Home Paramedicine/The Job A Train Wreck

A Train Wreck

6

Or maybe a bus wreck. You’ll see why in a second.

After a relatively quiet shift we were dispatched with about 45 minutes to go for a “Cardiac Disorder”. Which sounds specific, but because of our goofy phone triage system is actually pretty generic. In this case it was “female with chest pain and shortness of breath”. This figured to be an easy call as the address was only a few blocks from the station, and only a few more from a hospital. So, I figured this would be an easy way to end the shift. Silly me.

We arrived to find the male patient (see above) sitting on a chair inside the garage door of a school bus garage/dispatch center. Patients sitting up are generally better than those lying on the ground because if nothing else sitting patients are generally, if not always, conscious. Conscious is better than unconscious when it comes to patients. At least generally speaking.

We pulled in, a BLS ambulance pulled in, the fire department pulled in but took the wave off. We alighted the ambulance and walked over to the patient. Who looked like crap. Which is a medical term, really. Cold wet skin, having trouble breathing, complaining of chest pain. Not. Good.

My partner started with the usual questions and within 10 seconds we knew that that patient had had a “heart attack” a week or so ago, had gone to the cardiac catheterization lab “cath lab”, and had two stents placed. I wasn’t sure if he had been told to go right back to work on the school bus or had decided that it was OK on his own. It didn’t much matter, though, as he had something bad going on. Which is more highly technical medical talk.

We decided we didn’t need an audience of bus drivers to help us, nor his supervisors for that matter. So, on to the stretcher and into the ambulance he went. And so an intricate ballet started. Or maybe intimate is a better term. My partner kept talking to the patient while I started the cardiac monitor and attached the various sensing devices, one of the EMTs tried to get a blood pressure, the other EMT started to put and IV together. Through the miracle of modern electronics we soon had an answer to exactly what was going on with the patient. Ventricular Tachycardia, of a rather rapid kind. Not good. No discernible blood pressure, worse. Then the patient started to seize, worst of all because that meant that his brain and other vital organs weren’t getting perfused with oxygenated blood. It took a second or two to convince my partner that the patient really was seizing, but he (the patient) wasn’t faking. Time to get the pads out and on and try better living through electricity on the patient.

Pads on? Check.
Press the CHARGE button? Check.
Annoying sound as the defibrillator charges up? Check.
“Everyone clear?” Check.
Press “SHOCK” button? Check.
Patient jumps and yells? Check.
Rhythm converts? Not so much.

Now the paramedics and/or other medical professionals will notice that we did not use synchronous cardioversion, did not have an IV in place, and did not use sedation. Which under ideal circumstances we would have done. Well, truth be told, under ideal circumstances the patient would not have been in VT in our ambulance and doing his level best to die. Back to our story.

Oh, the defibrillation pads didn’t stick all that well because he was so diaphoretic. Which meant that we had to replace them in the middle of everything else going on. First time I’ve ever seen that.

Now came the fancy stuff. I tried to start an IV while my partner talked to the patient. Who wasn’t seizing any longer, but who was still heading down the road to death. While I was trying the IV, my partner shocked the patient a couple of more times. Of course the patient had no peripheral veins that were accessible because his heart wasn’t pumping out much, if any blood. So, I gave up on that and whipped out the intraosseous drill. Which looks like most other cordless drills, but costs a lot more because it has to be FDA approved, unlike your Ryobi or DeWalt. A great device, you can hardly miss if you pay attention. Which I did (pay attention) and I didn’t (miss). The thing that they tell you about intraosseous needles is that they don’t hurt any more than an IV when you put them in. What they don’t tell you is that when you push fluids in, the pain is excruciating. It’s almost enough to wake the dead. More accurately, it’s enough to wake the almost dead. Which it did in this case, causing our almost dead patient to lift his head and stare at me. Undeterred, I attached the IV and then drew up the first drug we were going to give. Which is, thanks the the American Heart Association, Amiodarone. Which is supposed to be a potent antiarrhythmic and maybe it is, but it’s a pain in the ass to draw up. Which is not what you want when you have a critically ill patient, but it’s what we are supposed to use.

Sidebar: Here is what we have to do to administer Amiodarone. Draw up 3 ml (150 mg), then draw up another 3 ml into the same syringe. Then we are to draw up the saline solution to make up the required volume. And then administer it. Try doing that in the middle of a cardiac arrest. Which this now was. Well sort of. Back to the story.

The patient was in no man’s land. Not enough perfusion to keep him fully alive, but enough so that he wasn’t dead. He was still trying to breath, his eyes were open and he was still looking around, although I don’t know that he was comprehending what he was seeing. It’s something we don’t see often, for which I’m grateful. Here is a patient who is about to die and all that stands between him and death is our skill. That’s pretty scary, probably for the patient as much as it is for me. Through it all my partner was telling the patient what we were doing because hearing is one of the last senses to go and there is pretty good documentation that even gravely ill and unconscious people can hear and remember what is being said. Eerie, that.

It was time to intubate the patient because his airway needed to be controlled and he needed to be ventilated. Only was too conscious to intubate without some drugs. So, in went the sedative, to make him less conscious. Yes, we had to make the almost dead guy less conscious so that we could intubate him. This is not what you see on House, or ER, or anywhere except maybe Scrubbs if you ever watched that show. Once again the patient failed to do what the text books say he should do.

The intubation was easy, or it looked easy. It was done in any case.

More defibrillations, some CPR, more Amiodarone, and now we had a nice sinus rhythm, well sort of. Whatever it was, it was perfusing the patients vital organs enough to keep him alive. His heart was still trying to go back into Ventricular Tachycardia, but the Amiodarone was sort of working to prevent that. Still the rhythm was stable enough for us to do a 12 lead ECG. Which didn’t look at all good.

We seemed to have the patient stable enough to drive to the hospital. Not the same one that had done his stents a week or so ago, but the closest one with a cath lab. Which was actually pretty close. While my partner called the hospital to give them a warning that we were coming in with what had been a train (or bus) wreck, I gave more sedation while fervently wishing I could give me some sedation.

It sure seemed like we spent a long, long, time on scene, but it really wasn’t too long at all. Time just sort of compressed, I guess.

Anyway, we got the patient to the hospital alive, which is a victory in and of itself. After a bit more stabilization in the emergency room, he went of for another cath. Given the short period of time between the first cardiac event and this one, I’m not overly optimistic about his survival. Time will tell, I guess.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

6 COMMENTS

    • We’ve all got a few calls that stick with us. Anybody who says different is a liar, needs therapy, or both.

      I don’t think we’re any different than most people in terms of dealing with it…. I think we might train ourselves to just turn a certain portion of our brain or emotions off. Or maybe some of us are just pre-disposed to that ability.

      Plenty of people have left the field (in various forms of distress) because they couldn’t make that adjustment.

      The trick is stop turning things off before you start losing pieces of your humanity. Plenty of those people still riding trucks too.

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