The MacMedic

Quite the busy day. The ED was busy for the entire day and my partner and I spent the entire day in between the several calls that came in drawing blood, starting IV’s, and doingECG’s. Drone, drone, drone just nothing with a challenge and nothing requiring much thought. *sigh*

My partner worked full time for a high volume urban non-transport service about 45 minutes away in the next state and also volunteers at the same service I do. We had talked on several occasions about his job and I would be lying if I didn’t say that I was tempted. The idea of being in a high volume system that is also progressive is very appealing. I have to say that the only things that would hold me back are the fact that it is more than an hour from home, it would mean maintaining a license in yet another state, and it’s only eight hour shifts.

I really enjoy working with this partner, we have similar outlooks on our job and similar styles of treating patients. It’s a great feeling when you find a partner like that and I wish we were working together for the entire shift but we would be working together only for the day shift and then he would be going home. The paramedic coming in is a person that I have a hard time getting a feel for. No matter when I see him it is impossible to read how he feels, if he likes you or doesn’t like you, if he likes his job or not, and generally what kind of a person he is. I have to admit that working with a partner like this is just as unsettling as working with a partner like I had for the first half of the shift is enjoyable.

The night was pretty uneventful with only a couple of cancelled calls which required very little effort on our parts. Even then, I finished the shift with just as little understanding my partner as I started with.

Another busy night in the ED. We were short a nurse which meant that the tech and I got really hammered on all night. By morning everybody looked pretty well shot.

The most interesting part of the night happened outside of the ED on one of the med/surg floors. The hospital I work at developed a Rapid Response Team (RRT) a few months ago. The idea of the RRT is bring a skill set to the bedside of a patient anywhere in the inpatient areas of the hospital to act as consultants and assist the floor staff in dealing with patients that may be becoming unstable. All the studies have shown that hospitals that utilize a Rapid Response Team have far better outcomes when it comes to patients who suddenly destabilize. Our team is still in its infancy and is only active from 0700-2300 every day. During that time any request is answered by the paramedic assigned to the ED, a respiratory therapist, and a nurse from the ICU, all people who have some experience dealing with unstable patients and providing rapid interventions as indicated.

I was a bit surprised when the RRT pager went off at around 0500 requesting the team to one of the med/surg floors. The initial page gives no information on what we would be responding to and the assumption is that all the equipment we would need is on the code cart on each floor or in the med locker.

I knew I was in trouble when I stepped off the elevator and nurses were running in both directions in the hallway. The respiratory therapist was about 40 feet in front of me and when we entered the room it was quite the chaotic scene. The patient was a female in her 60’s who had been admitted with a blood clot in her leg. Last seen at around 2230 when she was given her sleeping medication she was found about 20 minutes prior to the activation of the team in bed, hypotensive, drenched in sweat, posturing, with a clenched jaw, head turned to the right, and a rightward and upward gaze.

The staff had started an IV, pushed fluids and paged the admitting doctor. While waiting for him to call back they removed the patients Duragesic patch and administered Narcan, a medication to reverse the effects of narcotics, but the patient didn’t respond. After some time without a response from the admitting doctor they call for the team.

My frustration started almost as soon as I walked in the room. The respiratory therapist and I said almost simultaneously “she’s seizing, we need to do something about that”. I cracked the code cart but found that the medication I wanted, either Ativan or Valium, was not in the cart. Somebody left to go get some and in the meantime the respiratory therapist started to bag the patient which improved her oxygen saturation significantly but did not stop the seizure (not that we expected it to). The staff still seemed to think that this was due to either the pain medication that she was receiving via slow release patch or the sleeping medication she got almost seven hours ago. Unfortunately my thoughts were that the cause was a much more ominous cause.

After a couple of minutes the nurse came back with the Ativan but wanted to know what doctor was the ordering physician. Well, at that moment there wasn’t one, and it became clear that the Ativan would not be given without and physicians name and verbal order. We had just discovered a kink in the system. While the nurses in the unit have standing orders for some medications the floor nurses have a smaller, more limited set of standing orders, Ativan was not one of them. While I have broad standing orders in the field I do not have them in house and would have been relying on the ICU nurse’s standing orders. Problem was, no ICU nurse was there, since the team wasn’t active at the time of the call nobody from the ICU was assigned to the team. A major oversight in my mind but at the moment we had a situation. I called down to the ED and the ED doc, rather than giving verbal orders on the phone (why I don’t know) decided to come up.

Fortunately, the hospital is pretty small and he was there in about a minute and a half. Ativan was given, the patient was quickly intubated using RSI and an emergency CT Scan had been ordered. Shortly the patient would be moved down to the CT scanner and then to the ICU. Finally, what needed to happen did happen. I was thankful that the ED doc was able to leave the department, if he had had a critical patient there he would not have been able to.

As I walked back down to the ED I kept shaking my head. What a fiasco. So many problems. At first I thought the biggest problem was the staff on the floor. They were part of the problem, not recognizing just how critical the patient had become, but then again they don’t deal with unstable patients in a regular basis and therefore would not be as familiar with them. Was the nurse who didn’t want to give the Ativan the main part of the problem? No, she was following the limitations of her scope of practice, it wouldn’t be fair to expect her to step outside the lines. Was I, rather my position, the problem? Me personally, no, my position, not exactly. The problem I decided was that the capabilities of each member of the RRT were not fully thought through and a scope of practice implemented to play up the strengths of each one. Leaving the ICU nurse as the only one with drugs in her scope was a weakness that came into play and turned this into a poor response to a critical patient. By the time I hit the ED I was already drafting the email to my boss with suggestions as to how to avoid this problem in the future. The Rapid Response Team is a sound idea that needs a little more fine tuning.

Another night in the ED. Somehow this one didn’t feel quite as rotten as the lest few even though we were busy all night long and short staffed and I was short of sleep. The EDitself is chaotic anyway as the preparations continue to move our entire department to the newly constructed part of the building and close down the current department for further renovation. Management insists that this will happen July 10th but from what I have seen on a couple of walk throughs it is going to be a very tight schedule as the construction still has some very rough areas that need lots of work before they can be occupied.

It’s going to be a double edged sword to move into new, larger digs. While the number of beds will increase and the actual floor space will increase the staff has not increased yet no matter how hard management has tried to recruit nurses, paramedics, patient care techs, and other support staff. With two-thirds more beds and no increase in staffing the word that comes to mind is “nightmare”.

The day started out busy with several calls coming in one after another. Unfortunately they were all cancelled enroute. From 0800 until 1130 we were steady in and out of the department for calls but no patient contacts. The ED was cranking from pretty much the first minute of the day shift and they continued steadily for the remainder of the day.

We stayed in the thick of the chaos until we finally were dispatched on another call around 1630. Difficulty breathing in a town that frequently has a paramedic on their ambulance. Before we even left the hospital campus another call was dispatched for an unresponsive on the beach at one of the state parks. A BLS ambulance would be responding and there was no possibility of another paramedic unit being sent to the scene.

We got on the highway and started to accelerate up to highway speed having a little difficulty getting through the heavy traffic in the slow and travel lanes to place us in the high speed lane. It wasn’t for lack of trying on some of the other drivers parts, there was just no room for them to maneuver to get out of the way.

Before we even managed to get into the left lane we were cancelled on the difficulty breathing call and redirected to the unresponsive. when the ambulance for the first call signed on with a paramedic. Fortunately it wasn’t a major adjustment in our route of travel to get us headed in the right direction. Twenty minutes later we were going through the park gates and getting directions from the rangers on the best way to get to the beach where the patient was located. We followed the directions and the roads got smaller and smaller to the point where my partner and I looked at each other and it was clear that the ambulance was never going to get through following these directions. We radioed the ambulance to let them know and were relieved to find out that they were already on the same page and had gone a different route.

We arrived on scene to find that 26 minutes after the first tone we were the first EMS providers on scene. A single cop and one ranger were there but neither had much medical training and were doing the best they could. They were quite relieved to see us and quickly shifted from providing medical care to providing crowd control, something that was needed badly.

The patient was a woman in her mid-thirties who was awake and alert complaining of a severe headache (similar to her migraines) and nausea. She related being at the beach all day with several kids with little intake of food or fluids. This afternoon she started feeling fatigued and thought she might feel better after a swim. On her way back from the water she became extremely dizzy and passed out. Her husband and children relate that she was unresponsive for almost 2 minutes and was very confused when she regained consciousness. Even now, she was somewhat slow to respond. They did not witness any seizure activity.

Her skin was warm and dry even though the temperature was topping 90 degrees, another concerning finding. Her vital signs while lying on the sand were BP 102/46 pulse of 96, respiratory rate of 24 with oxygen saturation of 96%. Her blood sugar was 108. Not all that bad, it wasn’t until the patient tried to refuse treatment and transport and sat up that her vital signs got lousy. Her heart rate shot up to 130 and her BP dropped to about 80/palp. We carefully but forcefully guided her back down into the sand. It didn’t take much effort to convince her to change her mind about seeking medical attention.

It was another five minutes before the ambulance arrived, parting the crowd like Moses at the Red Sea. Unlike Moses the parted sea immediately filled their wake. With the ambulance on scene we were able to quickly get her onto the stretcher and into the back of the air conditioned ambulance where the two sweat drenched paramedics were relieved and the patient would have some privacy.

In the cool, well lit ambulance with privacy windows we were able to get a much better assessment. ECG and neuro assessment were unremarkable. Her mouth was incredibly dry as were her mucous membranes. She denied recent illnesses or difficulty with intake by mouth, today was the exception with her not having much time to eat or drink while watching several kids ranging from toddlers to teenagers. Her temperature was higher than normal but not exceedingly so, 100.0 (F) by mouth.

Between my partner, myself and the EMT-Intermediate on the ambulance it took us a while to get an IV started and then it was a small one on the back of the patients arm, not a preferred position but, well, any port in a storm. I opened the IV up so the fluid was running as fast as possible which was not very fast.

My partner bailed out to go on another call and we started transporting to a more distant hospital where the patient wanted to go, about a 30 minute transport. Between the air conditioning, the fluid, and some Zofran (an anti-nausea drug) the patient was feeling slightly better after the transport was halfway done. At the hospital she could say that she felt a little better but was definitely back to normal.

With my partner on another call I would ride back to meet him on board the ambulance, something that I am very familiar with and actually enjoy as long as I don’t have pending calls. We met my partner about 20 minutes after leaving the hospital at one of the highway exits, his call had been a cancellation and the ambulance would not need to take me all the way back to the hospital.

My biggest disappointment with this call is that I will get no feedback from the ED as to what the final diagnosis was. With a couple of different possibilities, none of which are mutually exclusive with the others, it would be interesting to see what was actually up.

Another interesting/frustrating patient was one that came into the ED via one of the fire department paramedic ambulances. The patient was a male in his mid-fifties with advanced pancreatic cancer. While traveling along the highway on his way with his family to a fathers day celebration, he suffered a sudden onset of unresponsiveness.

Because of his cancer he was on huge doses of Morphine and other narcotics for pain control and was a Hospice patient. When the ambulance arrived they found the patient unresponsive in the back seat with pinpoint pupils and administered Narcan (a narcotic antagonist) in an attempt to improve his responsiveness. The Narcan did nothing and they began to transport. About 6 or 7 minutes out from the hospital the patient had a sudden onset of seizure activity that lasted until he was given 5mg of Valium. From the radio report it sounded like an interesting call that could be a diagnostic challenge. I wish I had been on the call.

When they arrived, though, my frustration level started to climb. While the patient was no longer having seizure activity in his limbs he was rapidly clenching and unclenching his jaw with a gaze up and to the right and a rigid neck. To me (and the nurse taking care of him) it seemed pretty obvious that he was still seizing. On top of this his oxygen saturation was hovering around 80% on a non-rebreather with sonorous respirations that appear to be Kussmaul respirations. I slipped a nasal airway in with little difficulty and replaced the non-rebreather with an increase in his oxygen saturation to 97%. His seizure activity didn’t stop.

The doctor came in and examined him and ignored the nurses request for some Ativan for the seizure activity. Instead he ordered an Arterial Blood Gas and a chest x-ray. The patient was left to seize some more. What happened next just boggled my mind. Leaving beeper and cell phone on the counter the only doctor in the department went to the cafeteria for lunch. When the ABG results came back the respiratory therapist had to hunt down the doctor in the cafeteria to look at the rather dismal numbers.

Back in the department the patient continued with his jaw clenching, stiff neck, and rightward and upward gaze. His oxygen saturation was better and his colour had improved but he was still, at least to me, in serious shape. While I was drawing blood the nurse cried out in alarm and I looked over my shoulder to see the patients monitor and Ventricular Tachycardia marching across the screen. A quick check showed that the patient still had pulses. The V-Tach resolved spontaneously after about 30 seconds. The doctor was called back into the room and more odd orders given, chest and abdomen CT scan and an chest and abdomen MRI. Nothing for the continuing seizure activity and nothing for the arrythmia.

We, collectively, we pretty well baffled by what was going on and even when approached the doc provided no insight into what he thought was going on and why his treatment plan was so far off from what we thought was appropriate.

The patient left and returned from CT scan with nothing unexpected found on the study. Twenty minutes later the MRI staff showed up to prep the patient from the MRI and transport him to the scanner. He would not be returning to the ED after the MRI but instead admitted upstairs directly from the scan.

We didn’t learn until later that the patient never made it upstairs. He had another episode of V-Tach which quickly degenerated into Ventricular Fibrillation (a total lack of organized beating of the heart) and he died on the MRI scanner table.

I can’t say one way or the other if anything would have changed the outcome but I was frustrated by both the out of hospital care and the ED care.

The out of hospital care was aggravating because the crew neglected to manage the airway, something that made a huge difference in the patients oxygenation. The failure to recognize that the patient was still seizing was also a bit upsetting.

I was really frustrated by the lack of communication on the part of the doctor. The nurse and I were pretty clear about what we were finding and what we were asking for. The orders that came had no relationship to what we expressed as concerns and if there was something that we weren’t aware of the opportunity for a learning experience was lost. Were we less clear than we thought? Was there other information that we didn’t have? Was it simply that the patient had a terminal illness and a DNR order that prevented the treatments that we felt were appropriate? Do Not Resuscitate does not mean Do Not Treat does it? I just don’t know what to make of it.

I was just glad when my partner and I were released to quarters for the night. As busy as the morning and late afternoon had been I expected some of the volume to continue over into the night as well. As it turns out it didn’t and we had not a single additional dispatch for the remainder of the shift leaving me with plenty of time to think about the day.

The end result? I know that I provided the best care that I could, and that I took every opportunity to have my voice heard as to what I felt was needed. Maybe the doc knew something that he didn’t share with the rest of us and maybe he didn’t. Either way I decided that I did my best and that my conscience was clear.

The ED was packed when I arrived and I found that not only was the crew busy but they were also busy enough to have the manager out of the office to pick up some of the slack. It didn’t take long for the first call to come in and my partner and I were responding (with our manager in the back seat) to an ATV rollover with injury.

We arrived on scene several minutes after the ambulance and as I approached I found one of the techs holding a towek against the right flank of the patient while the other two affixed oxygen and were taking vital signs. They had waited to trade the towel for a trauma dressing so that we could see the injury. The bystanders had used the towel because it was what they had available and, although there was very little bleeding, they wanted to keep the hordes of mosquitos out of the injury. Probably not a bad idea as the mosquitos were so think that they swirled around us like a swarm of locusts.

The patient was a male in his early twenties. Seated at a picnic table, he was pale, cool, diaphoretic and covered with what looked like vomit. He denied vomiting and the more I looked the stranger it seemed. The “vomit” was primarily on his back and shoulders, nothing on his bare chest or abdomen.

He had been the unhelmeted operator of a four wheeled ATV that rolled over while going up a steep hill. The way the patient described it he was traveling at a high rate of speed as he approached the hill and did not slow down when he got there, something he had done several times earlier in the day. This time as he started climbing the slope the ATV flipped end over end thowing him off. Had things stopped there he probably would have been OK. Unfortunately for him, the ATV itself continued flipping end over end and landed on him after he hit the ground. He then got up and walked back to the house he was visiting to have them call 911.

Having the story and with the crew ready to change the dressing we removed the towel and found a gash in his right flank that was close to 15 cm long gapped widely and penetrated deeply. The patient kept trying to insert his hand into the gash and suceeded while the crew was unwrapping the trauma dressing, placing his right hand behind his back and slipping his fingers in the the gash up to the base of his thumb. Clearly this was either a very deep pocket like gash or the gash itself penetrated into the retroperitoneal or peritoneal space. Even after the trauma dressing was in place we kept catching him trying to slip his hand under the dressing to touch the wound. At the same time that the dressing was being applied I realized that was I was taking for vomit across is back and shoulders was actually fatty adipose tissue from the wound itself. I hadn’t seen anything like this from this kind of trauma before, gunshots yes, but never trauma of this type.

The seemed a little annoyed with me when I insisted that the patient be collared and boarded but I felt that the mechanism of injury warranted full spinal precautions even if he had no neck of back pain. I also felt that the wound qualified under the “distracting injury” part of the guideline and with a little grumbling the patient was collared, boarded and removed to the ambulance.

His vital signs were remarkably stable, BP 108/64 HR, 76, R 24, O2 sat 98% on room air. Enroute I tried to establish an IV with no success. After four attempts and the patient laughing at me (”nobody can get my blood”) I just stopped. An IV was just not going to be established in the ambulance. The ED would manage to get something eventually but not before a couple of other attempts would fail. The IV would eventually be established using an ultrasound machine to guide the placement of the catheter.

The patient remained stable in the ED and after evaluation by the ED physician the surgeon came down and agreed with the ED doc. The retroperitoneal space was compromised and would need to be opened up more, and flushed completely before being closed again. They would also need to look closely at the structures in that space, especially his kidney and ureter which were close to the location fo the injury. The last feedback I got before the end of the shift was that he went to the OR and was cleaned out with quite a bit of foriegn material being found in the cavity, closed up and admitted to the ICU for IV antobiotics and observation. That wound was the only injury that was found.

A little later we would go out for a car versus motorcycle that my partner would work up and transport with along with a single cancelled call that would round out the night. TheED stayed busy until well after midnight and then died down very quickly. It was almost pleasant. The only bad thing was that around 0430 I started to get drowsy again and, with little to do, I had a difficult time staying awake. Still, it amazes me how just one interesting call can make the entire twelve hour shift feel much better.

Not as much sleep as I really wanted to have but between having kids home today all day (school ended for the summer yesterday) and the fact that our air conditioning is still busted it was understandable. I think I got enough to see me through but it’s going to be a bit rough towards morning I’m sure.

When I went to sleep this morning I really wasn’t feeling to kind towards my job and was sorely tempted to call in for tonight. After some sleep I am feeling a little better. I still feel like I was worked like a dog and my capabilities were underutilized but I’m ready to go back, the night charge nurse will be back and the staff will be different.

I suspect that they will be around to finx my air conditioner tonight or tomorrow. A truck arrived this afternoon and dropped of a bunch of supplies including a compressor, 20 feet of copper pipe, and 2 cans of the refrigerant. Maybe tomorrow moring I will get to sleep in a cool dark room again, just like I like it.