Thursday, April 27, 2006

CHF - Trend Summary

I am the tallest person in the company and today I worked with one of the shortest. The day started off slow, just sitting covering an area. Unfortunately, the area was close to the base. When a call came in for the bareatric ambulance, it went to us. So we had to drive back to the base, switch into the big ambulance and were sent off to pick up the 400-500 pound patient. Fortunately, they had to send another ambulance to back us up as is required by policy. My partner who has taken this guy before said he looked like he had gotten bigger. He was so big that when he got on the big stretcher, which is rated for up over 1000 pounds in the down position and 800 in the up position, he thought he was on the regular stretcher because he was hanging off both ends. Yeah, he's getting bigger, she said.

The problem with doing one big person run is you can never get back to the base to get in your regular ambulance. We were just about back when they sent us to another big person call. This lady was probably 500 with legs the size of an average person's torso. She could stand and pivot, but the stretcher in the medium position was too high, so we made the mistake of putting it all the way down so she could sit on it. My partner doesn't lift well, so we thought about calling for another person to have four strong lifters instead of three, but I said, I could take the end and the two guys from the other ambulance could take the head. I got down in squat position, squeezed the release and drove my legs up, but the stretcher stayed down. I had to stop or I would have ripped every muscle in my back. I was a little embarrassed. One of the other guys took the end then, he's younger than me by a good deal and very strong and squat. He got it up, although his head and throat turned purple. I think the stretcher was just too low for me. That and I haven't been as regular at the gym as I used to be, although that is changing. I was in the gym this morning for cardio.

Anyway, we finally got back to the base. While my back was slightly strained, I wasn't hurt. We got in our regular ambulance and went back out on post. We were sent priority into the city for a child struck by a car, but it just turned out to be a thirteen year old who had his foot run over. It hurt when I pressed against it, but he was very stoic. Thirteen year old wearing a do-rag, looking like Tu-Pac.

We were a half an hour from crew change when we cleared the hospital and instead of being told to come in, we got sent to the one area they send you too when they have no other cars available. Sure enough we got a priority one call. Difficulty breathing at the nursing home. It turned out to be a good one. CHF in a DNR patient. She was sucking when we got there. Altered mental status, cool, pale, clammy. As usual the staff didn't have much to say other than it came on very quickly. They said she was wheezing and they gave her a nebulizer by mask. I listened, but couldn't hear any wheezes. I did hear a lot of rhonchi and rales. I used the capnography and she had a decent wave form indicating no bronchospasm.

Her CO2 reading was in the 50's, which is high. Her respiratory rate was around 30. Her BP 180/115. Heart rate was 116. Her Sat was 80%. We switched her to a non-rebreather. I got a line and gave her three nitros, and her Sat was now 99%. Her heart rate and BP came down, and she was finally able to converse with me. Her capnography stayed on the 50s. Still she looked like a different person at the hospital. I printed out a trend summary afterwards.

It is amazing we had this feature on our monitors for some time and I at least never knew about. I have been trying to spread the word, and have only found one other medic who knew about it.

For any of you with Lifepack 12's out there, do the following:

Hit Options.

Hit Print on the options menu

Hit Report, which on ours is defaulted to Code summary.

You should get a trend summary option. Hit that.

Then hit print again on the options menu and the trend summary should print out.

I have found one monitor that doesn't have the trending software on it. Yours may or may not, but if it does, that's how to get it.

Looking at this trend summary, you can see the gradual reduction in heart rate (3rd graph), as well as the early SAT readings and later ones(4th graph). Next time I will try to get the capnography on in the room, rather than waiting to get out to the ambulance, as well as trying to keep the pulse SAT on.

When I got home, I tried to read more about capnography. The literature is so sparse, I can't always find the answers. This is about what I came up with. Her wave form shows no bronchospasm. Her high CO2 indicates tht she is getting tired and was in a hypoventilation state. Even though she is breathing at a higher than normal rate, she is not getting enough ventilation with each breath. She did look very tired. The literature I read said a sudden decline in her ETCO2 from the 60 area down to the 20s would let you know that in a few minutes or so you would find out she was completely flashing, fluid filling the lungs preventing poor CO2 diffusion. Fortunately we avoided that state. When I was done with my paperwork, I checked on her and we were able to have a good conversation. Unfortunately the hospital didn't have capnography as I would be curious to see what her numbers were.

Anyway, I am excited to learn about this all. I apologize if I am explaining any of it incorrectly as I am still a novice at it.

Tomorrow I am working 8 hours. All they had open was the so-called High Performance car, which is a transfer truck, where they let you go home after 8 calls and pay you for 8 hours even if you finish earlier. I wanted a regular shift, but told them if they could get my friend to work it, I'd work it, so they promised me that if I would come in. I don't particuarly like transfers, but I'll do them if I can hang out with someone I like working with.