Internal Debate

I have a new preceptee again, and while we have been busy, most of our ALS calls – even our good ones — have been routine – CVA/TIA, chest pain, asthma, dislocated shoulder, allergic reaction, pneumonia, nausea and vomiting. Lots of IV, 02, monitor with the basic drugs – NTG, Aspirin, albuterol, solumedrol, benadryl, zofran, morphine. I think the CVA that was really just a TIA was the only one we went lights and sirens to the hospital on. These calls are all good for getting into a routine, but as always, we need the knee buckling calls – the shooting to the head, the respiratory arrest, the tombstone ST MI.

Last week we get called for the patient not responding. Sounds like it has a possibility to be a code, but when we get the update – lethargic and low blood pressure, I think not. “Visiting nurse call,” I say. “Gotta be.” Whenever we go to a private home and the EMD update includes a blood pressure, it usually means there is a visiting nurse on scene, and if there is a visiting nurse, then it usually isn’t too bad of an emergency. After all the visiting nurse came by on a schedule. The patient or their family didn’t call.

The seventy eight year old woman is sitting up in bed. Her hands are cold and she says she doesn’t feel too well, and hasn’t been for a couple days. The visiting nurse asks my preceptee what he gets for a blood pressure. He says he can’t hear anything – that we will try again in the truck. The patient has thick edemadous arms, plus a left side mastectomy keeps us from using that arm.

We carry the patient out in the stair chair and then once out in the ambulance with the heat on, we try again for the blood pressure. Can’t hear anything. We go to the monitor’s automatic cuff and are pleased to see 90/60. At least that’s something. When my preceptee puts her on the monitor, the story starts to come clearer. Her heart rate is 34. The rhythm is a little funky – definitely not a third degree block, but not a sinus brady either. The ECG print out calls it a junctional rhythm. We put her on oxygen and start to the hospital. She denies any pain, just reiterates how weak she has been feeling. Neither of us can get an IV – I try twice and can’t even draw blood. Can’t see a vein, can’t feel one. Try by anatomy, but nothing. When I touch the jugular vein in her neck, she says, don’t put an IV in my neck. Just looking, I say.

Her heart rate is staying steady at 34. Her end tidal CO2 is also trending steady at 28/29. Not too bad considering. We aren’t even going lights and sirens. This is after all a visiting nurse call. The patient may have been in this rhythm for a couple days. Maybe it is an electrolyte imbalance. If we get an IV, we can try some atropine, but that may not work. We could also try dopamine or pacing(I’m not buying our monitor’s BP). But we are after all only ten minutes from the hospital now. I touch the patient’s neck again, she again shakes her head. Don’t even think about it.

We try another pressure. Can’t hear anything. The machine comes up 150/110. I don’t trust that. We check it again by electronic cuff 138/78. Don’t believe that either. Still, even though we can’t hear or feel a pulse, the machine, for what it is worth, has read some kind of pressure three times. She’s stable enough, I tell my preceptee. Let the hospital put in a central line if they have to.

But even as I’m saying that, still I’m thinking here’s a chance for him to get an EJ or maybe even better, we just got the EZY-IO. I’ve never used it before. I might just pull rank and pull that baby out and drill her right in the leg. With IV access, we can really play.

But I say nothing. Her rate stays at 34. Her ETCO2 at 29. She’s 78 years old. No sense in getting her all riled up by jabbing her neck or pulling out the power drill.

We just take her on in with supportive care.

“She’s really sick,” the doctor says, looking at her. “You have access?” No, sorry. He tells the nurse to get the IV try. He sees me shaking my head, and then adds, “and bring a central line kit in here just in case.”

They can’t get an IV line. They do get a pressure. 50 is all the nurse can hear, doing it manually. Their electronic cuff can’t get a reading. They hook her up to the standby pacer, and open up the central line kit. After two tries, they finally gain access. The atropine bumps her up to 40. The dopamine gets her pressure to 70. When we come back later we learn she is intubated and up in the ICU – likely dying of sepsis, multi-organ failure, including an infarct that started after she’d been in the ER awhile.

I’ve written about this before in Practice. When you have a preceptee you always weigh the educational experience for him. You get him an EJ or an IO, and you push atropine and dopamine, it makes for a good story, something for him to boast about to the other preceptees – all hoping for the bad one.

I feel a little bit of a failure – I certainly could have justified the aggressive treatment. But on the other hand. We didn’t overly traumatize her, we kept her calm, got her to the hospital – a higher level of care. Some days, you lean one way, some days you lean another.

I’m hoping that the lesson, if there is one, is you do what you can with what you have to work with on each particular call according to the texture of the call. I don’t mean to teach him that on this particular call less is better than more or that more is better than less — just that, on each call, you need to have that debate within yourself.

Either way, she’s probably going to die.

10 Comments

  • wealthandtaste says:

    Howdy, I’m a long time reader and just looking to add some comments regarding this call. Obviously I hate to second guess a fellow paramedic when I wasn’t on the actual call, however I’m not sure your conservative approach was the best course of action. I think the fact that you weren’t able to palpate a BP + a HR in the 30’s should have prompted the placement of TCP pads immediately. As for getting access, I understand the hesitancy with subjecting a frail patient to unnecessary interventions, but this type of patient (multiple peripheral IV’s have failed and the patient is borderline crashing) is almost the perfect time for an IO. One is certainly better off placing the IO while the patient is somewhat stable rather than doing it in when the patient is unresponsive, or worse, pulseless. Her low PCO2 is likely indicative of respiratory compensation for a metabolic acidosis (the sepsis + MOF fits), and if we have learned anything from the surviving sepsis campaign, it is that early fluid+pressors+O2 are truly lifesaving. We all know how things can take forever in the ER between giving report to the nurse, the doc taking a look, the doc writing orders, the nurse getting the drugs from pharmacy, the nurse completing the order, etc., plus it sounds like getting the central line alone took >10-15 minutes. During this time the patient is getting increasingly acidic and tiring from respiratory compensation. We can do this patient a great service simply by getting that fluid running in wide open and getting their HR/BP in a better range. Again, I was not there and cannot condemn anything you did. Just wanted to add some food for thought.Keep up the good work.wealthandtaste, nremtphttp://wealthandtaste.livejournal.com/

  • Shane says:

    Peter:A great call where things aren’t quite as they seem. You are a great precptor and I still remember some of the calls we did while I was precepting. I think you did the right thing, and it was a good lesson for your preceptor to learn. There are always decisions to be made on a call. It’s just a matter of how handle them and having the ability to think all the way through to the hospital portion of patient care.As far as IO placement, I think I might have taken it out and had it ready. But I’m not sure that I would have used it. Having used the IO multiple times, I can say that my impression is that it’s not as “pain free” as the literature would like you to believe. I’ve had patient’s show significant visual discomfort. Not always with the insertion, but when the fluid starts (even when the inital flush is Lido). If she were to turn unresponsive, you already had a line established and the IO would take seconds to place. There’s no point in traumatizing this patient when the IO placement is only good for 24 hours anyway. The hospital can place a central line that will last for her hospital stay.Definatly a good precepting call.

  • TrekMedic251 says:

    Hi,..first time dropping by. Been a medic for 25+ years.First, you’re right, she’s going to die. In our area, the kind of work-up you’re contemplating would probably get you a weird look or two by the hospital.Second, I work in an area where the hospitals are pretty close together and IV access for these kinds of patients isn’t as big a priority as airway patency, etc.Hope to drop by again, soon!

  • Mordechai Y. Scher says:

    Good call. Wealthandtaste presents a good rationale. If you wanted to put in an IO on a conscious patient, how would you do it? Already brady and hypotensive, so sedation won’t be a very good idea. This one’s gonna hurt. Convince her of the importance, and use the EJ? Maybe. Make sure preceptee doesnt’ reassure her with ‘this won’t hurt’. It will.I think in any case the most important lesson your preceptee learned was the validity of conservative thinking, and not torturing the patient just for the learning experience. We are there for the patient; the patient isn’t there for us. The patient isn’t just a SimMan with a real body temperature!I’ve had new medics angry with me for not tubing an OD or a dead guy; but the patient wasn’t put there for our convenience, practice, and learning experience. Yes, one should take and provide all the legitimate opportunities; but you put the patient first here and that is the most important lesson your preceptee can repeatedly get: all of our thinking revolves around the good of the patient from one moment to the next, as long as it does not put us at risk.Good job. You’re a good example. Maybe discuss wealthandtaste’s alternative thinking on this by way of continuing the learning.Thanks for a great blog.

  • Tom Reynolds says:

    You’ve just given the reasoning that goes on in my head for every patient I meet – Will it be in their best interest?A fine line, but I think that it gets easier with experience.A good post, and food for thought. Cheers.

  • Podmedic says:

    Peter, this has got to be one of your best posts. It brings up a common conflict seen in the field and I think as valuable a lesson for your preceptee as any exciting, multiple intervention style call. WealthandTaste makes some good points and I think that what might be learned here is that there can be several ways to arrive at a treatment plan for a patient without either of them being inherently wrong.While I have access to I/O, my protocol wouldn’t allow me to use it in a conscious patient so that would have been out of the question. I probably would have had it handy, in case she crashed. The question that your post brings up is whether a more aggressive treatment plan would have made a difference?I’m not sure if I would have.You had a reasonably short transport time to the hospital and a patient who was presenting with an odd combination of symptoms. I tend to be more conservative when the patient is tolerating their condition as this patient seemed to be.Just because we can jump to the next level of intervention in the field, doesn’t mean we automatically should. I have contacted medical command in situations like this and I have rarely gotten the go ahead to step up to the next level of intervention.Thanks for spurring this discussion and Happy New Year to you and your readers from the Podmedic!MedicCast Podcast

  • PC says:

    Thank you all for the comments. I don’t disagree at all with wealthandtaste. You make excellent arguements. I was truly on the line of which way to go. I think the factors that kept me from being more agressive were 1) while we couldn’t hear or palpate a BP, our trusty (ha) automatic cuff was hinting she had one. 2) she was mentating well enough 3) I would have expected her ETCO2 to be significantly lower with a BP of 50 and more importantly she was maintaining a stable trend 4) her respiratory rate, which I failed to mention was also stable at 18-20 5) a factor that comes into play quite often is past experiences. I have had many severely bradycardic patients (20-30s) who have been quite stable, although just about all of those were in third degree block as opposed to a junctional. If I had had similar patients who had crashed on me, I definiately would have been more aggressive 6)proximity to the hospital and trust that they would give the patient immediate treatment 7) her request against an IV in her neck 8) the fact that the call was gennerated by a visiting nurse and the patient’s malaise was not of sudden onset and (9) my belief that had she crashed it takes only a few seconds to slap on pacer pads and put in an EZY-IO. Factors that were making me think of doing the EJ or IO were her hands were cold, her rate was 34, she needed meds, she could concievably, even though she had been feeling this way for awhile, just suddenly have enough of it and crash, and the chance to give some skill experience to my preceptee.I weighed both sides and choose supportive care. I have done that in the past and been burned for it(although not too often), had to suddenly jump into action when the patient crashed. Sometimes I think on a different day with the same patient I might have leaned the other way.My point was not so much that there was a right and wrong decision on this call, but that there should always be an internal debate(even if just takes as little as a few seconds) before making a decision. Sometimes the most aggressive course isn’t the best. Other times it clearly is.Thanks again for the comments.

  • Epijunky says:

    Fantastic Post. Thank you for sharing it.Hope you have a fantastic New Year.

  • Anonymous says:

    I’ve gone back and forth on calls like this. Where the patient is “A&Ox4, GCS 15, able to follow commands” as the standard line on the run report goes, and initially when I was new, I tried to be fairly aggressive with interventions, sometimes coming quite close to the line of doing things the patients really didn’t want. I was really pushy and very hard nosed about things like getting that line, pushing the drugs, etc.Now, in the past few months, I’m kind of like, “Well, if you don’t want that, fine.” I explain the procedure to the patient, and run down the consequences for refusal. I figure, if our protocols permit patients to refuse all treatments and all transport, they allow patients to refuse some treatments during transport. I give them more than enough information to make an informed decision, and document it as such using their words and my attempts to persuade. It’s a lot easier than arguing with a patient. Not everyone gets to refuse, and some people just aren’t capable of making an informed decision, and some cannot understand the consequences of their refusal, which is really the key part of it. But for those that do, they have a right in my book to say, “I don’t want an IV.” Or, “I don’t want that oxygen mask.” Whatever, it’s their life. I am just here to document it in a way that makes it clear I tried.

  • Anonymous says:

    Well done! Highly competent reflective and professional choices, and care for the patient’s needs including the big ones- respect and understanding what happens at the definitive hospital care stage. My service does not have EJ and IO protocols current, mainly because of the concern that the clinical evidence for some aggressive treatments simply doesn’t wash. Whilst our Medical Director is somewhat prehistoric in his thinking despite his young age, he does have a point in wondering whether we are really there for the patient’s needs or simply wanting to be superman/boys and girls with toys. If she was talking and could indicate preference for IV, her systolic BP was above 70. Ten minutes away from a hospital, is not a time to risk IO infections and sepsis in a moving ambulance. The reality of peripheral oedema and IV access for the elderly is that just maybe a higher power than us has designed it that way! Thanks for the posts.

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