Yesterday was my last day riding with my preceptee. She rides with the chief paramedic on Friday to get cut loose. She will do great. She was a pleasure to precept.
We were still checking out our equipment when we were sent for a difficulty breathing. It was an area of one of the towns we respond to where it almost always turns out to be a major call -- either a heavy duty overdose or a big MI or serious trauma. It is a lower middle class working area with a big drinking/substance abuse problem. Anyway, when we arrived two cops were standing on the front lawn, not looking very excited. They explained the man in his forties was having trouble breathing, but the visiting nurse was in there with him. He had a host of medical problems, including ascites and pulmonary hypertension and was on home 02. The nurse said his pressure was 70 and she couldn't feel a pulse. The man was breathing about thirty times a minute with clear lungs and warm, dry skin. I tried for a pressure, but couldn't hear anything. We popped him on the monitor and he was cranking away at 200, which certainly explained it. While I felt bad for the gentleman to be in this condition, I was glad for my preceptee that she was getting a PSVT. I suggested we put him on the stretcher, do a 12 lead and then treat his rhythm right there in the living room. But when I mentioned doing an IV, the man said, "No, no IV. No IV. Uh-uh. NO!"
I hate that when that happens. We preceded to then have a battle royal about the need for an IV. He was not only adamant, but knew the right lingo. "You can't treat me. I have the right to refuse. I will not let you put an IV in me. Let the IV nurse at the hospital do it. It took them 4 tries on me Friday. Wait until the hospital. You do not have my permission."
We kept at it all the way out to the ambulance. When his wife showed up, I tried to enlist her, and she gave her best persuasive case, but to no avail. The patient was just yelling at us to get moving to the hospital if he was so seriously ill. We kept up our arguments. Your heart, particularly with your medical conditions isn't strong enough to last long beating at 200 times a minute, its just a small prick in your arm versus possible lifelong disability. We are IV professionals. We teach the IV team how to do IVs(so we fibbed on that one). He finally, surprisingly relented and agreed to let us do one IV, but only in the hand. My preceptee later said she thought I was going to push her out of the way and do the IV myself, but I told her I had faith in her and she got the IV in the hand -- a #20. The patient was very impressed. "You got it? It's in? On the 1st try? I'm sorry I gave you such a hard time, its just that they never get it."
But a problem was the IV was in the hand and adenosine is better given in a vein closer to the heart. Still you get what you can get and I have had adenosine work many times with hand veins.
The first dose of adenosine did nothing. We did it again -- this time it temporarily broke the rhythm, but caused him much distress as adenosine does when it briefly disrupts the electrical charges in the heart in an attempt to reset them. He was clutching at his chest in terror and we were shouting it will pass, it will pass, which it did (as it does) in about ten seconds, but then the heart rate went right back up to 200.
After that he didn't want anymore medicine. Our option was electricity by shocking him or try to convince him to let us try another medicine. I didn't think he was going to be happy with us placing pads on his chest and jolting him -- not at all, plus I am from past experience uncomfortable with shocking people who are talking to me(admittedly those were patients with VTack, diaphoretic and no pressure who needed immediate shocks and who did not have good prognoses). We managed to talk him into letting us try Cardizem, which we said he wouldn't feel. We were just about at the hospital now, and my preceptee finished slowly pushing the drug into the IV line while our driver partner stood at the back door waiting to pull the stretcher out.
In the ED, while the nurses tried to argue with the patient that he needed another IV, and he was shouting, "No, no, no more! No IVs! It took you 4 times last week, I'll get up and leave," the doctor came in, introduced herself to the patient and asked "What brought you to the hospital?", and he smiled, looked at us and said, "the ambulance." "No, no," the amused doctor said, "Why are you here?"
Just then we looked up at the monitor and the rate was down to 120, showing an afib as the Cardizem finally kicked in. The patient said he felt much better. The rate stayed down and he and his wife were very thankful to us, and shook our hands when we said goodbye.
I'm glad my preceptee got the IV. Grace under pressure.
I wish her great luck in the future. She will be a credit to the profession.
