I watched my patient die...

[firedoc5]

Doczilla gave the best advice. These are words to live by so you do not beat yourself to death.

I agree.

Been there, done that. I think any Medic with any time in the field has had that happen.

Was it a 'rent-a-doc', or a full time ER physician, or a local practicing doc that was in rotation to cover the ER that day? An ER doc that doesn't know how to intubate without causing trauma, and does not check for tube placement him/herself needs to learn a thing or too.

But on the call itself. It was not your fault. Please don't kick yourself. Yes, there were lessons learned, but you just happen to be in a profession that errors can cost lives. Like a doc I knew said, " We visit our mistakes in the grave yard." That has always stuck with me for some reason.

I was a Fire/Medic and there is no way I would not at least listened to you. Yes, I would have given the nitro in a heart beat (no pun intended). At that heart rate it would not "tank". Lasix and MS would also have been given. In the house, starting the IV, give 'em one shot while preparing the pt. to be placed on the cot and go. Your crew and the FD crew needs to work as a team and multi-task as such. Maybe I was spoiled but when I worked with a private service and ran calls with the FD we pretty much all worked closely together, as a team. Later on is when I got on the same FD full time. So I was still working with the same team, just flip flopped who I worked for.

OK, I'll stop rambling. Point is, the ball was dropped. Not by you, not fully by the Fire/Medic, but as a team. The ER, that's a different story. Since I never worked in an ER full time, I won't slam them.

But as an ACLS-Instructor, me and that doc would have had words.

[Arctickat]

Impressive posting Kaisu. You sound like a medic who learns exceptionally well from her experiences and is very much open to taking the advice of those whom are asked. A medic with a good head is a valuable one. It appears you have learned the most significant lesson...Be Assertive. If Dust hadn't already offered you a job, I would have.

[rat115]

Kaisu,

It sounds like you've looked back over the situation and come away with some good insights between you're own QA/QI and what has been commented here.

One thing I notice is that you said that the medic who took over knew the pt for 18 yrs. In the system I work in, we are supposed to call in someone else if we know the pt really well. We are a rural eastern CO service, so it's common to know the person. If it's someone that's a close friend or relative, we've found that it's easier to make mistakes because of emotion. That's why it's part of our protocals to call in help or turn the pt over to the other EMT on the call.

I have a hard time believing that you're director was so flippant about the drug box, too. That would be something I'd be documenting and keeping track of. Mistakes on meds can get you in legal trouble, so it's your job to watch it. I've seen the stack of paperwork that goes with a messup on something the FDA oversees. It's a B****!

Hope things improve with the new hospital.

[zzyzx]

I was wondering who took the BP. A firefighter? Your newbie partner? Often the firefighter taking the BP is a boot or volunteer, and if they can't find a BP, they're afraid that they'll look incompetent in front of their crew. They don't exactly make up a number, but they'll got with whatever they kinda-sorta-maybe hear. To be honest, when I was an EMT in training, I did this once myself. I think a lot of firefighters and EMT's don't realize how critical a proper set of vitals is for us medics when we're treating patients like this. This is why I always get my own vitals before the ambulance starts moving.

I've had quite a few patient with flash pulmonary edema and no prior history of CHF or MI. They all responded quite well to treatment, actually, but they were not in cardiogenic shock, which I suspect was the deal with your patient. Like you already know, patients with cardiogenic shock and rales usually have bad outcomes.

I'm still relatively new myself (about 3 years as a medic now), so I know how you feel. Seems like you did a fine job though, so don't beat yourself up.

[fiznat]

Its tough being a new medic working alongside someone with many more years behind them. Keep in mind though that years of service dose not necessarily correlate with competence. In fact, these people are sometimes even less competent than their newer/younger counterparts. You ARE a medic, and I don't think you can ever be out of line questioning another medic on a treatment decision when you are jointly working a patient. I'm not saying you did anything wrong really, just don't be afraid to stand up for yourself and your patient. Part of being a good paramedic is controlling the scene and advocating for your patient: even if that means you need to battle a little bit with another provider.

I don't care how many years he's got, that paramedic would need to very clearly justify to me why solu-medrol of all drugs would be appropriate at that time, while NTG was not. With time and a little more experience I think you will (as I have) develop a sense of pride and protection over what happens in the back of *your* ambulance. To hell what everyone else thinks. If you don't agree with it and the other provider can't make a strong case then it isn't freaking happening. Just make sure you're right, haha

Doesn't your protocol have a BP cutoff point for NTG in these patients anyways? Or is it up in the air... Anything over 100 should be plenty for someone who is in this much trouble...

I donno man, it sounds like a terrible call. These things happen, but like others have said: take the most out of this experience that you possibly can so that next time is different.

[p3medic]

I wasn't going to mention it, but since Fiznat brought it up, I too wonder as to why Solu-medrol was given to a suspected CHF patient. It seems unlikely to be part of a CHF protocol, and if CHF were in my differential, I probably wouldn't give it. Just curious.

[ccmedoc]

Since I have not been here much lately, can someone tell me where this took place..State and county area..

I dont think I can say anything that wasn't already said, at least not any better than Doczilla.

It's still hard to deal with, and second guessing whats already done is futile. We learn and move on.

Not to be a sh!t, but I dont really want to be caught ill in this part of the world. Nothing personal :shock:

[stcommodore]

The entire story sounds like a rather rough call, sorry but welcome to the job. In regards to working with an EMT as a new medic, you may be new and I'm not far from where you are but being nervous is one thing but it shouldn't keep you from being competent on the call.

In regards to RSI, for all the people that seem to be talking your system down its not as commn as they make it seem. But CPAP/BiPaP is the standard of care and the service should be moving toward having the ability to provide that to a patient.