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Tuesday, September 7, 2010

Truama Preceding A Medical Problem?

The call came in for a fall victim, unconscious but breathing. As we were pulling out of the station I told my crew that this was going to be a bad call.

As we pulled down the second to last street, family members could be seen frantically waving their arms trying to get our attention to direct us to the patient. Not a good sign.
As I jumped off the engine, I was greeted by a slightly hysterical woman who I assume was a daughter. She said that my patient had fallen about 15 minutes ago onto the concrete. As I came around the tailboard I saw an old man sitting in the driveway with his back towards me. He was sitting in a walker/chair. The son was leaning in trying to arouse his father. As I approached, the son told me that he didn't think the old man was breathing. One quick look at the face was enough to tell me what I needed to know. Out of habit I checked for breathing and a pulse. Nothing.

I quickly wrapped my arms around the patient from behind and started to pick him up. The son was trying to help but without knowing what I was doing all he managed to do was get in the way. After forcefully telling him to get out of the way, I lowered his dad to the ground and started chest compressions. As I was doing this, my crew kicked into high gear. My engineer grabbed the airway bag, popped in an OPA and started breathing for my patient with a BVM using pure oxygen. My captain grabbed the heart monitor and pulled out the defibrillation pads. In between compression sets he put them on the patient.

By this point I had been doing chest compressions for about 2 minutes and we checked the heart rhythm. My captain said that we had a rhythm. The monitor showed that he was in a sinus bradycardia but he still had no pulses. This means that he was in PEA (pulseless electrical activity). The electrical conduction system in the heart is working well but for some reason the heart does not respond to the electrical impulses. As I continued compressions my heart sank as I heard the family members, with hope in their voices, state that they had heard us say he had a rhythm. I wish I had had the time to stop and tell them what exactly was going on.

Just then AMR pulled up. They grabbed a backboard and in between compressions we slid the patient onto the backboard. While continuing CPR the others strapped the old man to the board. We then took a moment to load him into the ambulance.

Once in the bus things really started to get going. My engineer and I switched places. The AMR medic obtained vascular access by starting an IO infusion on the patient's right leg. While this was going on I grabbed the medications that we were going to need and passed them over. Several Epi's, some atropine, some sodium bicarb and a calcium carbonate just in case. While the AMR medic handled the drugs and the monitor I bagged the patient and set up to intubate.
I had forgotten how hard it can be to try to intubate someone in the back of a small ambulance. I squeezed down in between some equipment in a weird contorted way that would have made me look like I was auditioning for Cirque de Soleil. I managed to get an okay look at the vocal chords and passed the tube. While the other medic popped on the capnography I listened to lung sounds. I had good lung sounds in both lungs AND in the stomach. The tube's cuff must not have been fully inflated so I grabbed the syringe to give it a little more air. Somewhere during all this I think the tube became dislodged so I pulled it out. Since we were only a minute from the hospital I just went with a BLS airway.
More or less what we see when we are trying to intubate someone. 
We want the ET tube to go right through the opening where the #2 is.

After getting to the ER I found out that the patient now had 3 rounds of epinephrine, 1 round of atropine and 1 amp of sodium bicarbonate all on board and was now in a sinus tachycardia PEA at a rate of 120. Somewhere in there the other medic had checked a sugar as well. It was 135.

We gave our report to the staff at the ER. It took the doctor 2 attempts and my help with some cricoid pressure to intubate the patient so I don't feel to bad. My engineer and I didn't stick around long enough to
see the outcome of the patient but we didn't have to. We've seen enough to know he wasn't going to make it.

So the question is did his fall cause the full arrest or did his full arrest cause the fall? It doesn't really matter. Dead is dead. If trauma had caused it there would be no bringing him back. If it was a medical problem, then we gave him the best chance at survival.


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