38 replies to this topic

[chbare]

I am not sure I see that Mike. Perhaps I'm becoming a bit soft or overly optimistic, but it seems that the OP has been doing a fair amount of introspection and has ultimately decided that he/she did in fact fail to protect a patient. The OP has been upfront about being young and inexperienced as well. You don't often see people come here and admit they messed up. I'm hopeful because I was once an young EMT-B who thought I would be taking on the world with a false sense of arrogant overconfidence. Luckily, the world beat me down and I'd like to think I'm a bit more realistic and cerebral in how I provide care.

[Eydawn]

I agree... when you're newer to your career, "doing the right thing" and "doing what won't get me fired" or "doing what will get me hired" get all mixed up. Paramedicmike- I think this guy's motivations seem OK- he's trying to get his bearings and obviously he knows SOMETHING needed to be done... he's just trying to process where he screwed up and really feeliing guilty because he knows he should have done more.

Take my example- I allowed a FTO when I was in a probational employment phase to prevent me from verbalizing important information (observations I had made) in a potentially criminal situation (pediatric death, could have been negligent and prosecutable for all we knew) to the police and receiving hospital staff. I felt sick to my stomach that whole day, it still comes back to bother me that I didn't speak up (even with all facts known, charges were never brought... just turned out to be a very sad situation that never should have happened). I now know, NEVER AGAIN will I let someone keep me from telling the truth.

I was young (er). I desperately wanted to work prehospital EMS. I was trying to fit in with an agency that I really and truly did not fit into well. Part of that is that I didn't know as much about working with people then as I do now, part of it is that our approaches to care were so different (at least, between myself and the FTO's) that it just wasn't going to work out. I thought about the medicine too much. (Direct quote.) Did a patient directly suffer harm due to my actions or inaction? No... but there were other things that I saw that weren't right, and I learned to shut up if I wanted to stay employed (until it reached a point where we mutually decided that this employment encounter just wasn't for me).

Sometimes, you just have to stand up and do what's right, and sometimes, you don't learn that until you've epically screwed up and you know in your heart that you could have done the right thing.

Move forward from this. Realize that there are always other employers, (even in a bad economy) and that caring for your patient is your number one priority. Be ethical. I bet you won't let another situation like this past you- if you do, or you start to become complacent with "well, it just wasn't my problem, it was the other guy's deal" then you need to take a good hard look at your motivations and get out of dodge before you really do kill someone.

We make mistakes. It's how we respond to those mistakes that speaks to our character and our ability to be excellent, compassionate providers-- or not... the choice is ours.

Wendy
CO EMT-B

[DwayneEMTP]

Yeah, what chbare said, both times.

You weren't born knowing what to do in these situations. We've all had them, and that is how we've learned. You will again be challenged to do what's easy, or instead what's right, and in the future you will have much better information to procced with.

But you MUST choose early on...securly employed forever, or less so and a patient advocate...and I'm speaking from experience here...

I too look at your posts and see them changing not just in tone....from the "Hey brothers and sisters, lets talk shit about the assholes at the ER!" with horrendoes spelling and grammar, to much more well presented posts, and even just in this thread, a tone that seems to say, "Man, maybe I need to rething some things...."

When Wendy posted something like, "How about if we don't neuter our new posters until they have a chance to catch their breath.." I think that you are exactly what she was referring to....Good on you.

Tough call Brother, but you know what? There is no other way to learn this lesson. No one can explain it to you, you can't read about it, you can't figure it out on your own...there is only to live it, see how it feels, and then make new decisions based on those feelings should you find them distasteful.

I'm excited to have you here...

Dwayne

[paramedicmike]

I agree CHBARE and Wendy. Please let me reinterate my point about my thoughts presenting in much more harsh a tone than they are actually intended. As I mentioned, our young friend has, indeed, presented several good scenarios for discussion. There does seem to be some genuine desire to learn from his experiences. My concern, however, as I read his comments, is that the motivation to succeed doesn't primarily stem from wanting to improve patient care. Rather, he has made several comments about his concern over not being able to impress people within his organization. My overall point is that this is the wrong approach.

My inital reply to the OP was not a knee jerk reaction. This was something I'd noticed over several threads and today it just brought me to the point that I felt it needed to be mentioned. There is no ill will intended and I stand by what I said.

Could I be reading him wrong? Absolutely. Would I like to see him succeed for the right reasons? Without a doubt. This is why I've tried to temper my comments instead of the bashing that the me of several years ago would have reflexively thrown out there.

It seems, perhaps, I should be trying a little harder.

[systemet]

*Back story to this post*

We were dispatched for a 0.2 mile Inter-facility transfer from one ICU to another because this pt had a type of pneumonia that couldnt be handled at his existing location. We arrive there and we have the following

0.2 mile? 3 blocks? Was it downhill? Could you push him there? Just kidding.


approx 65 yo male who is sedated running 3 infusions controlled by a pump

norephinephrine
fentanyl
and a antibiotic which I cant think of at this moment


Ok, so he has a pressor (norepinephrine) to maintain his pressure because he's septic, got all sorts of inflammatory mediators and bacterial toxins floating around that are dilating everything inappropriately, and possibly if he's been sick for a while, his adrenal glands aren't putting out enough epinephrine, and the endothelium is all dysfunctional, and the vessels aren't responding appropriately in any case. If there's not enough arterial pressure, the organs don't get perfused, and badness ensues. The norepinephrine is to treat/prevent this.

The fentanyl is for ongoing sedation. The antibiotic is to treat the pneumonia and/or any secondary infections.

I realise you're an EMT, but it's a good practice here to work out what sort of lines the patient has for access before leaving, work out where everything is running in, especially if you've got multi-lumen central lines, and get some sort of idea why each medication is being used. You want to know the drip rates, even if they're on pumps (hopefully the norepi is), in case you have a power/equipment failure. Before leaving, you should have an idea of which can be turned off if there's a power failure, or a problem with one of the pumps.

In this case, the critical med to be on a pump is the norepinephrine. The antibiotic could be discontinued, if absolutely necessary, and the fentanyl could be given as a bolus dose. But the norepinephrine is the highest priority. Turn if off for any length of time and the patient becomes hypotensive, and probably dies. If it runs away on you, they probably stroke or infarct, or go into VT or VF arrest.

You don't absolutely need to know this stuff as an EMT, but if you can ask a bunch of questions, and try to learn, it will help you later on.

A lot of people treat transfers as a glorified taxi ride. They're not, as your call clearly illustrates. A lot of these patients, the difference between a ground transport and rotary/fixed wing is weather conditions, availability, or the fact that you're moving them between two ICUs or an ER and ICU that are in the same city.

His vitals at the time of arrival

Pulse 77
BP: 105/58
Spo2: 98% via 100% O2 delivered by a vent
GCS: 3 (patient was sedated)
Weight: approx 250 lbs. or 113.6 kg

A little hypotensive, but ok.


We have an

auto-vent 3000
Zoll M series cardiac monitor (ETCo2 not equipped)

This is a problem. Not your fault, but really, no one should be running around as an ALS truck without waveform capnography. It's a system issue if it's not there. If all you've got is quantitative cap, or a simple yellow/purple detector, this should be on the trach/in the vent system. It would make managing situations like this easier.



Short after switching it the medic and myself hear this high pitch squeak come from the vent (more specifically the part where it connects to the trach or ET tub) I see there's a clear window on top of that piece and every time it delivers a respiration the sound comes back and a little green piece inside the window goes red. (sorry I dont know my terminology of the equipment)

This is a problem. You should try and find a copy of the manual and read it. Whenever you get a competent partner, ask them about it.

You shouldn't be altering vent settings yourself, but if you're going to be present on these calls, you should educate yourself about the equipment being used as much as possible. Any decent paramedic should also be more than willing to help you learn --- and should be proactively encouraging you to learn more about it, whether you want to or not. That's part of building a decent team environment / organisational culture.

Being an EMT may limit your scope of practice, but doesn't need to limit your knowlege.

I'm not familiar with this particular vent.


We checked the monitor and SP02 normal with the 3 lead showing a NSR.

About 2 minutes this bloody squeaking is still present and driving me and my partner nuts.

I start getting this gut feeling that something is really wrong and shit is about to hit the fan. So I start checking and re-checking that monitor and I begin to see a negative trend. His spo2 is falling rapidly and his heart rate is steadily increasing.

So there's a lesson here. Pulse oximetry is a poor indicator of acute changes in the patient condition. It can lag the change, e.g. apnea, by several minutes, as probably happened here. This is why we preoxygenate patients before doing an RSI, whenever possible.

The first clue that something bad was happening was the warning indicator on the vent, and the squeaking sound. The story you're telling suggests this is some sort of peak pressure alarm / blowoff device. But I'm not certain. What I am certain about, is that ignoring this for two minutes was a bad idea. This was 2 minutes you had to act before the patient desaturated.

This is mostly on your partner -- he's the paramedic, and most responsible. He should know much much better than to do this. But you do have a responsibility to speak up when you beleive the patient is in life-threatening danger. I have always encouraged the EMTs I work with to do this. I ask them, don't do it in front of the family, unless you're convinced I'm doing something boneheadedly stupid, but whatever you do, don't be quiet and watch me do something you know is absolutely wrong. Speak up.

At this point I tell the medic somethings not right here. He looks at the monitor and yells up to the driver to go.

"Yells at the driver to go?" --- were you still at the sending facility? Or is he telling the driver to drive stat now? Good on you for voicing your concerns, even if it's quite late now, but better late than never. The medic should have a better set of corrective actions than this.

That moment I suggested a possible displacement of the trach.

This is a possibility, especially if the trach tube is particularly long or is improvised from a cut-down ETT (unlikely in an ER transfer). It's probably more likely to be obstructed with a mucus plug (or one of the bronchi are), or a pneumothorax has occurred. There's an outside chance the tip has ended up outside of the trachea, but this isn't too likely either.

This is something any competent medic should be all over. Obvious trouble-shooting steps:

* As chbare, (who knows way more about this than me) already said, remove the vent from the circuit and use a BVM with a PEEP valve. This eliminates problems with the vent, and if it doesn't have a decent display, you get some sense of the compliance from the bagger.

* At the danger of making the heads of chbare and other RRTs the world over explode --- run the mnemonic. This is a situation where time is critical. What's the mnemonic? DOPE. It covers immediate management in these situations.

Displacement?
- has the tube displaced? Capnography would probably have answered this right away. If the waveform disappears, it's probably obstructed. If the ETCO2 has shot up suddenly, there's a chance it's gone mainstem, although this is hard to do with a commercial trach.
- lung sounds? epigastric sounds?


Obstruction?
Run a french cath down the ETT/trach. If it runs the length of the tube, it's not obstructed. If it doesn't, you either need to suction the tube to remove the obstruction, or it's time to exchange / replace the tube.

Pneumothorax?
If there's no air entry on one side, and the tube's at the same depth, and not obstructed, either there's a deeper mucus plug that you can't remove without a bronchoscope, or you have a pneumo / hemo. He's getting decompressed.

Equipment failure?
We remove the vent, and if we're not using one, we check our bagger and PEEP valve, make sure we haven't overtightened it by accident, etc.

This guys vitals still deteriorating and Im thinking of pulling out my stethoscope to check but something kept me from doing it.

You were probably expecting the medic to take charge, like they should have, probably afraid of doing something wrong, and probably just a little scared / surprised by a situation you hadn't encountered before. It will be easier next time.

You should have. It would have given you valuable information. It might have spurred the medic into action, as well.

My medic was quiet and said nothing he just was occupying himself with tasks and I didnt know what.
We had no further communication.

Sounds like the medic got trapped on spin cycle and shat the bed, if I may mix my metaphors. Again, this is more on him than you.

I can only say that panic is infectious, and spreads rapidly. If the senior medic on a scene loses control, it becomes much harder for junior staff to regain control of the situation. That being said, when things start getting excited, sometimes it just takes one person to take the stress level down a notch and get everyone thinking again, and that can sometimes be the junior person.

In this sort of situation, "Hey do you think the tube's obstructed?", "Do you think there could be a pneumo?", and "What do you think that red thing means"(about 2 minutes ago), are all good options.

I have seen quite a few scenes spinning out of control, only to be rescued by someone saying, "Ok, let's sit on our hands, take a couple of deep breaths, count to five, and jump back in again". Sometimes a couple of seconds of collecting yourself enables rapid focused action. The chances are if you feel the necessity to do this, you're not being effective at that point, anyway, so you're not losing anything by taking 5 seconds to regain your cool.

Remember slow is smooth, smooth is fast. If you can develop the ability to talk slowly and calmly, but move deliberately, it will serve you well in almost every situation. See something simple, like a cardiac arrest run by a good crew, and you'll see what I mean.

The patient began to cough and gasp and appeared to struggle for air and at this point Im about to press the internal oh shit button cause im in the captain chair watching this guy spin down the drain before my eyes and im just sitting here. I didnt want to get in the way of my medic but at the same time I was frustrated because I keep feeling their must've been something I can do.

We arrived to the hospital and I was thinking we were going to hit the ER with the way things are going with this guy. But no, we head to the elevators and begin to take this guy up. My eyes were set on that monitor fearing he was going to code right in that elevator. By now his pulse was 140 spiking at 170 and his SPo2 leveled out at 80. His skin showing it too.

I don't think he likes being hypoxic.

Running to the hospital because there's an airway problem, and deciding to take your time to go up to the ICU are illogical and contradictory actions. Either there's an airway issue, and you need to be in the first place that can fix the airway problem, or there's not an issue, and you're going to the ICU.

This mostly isn't your fault either. Although you should, hopefully, have recognised the situation as being serious, and suggested the ER to your partner.

Once up to the ICU he was transferred over. And it was clear with the amount of staff in the room he didnt fair too well on the way over to their facility. After he was on their bed I removed myself from the room and went back to the truck. Hands trembling.

Adrenaline dump. Happens to everyone, becomes less of a problem over time.

How do you ladies and gentlemen manage to maintain composure when a perfectly uneventful transfer spirals into a oh shit run.

It's a learned behaviour, that comes from prior experience, and an understanding of the pathophysiology of the patient, the tools at your disposal, and how they apply to the situation. And even then, sometimes calls still get messed up. Talk to some ER or ICU docs and ask them about times they screwed up. It'll open your eyes. There's a lot of weird presentations and crazy situations out there that can catch you, sometimes even when you're on your A game.

Do enough decent calls, and you learn that when it gets exciting, you need to slow down. This takes time, and it gets a little harder as a medic, because you can't show any fear / concern you might be feeling, because it will spread to your crew, or encourage other medics to start intervening, which is only helpful when everyone's working together.


Save this experience, learn from it. Once you collect enough experiences like this, go to medic school.

-------------------

Edit: Sorry for the long length and messed up formatting.

Edited by systemet, 27 January 2012 - 10:37 PM.

[Kiwiology]

First of all let me say you didn't do anything wrong bro.

In this part of the world if we get uber crook people like this bloke who need to be transferred between emporiums of doctorologists we send a hospital transfer team with them. Why? Because we recognise that dealing with complex patients who are critically ill and often on more pumps and drips and bits and pieces than you can shake a stick at is well beyond the scope of the Ambulance Service to deal with.

Your Paramedic screwed up big time but then again, perhaps he knew very little about the situation in which he found himself and didn't actually know what to do?

I'm a knowledge freak but that doesn't mean I should be in charge of inter hospital transports of mechanically ventilated super-crook people because I know sweet fuck all about mechanical ventilation and how to troubleshoot it when things go wrong.

It is clear you wish to learn from this situation and I commend you for that.

[Asysin2leads]

Mike, good for you for not being afraid to admit a mistake. That being said if I saw the situation you described I would have had some serious words with the paramedic. Very serious words. In a kind but firm voice. I would say to you that, you unlike the paramedic, obviously recognized this person was having trouble breathing. Part of EMT curriculum, I believe, is being able to ventilate BVM to stoma. As an EMT, you did recognize the situation, but it sounds like you failed to act accordingly. Forget liability. You knew he was having trouble breathing. You are fully trained on a BVM and should be able to ventilate a person via stoma. There really isn't any excuse for that. Being an EMT on an ICU bus is putting you in the deep end without swim lessons. You need to be on point with this stuff.

[runswithneedles]

I'm going to take a different approach to this just a little. I agree with the comments that have been presented so far. What bugs me, however, is that your response to this has been, at least as far as your written word goes, that you missed your opportunity to "shine and make yourself known in the company".

What kind of approach to PATIENT care is that? Are you doing this simply to be known to your boss? Or are you doing this for the recognition from your coworkers? Or are you genuinely interested in treating patients and maintaining, if not improving, their condition/status from when you met them?

Again. My poor choice of words has no bounds and gets a foot shoved in my mouth and breaks a few teeth. It was meant to come out as doctors and nurses would trust me with their patients and they would have piece of mind because I know how to handle a unstable patient. Take for example if My dad fell over from an MI in my home town and he had to go by ground to another facility. If I saw my medic from the run walk in to take my father I would tell that nurse to get another crew.THATS NOT THE MEDIC I WANT TO BE NOR WILL EVER LET MYSELF BE!!!

Heres another one. If a 4 year old child needs to go six hours to a pediatric hospital where mommy cant ride in the back. As a parent would you like to hear how the medic (who just so happens to be taking your daughter) Almost killed a vent patient who was perfectly fine and dandy in a short trip down the damn street. F***K NO!!!!! Or would you rather take the medic who nurses and docs alike know him for being a quality out of hospital care provider whom have brought them crappy patients from hundreds of miles and keep them in the same condition or better condition than when he picked him up.

I would go with option 2

In conclusion I wish to be a care provider who is good at what he does and perhaps maybe one day so good that he is known in his region for it. I want to be able to step into a ER where im from and the when the nurse sees me they are relieved and at ease their patient is in good hands. I was blessed to meet several of those And still have them in my life. With the exception of one who died in a medevac crash. And im further blessed I have one I work with regularly who has tought me so much and in the period of only 3 weekends working here the regions nurses were requesting him BY NAME to take their vent patients and their unstable ones and if he wasnt working they would send it somewhere else.


As for the glory jocky.

If I wanted to be that kind of emt. I would've purchased a penis extender, steroids, LED lights for my truck and joined the fire department in my area. (They pay more, work less, and have better benefits anyways)

Im now off my soap box. We will now continue with your regular broadcasting

This mostly isn't your fault either. Although you should, hopefully, have recognised the situation as being serious, and suggested the ER to your partner.


Save this experience, learn from it. Once you collect enough experiences like this, go to medic school.

I did. He Said nothing.

I am. Second semester out of 3. Already completed advanced airway managment COVERING VENTS!! Why the hell didnt I think it was the PEEP indicator!!! UGH whata bloddy brainfart from hell.

And 1+ (wouldve given you 5 but it wont let me ) for your post. Thank you very much for the in depth breakdown and your view on each section. Furthermore by adding the possible complications that mightve arisen. I did think of all of those but a mucus plug. Which couldve been easily fixed.

Than again. That BVM sure looked real shiny at that moment.

[island emt]

this is easy:
Mike is a newbie working for a crappy transport company doing the granny shuffle and is terrified by every stiff he hauls.

[Captain ToHellWithItAll]

this is easy:
Mike is a newbie working for a crappy transport company doing the granny shuffle and is terrified by every stiff he hauls.

Just where did you get that understanding from his posts? I don't see him as terrified of every stiff he hauls.

Care you explain your comments? Just asking as I didn't read any of that into any of his replies on this thread.