batgirl
03-18-2013, 09:03 PM
Some might think that this is a common occurrence for us paramedics. Walk in, save a life, walk out, haters gonna hate. But it's not. There are a very specific set of circumstances that need to go in our favor for someone to come back from a cardiac arrest and have a favorable outcome, aka not a vegetable. This includes the time the patient has been in arrest for, (there's only so much time the brain can go without oxygen before it begins to break down), the cardiac rhythm the patient is in (ventricular fibrillation/tachycardia where the heart is still beating, but too fast to sustain life has a much better chance than asystole/pulseless electrical activity, where the heart is not beating but there is still electricity being conducted) and how long it is until the patient gets emergency care (including whether we can provide it or we fuck up).
I want to paint the picture for you as completely as possible, since I'd like for you all to understand how much work actually goes into a pre-hospital cardiac arrest. It's very different than in the hospital where there's a doctor, respiratory therapist and nurses in a huge room and they are all calling out medications with an endless supply of staff.
A 79yo male complains to his wife of upper gastric pain about an hour before bedtime. She assumes it's just a stomach ache and thinks nothing of it. Around 10mins prior to her calling us she finds her husband snoring with agonal respirations and a very weak pulse. The fire department arrives first and finds the man not breathing and with no pulse. They attach a defibrillator to him and begin CPR. The defibrillator shows asystole so they cannot shock him (you can only shock v-fib/v-tach). We show up with the EMT basics and get to work. We attach the patient to our cardiac monitor, much more advanced, and find the man still in asystole, pulse 0. The room is very tiny, very hot, and the man is 300lbs and on the floor. My partner squeezes by the man's head and intubates (passes a tube down the person's trachea - a difficult skill) right away. I find a vein in his arm and get an IV right away (also difficult, especially with larger people). We attach the man to what's called End Tidal CO2 monitoring, or capnography. This measures the amount of carbon dioxide in the expiratory phase of breathing, which tells us how much oxygenated blood is being circulated. In a normal person you want to see numbers between 35-45. In a cardiac arrest, a favorable number would be anywhere from late teens to early twenties. If you see those numbers you know you have a chance of getting them back. Our patient had a capnography of 13, not a good sign. We are now giving the man CPR and breathing for him.
The IV is hooked up to chilled fluids to help lower the core body temperature and preserve organ function. I begin to push the cardiac arrest IV drugs. Vasopressin (constricts blood vessels), epinephrine (adrenaline), dextrose (sugar). Suddenly, we see a rhythm change to v-fib. My partner charges the monitor and gives a shock of 200 Joules strait into the man's body. I prep another drug, Amiodarone (helps with funky cardiac rhythms). After a minute, he goes into PEA (pulseless electrical activity). We keep working, and call our doctor for more drug orders (we can only give certain drugs without permission) or for termination (we cannot pronounce anyone dead if we start working on them, we need a doctor's ok). The doctor orders us to give Sodium Bicarbonate (used to treat the ph imbalance in the body). We do so and after another minute we get a rhythm change and a pulse. The patient is now in a living rhythm at 60 beats per minute, but not breathing. We call our doctor again and get orders for a dopamine infusion (a drug the increases blood pressure and pulse by constricting vessels, used a lot in post cardiac arrests to keep them alive) and begin to get the patient ready to go to the hospital. Taking him on a spinal board, we carry him (takes a few of us, 300lbs plus our equipment) into a small elevator and down to our stretcher in the lobby. As we wheel him outside we lose pulses and start CPR again, getting him into one of the ambulances. Where there were at first 4 healthcare workers plus firemen (2 EMTS and 2 paramedics - myself and my partner), there is now no firemen and just myself and my partner with the patient (the EMTs need to drive the ambulance).
I am doing CPR and I hear a noise. I stop for a moment and there is a whooshing sound. I look at the tube down his trachea with the bag valve mask attached to it and realize he is breathing on his own. We feel for a pulse just to make sure we aren't dreaming and it's there, his capnography now at 40, perfect. We help him breath since he isn't breathing well enough for our liking and get an EKG now that he has a sustainable cardiac rhythm. Therein lies the answer to the 64,000$ question: what killed him? Reading the EKG we realize that this man is having a massive heart attack. We call the hospital in advance and drive like hell.
Getting to the ER, we bring the man into the trauma room and give the complete story to the nurses and doctors there while helping them move the patient to their bed. We show them the EKG and they confirm with their own machine that he is indeed having a heart attack, the big one. They place him on a ventilator, get necessary blood tests and whisk him off to the catheterization lab to fix it.
I sit down to what amounted to 45minutes of paperwork. We then have to go back to our base to restock the ambulance with all the stuff we used. Complete call time from the moment we got the call to the moment we left the ER to do paperwork: 1hr 45 mins. We were both a sweaty mess and exhausted, and this only amounted to one out of the 6 calls we did that night.
As of this morning, the man is still alive and breathing on his own. He went for surgery and they found a complete blockage in one of his arteries. I don't know if he'll ever get home, that depends on his course in the hospital and probably a rehab facility, but he can still see his grandkids, and that's because of us.
We worked him hard, he fought for life. This is not my first life saved in my career, but it certainly feels good that's for sure.
I want to paint the picture for you as completely as possible, since I'd like for you all to understand how much work actually goes into a pre-hospital cardiac arrest. It's very different than in the hospital where there's a doctor, respiratory therapist and nurses in a huge room and they are all calling out medications with an endless supply of staff.
A 79yo male complains to his wife of upper gastric pain about an hour before bedtime. She assumes it's just a stomach ache and thinks nothing of it. Around 10mins prior to her calling us she finds her husband snoring with agonal respirations and a very weak pulse. The fire department arrives first and finds the man not breathing and with no pulse. They attach a defibrillator to him and begin CPR. The defibrillator shows asystole so they cannot shock him (you can only shock v-fib/v-tach). We show up with the EMT basics and get to work. We attach the patient to our cardiac monitor, much more advanced, and find the man still in asystole, pulse 0. The room is very tiny, very hot, and the man is 300lbs and on the floor. My partner squeezes by the man's head and intubates (passes a tube down the person's trachea - a difficult skill) right away. I find a vein in his arm and get an IV right away (also difficult, especially with larger people). We attach the man to what's called End Tidal CO2 monitoring, or capnography. This measures the amount of carbon dioxide in the expiratory phase of breathing, which tells us how much oxygenated blood is being circulated. In a normal person you want to see numbers between 35-45. In a cardiac arrest, a favorable number would be anywhere from late teens to early twenties. If you see those numbers you know you have a chance of getting them back. Our patient had a capnography of 13, not a good sign. We are now giving the man CPR and breathing for him.
The IV is hooked up to chilled fluids to help lower the core body temperature and preserve organ function. I begin to push the cardiac arrest IV drugs. Vasopressin (constricts blood vessels), epinephrine (adrenaline), dextrose (sugar). Suddenly, we see a rhythm change to v-fib. My partner charges the monitor and gives a shock of 200 Joules strait into the man's body. I prep another drug, Amiodarone (helps with funky cardiac rhythms). After a minute, he goes into PEA (pulseless electrical activity). We keep working, and call our doctor for more drug orders (we can only give certain drugs without permission) or for termination (we cannot pronounce anyone dead if we start working on them, we need a doctor's ok). The doctor orders us to give Sodium Bicarbonate (used to treat the ph imbalance in the body). We do so and after another minute we get a rhythm change and a pulse. The patient is now in a living rhythm at 60 beats per minute, but not breathing. We call our doctor again and get orders for a dopamine infusion (a drug the increases blood pressure and pulse by constricting vessels, used a lot in post cardiac arrests to keep them alive) and begin to get the patient ready to go to the hospital. Taking him on a spinal board, we carry him (takes a few of us, 300lbs plus our equipment) into a small elevator and down to our stretcher in the lobby. As we wheel him outside we lose pulses and start CPR again, getting him into one of the ambulances. Where there were at first 4 healthcare workers plus firemen (2 EMTS and 2 paramedics - myself and my partner), there is now no firemen and just myself and my partner with the patient (the EMTs need to drive the ambulance).
I am doing CPR and I hear a noise. I stop for a moment and there is a whooshing sound. I look at the tube down his trachea with the bag valve mask attached to it and realize he is breathing on his own. We feel for a pulse just to make sure we aren't dreaming and it's there, his capnography now at 40, perfect. We help him breath since he isn't breathing well enough for our liking and get an EKG now that he has a sustainable cardiac rhythm. Therein lies the answer to the 64,000$ question: what killed him? Reading the EKG we realize that this man is having a massive heart attack. We call the hospital in advance and drive like hell.
Getting to the ER, we bring the man into the trauma room and give the complete story to the nurses and doctors there while helping them move the patient to their bed. We show them the EKG and they confirm with their own machine that he is indeed having a heart attack, the big one. They place him on a ventilator, get necessary blood tests and whisk him off to the catheterization lab to fix it.
I sit down to what amounted to 45minutes of paperwork. We then have to go back to our base to restock the ambulance with all the stuff we used. Complete call time from the moment we got the call to the moment we left the ER to do paperwork: 1hr 45 mins. We were both a sweaty mess and exhausted, and this only amounted to one out of the 6 calls we did that night.
As of this morning, the man is still alive and breathing on his own. He went for surgery and they found a complete blockage in one of his arteries. I don't know if he'll ever get home, that depends on his course in the hospital and probably a rehab facility, but he can still see his grandkids, and that's because of us.
We worked him hard, he fought for life. This is not my first life saved in my career, but it certainly feels good that's for sure.