I come into work and find a note posted on the door for me. "The only current lidocaine prefilled are in 280. There are none in reserve. 270's are expired." The note is from the medic who shares 270 with me. I have ordered more lidocaine, but the order is a couple weeks late. I am not that concerned because we have plenty of amiodarone, and under the new AHA guidelines, amiodarone is preferred to lidocaine anyway, and in the case of v-fib with pulse, lido has actually been removed from the algorithm.
I check my ambulance out, and then get in bed and sleep for two hours. At ten, the call comes in for the nursing home patient with the skin tear. We walk out to the ambulance and I hear on the radio the cops being sent to a chest pain. We should be going to that I say, and no sooner said, then the dispatcher calls us and reroutes us.
It turns out I know the son and daughter-in law of the eighty-year old man with the chest pressure that has now gone away. His twelve lead looks good, he's already had his aspirin, so I do routine ALS and take him in without lights and sirens. It is a good call, the kind of call EMS should be about. Helping a neighbor. The man was a little stubborn about the chest pressure, but his family finally convinced him to go, and we helped them negotiate the hospital. Afterwards, we all shake hands and wish each other the best.
The next call is for an elderly man not acting right. We arrive at a nice private home where a picnic is in progress. Uncle Morty is in the bathroom, cool, clammy and not recognizing his grandniece, who helps hold him up. He is an insulin dependent diabetic. His sugar is 36. We give him some D50, and he is back as good as new. His grandniece brings him a plate of food while he tells me he has been married to the same woman for 57 years. He refuses to go to the hospital. He neglected to eat because he was too busy talking to everyone and the food wasn't ready yet. He agrees to follow up with his doctor.
Later we get sent for a woman in her thirties not acting right according to her husband. The only history she has is lupus. When we arrive, the police officer tells us she can walk out. We leave the stretcher in the garage and walk in. She is sitting in a chair with a faraway look in her eyes. Her husband says this is not like her at all. Her skin is warm and dry. She has no facial droop, good equal grips and no arm drift. Her pupils are equal but not reactive. I have her get her shoes and we walk out to the garage where the stretcher is set up. I have a hand lightly on her arm because her balance looks a little bit off. Her husband has her meds. He tries to get in the back with us, but I tell him he needs to sit in the front seat. For a moment, I think about having him sit in the back, but since I have another crew member with me, I think its better he is in the front. After I have assessed her, I can stick my head into the front and interview him more thoroughly.
My partners are fairly new to EMS. Driving for the first time is the young man I wrote about in the story Compressions. In the back with me is another new EMT, who is very eager, but still needs more seasoning. I have him take the blood pressure while we start to the hospital on a nonpriority. I strap a tourniquet around the woman's arm and find a vein. He says the pressure is 160/100. Hmmm, I think.
I get a flash on the IV, and withdraw the needle, and start drawing blood. I have about half a tube, but it is drawing so slowly, I decide to just attach the saline lock. I detach the vacutainer, and while I am clamping down on the vein with my left hand, suddenly the patient starts to shake. She isn't just shaking, she is seizing violently.
"What's going on back there? What's going on?" the husband demands.
"She's having a seizure," I say. "It's okay; I have medicine to stop it."
"What's going on? What's going on! Is she all right?"
I am holding on to her arm, clamping the vein off for dear life. I can't reach my narcs, which are locked up in a cabinet behind the captain's chair. I'm not panicked because I'm thinking maybe she had a seizure earlier and was acting so weird because she was postictal. Besides, most seizures stop after a couple minutes. I manage to get the saline lock attacked to the catheter and taped down, just as she stops seizing. She sits there now, looking off to the left, and I don't think she is breathing. I look at her closely, but I can't see any movement. I do a sternal rub. No response. I don't feel a pulse, but we are bumping down the road.
The man in front is flipping out. "Shouldn't we be going faster? Shouldn't you have the lights on?"
I ask my partner to get out my airway kit, while I quickly put her on the monitor.
Here's what I see:
I cut off her shirt and slap the pads on.
"Step it up to a three," I say to the driver.
I am tempted to shock her, but I flash back to calls I have had in the past -- few with a good outcome. I shock them, they die. I have an IV. My med kit is on the bench next to me. I open it up and pull out a vial of amiodarone. I draw up 150 mg and push it in into the lock. I look at the monitor.
EMS is all about the action, but sometimes it’s about waiting.
She's in v-tack. I'm not certain if she is breathing. My old instinct would be to drop her down and tube her, but the new ACLS is saying you can delay the tube while you deal with the rhythm initially. What happened? I'm thinking. Did she seize because she was in v-tach or did she go into v-tack because of the seizure? It was a true gran mal seizure, not a hypoxic seizure. People stop breathing after a seizure sometimes, but then start up again. But she's in v-tack. What the ?
I do not want to shock her because if I do, the next minute I know I'm going to be doing CPR. But soon I am going to have to do something.
Should I have the driver pull over and grab a board out of the outside compartment so we can lay her down on it and start CPR? I look back at the monitor. She is out of v-tack. Thank the Lord. I'm not certain if it’s a sinus tack or a rapid afib. The rate runs from 140 to 170.
I have the ambu-bag in my hand, but now I tell my partner to get a nonrebreather out of the cabinet.
I have a pulse. There's some small chest rise. I get a blood pressure 170/120. She still doesn't respond to a sternal rub. We check her blood sugar. HI, which means it’s over 600.
I try to patch to the hospital, but all I can hear on the radio is a high-pitched whine.
"What's going on? What's going on back there?" the husband demands. The driver is trying to calm him down.
The whining stops on the radio and when I ask if the hospital is on, the operator tells me they are off now, but he will try to get them back on. They come back on, I give my patch, but get no acknowledgement.
I put in another IV and start running fluid in. She is still unresponsive. Her rhythm is looking better.
I think about tubing her, but she is satting at 98%, so I just watch her airway.
We park at the hospital, and the husband, comes around to the back and when we open the doors, he sees her laying there, her breasts hanging out in the open. I quickly grab a sheet and cover her up.
The husband wants to know what's going on. I tell him I'm not really certain. She had a lethal heart rhythm, but she's out of it now. Her sugar is high. He confirms she is not a diabetic and has never had seizures before.
We wheel her in. They never got our patch so they are not expecting us. They quickly get us a room. She is responding to the sternal rub now, and mutters a few words. I give my report while they get the rest of her clothes off.
When her lab results come back, her sugar is 1200, and most of her electrolytes are way out of whack.
The nurse tells me her husband kept saying how slow we drove to the hospital.
Here’s what her final rhythm looked like when we turned her over.
Last call of the day is for a dehydrated alcoholic.