I've been doing this a long time -- 15 years as a medic -- and it amazes me how often I find new ways to do things or think about things.
I did another cardiac arrest yesterday. Fairly routine. Yet another nursing home hospital bed one legged diabetic dialysis patient pulseless, apneic, CPR in progress, first responders defib - No shock advised. Patient a full code. Done it many times before, so what was different?
1. My eyesight is getting worse. I've remarked on it before how I have to squint sometimes when I am trying to thread a 24 gauge catheter into a tiny vein. Yesterday I had trouble reading the lip line markers on the ET tube. The lighting wasn't great and there was some thick mucus on the tube, but I couldn't tell if the number at lip line was 21 or 23? I couldn't make it out. I squinted harder, but still couldn't see it clearly.
Also when the nurse handed me the W10, I was trying to read the medical history and again, I couldn't read it. It is one thing to sit on an ambulance bench seat on a nice easy ride to the hospital and read a W10, but in the middle of a code when you are the only ALS provider, it is quite another. I have decided in the future what I will do is have the nurse stand by me while I am doing my code things and read the W10 aloud. Start with medical history and proceed through the medications. I have of necessity over the years learned to make use of nursing home staff on codes -- yesterday they did a fine job with CPR and handing me what I asked for from my gear, that this is just a logical extension.
2. ETCO2 and cardiac arrest. I have also written about this extensively (See Post), but I continue to gain new insights. The clear utility of continuous capnography is a quick verification that your tube is good (you still have to listen to lung sounds because ETCO2 won't detect a right mainstem). The other benefit is it can provide a glimpse into your patient's survivability chances as well as measure how well CPR is being done. This woman had an ETC02 of 35 on intubation (with CPR), which suggested she was not as dead as she looked. She was initially in a PEA but after some epi went into v-fib. I shocked her a total of three times, then she went back to a PEA, which dwindled to asystole and then back and forth between PEA and asystole for the duration of the call. I don't like to transport dead people, so I usually follow the 20 minute and out rule for patients in asystole, and under our new guidelines I can call medical control to cease resuscitation even on patients who have been in v-fib or PEA for a period of time if after 20 minutes, they remain pulseless. The problem here was we were getting such good ETCO2 readings. The patient stayed in the 20-30 range. What was most interesting was every time I gave her epi, the ETCO2 rose up to the 30's. We never did get pulses back. My guess was a dopler would have showed a BP in the 50's or 60's during the epi effect. Anyway, I felt we had to bring her in.
Now in the past without ETCO2 to monitor the effectiveness of CPR many of us became rather casual in our efforts. The patient was dead and wasn't coming back but was still alive enough that we had to work them. Now with ETCO2 measuring the effectiveness -- basically, the better your CPR, the better the cardiac output, the higher the ETCO2 number -- you are obligated to maintain maximum CPR efforts. As soon as you start to get lax, the monitor is going to tell you. 28, 27, 26, 25, better start pumping harder. 26, 27, 28. You stop CPR briefly to switch positions or administer a drug and your ETC02 is down to 18, 17, 16, 14. And it takes some pumping to get it back up into the mid 20's.
I had just one partner yesterday so he drove, while a cop rode in the back with me, which leads to another thing I learned.
3. IOs -- I love the EZ-IO. One legged diabetic, dialysis patient with me the only ALS responder, it's a no brainer -- I don't even look for a peripheral vein, I just get out the drill. Brrrrrr. I have access in the tibia. But here's the problem. In the past, I would have put in a line in the AC or an EJ, which would enable me to sit at the head and bag the patient while also administering drugs. I could do a code with just two people in the back. But now with the line just below the knee, no way. So, I'm trying to administer drugs and do CPR at the same time. That's challenging. You stop CPR for a moment and the ETCO2 plummets because your circulation/pressure has just dropped to Zero. Epi and atropine push pretty easy and quick, but due to the patient's history and down time, I decided to try some bicarb. Let me tell you bicarb is a bear to push through an IO. Its like pushing D50 through a 24. It is slow, so I'm doing one-handed CPR, and one handed bicarb pushing against the bristojet, all trying to maintain my balance as we go over the bumps in the road. Bottom line, I really need to get a third person in the back.
4. The patient's husband was in the nursing home lobby. When I saw him, I do as I often have done in the past -- have him come over and say something brief to his spouse. I do this to give them a chance to say goodbye. I tell them we are breathing for their spouse, but they may still be able to hear. And then the one says to the other, I love you, etc. I want them to have that moment, and it usually works out well. Yesterday, I did it, and the man told her heartfully he loved her and then we pushed on through the door and then behind us came an awful howling. A howling that did not abate. I could only picture the man on his knees crying out to the heavens.
It is hard to know what is right sometimes. Did I give him a chance to say goodbye? For him to know that his loved wife heard his words? Or did I give him an awful memory that he'll never forget -- a picture of his unresponsive wife on a board with a plastic tube sticking out of her mouth and people pounding on her chest?
They worked the patient in the ED for another twenty minutes. She had a recent admission for hyperkalemia so they gave more bicarb and then calcium, but to no avail.
