Saturday, December 23, 2006


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.


* * *

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.

Friday, December 22, 2006

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.