worst week

[PCP]

Last week was my worst week so far since I began working in EMS and as a first aid attendant. Started off on a night shift when we paged out for a S.O.B call. On our arrival we got a hx from the fire dept. that the pt. was a diabetic and was complaining of back and was confused. The pt. was lying on the couch on her side and was moaning. I introduced myself and asked what was wrong? The pt. responded by stating that her back hurt. Airway was clear, breathing was laboured, and the pulse was weak, skin cold to the touch. RBS was remarkable, SpO2 was 89% on adult face mask, heart rate was between 79 and 86. My partner switched the adult mask to a non rebreather. I asked the pt. if she had suffered a fall due to the back pain and she said " Yes " and then said " No ". At that moment her grandson walked by and I asked him the same question and he responded with a " Yes " and then just kempt walking. My partner was getting the vital signs while I was trying to get more information from my patient. The grandson walked by again mentioned that he thinks she is an Asthmatic as well but was not sure? My partner said she had equal air entry bilatral to the bases. I questioned her if she was experiencing any chest pain? Her response was no.

Mean while she kept on trying to sit up but would just slump back over. At this point I had the fire guy's bring in our clamshell and set up our cot at the top of the stairs located just outside of the basement sweat, as I made the decision at this time that my pt. was very sick and needed to be at the hospital. As the fire guy's where finishing up strapping the pt. to the main cot, I had a chance to ask the gransdosn who had called for an ambulance what had happened and what prompted him to call for the ambulance. That was when he told me a very vital piece of information. He stated that earlier in the day he had come down to check on his grandma and he found her laying on the kitchen floor which was around 1pm. He helped get up and from there she seemed to be okay, but said to him she was having CRUSHING Chest pain and felt like vomiting. I said thank you and walked away.

As my partner and I where wheeling the pt. to the ambulance I mentioned the new information that I had just obtained. The fire guy's asked if we needed any help once we got the pt. loaded up and we said no thanks, but thank you for your help and we sent them on their way. within 2 minutes of sending them away our pt. when unresponsive on us. The pt. had gone into cardiac arrest. So with only two of us stuck in the back of the ambulance running the cardiac arrest call and doing a million things at once I mangaged to get my portable radio off my belt and radio dispatch requesting our kilo car to respond to our location code 3.

It seemed to take for ever and of course it was one of the hottest days we had had all summer long. Once the other crew arrived my partner contacted the ED and he requested that we bring the pt. to the hospital due the arrest being witnessed and that we mangaged to get one shock. Once we arrived at the hospital we worked on her for about 15 minutes before the dr. pronounced her.

For me this was a good call but also a not so good call. It was good because it was the first time inserting the OPA, nasopharngeal airway, as well as the King LT airway, hooking up the AED on a actual pt. and setting up the bag valve mask. In the past when doing a cardiac arrest I did not have my endorsemant for the KIng LT and typically the pt. was being ventilated by the fire guy's on our arrival. I was able to run the entire call from start to finish. I wish the outcome was better and I always think what could I have different. I couldn't believe the grandson had not mentioned to us on our arrival that previously in the day the pt. had been experiencing crushing chest pain. At least we would have had that information alot sooner and we would have probably loaded the pt. alot sooner and had been more prepared for any cardiac realted problems.

Now the second thing that happened that week was I had just started my first shift at my full time first aid job at a mine site two days later when I got a call for a worker who could not stand up. I responded underground to find my pt. pale, cool, diapheretic and complaing of abd. and groin pain and vomiting. I did not waste much time underground and loaded him onto the stretcher and brought him to surface where I had the onsite ambulance waiting. No signs of trauma on my RBS and vital signs where stable. We are an hour and half away by ambulance to town and at this point I did not know what was wrong with my pt. I questioned him on having any chest pain, ulcers, diabetic, bowel momemants and his response to each question was No chest pain, no ulcers, not a diabetic, good bowel movemants. I could tell this guy was sick and needed to be at the hospital and my suspicion which I told him due to him asking was he had a internal bleed. But I was not 100% sure of course. The pt. was unable to sit still, so I was unable to get a BP the entire way to town, his heart rate was within the normal range, SpO2 was 98% on High flow O2. I administered Entonox for pain, but did not help him at all and also his SpO2 stats dropped to 90 so I put him back on HIgh flow O2.

Abiout half way to town I popped my head through into the cab and told my driver to get me to the hospital as soon as he can cause at this point my thoughts had gone to thinking he might have been experiencing a Triple AAA due to some reading I had done and he was showing signs and symptoms of a triple AAA. I noticed when we were about 20 minutes from town that his abd. was slightly distended and for me that confirmed he had internal bleeding. After I gave my report to the attending nurse I stood back and listened to the dr. and he confirmed that it was a Triple AAA and that he was going to be flowen to another facility.

I learned that night that he suffered a cardiac arrest while en route to the hospital in the helicopter. The following day was tough as I had to face his coworkers and answer questions by his coworkers and upper managemant as well as the mine inspector. I know things happen and I did all I could do for my patient, but when you acutally know the person and have had detailed conversations with that individual its harder seeing someone in so much pain and knowing you are doing everything you can for them and its not helping.

Sorry for such a long post but I just wanted to share my experience of having my worst week so far since working in the EMS field. I just hope my next pt. I deal with has a better outcome than my past two pt's. Sure is different doing a call where you are talking to pt. then within minutes they are in cardiac arrest or you find out that they did not make it and you where the last person they may have seen or the last familiar face they had seen.

Thanks for reading and be safe out there everybody.

Brian

[island emt]

Sounds like you had an exciting week and are no longer a virgin.

Good pick up on the AAA.

Remember the first rule of EMS

All patients will die eventually!

sometimes we can prolong the inevitable.

[Bernhard]

I see that you have to vent your feeilings. That's OK, and I don't want to teach you or make you look as you forget something, just want to ask and point out a thing or two:

...a diabetic and was complaining of back and was confused....pt. responded by stating that her back hurt. Airway was clear, breathing was laboured, and the pulse was weak, skin cold to the touch. RBS was remarkable, SpO2 was 89% on adult face mask, heart rate was between 79 and 86....

What do you mean with "remarkable" on RBS (= Random Blood Sugar?)?

By the way my very first reaction on those symptoms in your first paragraph was: "Think of myocard infarct!". Especially with woman there are a lot of unspecific signs, as a pain in the back compiled with slight significant circulation signs (pulse weak, skin cold). No need to have a clear "chest pain" to ring a bell here.

How old was the patient? Did you have a 12 lead ECG? What was the SpO2 before you applied oxygene?

However, even if I'm right at the MI suspicion, it most probably wouldn't have affected the outcome. Just something to have in mind with "backpain", expecially if combined with other circulation symptoms.

After I gave my report to the attending nurse I stood back and listened to the dr. and he confirmed that it was a Triple AAA and that he was going to be flowen to another facility.

How did he confirmed this and - not so technically questioned - why the hell did he loose time then? Didn't they have surgical capabilities when they're called a hospital? An AAA doesn't have much time to intervene or get a second transport anywhere.

I think you hadn't much choice here than to transport to the nearest facility. Maybe a helicopter would have been the initial thing to call on scene but this depends and I agree that it may not seem to be indicated at this time.

Had a similar case some months before, 45 y/o mother of three childs, fully alert and in extreme pain with unspecific symptoms. Diagnosis was very difficult, we opted for a helicopter call in (night landing). Until then she had to be defibrillated once, came back conscious and thanked us (just like in a bad movie!!!), then eventually died despite all efforts in the ambulance on the way to the landing zone. Had to comfort the family for a while until more relatives arrived - not easy, since I was the first unit on scene and actually talked to the patient. It was my young partner's first death call, too.

Sometimes we simply can't help than beeing there on their last way.

Thanks for posting.

[Happiness]

What do you mean with "remarkable" on RBS (= Random Blood Sugar?)?This is the Rapid body survey and he probably wanted to say it was unremarkable

How old was the patient? Did you have a 12 lead ECG? What was the SpO2 before you applied oxygene? I think in the field they use the 3 lead if trained for it. PCP's do not use 12 lead

How did he confirmed this and - not so technically questioned - why the hell did he loose time then? Didn't they have surgical capabilities when they're called a hospital? An AAA doesn't have much time to intervene or get a second transport anywhere .Our hospital here has no surgical abilities. We go by Heli for the emergencies. So where PCP is they may have the surgery but may not have the ability to do a AAA repair. In my career I have had 3 AAA. One survived but it hadnt dicected yet. His ONLY symptom was when he would climb into his logging truck he would faint. That is accually what we were called for. He did make to the surgery in time. PCP if you read this another thing to listen for is a swooshing sound when your doing your listen for tummy sounds. You dont always here it, obese pts its hard to hear, but if you do you will never forget that sound.

.

Crappy week PCP but you have to learn real quick if they are the road to 6 ft under sometimes your the one driving the car.

[Bernhard]

RBS ... = ... Rapid Body Survey

Thanks a lot! Then I'd miss the blood glucose level. Yes, i know, the post is not intended as an exact call report. But PCP presented two interesting patients - too bad, that he most probably never had a chance to see them with a better outcome and it happened so short after another in a new job.

I think in the field they use the 3 lead if trained for it.

Well, a (STE)MI could be diagnosed with a 3 lead as well. Was it done?

But maybe I misunderstand the concept of a Primary Care Paramedic as a first aid attendant completely ("if trained for it"). Is wikipedia correct here?

if they are the road to 6 ft under sometimes your the one driving the car.

Ouch...(I sure will steal this line).

[Happiness]

If you look at Wiki you will notice that the Ontario PCP will be trained for the 12 lead. We are in BC and we are not trained for it. Now I did my PCP along time ago and they have started to do the training.

[DwayneEMTP]

...Well, a (STE)MI could be diagnosed with a 3 lead as well. Was it done?

If you're talking about moving the leads around, do you think it likely that someone not qualified to do a 12 lead with todays technology would like have been taught that? Or be able to interperit it if he was? Or maybe you know of a different way?

And even then, I've heard of doing 12 leads with a 3 lead, but with 3 leads being unfiltered would that truly give you cardiopathic (is that even a word?) diagnostic ability? Not sure....

Not busting your balls brother..you're a gift here..just trying to see what I might be missing...

Dwayne

[PCP]

Happiness thank for the tip on listening to the stomach for any swooshing sounds. I will remember that for next time. As Happiness has explained we do not do 12 leads in BC as a Primary Care Paramedic and we do not have Advanced Life Support in the town I was stationed at.

My partner at the mine site and I discussed calling for a helicopter due to the pain the pt. was in but we did not know why the patient was in so much besides what he was telling me about his lower abdomen and groin. Its sucks to say, but now that I have had my first pt. with a triple AAA I hopefully will be able to recognize it sooner and hopefully get the person to where they need to be sooner. Not saying all triple AAA patients will show the same signs and symptoms as I am sure they don't.

I feel good about the treatment that I gave to both my patients and I feel comfortable that I did everything that I could for them, just that it was out of my hands at that point.

Thank you to everybody who commeted on this post.

Brian

[chbare]

If you're talking about moving the leads around, do you think it likely that someone not qualified to do a 12 lead with todays technology would like have been taught that? Or be able to interperit it if he was? Or maybe you know of a different way?

And even then, I've heard of doing 12 leads with a 3 lead, but with 3 leads being unfiltered would that truly give you cardiopathic (is that even a word?) diagnostic ability? Not sure....

Not busting your balls brother..you're a gift here..just trying to see what I might be missing...

Dwayne

On the right track. A 3 lead typically will not record diagnostic quality data. Many of the XII leads will transition to diagnostic when you perform a XII lead. Therefore, definitively diagnosing a STEMI'S based on 3 lead data would be exceptionally difficult and possibly low yield at best. Personally, I do not see much use for moving the three lead all around the place when you likely have other priorities and in this case not really educated to do XII leads under "normal" circumstances.

Hang in there OP.

Take care,

chbare.

[Siffaliss]

I had a similar call 2 years ago, questioned myself for a year following the call on my treatment decisions and speed of. Bottom line was, this guy had no chance even if a surgeon was right beside his crushed body.

I also recall a question I asked of one of my EMR instructors 6 years ago when I was green and shiny ... "So what happens if you've done everything you can do and the pt still has no heartbeat, even after all that work? Can we do more?" He replied, "Then they die".

This seemingly basic Q&A stuck with me through early schooling, my 5 years working in the field and now medic school. I think you already know that nobody is perfect and the good ones learn from their mistakes. You were probably running through that day over and over again, questioning yourself and the judgements you made. We all have those.

Shit just went seven ways from Sunday for you that day. Don't beat yourself up over it, sounds like you did everything you could.