I watched my patient die...

[Kaisu]

The call came in at 4:00am. I was on duty at the quiet, rural station where we are assigned after serving at the busy, high call volume station. The theory is that we get to rest up a bit. I had run one 5 1/2 hour transfer earlier in the shift. The call was dispatched as female diabetic, difficulty breathing.

We were given the wrong cross streets, so it took about 15 minutes to get on scene as opposed to 6 - 8 had we had correct dispatch information. We arrive just in front of the fire department. They are first response and normally get there before us. They go into the house with the monitor and first in bag, my green as grass EMT and I follow with the gurney. We have trouble getting into the house. The driveway is blocked with 2 vehicles and we have to drag the gurney with two wheels on the concrete and the other two in the air. The house is clean and well ordered. There is a male, approximately 35 years of age directing us into the front room. I ask him to locate car keys and move the pickup to enable us to move the patient out if need be.

Our patient is sitting on the couch. She looks exhausted. She is soaking wet, clammy and with very weak radial pulses. The patient is speaking in one word sentences. Initially appearing obtunded, fire gets an SNL mask and A/A treatment going immediately. The high flow O2 helps and the patient is more responsive. The patient has a BP of 115/80, heart rate of 125 and respirations of 28, labored, with retractions and accessory muscle use. Fire is starting an IV. We have a 15 - 20 minute ETA to the regional hospital and I think we should have done the IV en route, but until they transfer care to me or get in the ambulance, they are in charge of the scene. I am tapping my foot. I want to get moving RIGHT NOW.

The patient's son, (the 35ish man mentioned earlier) cannot find the truck keys. I ask the FD to pick the patient up and lift her on my gurney. They do and my partner and I fly her out of the house and into the ambulance, second set of wheels in the air not withstanding. The patient is 61 years old, looks much younger and has a history of hypertension and type 2 diabetes. She has no cardiac history or history of CHF but I can hear rales in all 4 lung fields. She is wet and full.

The FD medic jumps on board. He is a 15 year medic and knows the patient personally. I instruct my EMT to go in hot and I put the patient on the heart monitor. She is sinus tach at 130, BP is 113/77 and respirations are 26. Unable to obtain an O2 Sat. BGL is 235. The FD medic wants my drug box keys. When we got in the ambulance, he took the attendant seat at the head of the patient, I am beside her on the bench. I toss him the keys and he pulls out 125 mg of methylprednisolone and draws it up. I am getting a history. It is slow going but she tells me that she has been feeling badly since 10:00pm when she had nausea and vomitted. The medic passes me the Solu-Medrol and I push it.

He patches to the hospital and tells them to have respiratory ready. We have no CPAP in the ambulance. I want to start the CHF protocol with nitro. The fire department medic says NO - he doesnt want to tank her BP. He has 15 years, I have 2 1/2 months. While technically I am in charge because we are in the ambulance, he has not transferred care to me. I think that as we have a nice patent line in her AC and as her systolic is well over 100 we should do it, but I do not push the issue.

Meanwhile, I can now hear rales without my scope. My patient is sagging in the gurney. l reach over and pick up her upper body, supporting her in a tripod and assessing her mental status. The FD medic goes rooting in my airway bag for the tubes and the scopes.

We should have pushed lasix and morphine too. l don't think of the lasix and while the thought of morphine did go through my brain, I figured if he says no to nitro he will say no to morphine too - PLUS our medical director makes us patch for morphine even in chest pain. It tends to discourage use of the drug when you are told no 90% of the time that you ask for it.

I am watching this patient waiting for her to go down enough so that we can tube her. We have no RSI protocols. (No CPAP - No RSI - I told you this is the wild wild west.) The medics here get around this problem with nasal intubations. I have never done one, never learned to do one, and am not about to start now.

We get to the hospital and take the patient directly into critical care room 1 where a team is waiting. Doc asks for BiPap but respiratory is not there. (Later the fire medic, who has known this patient for 18 years, is upset because the hospital did not take action on his request.) The fire medic is giving report. l leave the room for a few minutes to deal with paper work. When I get back, they have knocked her down. (RSI'd her). The ED doc is digging in her mouth with the scope. When I went to school, we learned to intubate in the OR. The anestheologists get upset if the cosmetic surgery patient wakes up with busted teeth and broken lips. This does not seem to be a consideration with the ER docs. He pushes in the tube and they put a colormetric device on the end. Seems to me that as we carry capnographers in the ambulance they would have one in the ED, but they don't. I don't see a color change. Someone listens and says the tube in. The patient begins to brady down. I can see her stomach start to inflate. Now the patient goes into complete heart block. I say "that tube is not in". My EMT cautions me to "shut up - they will kick you out of here". Patient goes into non-perfusing ventricular rhythm. I say "the tube is not in". No one listens - Doc commences chest compressions and they shock her. - She goes into coarse Vfib. Her stomach keeps getting bigger.

Doc's chest compressions are ineffective. I offer to take over. He gives me a look and then moves. I step over to the patient and the ED tech literally pushes my hands aside and commences equally ineffective chest compressions. 3 rounds of drugs, two shocks later and my patient is in fine Vfib. Out comes the sodium bicarb and I leave the room.

I go to the pharmacy to replenish the SoluMedrol, 3cc syringe and the needle. Then I open my drug box. We carry 2 SoluMedrol and there are 2 in the box. 20 hours earlier when I had checked out the drug box, I hadn't noticed extra SoluMedrol. What the F*** did I push? I inventoried the entire box. Nothing was missing. How did the extra SoluMedrol get in there? I called my supervisor. He didn't seem concerned about the drug discrepancy. He just wanted to know if I followed CHF protocol.

I cried all the way home. We all failed this patient. I will get another chance with another patient, but this lady doesn't get another chance. When I talked about it to my medic co-workers, one told me that I better get used to the hospital killing my patients. Another told me that she turns over the patient with report and leaves because she would just as soon not know.

Thank you for listening. I appreciate any comments you may have.

[spenac]

I am sorry. The first death that we feel maybe we could have done something else hurts. I have been there. Do not beat yourself up. You did what you thought was right by allowing the more experienced medic to take the lead. Never second guess yourself or you will not last long. Look back and QA/QI yourself then move on. Next time you will probably do something different but sadly even then at times our patients die. In the 90 mile transport to our nearest hospital I have been the last person many of my patients ever saw, and everyone of them I know I did what I thought was best for them at that moment. When I look back to long I beat myself up, so I learned to do a quick review and then move forward.

I am sorry not much help.

[Eydawn]

GET OUT OF THERE. The hospital sucks, the system sucks... you need to get out of there.

Your hospital shouldn't be so sub-par that you feel like you have to step in to do effective CPR. You shouldn't have to accept a failed intubation just because the doc fails to do capnography and doesn't see that the stomach is getting bigger with ventilations. You shouldn't have a procedure as your only alternative for an airway that you haven't been trained on.

Yes, there are things you could have done better... but everything was set up to cause failure in this case. And it doesn't matter how much progress you could have made transporting, nitro and lasix aside, that failed tube would have killed her no matter what.

Hang in there, Kaisu. I know this can't be easy.

Wendy

CO EMT-B

[itku2er]

Kaisu You really need to take our advice and get the HELL out of that place. It sounds like a bad system all around. Your partners suck the hospital sucks and the system sucks. I know you can find a good medic job somewhere else and you can make a difference somewhere else. I am here for you if you need me just shoot a pm my way.

Love ya gal hang in there god closes a door and he opens a window. (and personally I feel this is one door that needs to be nailed chained glued and duct taped shut!)

[crotchitymedic1986]

You didnt give the patient CHFor diabetes -- you will never know if she was really saveable. She may have still arrested if everything went smooth.

[p3medic]

I feel for you kiddo...I don't know your personal situation, but I tend to agree with those that are telling you to run away. One thing I will add, not having been there, is I never push a med if I don't get the vial with it. I have a partner that I have been working with for 13 years and I won't push a drug he draws, and vise versa if it doesn't come with the vial. Always confirm what the drug is, especially at 4 am when the synapses aren't firing like they should. Good luck.

[mobey]

I am going to go against the grain a little on this one. If you can handle a few deaths, hang in there. Take this scenario and bring it up at the next in-service or staff meeting. Discuss the CHF protocol, find out who supports you and who supports your firemedic. This is a good time to "Test the waters" to see if this service is open to any new ideas. I know you have had problems there before and this may be bad advice, but I would definatly DO something before I left (haw about a chat with the MD about witholding the nitro?). What about a supervisor? The choice to let her drown to save the BP was clearly the wrong decision IMHO, audible crackles have only one outcome in the absence of treatment.

And to clarify... I would have done exactly the same as you, you had a SR. on car and followed thier lead, in traditional EMS that is what we are TOLD to do.

keep your chin up

[triemal04]

Something like this should not cause you to change your career. Something like this should, most absolutely, definitely, positively, should cause you to change where you spend your career.

Bottom line for this comes out to be that yes, there where things on that call that you screwed up on. Period. But how much of that comes from being a paramedic with 2.5 months of experience being put into that situation on your own (and yes, you were most definitely on your own there)? Any service that allows something like that to happen is not where you need to be.

[Arctickat]

It's a tough call and everyone screwed up. That is a rare occurrence but try to bounce back as best you can and learn from your mistake.

I will never push any med I did not prep myself or at the very least have the individual who did prep it show me the container the medication came in so I can verify it myself. remember the five rights of drug administration:

Right Drug

Right Dose

Right route

Right patient

Right Time

You can't verify that it was the right drug if you didn't see what it was.

[Dustdevil]

I called my supervisor. He didn't seem concerned about the drug discrepancy. He just wanted to know if I followed CHF protocol.

What was your answer, and what was his response to your answer?

Tough one, for sure. Lots a factors working against you and your patients. Non-supportive partner with no education. Flaky protocols regarding who is in-charge. Lack of state-of-the-art equipment and procedural protocols. And, of course, your own lack of experience. I don't think that lack of experience is so much of a factor medically as it is procedurally. Without a frame of reference for how things should work, it's hard to see and deal with the problems that exist in your system. After all, it's all you've got and all you've ever had.

This scenario was a cluster from the beginning, but I certainly don't think you can be held responsible for that. Sure, it would have been nice if you had pushed the firemonkey out the side door of your moving ambulance and taken over. Might have made a difference in the outcome. Might not have. But obviously, that is not a reasonable expectation. And ultimately, it was the hospital that sealed this lady's fate, not you or the firemonkey. This is not the last time you will see that happen.

The best you can do with this experience is to make sure that you learn every lesson offered by it, and pass that knowledge on to the benefit of your future patients. I just wish I were somewhere that I could hire you today.

I really wish I could post something uplifting and positive here that would make you feel a lot better about it. But that would require knowing you a lot better and blowing a lot of smoke. My only real advice here is to never forget what happened this day, and use it to make you a better practitioner, and to not let these kind of incidents sour you on the profession. You are quite probably the only person involved who even realises that there was a problem. If you give up, things will never change.