The MacMedic

I was only in for half of a shift tonight, twelve hours instead of twenty-four which meant that while my partner would be released to quarters a little after 1900 I would remain in the ED playing the support staff role. For a change the ED volume declined steadily from the time I got in to the point where I was able to sit down and do some of the CQI work that I had agreed to assist with. By the end of the shift I had managed to plow through two months of run reports for three different services without being interrupted for a single call. Not that I would have minded a call.

It was a hot, sticky day yesterday that saw us with several cancelled calls during the day part of the shift. I was OK with that, I was uncomfortable with the heat and humidity, and for some reason just wanted to be on the road without having to work up many patients. Fortunately for me my partner felt the same way. We had a newer employee riding with us for orientation which would have made calls desirable but secretly, or not so secretly, my partner and I were just not that interested.

We did pretty well during the day part of the shift with only a half dozen calls that were either cancelled or downgraded to BLS. By 1830 we were starting to think that we were home free and would be released to quarters where it was cool, comfortable, and we could just relax.

It wouldn’t happen that way but when it was all over both my partner and I would be reasonably happy with some of the results (although not all of them).

The tones dropped at around 1840 to send us to the fall victim with difficulty breathing in one of the towns towards the northern border of our coverage area. Usually we get cancelled within a couple of minutes when the ambulance in that town signs on with one of their several paramedics. Today that didn’t happen and it was soon clear that we were going “all the way in” and would end up being the responding paramedic. We still were a little cynical, lots of fall victims have difficulty breathing, but frequently they don’t need much in the way of ALS. That cynicism continued all the way into the trailer park that we were going to when the dispatch center came on to tell us that the police were requesting that we “step it up”. That was bad sign number one.

Bad sign number two showed up when we pulled up in front of the address and one of the crew members from the ambulance sprinted across the lawn to direct us in. When we asked what was going on she replied that she wasn’t sure but that they needed us inside right away.

Bad sign number three was the sound of a portable suction unit that we heard as soon as we entered the residence. Never a good sign.

My partner and I looked at each other, three bad signs could only mean one thing and after we all got in, closed the front door and opened the door to the room where the noise was that “bad thing” was confirmed by the sight of two of the ambulance crew members doing CPR on a morbidly obese man supine in the narrow walkway through the room surrounded by stacks and stacks of “stuff” on either side.

One of the nicer things that I have found about having another paramedic on a call is that you can divide the labour. In this case it was three paramedics so the division was even easier. We threw our orientee to the wolves so to speak and told her that she was in charge while I carefully climbed over the patient to get to the head and my partner started setting up for the IV start. The orientee found a clear spot amid the piles and set up the monitor while the third ambulance crew member went back out to our truck to get the one piece of equipment that we didn’t have with us since we didn’t know we would need it.

The ambulance crew had a Combitube in place and had been able to manage the airway reasonably effectively but it was time to get an endotracheal tube in. It had been about eight months since I had last intubated anything besides the plastic mannequin and anybody who thought that were going to get the tube instead of me was sadly mistaken. It was not an easy tube. The patient had short bull neck, was obese, his larynx was very anterior, and his airway was filled with rum smelling vomit. Adding the fact that the suction unit was almost dead and I was unsure just how rusty I would actually be it was going to be a challenging tube. I felt an enormous sense of satisfaction (and not a little relief) when I watched the tube finally pass through the vocal cords.

My partner, in the meantime, was not having much success with the IV. He made one attempt at the antecubital space on the side that he had access to but was unsuccessful. He searched for a while longer but couldn’t find another appropriate sight. With no IV access he grabbed the Easy-IO unit and put an intraosseous catheter into the patients lower leg. We now had vascular access.

An intraosseous infusion, in simple terms, is a catheter driven through the hard outside of a long bone and into the marrow where there is some vascular access. Anything we can push through the IV can be given through the intraosseous. In the past intraosseous infusions had primarily been a skill reserved for extremely sick children as vascular access of last resort but has recently been becoming widely used in adults with no IV access in critical situations.

My partner was happy with his IO, I was happy with my tube, our orienting paramedic was not as happy with her part of the care. She was able to get the defibrillator pads onto the patient to find that he was in an agonal rhythm with a rate of less than 20 and no pulses. It was an ugly looking rhythm, the rhythm made by a dying heart but with an endotracheal tube and vascular access accomplished she could start getting some medication on board and seeing of we could work this agonal rhythm into something better and maybe even perfusing. Balancing the drug box on top of one of the piles of “stuff”, the only space available, she started to pull out and administer the medications that were called for.

The first round of drugs had just finished going in when the ambulance crew member returned with our final piece of equipment. We had been trying out the “Autopulse”, a mechanical CPR adjunct that is supposed to provide more effective compression of the heart and better cardiac output than traditional CPR. By rolling, lifting and a little of blatant manhandling of the patient and the machine we were able to get it in place and hooked up. I was a little uncomfortable with all the movement, not because I was worried we might hurt the patient but because even as obese as the patient was his liver was so swollen that with minimal effort you could see the outline of it in his abdomen. This would fit with the patients hard-core alcohol use which would abuse his liver terribly. I was truly wondering if we could make his liver blow up by putting any more pressure on it.

To this point I had only seen the device in use on a mannequin or in a video so this was a new experience for me. One of the ideas of the autopulse is to provide circumferential compression of the chest to maximize cardiac output. It certainly did provide very effective compressions. It does this via a wide band that runs from one side of the board to the other. Each end of the band is connected to a roller which can draw the band in thereby reducing the circumference of the resulting chest shaped opening. Since it is automated the compressions are perfectly timed and an audible indicator even signals the person bagging when they should squeeze the bag valve mask.

Seeing it on a real patient for the first time I was struck by how this device so dramatically reduces the number of people needed to run a cardiac arrest case. Add a mechanical ventilator and cardiac arrest could conceivably be a two person call (something that I hope does not ever become commonplace). While the contractions of the band are perfectly time as to when they will start and finish it still appeared to me that the the contracting motion bordered on violent with the rapid contraction, pause, the rapid release. This process cause the patients entire body to move including his head that lifted a couple of inches up off the board with every contraction and drop back unrestrained onto the board again when the contraction released. I slipped a bunch of trauma pads under his head to act as a cushion and make me more comfortable with what I was seeing.

After three rounds of meds we were unchanged on the monitor and decided to head out to the ambulance. Between the obesity of the patient and the added weight of the autopulse maneuvering the patient onto a backboard, lifting him, and snaking him out amongst the piles of “stuff” was. Extraction from the house was a nightmare. It took the three of us from the paramedic unit, the three technicians from the ambulance and the two cops who had been sent to finally get past all of the obstacles and get the patient into the ambulance.

Once there we started the 18 to 20 minute transport to the nearest hospital, not my base hospital. The first four rounds of meds were not giving us any change and we started to think about other things to consider. We knew nothing about his medical history so we administered some Dextrose. That was followed by some Sodium Bicarb, continued doses of Epinephrine and Atropine and continued CPR with the autopulse. We kept checking the position of the band that was across the patients chest but found that we needed to make very few minor adjustments to it and that it stayed in place pretty well.

About 9 minutes out from the hospital the patient had a sudden change in his rhythm. We saw ventricular tachycardia, a rhythm that is generated by the ventricles rather than the sinus node in the heart, that has the possibility of perfusion. No pulses with this but it was something that we could work with. Defibrillation with 200 joules (or 200 watt/seconds for us dinosaurs) resulted in a change to a rapid, narrow complex rhythm with, surprisingly, a pulse and blood pressure.

I had to remind the paramedic that was orienting to start some type of antiarrhythmic on this patient post-conversion and she struggled to do the math in her head to come up with the 2mg/min Lidocaine drip rate. Two things that didn’t do much to impress me and that I wouldn’t expect from an experienced paramedic like she is supposed to be. But the medication was pushed in a reasonably timely fashion and the patient maintained his pulse and blood pressure for the remainder of the transport.

We delivered the patient to the ED staff at the hospital with pulse and blood pressure, something that rarely happens in cardiac arrest scenarios. The ED doc was happy and stroked our egos a bit complimenting us on the thoroughness of our treatment. I was just happy that it was over.

For a change I will be able to get some followup this evening on this patient. One of the nurses at the ED we transported to will be shadowing one of the nurses at our ED tonight to see if he wants to come and work in our ED. He promised to bring word as to what happened, at least what happened during his shift.

Thinking about it on the way back to our hospital it was a little frustrating. We manage to resuscitate the hard core, elderly alcoholic and the previous week one of the crews had been unable to resuscitate the man in his thirties who passed out while exercising and went into cardiac arrest in front of them. One had nothing going for him and was alive (for the moment) the other had everything going for him and was not. If anybody can explain this please do, it just seems so unfair.

By the time we were cleaned up, restocked, changed into clean uniforms, and done with the paperwork it was close to 2300. Our orienting paramedic had gone home and my partner and I were thoroughly exhausted. To our surprise we crashed and got close to four hours of sleep before the next call came in. Another elderly male, this one who passed out while trying to move his bowels. Vasovagal syncope, not an uncommon occurrence, especially in the elderly. Straining to move the bowels stimulates the vagus nerve which in turn slows the heart rate, decreased heart rate equals less oxygenated blood going to the head and the nervous systems saying “hey, not enough oxygen up here, time to lie down”. My partners time to transport with this one and I just followed behind the ambulance all the way to the ED.

The remainder of the night was uneventful and we both slept for the remainder of the night. It was a nice break to actually have the chance to get some sleep for a change and I know it certainly made the shift more bearable.

Another twelve hours in triage. These twelve hours were only a little better than the past time simply because the patient volume was slightly less. It was still steady with a two to three hour wait almost all night. I still had several patients stalk out of the waiting room saying that they were going to this hospital or that hospital where “they would get treated right” (even though all of the hospitals mentioned were quite likely to have even longer waits and be much busier).

I knew I was going to be out there all night when the charge nurse asked me to go out there she started by saying “You are so good in triage….”. For the first time in my life I find myself almost wishing I was less good at something.

After my last shift I still wonder if I am not getting too old for twenty-four hour shifts. We ran for almost the entire night getting maybe 45 minutes of sleep for the entire night. It was uncomfortably warm and muggy for the entire night as well.

We did 8 responses for the entire shift. All cancellations during the day and all transports at night. I wish I could say that the transports were challenging and interesting but each and every one of them was nothing more than IV, oxygen, and cardiac monitor. That’s just the way it goes sometimes.

Another night in the new ER and as far as I am concerned it was enough to make wonder if I wanted to come back for my next shift. Since we moved into the new ED we have been either at or almost at maximum capacity for the entire time. The staff is frazzled, the department is still not operating smoothly, the construction is still incomplete with some areas still showing bare metal studs. The loss of these areas has made us four beds short which is having some impact on our ability to keep up. The Clinical Decision Unit (CDU), the area of the ED that was designed for patients that were being boarded in the ED because of a lack of beds upstairs has been used since day one as additional treatment rooms. Beds in the hallway, supposedly a thing of that past in this department, are common place at the peak hours.

Last night things were so busy that we needed all the nurses on the floor which meant that someone had to take over in triage. They said “someone” but they were looking straight at me since triage needs to be either a nurse or a paramedic and I was the only non-nurse person who could do it. I don’t mind doing triage for a few hours at a time but it can be a little dreary and draining simply asking the same questions and performing the same set of vital signs on every patient that comes through the door.

I ended up being in triage for my entire 12 hour shift. It was dreadful with just the sheer volume of patients. When you added in the fact that there was no air conditioning in the area that triage was in (disabled due to the ongoing construction) it was just downright unpleasant and I had had enough.

I’m hoping that after a few hours of sleep I will feel less irritated about it.

Another 24 hour shift and another partner to get used to. Today was a bit stressful when I realized that neither I, nor my partner, were very familiar with the geography of the area. We would have to rely heavily on the GPS software installed on our laptop. As it turned out it was less of a problem than it could have been. Primarily it wasn’t a problem because we only did four calls during the entire twenty-four hour shift. 1 ALS transport, 1 ALS turned over to an ALS ambulance, and two cancellations.

The ED more than made up for the lack of calls, working us hard, to try and keep up with the heavy patient load and the large amount of work that the nurses were trying to transfer to the techs and the paramedics. We actually managed to stay almost caught up for most of the day which kept it bearable but the neediness of the nurses continues only this time my boss was working as the ED paramedic and got to see it first hand. Perhaps now some action can be taken. I like my boss and he does not leave problems unaddressed.