Glitches

“He’s upstairs on the back porch, the EMTs are with him.”, came the report from the fire department first responders as they walked down the stairs and headed back to their truck.

My partner and I looked at each and said in unison, “We better bring the CPAP up with us.” We’ve been at this long enough to know that when a patient goes outside or is hanging out a window trying to get a few extra molecules of Oxygen into his system the end is near for them. It’s one of those things you don’t learn in EMT or paramedic school it comes with experience and paying attention to those experiences. As Ambulance Driver says, “There are paramedics with twenty years of experience and paramedics with one year of experience repeated twenty times over.” My partner is one of the former and I try really hard not to be one of the latter.

We walked up stairs, all of our normal gear, plus CPAP and one extra “D” sized tank. For it’s wonderful characteristics, CPAP is a voracious user of Oxygen so a spare tank is in order most of the time.

We got upstairs and the BLS crew told us he had Asthma, had tried his inhalors without relief, and had come out on the back porch seeking more air.

“Can’t breath.”, was all he could say and he wasn’t exaggerating. Respiratory rate over 40 per minute, not able to speak, working just to get enough air to stay alive.

My partner set up the cardiac monitor, which of course does way more than just that, while I stuck the ear pieces to my stethoscope in my ears.

“We heard wheezes.”, one of the EMTs told me.

So did I, but only in the upper lung fields. Below that it sounds like a kid blowing bubbles through a straw. Which meant fluid in his lungs, where there should be air. It’s like drowning, only you’re on dry land.

“Failure.”, I said, and for once I wasn’t talking about management.

“BP 220/110,  pulse 140.”

I lifted up the Oxygen mask and sprayed some nitroglycerin under the patient’s tongue while my partner set up the CPAP and the EMTs set up the stair chair.

It took a little coaxing to get the patient tolerate the mask, but my partner is really good at that. I’ve called him the “Patient Whisperer” before because he can talk people down from their anxiety and gain their cooperation.

The move down the flight of stairs went smoothly except for me stepping on the supply tubing to the CPAP and almost falling down stairs. A small glitch, nothing to worry about.

We moved into the ambulance and continued treatment. The plan would be continue CPAP, an IV, a 12 Lead, all done while transporting.

Well, that was the plan, anyway.

I turned on the big Oxygen tank in the ambulance and we did a well coordinated move of the Oxygen supply tubing over to the connector in the wall of the ambulance. The nice, reassuring hiss of the CPAP was, well, reassuring. I turned my attention to a couple of other things while my partner get ready to start an IV.

The BLS crew got ready to drive us and all was going according to the plan. We’ve done this hundreds of times, it’s chaotic from the outside, but it’s really not.

There is nothing so loud as the sound of silence.

Big glitch.

“Hey what happened to the CPAP?”, my partner asked as the patient started gasping for breath.

They teach us that when something like CPAP fails to look at the basics for the point of failure.

Oxygen gauge? Says full.

Supply tubing?  Not kinked.

Device settings? Correct.

“There must be a problem with the circuit, let’s change it.” Done, no change.

Now, the patient is becoming frantic and we pulled the mask off so he could get some air even if it wasn’t under pressure.

Something wrong with the Oxygen supply? Check again, stick my head into the compartment where the tank is and looked at the mechanical gauge as opposed to the digital read out. Zero. Shit.

I grabbed a portable tank, plugged it in, and was rewarded with the hiss of Oxygen. My partner had spent the time I had been doing trouble shooting giving the patient nitroglycerin. That helped, but CPAP was what was needed.

Of course while all this was going on, the end tidal CO2 monitor stopped giving reliable readings and started sounding false alarms that the patient had stopped breathing. Which he hadn’t we knew because we actually were looking at the patient. Why did it have to pick now to go all gaflooey on us?

Another glitch. Really, what else can go wrong. I’d probably be better off not asking that question.

I yelled up front for the EMT driving to stop and grab some portable Oxygen tanks. The rest of the trip to the hospital I spent switching out “D” tanks as they ran dry. By the time we got to the hospital it looked like we had about a six pack of empties, but it wasn’t that many. We had used all of our portable oxygen with just enough to get into the hospital.

While all this was going on, my partner calmly finished the IV start and did a 12 Lead ECG.

The patient was looking and feeling better when we wheeled him into the ER and I think he’s going to do OK, at least this time.

So, what went wrong?

Like a lot of modern ambulances, ours have electric controls for the Oxygen. They also have an electronic read out with a sensor on the regulator attached to the big tank. In this case the sensor is encased in a plastic housing. The older units were made of metal and fairly rugged, but someone saw a “cost saving” by specifying a plastic part. Which had broken somehow, which happens. The problem is that when the sensor breaks instead of failing to zero and alerting the crew, it fails to read that the tank is full. And so you can use a lot of oxygen, but not know it. Of course we check the gauge reading at the start of the shift, but given no reason to think anything is broken, I at least don’t look at the mechanical gauge. I might have to change that procedure.

While things like this happen from time to time, I think the important thing is remaining calm and taking a systematic approach to trouble shooting. And having a good partner, of course.

It’s not the glitches, it’s how you respond to them.