For years I have been on the regional medical advisory council. One of our responsibilities is to come out with the regional paramedic guidelines. It is always very exciting for me to get to use a new guideline for the first time. I think we worked on this for so long, went though many drafts and discussions and now here I am actually putting our work into play.
I remember the thrills of giving ativan on standing orders for a seizure for the first time, utilizing the spinal immobilization guidelines where I no longer had to put a collar around their neck and strap to a board every patient from a fall or MVA, and ceasing a futile resuscitation after 20 minutes of ACLS. Recently I gave Zofran for nausea for the first time and was able to give up to 15 mg of Morphine for pain on standing order.
I think wow all that effort around the meeting table actually made a difference here on the street.
***
Last week we got called to a person collapsed with no pulse. Okay, I told myself, I'm going to get a tube. I haven't had one for a while. This will be my first tube under our new regional intubation guidelines. After much discussion our committee decided to limit the number of intubation attempts to 2. An attempt is defined as putting the blade in the patient's mouth. You do it twice and don't get the tube, you use a rescue airway or allow a second medic one attempt. (There is an exception clause, which permits another attempt, but requires significant justification). I usually always get the tube on the 1st or 2nd attempt, but still there have been a couple times I have had to go in again. I ask myself, what will I do if I don't get the tube on the first two attempts. Will I go to the LMA or will I try again. I didn't particularly agree with the committee's decision on this one but I did agree with their point about if you are going to intubate, give yourself your best chance to get the tube -- set up right, get the head in proper position, have suction available, have the bougie out if needed. Don't just go in blindly.(I guess the literature shows the more intubation attempts the worse outcomes and greater the trauma to the patient.)
As we approach, we get updated. CPR in progress. Oh, yeah, and by the way, the patient weighs 500 pounds.
When we pull into the driveway I see a woman rolling on the ground screaming. A man approaches us, waving to us to hurry. He is in tears.
I get out of the passenger side, open up the side door and jump in the back. I detach the portable suction and grab a bougie, which lays on the counter and put them both on the stretcher where I already have my monitor, 02 and house bag secured. I jump back out, go around to the back and help my partner pull out the stretcher. The man tells us the patient -- his aunt dropped in the garage when a car backfired as it was pulling out. As we wheel around the corner we survey the scene -- a huge woman lies on her back. One police officer is doing CPR -- standing up straddling the patient, while another works the ambu-bag. Around them are several young men, who we learn are nephews, all anxiously asking how is she doing? How is she doing?
I apply the monitor -- asystole. The officers says they got in one shock, but the last check showed no shock advised.
I go to the airway now. The patient's head is purple and as large as I have ever seen a head. I learn she is only 40, but has a significant heart history. I strap the tube holder around her neck in preparation, then larengyscope in hand, a number 8 tube laid on a wrapped to the side, I try to open her mouth. She has protruding teeth and her jaw is heavy. I can barely open the mouth, and slide the blade in. Thankfully, there is no vomitus. I lift up and gaze in at the now lit airway. I can't see anything. I move the blade to the left and lift higher, moving the tongue out of the way. Again, I am in luck it is not the biggest tongue. At least there is room to pass a tube -- only there is no view of the chords. I can just make out the epiglottis. But time is running out and there goes my first attempt.
It's back to the ambu-bag.
"How's she doing? Is she breathing?"
I ask for a pillow to put under her head. I attach the capnography filter to the end of the ET tube and reach for the boogie. Here goes. I go in again. Again all I see is the epiglottis. I pass the bougie running it along the epiglottis till the tip disappears from view and then I feel the bumps of the tracheal rings. I realize only now that I have forgotten to place the tube over the bougie. No matter. I place it over the bougie and thread it down until it stops. I crank it to the right with a twist and have my partner pull the bougie which is now sticking out of the top out. I look at the monitor and am thrilled with what I see.
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The tiny oscillations of CPR. I'm in. I attach the ambu back. Good wave form. Check lung sounds. Equal.
I struggle to attach the tube holder, but it won't fit around her head. My partner hands me some tape and I finally get it secured.
"How come your not going to the hospital? How's she doing? Sir, can you tell us?"
What follows is chaos.
The crowd of nephews more seeming to arrive with each minute presses in on us. I send my partner for the board, and while on one hand I want the officers to hold the crowd back, on the other we are going to need them to help lift the patient. I also need to get an IV, but she has no neck and in the dimness of the garage I can't see any veins. I'm thinking let's get her in the ambulance and then maybe I can get something.
We still don't have the EZ-IO yet, so my only choice is down the tube with epi, which I do. Still asystole.
We need to tie straps to straps to get them to fit around the patient. I am still amazed that the officers switching on and off CPR are able to do CPR on their feet. The woman's sternum must be two and a half feet off the ground.
We finally get her rolled onto the board and strapped. The board starts to break apart as we lift, my partner and I, the two officers and at least five crying nephews, but we manage to get it on the stretcher and then with the same muscle power get the stretcher up. I am holding the tube. My eyes on the monitor.
insert strip.
Still good wave form. Thank god for capnography.
In the ambulance, one officer does CPR, while my partner bags and I look for an IV. The other officer sits in the driver's seat, ready for the word to go. I tell the other officer I'll cut him loose as soon as I get an IV and get some drugs in. The back door opens and a nephew jumps in. How's she doing? You need to get out. Why aren't you going to the hospital? The other officer says we better get moving, they are going nuts out there. I get the flash and start slamming in epi and atropine. I take over CPR while the officer gets out. We're on our way.
I look out the back window and see the other officer following us in his cruiser and behind him a caravan of speeding nephews.
The capnography is up to 70. I see an organized rhythm.
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But I can't feel a pulse -- there is no place to even attempt. No neck. I would have to cut her pants to get to a femoral if I could even find that, plus it is hard enough just keeping her on the stretcher with her belly shifting its center of gravity with each turn. The officer is doing a great job of driving slow. I look out the side window and see one of the nephews has overtaken the police officer behind us and is driving parallel to the ambulance, trying to see what is going on. I feel like I am in a movie chase scene -- a wagon train being overtaken by Indians or an undercover hero being chased by foreign agents.
The capnography drops down to 18, and now there is no question but to do CPR again. More epi and atropine. I try to patch to the hospital, and as I give the report, we go around a corner and the patient shifts on the stretcher and my legs are pinned between the body and the bench seat. I'll tell you the rest at the hospital, I say. Is the patient intubated? they ask. Yes! I throw the radio down. And with great effort manage to center the woman back on the board.
At the hospital the back door opens and the nephews pile in. How's she doing? Easy, I say.
Again, we need them to help ease the patient out of the back. I have to shout at them to pull out slowly. The capnography wave form is still looking good. I know the tube is still solid.
Into the ER we go, nephews and all. They have us go to one room, but it is too small, so we parade back through the ER to another room, we finally slide the patient onto their bed, and the nephews are lead from the room by the officers and security.
The patient is asystole. The total down time is deduced at almost forty minutes now. The physicians argue about whether to declare the patient dead, which they do.
A tech comes up to me and says he gives me credit for bringing the patient in and not calling her at the scene.
I don't even bother to explain.
Sorry, nephews, your aunts dead. We're not going to the hospital. Ashes to ashes. We're out of here.
I don't think so.
Later one of the nephews tearfully thanks me for our efforts. Another walks by seething and says nothing.
***
I am glad for many things. For getting the tube. For bougies and wave form capnography. Ten years ago, I wouldn't have gotten the tube and that would have made the situation that much more stressful.
I'm grateful that we will be getting the EZ-IO on our trucks, although I wish it was now and not "soon." Maybe if I could have gotten earlier IV assess the drugs might have brought her back and not just produced a temporary rhythm and possible marginal cardiac output.
I'm glad no one was hurt on the call.
I'm glad I'm not 500 pounds.
I'm glad that she was as loved as she was.
