Dialysis Transport goes south

[Needlejockey]

I work for a private transport company and drive the medic truck. I'm an EMT-B and my partner is an EMT-I. Well the BLS Trucks were full on calls so me and my partner get sent to take a pt back to her nursing home from her dialysis. I've run the pt before and normally take her by wheelchair van. She's ambulatory but has a hx of CVA and has dementia, tends to wander off if you don't keep on eye on her. Well well we picked her up she seemed a little more out of it than usual. My medic is driving (we run it so that I tech all BLS and he techs all ALS) and I take vitals on her. Got her sitting on the bench seat. Vitals were resp 16, bp 128/p, pulse 100ish (can't remember exactly right now). No sooner do we pull into the parking lot of the nursing home she slumps over and goes into full grand mal seizure. Lated approx 15 secs. I yell for my partner to get back there cause she's seizing. By the time he slams the truck in park, gets out and opens the side door on the box she's normal (well like when we picker her up normal). No memory of the seizure and no post ictal state at all. It's like she never seized. My partner goes inside to check with the nurse staff to see if she has a hx of seizures (especially since it's been about 2+ months since I've last run her and things might have changed). While he's inside getting info from them I take a 2nd set of vitals. Pulse 200+, bp 86/60, resp 14. I pick her up and put her on the cot and place her in trendelenburg. Shortly after that my partner reappears and I give him the updated vitals. He cracks the IV box and preps for a line. We put her on 15 lpm by NRB. He puts her on the monitor and it shows a-fib with occasional PVC, rate of around 160-180. I return inside to get a full hx and med list. No hx of a-fib or seizures. Staff reports that they think that they (the dialysis center) has been taking too much out of her because she has had several syncopal episodes but no seizures. We go enroute to the local ER (about 5-10 min trip). My partner is able to get about 250 ml of NS 0.9% into her during the trip. 3rd set of vitals show a bp of 124/68, pulse of 130-180 (constantly jumping between various numbers within the range), resp of 14, Sp02 of 99%.

After transfering care my partner is filling out paperwork and I fix up the truck and clean up his mess (only another year till I get to make my own mess as a P). The ER doc checks the pt out and talks to me about her. She (the doc) thinks that the pt may have went into the seizure due to hypoxia. She said that that would explain the lack of post ictal state. The hypoxic seizure makes sense to me.

I go back and tell my partner what the doc said and he dicusess meds with me. Since I'm in P school he wanted my view on what meds might have been useful and a reason why he didn't give any.

Here's what we came up with that I can remember:

Valium for the seizure. Didn't give cause she didn't stay seizing or return to seizure

Adenosine for the high heart rate. Didn't give cause the fluid bolus helped lower it and the rate wasn't too high and showed signs of decreasing

Dopamine for the low BP. Didn't give cause her bp went back up to a normal level after I put her in trendelenburg


***So what do you all think? Comments on any part would be welcome***

[hageremtp]

Always go with the most basic treatments and go from there. The idea in EMS is correct the underlying problems that cause the condition. As everyone knows Oxygen is the only thing that, in EMS, can correct hypoxia. Put that on and see what changes. The IV is a great next step. Invasive treatment but yet a rather simple procedure that can effect many patients differently. In this case, with the low BP and the a-fib, it is a good idea to fluid bolis her, could be that the lack of circulating volume has contributed to the a-fib.

The only think I would like to know was did the a-fib continue after the fluid and the oxygen? The transport time to the ER?

In my neck of the woods, acute onsets of A-Fib are to be treated in the feild, with Cardizem if the patient is stable and cardioversion if they are unstable. In this case I would question her being stable, as you stated she was more out of it than "normal" and her blood pressure is low, below 90 systolic. In which case, the idea of cardioversion is not out of the question. But once again, these procedures are invasive and you always want to start good BLS before ALS.

[Nate]

I agree with what hageremtp said; BLS before ALS. Since you were leaning towards the patient being hypoxic, I was wondering how did the patient look? What state was the skin color and temperature in? Was it warm/dry? Could she have been exposed to exhaust fumes (you get an exhuast leak in an ambulance and you'd be amazed at how quickly it can seep into the back) or is she COPD/CHF?

I would have placed her on oxygen, started a line, put her on the monitor, given her fluid, and transported. Everything your partner did. All you can go do is what the doctor did, and that is look at what could cause a sz and see which one your patient most likely suffered from.

[Epinephrine]

"Adenosine for the high heart rate. "

I think I'm posting for 2 reasons.... 1.) We got beat on about drugs in medic School 2.) Something similar happned to me...

Adenosine is not for "high heart rates" it is for SVT. The adenosine will only help the rapid afib for all of 6 seconds, Adenosine's halflife. Like Hager said... Cardizem (or your service's other choice of chemical cardiovert) or Electrical Cardioversion...

That being said... make sure you look at the rhythm closely Rapid A-Fib looks a hell of alot like SVT (that was my mistake, however the doc bought my diagnoses and lets us push adenocard)... AFib: irreg irreg SVT: rapid, but regular

[Nate]

That being said... make sure you look at the rhythm closely Rapid A-Fib looks a hell of alot like SVT (that was my mistake, however the doc bought my diagnoses and lets us push adenocard)... AFib: irreg irreg SVT: rapid, but regular

So the doctor made a mistake, or he knew all along and just let you save face?

[Epinephrine]

Well how it works here is that we call the recieving hospital to authorize drug pushes or certain controlled substances... The authorizing doc is not always the recieving doc... The authorizing doc never knew of the mistake, but we did when they ran a 12 lead.

Never really got bitched out since looking at out strip it was so close to being regular that they had to run a 12 lead to make sure... that and its alot easier to analyze an ecg in an ER than on a pt in the back of a medium duty squad on a bumpy road. :p

[Nate]

I'll agree with that, and have added your mistake to my list of why we need 12 lead in the ambulance.

[firechic]

I agree also with hageremtp: BLS before ALS.
We treat acute onset of a-fib with a cordarone drip.

[Nate]

Just call 911! :rotflmao: :p

[Needlejockey]

All in all it was very intersting. Initially scared the crap out of me. Here I have a routine transport that is not even done in an ambulance typically and it goes down hill without any warning what-so-ever. As far as all the meds and procedures I'm a bit fuzzy on what do to ALS wise. Obviously my partner made the call on what to do and he tried to explain everything that he saw to me, but I'm willing to bet he either left some stuff out and/or I misunderstood some. BTW the transport to the ER took me less than 5 minutes to get there.

[btroutm]

Here are some things to think about...

Why did you send your partner inside? After the patient started seizing, the EMT-I should have jumped in back while the Basic drove, went inside to talk to the NH staff, etc. This is why, around here, the medic must be in back on all calls, whether they are BLS or ALS.

Did you put the patient on a NRB as soon as she started seizing? As has been pointed out, BLS before ALS. If this was a hypoxic sz, oxygen would have solved the problem. Also, an NPA may be indicated.

Did you check her blood sugar? Remember, in all cases of AMS or Sz, you should check the patient's blood sugar.

Overall, it sounds like you did a nice job. I guess the patient got lucky that you guys showed up instead of a medicar.

From an ALS point of view, we would have immediately placed her on oxygen via NRB, checked blood sugar, started a line, and put her on the monitor. Since she immediately stopped seizing, I wouldn't give any valium. With a low BP, a fluid bolus is definately the way to go. Since the BP increased and the HR decreased after the bolus, I probably wouldn't cardiovert (but it is definately a borderline call - it could go either way). For rapid a-fib, I would give diltiazem (cardizem). For narrow-complex tach., I would give adenosine. Other than that, transport to the ED with continuous monitoring.

[hageremtp]

Dont always rule out adenosine. I have seen a couple of cases where the heart rate was so fast you couldnt tell if it was A-Fib or SVT. If its that fast, give adenosine, it will slow things down enough (hopefully) enough to figure out that it is actually A-Fib.

[totalpatrol]

I think you guys did a preety good job for emti scope of practice. About the only thing I would've considered is cardizem if it's in your protocols. you gave what sounds like some pretty decent BLS care, and performed safe and careful als care. But I wouldn't be afraid to use a little Valiam on folks, it never hurt anybody :beer: :v: :lol: , and besides you can always call for advice from your local MD, if you got any questions.

[CB-EMT]

This is why, around here, the medic must be in back on all calls, whether they are BLS or ALS.

I understand the rational, but the words "always" and "never" don't really belong in EMS, or so I was taught anyway.

[btroutm]

I understand the rational, but the words "always" and "never" don't really belong in EMS, or so I was taught anyway.
That's interesting that you should bring that up, being that I didn't even use those words. :) Anyways, I disagree...I think that "always" and "never" certainly have their places in EMS, but you do have to be careful. In regards to our policy, it wouldn't make much sense to say "the medic must be in back on most calls, whether they are BLS or ALS." As this call has demonstrated, you never know when a patient will crap out on you.

[CB-EMT]

I didn't mean it as a ball-busting statement if that's what you're saying. What I was talking about is that a policy that says, in effect,

This is why, around here, the medic must be in back on all calls, whether they are BLS or ALS.

kind of implies that

the medic must [ALWAYS] be in back on all calls, whether they are BLS or ALS.

which would in turn imply that "A Basic may NEVER be in back on any calls."

Which, at least to me, kind of seems like a waste. How is a basic supposed to advance their skills in a system like that? All because one patient in a hundred (or less) might take a dive?

I'm really trying not to sound like an *** here. But to me an arrangement like that says, "Basics are drivers. We give them EMT licences/certifications because.... well, we don't really know why, they aren't going to be doing anything. Every patient needs a medic, just because. All hail the medic."


...I really need to get my sleep patterns back in order.

[WELLAGEDEMT]

Not going to get on the bandwagon here but,, if we get our certification for EMT-B, "basic" we are able to do a hell of a lot more than drive the blankety blank ambulance. Our skill are limited because of protocols and sometimes because of some "medics" who chose to play God and chose not to think that we are capable of anything other than driving the rig and putting a bandaid on someone. Sound kind of ticked. You're right!!!!!! I am an EMT-B and have had plenty of opportunities to use the skills to keep patients alive and in viable condition enroute to the ER. :bang:

[RyanEMVFD]

One of the systems I used to work in had it in the protocols that if the patient is going to an ER then the medic must be in the back. No ifs, ands or buts about it. Kinda sucked to me.

[CB-EMT]

Logically, requiring a medic in the back DOES NOT preclude having a basic in back. Both could be back there :-)

Of course- can't have the Basic back there unsupervised, s/he might hurt somebody. *rolls eyes*

[btroutm]

CB-EMT...first, I understood your original statement and I didn't take any offense to it. I was only joking with the "always" and "never" business. As far as having the basic in back...

Personally, I agree with you. If the call is BLS, there's no reason a basic shouldn't be allowed to be in back. If the patient's condition deteriorates, it is not difficult to pull the ambulance over and switch places with the medic/intermediate. Most basics are certainly capable of monitoring a stable patient and determining if the patient's condition is deteriorating.

Also, let's not forget that the patient was assessed by a medic who decided that the patient was stable enough to be transported BLS (I know many basics can also make this distinction, but if a medic is present, then the medic should make the call). No medic is going to send a basic in back while they drive unless they feel comfortable that they don't need to be in back with the patient.

Unfortunately the systems around here don't base their procedures on my opinions (at least, not yet...but the day will come!). As it currently stands, the few systems around here that actually allow split crews require the medic in back on all calls, BLS or ALS.

This decision stems from a series of incidents in which incompetent, lazy medics decided to BLS calls that probably should have been ALS in the first place and incompetent basics failed to notice the changes in the patient's condition and were unable to treat the patient properly (including failures to appropriately bag a patient). A few bad basics and medics ruined it for the whole bunch.

[Nate]

One of the systems I used to work in had it in the protocols that if the patient is going to an ER then the medic must be in the back. No ifs, ands or buts about it. Kinda sucked to me.

That's how it is suppose to be here.

[CB-EMT]

A few bad basics and medics ruined it for the whole bunch.

Freakin figures.... :mad:

[WELLAGEDEMT]

We run a BLS squad so we have a lot of basics and I am proud to say that we have a wealth of experience. Volunteer squad all the way and hopefull soon to have a full time director. We have all the same calls that the full time paramedics have, but we don't rely on ALS for many of them. If we need ALS, we'll request it.

[hageremtp]

I think it is wrong of any service to require the medic to be in the back at all times, or to require the Basic to be the driver at all times. There are many calls that ALS skills are not needed, and then there are those calls in which ALS skills are needed. A good medic/basic team can have the lines well defined. I worked for a service where I was the "ambulance driver" all day long, wow how boring that was. Assisted in loading and that is about it, heck even on a code the fire department rode and I had to drive!!! Its not much fun, but that prompted me to want to become a medic (but it also made a bunch of basics loose interest in EMS). I feel that each medic should be left to use their head and make those small judgement calls. Like it was stated before, it does not take much effort for the medic to pull the ambulance over and just in the back to assist or take over patient care.

[Nate]

I think it is wrong of any service to require the medic to be in the back at all times, or to require the Basic to be the driver at all times. There are many calls that ALS skills are not needed, and then there are those calls in which ALS skills are needed. A good medic/basic team can have the lines well defined. I worked for a service where I was the "ambulance driver" all day long, wow how boring that was. Assisted in loading and that is about it, heck even on a code the fire department rode and I had to drive!!! Its not much fun, but that prompted me to want to become a medic (but it also made a bunch of basics loose interest in EMS). I feel that each medic should be left to use their head and make those small judgement calls. Like it was stated before, it does not take much effort for the medic to pull the ambulance over and just in the back to assist or take over patient care.

I have a basic for a driver; and I'm required to be in the back for all patients to going to the emgerncy department. She does more than just drive; she assists me in the back with my assessment; getting vitals; spiking my bag for me; putting the patient on the monitor; and doing other things.

I don't have a problem with riding in the back with my patient, even if it is a BLS call. I just got off shift this morning; and we did eight calls (it was a nice day) and I never touched the steering wheel. Didn't bother me any, and it doesn't bother her to drive.