I watched my patient die...

[ambodriver]

would it have been better to drop a few NTG and drop pressure so until you cannot give lasix, or just go straight to the lasix?

Also--are you sure the tube wasn't in? It's hard to believe a whole ER staff will not recognize a bad tube.

Sounds like a good pt. to use cpap on -- or even intubate. The vent might be able to do good things for her.

Your system sounds like crap, no RSI, no CPAP, and you are a 2.5 month medic working with a EMT? Also someone can jump in your ambulance and take over the call? Weird. Where is this?

Also you said there was no radial pulse, I'm wondering if the BP was correct, you gave it in odd numbers, were you using a machine? Maybe the medic was right about not give the lasix/NTG. Who knows--I am just throwing out ideas, I was not there

[under-dreaming]

That is an awful situation to be placed in.

First, I would like to thank you for sharing your story with everyone here. It is hard to relive these situations... then again, it's hard not to. They tend to stick in the mind for a little while.

You may find relief in another EMS system. Apparently, the common theme of the comments here are that you should get away from it. I personally couldn't disagree more. Places like that need you. The potential patients need you. You may not be in a position right now to have an overwhelming influence on the system you operate in, but eventually you will. The key is to allow positive growth within yourself as you operate in this system. Your presence will change things. Your positive and proper actions will change things. Believe in the power that you do have and hang in there. The hardest part will be keeping yourself pointing in the right direction. Often times, individuals will adopt the methods of their peers. In your case, that would be a negative thing to do. So keep that in mind as you carry on.

Not that you should think that leaving the system would be a form of quitting. I don't even know what your situation really is. Only you can know the reality of the situation, and how it is affecting you.

I have learned from your story. Your experience has made me more aware.

[WolfmanHarris]

What's this ER like? I know every hospital around here has an emergency department, but the one tiny rural hospital is often referred to by medics as "The Campbellford First Aid Station" as their one Doc is usually going to put the medics to work on anything big before they transfer to one of the bigger hospitals. I doubt they've done too many intubations in the ER in the last year, possibly less than the ALS crew that works out that way. Not all ER's are created equal.

[rock_shoes]

That's a tough call all the way around. Personally I probably would have kicked the fire guy out of the ambulance since it becomes your domain once your in the back. It's hard for me to imagine fire being in charge of the scene. Whenever I work with fire they defer to us and basically just do whatever we ask. That includes everything from a medical call to an MVI(Motor Vehicle Incident). They never tell us what to do they ask us what we need from them. So far it's worked out great and we have few problems maintaining a good professional relationship.

Don't beat yourself up about it too much. It sounds like your system needs an overhaul from the ground up and that is not your responsibility. Just continue to be the best medic you can with the knowledge and experience you have. I guarantee any similar call you get in the future will not go the same way.

[Arizonaffcep]

Wow. I'm so sorry that you had to go through with that. The only other thing I might have to add in addition to what everyone else has said is, maybe the FF/medic replaced the drug for you. If you checked the drug box in the AM, and everything was there, and there was everything back after the call, it would be a logical conclusion. Again, that other place we were talking about when I checked it out seemed pretty good.

[Doczilla]

Just because you saw them alive doesn't mean you can save them. Sudden onset CHF in a patient without a history of CHF is a very poor prognostic indicator. It means a) huge MI or blown heart valve from endocarditis or papillary muscle rupture. I've seen exactly this patient many times over, and despite positive pressure ventilation and any drug or airway device I want, they usually still die. The patient was doomed.

'zilla

[DwayneEMTP]

Sorry Lady, this sounded like a mess from the word go...

I'm guessing this ladies’ SPO2 was in the toilet, and I know it was used as the hosemonkeys do love their machines, so any idea why Solu-Medrol was Fire's second line drug for pulmonary edema, assuming that is what was pushed?

Also, I hear you about letting the 'experience' run the call, but this is what I've found for me; that each time I have allowed myself to lean on someone else's experience over my own logic and education, it has been a mistake. I can't think of a single time that I thought, "Man, I think A is right, but I'm not sure. Mr. 20yrs thinks B is right, and he's probably seen this 100 times before, so we'll do B." Every time I wish I had done my own medicine instead of hoping that someone else was smarter than I was.

Also, are you sure that you had control once you entered the ambulance? In the Springs Fire can choose to retain control all the way to the hospital if they want. They were pretty stand up guys/gals, so the only time I witnessed them doing so is when they had students on board that they wanted to give experience to…but just wondering. Hopefully in the future you will take that control if it’s available to you…

And I agree with others who say it’s time to move if you can. I know why you’ve told us that you stay there, but you’re too smart to believe that you can change this place and remake it into something completely different, which is what it needs. And you’re plenty smart enough to know that no matter how smart you are, that the choke hold they have on medicine there is damaging you as a medic. Right now you are leaving drag marks from your fingernails trying to hold on to the education you’ve earned at a very dear cost when you should be piling on new information from strong medics, from strong medical control doctors in a progressive system.

I know you want to stay, but I’m not sure you can be the medic you want to be there. I don’t believe you can be constantly around bad/lazy medicine without it polluting your skills and knowledge. You simply can’t live with pigs without getting shitty…just sayin’…

Me, and my two puny little brain cells think it’s time to reevaluate your motivations for staying.

Keep your chin up Babe…

Dwayne

[KSEMT122]

Let me first preface this with the fact that I am an EMT so I can not totally stand in your shoes, but a few things jumped out at me.

This whole situation sounds like one of those bad dreams where you can't scream "NO"! when something bad is about to happen. Except in this situation you were fully capable of screaming "NO"! Like many have said, it may or may not have made any difference in the outcome. I think the way I read your post you may be feeling bad because you didn't speak your mind. If you had spoke your mind and ran this call yourself at least you would have known you had done everything you could have thought of. A couple things...

I've NEVER seen a Fire Medic take control of anything other than a hose and cigarette... As soon as they see the Ambulance they are usually out the door with no more than 1 set of vitals if you're lucky. I darn sure haven't seen one jump in the back of an Ambulance and tech the call. That is YOUR Ambulance, you choose who to let in. You make the decisions. You have to have a voice to tell people that. If you don't these types of things will happen.

Go figure, the "ER" Doc (who is probably a dermatologist during the day) missed the tube... I can't tell you how many times I"ve seen this happen. And we seem to be the only ones that catch it time and time again. In fact when you say something you get ignored. The nurses can't believe you are going against "their" doctor so they ignore you or tell you to be "quiet". I've seen very confident medics literally push the doctor out of the way and pull the tube because it wasn't in. Guess what... The Doc might have a fit initially, but once things start to progress in the right direction the Doc realizes he was wrong and usually says nothing afterwards. Of course I ran in a system where we usually would run the codes in the ER because the Docs & Nurses weren't confident enough to run one.

So with all that being said. I agree with the people who say "get out of there" and those who say "stay, those patients need you". You should only stay if you can find your voice. If you can't find your voice, it's time to move on to a service with more progressive protocols where hose jockeys can't take control in your ambulance. Hang in there...

[spenac]

Just because you saw them alive doesn't mean you can save them. Sudden onset CHF in a patient without a history of CHF is a very poor prognostic indicator. It means a) huge MI or blown heart valve from endocarditis or papillary muscle rupture. I've seen exactly this patient many times over, and despite positive pressure ventilation and any drug or airway device I want, they usually still die. The patient was doomed.

'zilla

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

[Kaisu]

I want to thank all of you for taking the time to respond. Your answers are thoughtful, insightful, and compassionate and demonstrate the wide variety of experience available to those of us lucky enough to find this resource. I don’t know what I would do without all of you.

I want to respond to some of the points that you all bring up. For those of you who tell me to “get out” – I can certainly understand this. Please remember that I generally post only when the excrement hits the ventilation device. You are getting the worst part of the picture. One of the few good things about this incident is that whereas before, I was an outsider and felt very alone, this call had my fellow paramedics rallying around. I had not had this kind of support demonstrated so universally before. That notwithstanding, there is no doubt that this system leaves much to be desired. Initially, a big part of my desire to stay here was the idea that maybe I could be a force for positive change. While not totally discounting that possibility, now my primary motivation is the fact that this place has a lot of lessons to teach me. They will be painful and sometimes overwhelming, but hey – I got you guys right?

There is a new hospital opening in this town in less than a year. It is currently under construction and is owned by EMSC. A lot of us are holding out hope for this. Perhaps the town will attract more and better providers with a brand new state of the art facility.

The lessons I have learned –

1 – I will never again let anyone in my rig overrule my treatment strategy for flash pulmonary edema. The presentation, symptoms and protocols have been seared into my soul. Remember when I had the problem with the sharps? I am now the goto girl for proper sharp handling in both theory and in practice. I have been researching flash pulmonary edema and I know way more about it now than before this call.

2 – NO ONE draws up drugs from my box without showing me the vial first and then showing me the vial after. I don’t care if it’s the Dustdevil himself in there with me – they are showing me that stuff. (PS Dust – you honor me with your remark about hiring me. It means a lot to me.)

3 – A bad tube is a bad tube no matter who places it and no matter who thinks it is a good one. When I see it again, if I have to, I will rip it out myself and replace it. I am 6 feet tall and I lift weights. Those wusses can take it up with me after the patient lives.

For those of you who are concerned about my silence in the face of a lot of this. I want to refer you to the responder who says it is hard to believe that a whole ER staff will not recognize a bad tube. This place has been one shock after another. There is SOP here that made me stand back in disbelief. Sometimes I feel like I am practicing in bizarro world. This is a big reason I come to this board. It is a reality check. I also call on my instructors in Wisconsin. Between the people here on this board, the people I trust and respect in Wisconsin and the experienced medics at my service, I get a lot of input.

When I was about ¾ of the way through EMTB, my instructor said he would trust any one of us with him or his family in a medical emergency. I thought he was out of his mind. I couldn’t believe that anyone would let me on an ambulance with what they gave me in EMTB class. After I graduated medic school, they said – Congrats paramedic Kaisu. I thought they were out of their minds. When they threw me onto this rig after a two week orientation and no field experience whatsoever, I thought they were out of their minds AND I was scared s**tless. I am in no position to get forceful about my opinions and beliefs about a lot of things – EXCEPT the stuff I have directly experienced and KNOW in my head, my heart and my gut. Flash pulmonary edema, having someone else draw up my drugs, and speaking up when I see a bad tube are all things that I will have no trouble getting obnoxious about in the future.

Finally, thank you Doczilla for pointing out the fact that this patient was doomed. She really was. I can handle deaths without a problem when I know everything that could have been done was done. You reminded me that had everything gone picture perfect, this patient would still have died. There is a part of my mind that will always wonder. I will honor her and her memory by never forgetting the lessons she taught me with her death.

Once again, thank you all both for the wonderful PMs and for your responses, your willingness to share and to educate.