say.

To home.

Unbelievable.

* * *

Patient #4 was after New Year's. Taking a cold shower. Family heard him drop. We found him in the bathtub. Agonal brady rhythm. CPR, IV, epi. What do you know, his heart kicked right back over and got going again. 12 lead was unremarkable. He tried to tank his pressure on the way in, but the fastest med control consult later by my lead paramedic and we had dopamine orders. That perked him right up.

The consensus among us was that the cold water stimulated his mammalian diving reflex, which caused him to brady down, which caused either a hypoxic bradycardic spiral, or a syncopal event which closed off his airway. Either way it wasn't a big cardiac event and I'm hopeful for his prognosis. Haven't heard anything yet, however.

* * *

So, statistically, having saved had 4 field ROSC patients in 2 weeks, I won't have any other saves for a long, long time. We'll see about that, though. I've got four shiny little Code Save pins coming, and some Starbucks cards for sending in tubes of blood for a Sudden Unexplained Death study.

Oh, and I've got a few other stories to write up, like the apartment fire and the patient who Should Not Have Refused.

At this rate, I'll get those out by February.

Noxious Stimuli

He was in his 80s, chronically ill with something -- I don't recall exactly what -- and barely breathing.

The house was up in the hills, tucked back on a windy side street. My training officer drove while I looked at the Thomas Guide and the fire mapbook and the MDC and tried to make sense of the streets. As we pulled up behind the fire truck, we saw a firefighter run out, grab the suction unit, and run back in.

"Huh," I said. My training officer was less reserved.

"They're gonna tube someone. Let's get in there."

* * *

He was all the way in the back, on the bed, flat on his back. Gurgling respirations. Didn't respond to voice or painful stimuli. His son was there, visibly upset. A DNR was taped to the wall next to the bed. We explained to the son what the DNR meant. No mechanical ventilation, no intubation. No, no, the son said, the DNR is for the underlying condition, this is different, I want him helped, and I signed the DNR, I'm power of attorney!

My training officer pulled out his phone and called medical control. I suctioned him out, dropped an OPA in and started bagging. Not a twitch at the OPA. His sat was initially 68%. A few minutes of good assisted ventilations later, he was in the high 90s. BLS works.

The training officer came back in. Said the doc agreed that if the son signed the DNR, then he could waive it, and we should do what he wanted. The son asked what we thought needed to happen. We told him that his father needed a breathing tube inserted.

"Okay, are you good at doing that?" he asked nervously.

"It's what we do," my training officer said.

* * *

The fire guys passed me the stuff I'd need. A grandview blade on the scope, the first time I'd used one -- they work great on the mannequins, though, and why not? We moved him around, got a pillow under his head. I put the blade in, saw nothing but secretions. Suctioned. Looked again. Suctioned again. Saw the epiglottis, moved the tip of the blade towards it ...

The training officer tapped my shoulder. "Uh, he's looking at you."

I looked straight down. The man's eyes were open. He started to close his mouth on the blade. I yanked it out like it was electrified.

"Whoa there."

"I guess," the firemedic said wryly, "he just needed a more noxious stimulus."

* * *

We took him to the hospital without lights and sirens, a nasal airway in place, bagging him. Probably a stroke. It seemed like a laryngoscope blade in the throat was the level of stimuli he needed to wake up, but less noxious stimuli did help.

Ten seconds more and I would have had the tube, but in the end BLS airway management kept his sats up and seemed to get the job done. Never heard about an outcome.

* * *

Working Christmas Eve, Christmas day, New Year's Eve, New Year's day. Probably be some stories come out of that. Also some interesting developments with the wilderness ALS unit -- more on that depending on what happens.

Oh, and so far my white cloud is winning.

A Shift, In Haiku

Your Audi: totalled.
My IV: A bloody mess.
Bad day for us both.

* * * * *

First radiation,
Then dizzy, fall, cut your head.
Cancer is bad news.

* * * * *

Too drunk to stand up?
But you don't want medic help.
Go in handcuffs, then.

* * * * *

You said it's asthma.
But we can tell the diff'rence.
What a drama queen.

With apologies to the inventors of the art form, and thanks to EMS Haiku for the inspiration to describe my day like this.

An EMS Concerto

Sorry I haven't written much lately. Between my internship, some travelling, and a heat wave that's downright brutal for this part of the country, I haven't had much time or inclination. Rest assured I've been running lots of calls and learning a lot, and as soon as it cools down a bit and my brain begins working again, I'll try and post more regularly.

However! I do have an account of my latest shift ... in a slightly different form.

* * * *

Scherzo With Sirens

First Movement: Chest Pain Variations

Largo: Chest Pain With No Real Problems

Allegro: Chest Pain With Real Problems

Andante: Abdominal Pain Of Unknown Etiology

Moderato: Chest Pain With Cranky Old Man

Second Movement: Blood And Heavy Lifting

Poco Adagio: Leg Pain With Unexpectedly Massive Bleeding From Missed IV

Interlude: Change Pants

Molto Largo: Chest Pain With Morbid Obsesity And An Hour On-Scene

Interlude: Sleep Most Of The Night

Finale: Car Accident with Semi, Entrapment, and Trauma System Entry

Vivace: The Saddest Thing About Extrication Is I Have To Stand Back And Watch

Too Fast

Tuesday was a hot day. Around a hundred degrees. We took the ambulance to the store to get some food, and while we were there saw $0.79 squirt-guns. How could we not? When we got back to quarters, it became obvious that the battle would be ambulance crew vs paramedic intern, and I took refuge in the bathroom while loading. We had a great battle going for a while, but of course, at the peak of the fight...

*beeeeeeeeep* "Unknown medical problem, 9876 Elsewhere Drive..." Our district.

Laughing and swearing, we piled into the ambulance. When they realized how wet I was, they laughed even hearder ... but as hot as it was, I was dry when I got there.

This was not to last.

* * * *

The call was for chest pain and near-syncope (fainting). We arrived to find an elderly woman sitting on the bed, looking a bit pale, a bit sweaty, but generally alright. We put her on some O's, start asking questions. Nearly passed out in the shower. Cardiac history. 3 out of 10 chest pain. Some shortness of breath. I was just getting the aspirin out when one of the firefighters got the monitor hooked up.



(For my non-medical readers, this is [presumed] ventricular tachycardia or v-tach, a very serious rhythm that is often seen in cardiac arrest. It's indicative of something being Very Wrong. Her heart is beating about 240 times a minute.)

((For my medical readers, while we can go back and forth all day between VT and PSVT with aberrancy, the fact is that we only have a 3-lead in the field and we treat all wide-complex tachycardias the same -- lidocaine if stable, cardiovert if unstable.))

Uh-oh. Everyone exchanges serious looks. One of the fire medics rips open the IV kit while I pull out the pads. They miss their first attempt but get their second as my preceptor and I scribble drug calculations on our gloves and agree on a dosage of lidocaine. I push the first bolus. She slows down to the 190s, but doesn't convert, and slowly begins creeping upwards again. We all conference briefly and agree to load and go, with a second bolus and lidocaine drip on the way, and cardiovert her if she becomes less stable.

I'm no longer dry.

We take off, loud and flashy. She doesn't really change enroute. The second bolus doesn't do much, and I go ahead and hang the drip anyway (my first!). Call my report. If you key up the mic with sirens in the background and wait a couple of second before talking, there's no wait for a nurse to answer.

At the hospital, she does alright for a bit. The doc looks at the 12-lead and says he's not sure if it's really VT, or SVT with a bundle branch block. He starts a beta-blocker to try and convert her.

A few moments later, while we're still standing around, she goes unresponsive and starts having gasping, agonal-type respirations. They check ... no pulse. The doc gives her a precordial thump, glances at the monitor, and barks, "Shock her!" They light her up at 300 joules and she converts right into a sinus rhythm.

She goes to the cath lab with a massive MI. No word on how she did after that.

* * * *

That was the first and best call of the day. We did a syncope, a sweet old lady with a fall, a r/o neck injury from an MVA, a kid with an allergic reaction who was stable and didn't let me touch her, and, in the middle of the night, an elderly man with new diabetes. Half an amp of D50 brought him right around, and we left him with his wife, a glass of orange juice, and a slice of pie.

"Do I chart that? Blueberry pie bolus PO x 1 slice?" I ask, as we pull into the fire station.

My fire preceptor grins at me, taking off his turnout pants. "Go back to bed," he says.

Know Your Sources

At first I thought I'd call the day "Neb Day," because that was the theme of the first three calls. All elderly ladies, two with difficulty breathing and one with chest pain. All three got nebulizers because all three were complaining of shortness of breath. Ironically, I think the neb did the most for the chest pain patient, who we decided was more likely not cardiac. Nitro didn't touch her pain, but the albuterol and atrovent sure did.

One of the ladies was deaf, and I had to write everything out on a pad. She was terribly sweet, though, and informed me I should tell my mother that she raised a nice boy. I called my mom later on in the shift. Just doing as I'm told.

* * * *

But the defining call of the shift came later in the evening, when we went on an unknown medical that turned out to be a young lady who was, for lack of a better work, flipping out. Not psych flipping out, not upset flipping out, but crazy on drugs flipping out. She reminded me of patients on E and acid and more esoteric drugs (2C-T-7, anyone?) I'd treated at various concerts and events. Completely out of control.

We backboarded her, finally, just to keep her safe and us safe and get her down the stairs. She said, in lucid moments, that she'd only smoked some weed. We got her to the ambulance, headed off. She calmed down a bit, only to rile back up. I put a large-bore line in her, impressing both my preceptors. Fastest stick I've ever done.

Her sugar was fine. Narcan didn't do much. We left her at the hospital. I felt bad for her, really. During her calmer periods it was clear that she was pretty aware of what was going on, and very upset. It came out over the course of the call that the weed she had smoked came from a dealer she didn't really know. Hmm.

* * * *

In the morning, as I was getting ready to leave the fire station, my preceptor dropped a piece of paper in front of me. "Here's your girlfriend's lab results," he quipped. "I called the hospital after you went to bed."

Tox showed
- Cannabis
- Amphetamine
- Methamphetamine

Whoops. Poor girl.

Gone Too Long

I was working the ALS transfer car I usually work, on a Saturday. Just working as an EMT, with a very experienced paramedic alongside me.

We got tossed into the 911 system abruptly, given a code 3 call a long ways away out of the blue. No problem. Fire is there in a few minutes, so our long response doesn't compromise care. We get onscene eventually to a relatively simple chest pain. I drive, my medic does the regular ALS stuff on the way to the hospital. Prehospital 12-lead by the fire dept didn't show anything. We found out later it was cardiac.

Clear from the hospital. Cleared to quarters. Out of the system. We stop for fuel, and while we're doing so we're yanked back into the 911 system. The county's at low levels. We head back down the freeway, to a low-level post, basically on an overpass. As we're pulling up the onramp, the county alert tones go off, three monotone beeps on the fire radio, and--

"Dispatch with an echo response, 4321 Pringle street."

As the fire tones start to go off and I look for a place to turn around, I swallow nervously, and hope I misheard. As soon as I hear tones for a second station, I realize I was right.

Under the Medical Priority Dispatch System responses are coded (in order of increasing severity) Alpha, Bravo, Charlie, Delta, and Echo by calltakers, based on carefully determined criteria.

Alpha response is no lights and sirens, a nothing call. Bravo might be something. Charlie and Delta calls are serious. There are only a few things that can get an Echo response; generally they're for a patient not breathing or a full-on code (cardiac arrest). You rarely hear one.

Sure enough.

"For Engine 314, Rescue 332, Medic 34, echo response on a child not breathing, 4321 Pringle street. Repeating, Engine 314, Rescue 332, Medic 34, echo response, child not breathing, 4321 Pringle street. Fire map page 671 C-Charlie, working Tac 2, time out fifteen thirty."

Crap. I put the pedal to the floor as my partner starts talking to the dispatchers and mapping me in. We scream down the interstate, hop the divider at a traffic-clogged offramp, and go wailing up city streets.

On the way dispatch confirms that it's a pediatric patient. CPR in progress. Crap. But then a second update comes in: breathing now. Okay. Maybe this was new mom syndrome? Or something else less serious than it sounds?

As soon as we arrive I know it's exactly as serious as it sounds. The kid is primary-school-age, with a form of muscular dystrophy, lying on the ground next to a motorized wheelchair. Where he isn't pale as a sheet he's blue, and he's working hard to breathe.

We're on-scene for about nine minutes, just long enough for the medics to figure out they can't get a line easily and that he's not ready for a tube without the rapid sequence drugs. No IV, they can't sedate, paralyze, and tube this kid, and without that the only option is mask ventilation with high-flow oxygen. They can't get an O2 sat either.

We load and go, lights and sirens, my medic plus a firefighter paramedic in back. The children's hospital knows him, surely, and no doubt they can take care of him better than we can.

But a couple miles up the road he codes, for real, and I have to pull over, ask for the fire units to meet us (for more help), and jump in back to help do CPR and suction while the medics try and get him tubed. I glance at the monitor at one point, and I'm not sure if I'm seeing v-fib, or artifact from my compressions. Not my job. I remember the new CPR class I took recently, and push hard and fast with the heel of my right hand. With the other hand I reach over and poke the Yankauer into the corner of his mouth and suction vomit. It's all over everywhere, and the kid is gray.

They get their tube, finally, on the second attempt. I'm sure it would have taken me more than two tries. Tough airway. But now he's getting ventilated, effectively. Look at the monitor -- asystole. Flatline. The first dose of epi goes down the tube.

The engine and rescue show up again. I happily clear out of the back of the ambulance, making way for a few more medics. After looking briefly for an IV, they put an intraosseous line into his leg. At some point I realize I parked almost in the middle of the road, and somewhat blocking an intersection. Whoops. Someone from one of the fire units cones off the area.

Finally they've got what they need done so we can go again. We divert for the closest hospital. I don't even know how many fire department paramedics we have in back -- three, plus my medic, I find out later.

We arrive with the kid still in asystole. The back of my ambulance is destroyed. Supply wrappers are everywhere. Two or three laryngoscope blades lay on the flood by the airway seat. Suction tubing, oxygen tubing, IV tubing, monitor cables -- it's a spaghetti hell. My paramedic looks at me and says, "Just decon everything." As I'm getting started, one of the fire medics comes out of the ER.

"You guys aren't going to believe this, but he's got a rhythm. Narrow-complex. Sinus tach. I don't believe it."

We're all happy for a minute, then someone points out the downtime. Fifteen, twenty minutes. Too long? Hard to tell.

* * * *

Three months later, my name and the name of the medic I worked with that day are in the pat-on-the-back section of the newsletter at work. An excerpt from a letter about the call, presumably from the kid's parents, thanks us warmly. Nothing to suggest what the call was to anyone else. But to me the connection is clear, and when I go back and check the dates match. No outright statement of outcome, but the way it's phrased makes me think he died. They thank us for doing everything we could.

And a few days after that, I catch up with the medic I worked with that day. Yeah, he says, the kid died. Of course. Sick to start with, twenty minutes of downtime. No chance. But, he tells me, he got a nice letter from the parents, through our agency. Didn't I get a copy? No? He'll make me one.

They included a picture, the medic tells me, and I suddenly, desperately, want to see it, so that I can have a memory of the kid's face that isn't gray, limp, and streaked with puke.

* * * *

(Please note that like everything I write here, while this is based on a real call, circumstances, locations, and details have been obfuscated or changed. Any identifying information has been removed.)

Support

He was young, just out of brain surgery. I'm not sure what his condition was; I was on my respiratory therapy rotation, and helped take him from ICU to CT scan. He was intubated and sedated, post-op. I bagged him down and back.

On the way from ICU to the elevator, we passed the waiting room, and there was quite a crowd of people, maybe twenty or thirty, hanging around. I thought, "Wow, someone's got a lot of friends." As we passed them, they all turned to watch us go. Someone gasped softly just as I passed them, and I realized they were all there for this patient.

Somewhere between the ICU and the scanner there was a problem with an IV pump, and his propofol (sedative) drip stopped, so he was a little more alert by the time we got him back. Nothing that was problematic, and he was quickly medicated again, but during the ride back his eyes were open and he was looking around. We passed the group again, and they lined both sides of the hallway, like it was a parade. A few murmured words of encouragement. The nurses and RT and myself kept our eyes forward. Professional.

After we passed them and turned the corner, I looked down, and realized he was looking up at me. I patted him on the shoulder, and said, "Did you see all of your family and friends, _______? You've got a lot of people here who care about you."

And he nodded, and seemed to understand, and I told him to relax and rest, and he laid his head back on the pillow and closed his eyes again.