"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.

To the Anonymous Commenter....

How dare you question my writing and not have the guts to reveal who you are.

Since you feel like you need to nitpick and judge me and my personal thoughts, I'll respond to every single one of your "concerns" in public.....I don't need to hide behind "anonymous".

Anonymous said...

"I found this via a friend who frequents BBC and after reading these two lines I just had to say something.

"Thankfully, I didn't have to do anything really..."

"I don't really feel much like working today..."

I would hate to be the person who burdens you with my car accident when I have three kids and we all need calming down. And if you don't feel like working- you shouldn't! After all, when people need help but you just don't feel like it, why bother? And don't you worry- I'll drive safe because if I get into an accident I can not trust that you will want to save me (even though that is your job)!"
04 December, 2007 12:06


First of all, did you ever stop to consider that perhaps I was thankful that I didn't have to do anything at the wreck because NO ONE WAS SERIOUSLY INJURED?

Do you not think that I've seen enough children's brains splattered over the roadway, their lives cut way too short?

Or children who have lost an extremity?

Children who have suffered traumatic brain injuries because their parent chose to drive under the influence and didn't buckle them in properly?

Do you not think that I've seen one too many children whose parents have rolled over on them in the middle of the night while co-sleeping and suffocated them?

I've done CPR on far too many precious little children. I've pronounced too many babies dead.

So yes, I have earned the right to say that I am thankful I didn't need to do much more than try to calm down Mom and the children.

If further treatment had been needed, you bet your critically judgmental arse that I would have done everything in my power to have saved the lives of those children and/or their mother.

After triaging all the patients and determining what resources would be needed, I sat there with those children and held their hands, cuddled with the youngest, and helped to calm down Mom for nearly 10 minutes before EMS arrived.

I'd also like to point out the fact that I had no legal duty to act and was not required by current state legislation to stop and render aid. I did because I care AND because I have the training, the skills, the knowledge, the equipment, and the authority to provide emergency medical treatment to my fellow human beings.

As far as my other comment about hoping my shift is mellow....Have you ever worked in public safety? My guess is um, NO you haven't. If you have you'd understand that hoping we are busy is a double edged sword. If we hope to be busy, we are hoping tragedy upon our community. Because to get a "good" call (shooting, stabbing, bad wreck, heart attack, code, etc) that means something bad has happened to someone else.

What kind of fricking sadist would I be if I wished harm and tragedy on my community?

Now, with that said, just because I said that I didn't want to do anything doesn't mean that I wouldn't. Big difference, in my opinion. I ALWAYS do my job to the best of my ability, ALWAYS. And since you don't know me, you couldn't possibly have any idea how many times I've brought a patient "home" with me and cried over them. You don't have any idea how many times I see a patient's face as I close my eyes at night and attempt to sleep.

My partner and I assisted our local ER with the unexpected cardiac arrest of a school aged child earlier this year. We did chest compressions on this youngster for almost 2 hours, assisting while the doctors, nurses, and air medical crew valiantly tried to save this precious child's life. We did chest compressions even when it was clear that this child had already been cradled in the loving embrace of our Lord. We did chest compressions with tears running down our faces while Mom and Dad were brought back and realized the light of their lives was gone forever. After we returned the flight crew to their air craft, empty handed, our strong and stoic firefighters cried with me while our hearts broke for the loss of that child and for the parents who would go home mourning the death of their beloved child.

Until you have walked a 24 hour shift in my shoes, don't you dare tell me how I should think, feel, act, or write. Do you have a positive attitude towards your job 100% of the time? Are you always happy and upbeat when going to work? Do you never have second doubts about things that are happening at your place of employment?

And if you wreck your car with your three children, I will do everything I can to save your life and your children's lives because it is my PASSION and not just my job. I will do it because I care about serving my community and the people who live in it. I will do it because I provide medical care to my community without regard to your ability to pay, skin color, religion, infectious disease status, etc.

Please do not EVER question my dedication to my job again. It's insulting and demeaning. I would give my life for yours or your children's lives if it came down to it.

A few of my more memorable calls

I thought I'd share with you a few of my most memorable calls....

Earlier this year, getting dispatched to the sidewalk in front of the hospital for a female patient who had just given birth. Mind you, it's o' dark thirty in the morning and 20 degrees outside....

We arrived on scene and found a lady lying on the sidewalk, holding her newborn in her arms. We got her up off the sidewalk and into the back of the ambulance where she delivered the placenta. I clamped and cut the cord. After drying off the infant, we wrapped him up really well and I stuffed him under my pullover to try to get his body temp up. I stood with him in front of the heater and prayed for his core temp to come up. Other than being severely hypothermic, both Mom and baby eventually did fine.

We came to find out that this was the 5th child for this mother. She went into labor and Dad drove her to the hospital. Instead of dropping her off at the ER to go up to L&D, he parked in the parking garage. Well, she made it to the sidewalk when Junior decided he just wasn't waiting anymore.

I've worked numerous car wrecks where people should have been dead or seriously maimed and they walked away just fine! Mostly because they chose to wear their seat belts.

Then there is the patient who calls all the time for breathing problems and really she's lonely. I know the last time we had a city wide power outage, and we had to take her to the hospital because her air conditioner went out.....Uh, no kidding lady there's no power ANYWHERE in the city.

The saddest thing is people refusing care who really need to go. Several years ago I responded on a call, I don't even remember what the complaint was at the time. The patient absolutely refused to go. We did everything short of having him arrested and forcing him to go--We legally couldn't do that anyways as he was totally competent to make his own decisions. He looked horrible and had a significant history. He said he already had a doctor's appointment for the next day and just wanted to keep that. He signed a refusal and we left. 10 hours later, we were doing CPR on him as his family watched.

He COULD have been ok. He might have lived if he had gone to the hospital the night before when we were out there.

How about the patient who was trying to burn trash (hey man, watch this!) in a 55 gallon barrel and ended up with a fancy ride via LifeFlight helicopter to the burn unit at our local trauma center, with facial, airway, and chest burns.

The fact remains that as a prehospital provider, we are frequently given a unique glance into many aspects of peoples lives that they may not share with others. We also frequently see how stupidity equals job security...

Until next time!