"I would never do THAT..."

The EMT I worked with on Sunday is in Paramedic school so I took the opportunity to refresh some of my knowledge by quizzing him on his cardiac rhythms, ACLS algorithms, and other EMS related things. One of the questions that I asked him was, "Which drugs can you administer via an ETT?"

Of course the answer is LEAN (lidocaine, epi, atropine, and narcan), although NAVEL (the previous 4 plus valium) is also acceptable. ETT drug administration is falling out of favor as we realize that the drug absorption rate and dose widely varies and we don't really want to be putting fluids into the lungs of our patients unless it's truly necessary.

So the discussion included other options for drug routes if ETT and IV access weren't available. Those include IO (into the bone marrow space), IN (intranasal), and PR (per rectum--ie, in the bootie). He very seriously told me, "I will NEVER give medications rectally." So I told him this story:

It was late afternoon and the county had been steady but not busy. A few units were out but otherwise most of us were getting ready for dinner. The tones dropped and we were sent out of our zone to respond to an infant having seizures. Well, most of the time patients having seizures are done by the time EMS arrives and don't need further care, just a ride to the hospital and monitoring.

My partner and I checked en route. We talked about what to do when we got there and how we wanted everything to go. Dispatch radioed that the FD was already on scene and advising that the child was still actively seizing and had been for nearly 15 minutes now. They were administering o2 and would meet us on the sidewalk with the patient.

**Oh Hell in a Handbasket** Now we not only have a still seizing patient, but it is a child to boot.

I unclipped the narc keys and handed them to my partner. She got out the protocol book and we reviewed the pedi doses on Valium (IV and rectally). I told her that when we got to the scene, I was going to grab the pt and come back to the truck if she would get everything set up for us. About this time, dispatch advised that the FR was calling for Air Medical and did I want to go ahead and launch the helicopter?

Hmmmm....a seizing baby in what sounded like status epilepticus and no local pedi hospital...Well HECK YEAH.....gimme a fast ride to the level 1 pedi hospital.

So we arrived on the scene to find the FR standing on the sidewalk with the patient in his arms, still actively seizing. My partner dove through the pass through (space between the cab and patient compartment) and I went around and got a quick report. Mom was helped into the front seat and as soon as the pt was secured to the cot, I told my partner that I was ready to go. The FR asked if I wanted him to go with us. "No, I'm ok. I just want to go."

"But I am a National Registry Paramedic"

and so what if you are...so am I. DUH....Just get the hell out of the back of my truck and quit holding us up..... <--That's what I was thinking anyways. I would never be so rude as to say something like that to a FR on a scene.

So he went with us. The patient was hooked to a cardiac monitor (mostly artifact), o2 was continued, and my attentions were turned to gaining IV access. The FR made one attempt and it blew....so by my calculations the child had now been seizing for nearly 35 minutes. My priority, after securing the ABCs, was to stop the seizing. Without an IV, that meant rectal valium.

The child weighed 11 kgs as reported by the mother. So I broke the seal on the narc box and drew up the proper amount in a 3cc syringe. After discarding the needle tip, I took an 18 gauge catheter out and disposed of the needle, leaving me with the catheter tip. This I screwed onto the end of the syringe, and voila!! A way to administer the valium rectally.

Have you ever administered rectal valium to an actively seizing child? It's akin to giving a cat a bath. They wiggle all over and it's hard to keep the syringe in place after the drug is administered---necessary to keep the drug from running back out before it is absorbed.

It was the longest 8 minutes of my life. Watching to see if the drug would work, reassessing the pt status, determining my next course of action. As the seizing slowly stopped, I threaded a flexible catheter into the pt mouth and was able to suction his airway clear. A few minutes from the hospital, the patient began having irregular and agonal respirations. As the jaw was clenched, our only other option was to perform RSI to secure the airway, especially with the patient being such a high aspiration risk. I chose to assist the ventilations with a BVM as I could already hear the rotor blades from the helicopter. My thoughts were that the flight crew had much more experience with RSI for a patient that size and my efforts were better spent on good ventilations. They could figure out the proper doses of RSI meds MUCH faster than I could. I had the FR set up all the intubation equipment, we already had the length based resuscitation tape on the cot next to the patient.

When the flight crew boarded, I gave them a quick but detailed report and they agreed with my suggestion of RSI.

For my non medical readers:

RSI (Rapid sequence intubation) is a procedure that consists of administering a cocktail of meds that sedate and paralyze the patient in order to facilitate intubation. It is most frequently used for patients with traumatic head injuries, respiratory failure with impending respiratory arrest, and acute CVA (stroke). It can also be successfully used with patients who have overdosed on an unknown substance or with patients who are unable to maintain their own airways. It is not a procedure to be taken lightly, you must be sure of your intubation skills as a provider and feel comfortable that you can "sink" a tube on each patient. In my system, we used a combination of Etomidate, Succinylcholine, and Norcuron. We also premedicate with Atropine for the kiddos and Lidocaine for any with potential head injuries.

We prepared all the equipment and I successfully placed an ETT on my first attempt. Following intubation, the patient was ventilated well and packaged for transport. We got them all loaded into the helicopter and they flew to the Children's Hospital.

I called a few days later and was told that the patient was still on a vent and the EEG and brain scans had showed some kind of abnormality but because of the age of the patient, they weren't sure what it was or the treatment yet.

This patient was discharged about 2 weeks later and was home for 2 days before suffering another seizure. This patient has since become a regular for our service. They finally determined that there was some kind of lesion in this child's brain but determined it wasn't safe to do surgery because of the age. Unfortunately, the patient continued to have seizures despite aggressive treatment and today has significant mental, emotional, and developmental delays. We actually had a protocol written specifically for this child because it got to the point that all the Valium in the world wouldn't touch the seizures.

After relating this story to my partner, he said, "well, I guess I'll never say never again."

I told him that there was a big difference between saying that you would never do something vs. saying that you would prefer not to do something. I told him that the first time he laid eyes on a beautiful child with big blues eyes who had been seizing non stop for 30+ minutes, the thought of not giving a drug rectally wouldn't even enter his mind. I told him that I didn't want to perform a Cric (a different patient--for a different blog), but I did and because of it, the patient lived. But if I had always told myself that I'd never do one, the thought that a patient might need one would have never crossed my mind. And that patient would have died before he even reached a hospital.

Teaching moments...They are valuable when they come along and can be related to something that the student can easily identify with.

Until next time....

Ever had one of those days where you just don't get it?

So I was thinking the other day about some of my really "head scratching" calls. You know, the ones where you just never really understand what happened and decide that you probably never will?

It was maybe a year ago--I know it was freezing outside but I don't really remember when it was--that my partner and I were dispatched to a MVC with a "minor headache". It was also O'dark thirty outside and we had been asleep for a few hours.

So ok, we check en route and Mike (my partner) drives us the short distance to the scene. When we got there, I think that I dang near soiled my britches!

This was no minor accident--This was a full blown tractor trailer--18 wheeler--semi truck, half flipped over, and teetering off the side of the road. Regardless of the status of the patient, we needed more help to safely access this patient.

I radioed dispatch and told them what we had, requested FD for rescue and extrication assistance, and asked to have Air Medical put on standby. We could see skid marks at least a half mile up the road. As I surveyed the scene, I also saw a sign that read "WARNING--GAS PIPELINE UNDERNEATH. CALL BEFORE DIGGING" Oh crap.

Well, step one was to get everyone out of the danger zone, including the cops who were crawling all over the cab of the truck. I inquired about the status of the patient and was told that she was semi responsive and "talking out of her head". Hmmmm. Thankfully the FD was only a few blocks away and they arrived on scene in record time. As soon as they had the semi initially shored up, Mike climbed inside and started an initial assessment of the patient. Once he relayed his findings to me, we launched the helicopter. We were also waiting on a large flat bed wrecker that had the capabilities to rig up safety wires to keep the semi from fully rolling over.

I started hanging lines and getting the patient compartment ready. I turned the heat on, attached electrodes to the cardiac monitor. I had already taken Mike the portable O2 and a non rebreather mask as well as a ccollar, so we had the basics covered until we could fully extricate the patient.

We wound up having to remove her from the truck through the side window. The doors were jammed and we decided that trying to have the FD use the jaws of life to pop the doors and gain access that way was just too risky. We were afraid that the wiggling and moving might cause the semi to become unsteady. I just wanted all my guys away from any potential danger as quickly as possibly.

So out she comes onto a LSB and we secured her quickly and got her in the back of the truck. We did a full trauma assessment and began treatment. Continued o2, monitor, warmed her up, IVs, etc. Her BGL was in the 40s. So she also got an amp of d50 which helped to perk her up some as well, although she was still lethargic and not responding appropriately.

We were driven to the LZ and in short order had the pt packaged for the helicopter and report was given the the flight crew and they flew her to the closest level one trauma center.

We went back to the scene and stayed with the FD and the wrecker crews for several hours while they attempted to remove the semi truck from the ditch that it was half in.

I guess the moral of the story is if you hear hoofprints, look for the zebra.

NIU Shootings

Prayers to the victims of the NIU shootings. Please keep those innocent people and their families in your thoughts and prayers.

Also please keep those who responded (Police, Fire, EMS) in your thoughts as most who worked this horrific incident will struggle with the things that they saw and heard.

When your patients tell you....

I have learned that when your patients tell you they are going to die, it's generally a good idea to listen to them, especially when it is accompanied by a complaint of chest pain or breathing problems or some other such issue.

The last patient that told me that proceeded to code as we lifted the cot up about 2 minutes later.

My partner are I were able to obtain ROSC within a few minutes and delivered her to the ED blinking her eyes and indicating that she wanted the ETT removed from her trachea. She ultimately passed away a few days later due to severe cardiac ischemia, but we at least helped to buy her and her family some time to make arrangements and say goodbye.

So when your patients tell you they think that they are going to die, they probably are right (as long as they aren't in labor or strung out on crack or having a huge fight with their SO).

7 Random Things about Me

I was tagged by Shawn over at Live, Laugh, Blog to post 7 random facts about myself....Ummm so here goes:

1. I am the parent of 3 beautiful fur babies. 2 are pictured, the other one is shy and hiding.

2. My family lives all across the country, I'm the only one that lives in this state.

3. I am a die hard procrastinator.

4. I am addicted to using coupons and shopping sales to get the best deal that I can.

5. I have been a vegetarian for almost 20 years.

6. I don't know what I would do without caffeine. The best thing in the world is yummy coffee first thing in the morning.

7. I only have to wait 2 more months to see my very best friend in the whole wide world again.

In the general spirit of these things, I am now tagging:

Nurse K

and

Stork Nurse

to continue on with the random fun.

Happy blogging, everyone.

Uhhh, you'd better send some more help here...

It had already been a long and busy shift and I had grabbed a few minutes between calls to take a quick shower before going (hopefully) to lay down for a bit.

*tones drop*

Of course while I have shampoo in my hair and I am soaking wet.

"Medic X, need you to respond to 123 ABC Street. Female patient is unresponsive."

Crap!!!! I should have suspected it though, because the shift had already been long.

I heard my Captain check in route and knew that I had a few extra seconds to dry off before throwing my uniform back on. I grabbed a elastic band to pull my hair back and was grateful that I had a hat to out on my head since I didn't have time to drag a comb through my wet hair.

As I'm climbing in the truck, I hear several First Responders check en route to the scene, and my Captain checks out on scene. We check en route and a few seconds later I hear the weary voice of Captain D, "Uh dispatch, you'd better call the Anytown Fire Department. We're going to need some man power here."

Huh? Ok let's see...We've got my partner, myself, Captain D, and 4 firefighters. That's 7 people. What in the world is so bad that we need MORE help?

It became very apparent when we got there. We walked in the door and saw a mattress laying on the floor and a very very large woman was laying on it, unresponsive and with snoring respirations. We start to provide emergency care and the firefighters try to figure out how in the hell we are going to extricate the patient from her house. There wasn't enough space to bring the cot in to her, and frankly her estimated weight exceeded the weight limits of the cot (650 pounds).

We ended up using a spine board as a ramp from the bed to the cot and essentially pulled the pt from the bed, over the spine board, and onto the cot. She was so wide that she had to be placed on her side in order to secure her safely to the cot. That really was the best position for her anyway as the weight of her massive chest significantly impaired her respiratory effort.

We left the cot in the lowest position to roll it over to the truck, then the 11 of us raised the cot up and secured it in the patient compartment for transport. There was 4 of us in the back and Captain D drove us to the ER. We alerted them to get a bariatric bed. Once we left the patient at the er and transfered care, we returned to the station.

I punched Captain D in the arm..."Man Power? Geesh, man you could have come up with something better to ask for."

Severe Weather

You know it's going to be bad when it's 70 degrees in the February. Dozens of tornadoes ripped through Tennessee, Arkansas and Kentucky last night leaving a lot of destruction and causing many deaths.

Please keep these folks in your thoughts and prayers and also the responders that are doing search and rescue, body recovery, and clean up. This weather and it's aftermath taxes all the resources in those areas.

If you live in the affected places, please be careful.

I'll post some links once I find some reliable news sources.

Super Tuesday

So this really isn't EMS related....

But if you love in a state that has it's primaries today--PLEASE go vote. Men and women had died for us to have the right to vote. This is the way we get our voice heard and get to have a say in who our next leader is.

GO VOTE!!!!

And another one..

I received an email this afternoon from a friend who frequents this blog. She included a link to this article.

Folks, your Nation's responders are dying on a weekly, and sometimes daily basis. One day, we won't be here when you need us. PLEASE, PLEASE if you see the flashing lights on the road, SLOW DOWN, move over, and pay more attention. It will save you anguish and possibly jail time (many states add a felony if you kill a FR while they are in the course of their job duties). You will also help to ensure that that person returns home to their families.

Please be more careful...We all want to go home at the end of the day.

To my fellow responders--we MUST be more careful. We should expect issues when working wrecks on the interstate and the side of the road. This career we have chosen is dangerous. It is up to YOU to make sure that you return home safely.