Jump to content

My first day on the job.


mrsbull

Recommended Posts

Well today went well. I was being trained on a few things (besides ems) Went to lunch. Went to clock in and I get grabbed my mgr and dragged out to the train tracks. Reported pt fell on the mtn/train tracks.

That was when it started!! 86 y/o f, fell approx 6-20 feet off the mtn. Not onto train tracks but below. I nearly rolled my ankle and sup and other ems got hurt getting to pt. (we are ALL good at mtn rescue and well trained, Terrain was rough.) I think it was 10-15 ft. (poss 20 feet ONTO rocks). If it is calculated by where her shoe was it was 6-7 feet. But by the MOI was it was 15 ish feet on Rocks. 100 feet on rocks to get her to the summit.

Here is my ?? Pt was AAOx2 bp 170/90 resp 70 sats in the 80s. Keep in mind that anything above 70 at my (new) job is good. My sats are at 80-85 up there. Uncomfortable yes but adaptable. We are not to give O2 above 70% depending on pts MS and a few other factors. Pt was reported to have loc and fell reason unknown her family was not there. She knew time person place (mostly) but has poss dementia as she was asking what happened (dementia via daughter) Hx of glaucoma, family hx of heart problems. (pt states she has none) Pt broke her arm obvious break/avulsion 1 in lac on eye (Seen bone and "fat pad") on both injuries. Skin was like tissue paper.

I completed my Trauma assessment mostly clear but wounds I have spoken of. PMS appropriate pre and post spinal precautions and splinting of arm/body. Pupils Right was 2mm non reactive and left was pinpoint. Abd was rigid and felt like marbles (WTH MARBLES??.) At first it was normal on the ruq and rlq. LUQ and LLQ rigid and non tender to palp. Re assessment 5-8 min later (by me) was what felt like a tight pouch of marbles... I have never heard/seen/known of this.

We made the decision to have ALS intercept on the mtn. I TOLD my sup to get flight going and to get an LZ established. (keep in mind this is my first call and first time ANYONE on the EMS staff has met me). So we get her rolling via back of truck by Rangers. (I did not go) pt started to crash bp 130/70 o2 80%-85% and dropping(last vitals I heard about) pt was on 15 lpm nrb sats stayed about 85 pulse is unk but def below what I got. She has a hx of syncopal (sp) episodes via 1 yr @ last episode. Pt came from Texas and went to 14,110 feet within 2 days (not wise).

Question is what could have caused the abd full of marbles (feeling)? I have never felt it before never told of it. ALS was intercepted 2 miles from flight so they got a set of vitals and a line established (we cant do lines via med control we will be working on that tho). Unknown if pt is ok as we are not allowed to FU. However friends of friends can help!!

So this was my first pt and first call at this job. I have been told now that I am mgmt material because I am just that awesome!!

Thanks for reading I am just wondering about the "marbles" Mostly. I think it was just the altitude per syncopal episode. for reason of fall.

This gal was AWESOME!! She only complained once in the hour I had her of "my arm is sore". Family was great and it was so smooth. There was me and another guy who just started today and 3 other EMS personnel and it was/flowed like we had been working together for years. I know elderly pts are better with pain than younger pts. Hell I would have been complaining of of my arm and head, no way she did not feel that!! I would think.

I was told by my sup that this was the worst call she has had in 3 yrs as an EMt on the mtn) and the first call for flight in approx 5 yrs (besides mtn accidents which we do not normally go on, like the Pikes Peak Hill climb. Depending on # of ems ppl staffed.)

Edited by mrsbull
Link to comment
Share on other sites

...I nearly rolled my ankle and sup and other ems got hurt getting to pt. (we are ALL good at mtn rescue and well trained, Terrain was rough.)

Sorry babe, but they're not that good if they got hurt in such a short distance. And certainly not well trained unless you were having a meteor shower or some such at the same time.

resp 70 sats in the 80s.

I'm confident, though I had some pretty screwed up pts, that I've never had anyone with resps in the 70's, Sats in the 80's. You've gone off into the ditch there a bit. And if your Sats were normal in the 80's, (As I've heard those summiting Everest are sometimes in the 60's) that doesn't mean that a tourists Sats should be there. If you had someone with their Sats in the 70's, that's a medical emergency. Idon't care what your Sup says.

Keep in mind that anything above 70 at my (new) job is good.

Untrue.

My sats are at 80-85 up there. Uncomfortable yes but adaptable.

Nonsense. And I'll be more than happy to debate this with your supervisor. You can adapt to that, sure. But not for the hour or two long trip that most folks spend on the mountain. If you look at Sats of 70% and say, "Oh, it's just because they're on Pikes Peak, so it's ok." you're setting yourself up for a beating. I know several medics that run up there, and it's not OK. Below 80% with matching physilogical markers for a person not acclimated to such an altitude is a problem.

We are not to give O2 above 70% depending on pts MS and a few other factors.

Foolish rule. What is the down side to giving O's at that altitude?

Pt was reported to have loc and fell reason unknown her family was not there. She knew time person place (mostly) but has poss dementia as she was asking what happened (dementia via daughter) Hx of glaucoma, family hx of heart problems. (pt states she has none) Pt broke her arm obvious break/avulsion 1 in lac on eye (Seen bone and "fat pad") on both injuries. Skin was like tissue paper.

Same question. What is the down side to O's?

I completed my Trauma assessment mostly clear but wounds I have spoken of. PMS appropriate pre and post spinal precautions and splinting of arm/body. Pupils Right was 2mm non reactive and left was pinpoint. Abd was rigid and felt like marbles (WTH MARBLES??.) At first it was normal on the ruq and rlq. LUQ and LLQ rigid and non tender to palp. Re assessment 5-8 min later (by me) was what felt like a tight pouch of marbles... I have never heard/seen/known of this.

Where was the 'tight pouch of marbles?"

Can't help with the 'marbles' without more information, and likely not then. Good for you girl for having the gnads (or overies) to post. I'm not meaning to bust your chops, only to make you think more, and better, (hopefully) on your next call.

Dwayne

Link to comment
Share on other sites

Sorry babe, but they're not that good if they got hurt in such a short distance. And certainly not well trained unless you were having a meteor shower or some such at the same time.

As far as I was "told" most are sar trained. They did not get hurt. I mis typed (my fault) I should have said almost. I also said we are all good at mtn rescue. I am not, I really do not know what the hell I was doing. I just went with the most logical route and common sense method. This is why I am going to get on the SAR team to LEARN it. :)

I'm confident, though I had some pretty screwed up pts, that I've never had anyone with resps in the 70's, Sats in the 80's. You've gone off into the ditch there a bit. And if your Sats were normal in the 80's, (As I've heard those summiting Everest are sometimes in the 60's) that doesn't mean that a tourists Sats should be there. If you had someone with their Sats in the 70's, that's a medical emergency. I don't care what your Sup says.

Resps in the 70's. WHOOPS!! I meant sats. Sry mis type once again.

I agree with sats at 70 is WAY too low. This is the company and (supposedly Med Dir) who make this a "rule". Who btw is Dr Gifford, whom you may know at Memorial Hospital. I am completely uncomfortable with sats that low and to me it is a problem.

I fully plan on talking to Dr G about this. It is unacceptable to me. I feel that I am not taking care of my pts with sats in the 70s. And not being able to do much about it, besides O2, water and rest is the "basic" tx up there. Of course other factors in the mix as well. And letting them go in the mid 80s.

Sadly when I asked why o2 was to be administered ONLY with low 70s. I was told that it is a free service and the company does not want to pay for o2. I call BS!!

Untrue.

Just what I was told. All the pts I checked yesterday were above 86. I was the lowest in sats of everyone. My Partner is at 88.

Nonsense. And I'll be more than happy to debate this with your supervisor. You can adapt to that, sure. But not for the hour or two long trip that most folks spend on the mountain. If you look at Sats of 70% and say, "Oh, it's just because they're on Pikes Peak, so it's ok." you're setting yourself up for a beating. I know several medics that run up there, and it's not OK. Below 80% with matching physiological markers for a person not acclimated to such an altitude is a problem.

I completely agree!! I would LOVE to have better SOPs. Once again I WILL be talking with Dr. Gifford on this matter asap. Maybe today cause I am off. Sucky part is we only have NPA and OPAs up there. Not even a King tube. So should I have had to ventilate that pt yesterday I would have had to do what I could and not even be able to attempt to secure and airway.

Foolish rule. What is the down side to giving O's at that altitude?

There is NO downside. I fully agree. They also (usually) as far as what I am told don't write PCRs either unless O2 is given (sometimes not even then). I DID and WILL write PCRs for all pts but scrapes. Most pts are refusals up there. The best PCR she has seen btw in a long time I was told. Which is sad, my pcr was only 5-8 lines long.

Same question. What is the down side to O's?

None. I also treated a Paramedic/FF up there yesterday (he was embarrassed) I commended him for coming up to us and taking initiative. His sats were mid 80s and bp was a up a tad but normal for him. He knew he did not feel well and the standard tx got him in the low 90s. This pt REQUESTED some O2. Pt signed refusal for transport (for transport we have to call AMR and it takes them about an hr if not more depending on weather to get up there.)

While I was writing my PCR, I had a co worker come up to me and "told" me that I should not have given him O2. WTF, I will NOT refuse O2 to someone who knows they are not feeling well/knows what he is doing and requests it. He was fine after 5 mins on a NC a 3 lpm. This may get me in trouble up there but I will be damned if I don't take it up with someone if that happens.

Where was the 'tight pouch of marbles?"

When I first checked her abd it was soft and non tender on the LLQ and ULQ. RRQ and RLQ was rigid and non tender. The second time I checked The whole abd from ribs to just above her pubic area was rigid and felt like it had marbles in it. Think a tight bag of marbles, she never complained of ANY pain except the arm. I did not get the pain # She was a tough old lady. But sweet, called me her angel. :)

Can't help with the 'marbles' without more information, and likely not then. Good for you girl for having the gnads (or overies) to post. I'm not meaning to bust your chops, only to make you think more, and better, (hopefully) on your next call.

I agree with everything you said dude. I am not happy with this at all. If giving someone O2 gets me fired I will have a heyday with that. I just am waiting to talk to MED DIR and get the lowdown on that. I wish I had a copy of the SOPs to post. I will work on getting one.

I know you are not busting my chops. I dont agree with what we are told to do. I agree with everything you said. I apologize for my mis typings. I was tired. I also woke up this am with a bruised ankle and soreness after I took my boots off UGH, Hope I dont have to climb any mroe rocks for a few days.

Dwayne

Edited cause I forgot to bold something.

Edited by mrsbull
Link to comment
Share on other sites

What is the rationale for such guidelines? If you want to make a logical case use a concept known as the content of arterial oxygenation (CaO2). A formula exists that allows us to calculate a good estimation of the content of oxygen dissolved in the arteries with a few basic assessments and assumptions.

The entire formula is as follows: CaO2 = (Haemoglobin * Saturation * 1.34) + (PaO2 * 0.003) A normal CaO2 is around 17-20 Vol%. (17-20 ml of every 100 Ml of blood contains oxygen)

For our purposes, we can leave the PaO2 out of the formula because the amount of content due to PaO2 is negligible in nearly every circumstance with the exception of special situations such as hyperbaric conditions.

In addition, let's also assume the patient has a normal hemoglobin and use say 13 as our hemoglobin concentration constant in this series of calculations. 1.34 is a haemoglobin constant, as every gram will dissolve 1.34 ml of oxygen. Here goes:

Let's calculate the modified CaO2 with the patient who has a saturation of say 74% (Not that a pulse oximeter will be all that accurate, but you will get the idea nonetheless.)

Hemoglobin (13) * Saturation (0.75) * 1.34 = 13.1 Vol% As you can see, this is well below 17 and represents significant hypoxia IMHO.

Let's calculate this same patient, but increase their saturation to 85%:

13*0.85*1.34= 14.8Vol %

Let's calculate at 95%:

13*.95*1.34= 16.5Vol%

We can clearly see that well saturated haemoglobin is the significant deciding factor in determining the CaO2, therefore I cannot see any justification for allowing a patient who has sustained a traumatic injury at altitude experience hypoxia while at altitude.

Take care,

chbare.

Link to comment
Share on other sites

I would have had a major choke with the protocal about O2. Between her age, hx and the MOI, the best thing you could have done with your protocals was to get that O2 on her.

Older people are horrible about pain, IMO. They don't feel it like those who are younger do. This causes increased issues with treatment. Dementia makes it more difficult for them to understand their own pain sometimes and definately makes assessing LOC more difficult. You noted AAOX2, but the question to ask should be "Is this normal for her?" to assess, per family, how normal she seems. (I know you may not have been able to with where she landed, though.)

Kudos to you for stepping up and taking a lead position. Calling for flight when it's not a normal and being willing to question basic protocals for basic BLS is awsome on your part, IMO. I believe that you've got to remember your BLS no matter what.

Sounds like an exciting first day on the job.

Link to comment
Share on other sites

No need to apologize for the mistakes. That is what we do here...show that we have the balls/ovaries to post our ideas and then trust our friends to help us learn from those posts. Good on you girl.

No good ideas on the marbles. Perhaps you were feeling muscle spasms/fat deposits under the skin, but probably not. I really have no idea...

Also, you should ask your supervisor what you are supposed to tell your medical director when he asks why a pt with sluggish/unresponsive/varied sized pupils was brought in without O2 on board? Possible chronic issue, but possible CVA, right?

It sounds like a fun gig to work, but frustrating too. One of my friends that works the Springs tells me that they spend all summer running people from the peak to below 7000ft...You should make sure you know that absolute rule on O2, and not just hearsay, as you'll have need of it up there.

Thanks again for posting girl...

Dwayne

Link to comment
Share on other sites

For clarity I DID put her on an NRB.

For clarity I DID put her on an NRB.

Link to comment
Share on other sites

For clarity I DID put her on an NRB.

For clarity I DID put her on an NRB.

No worries, seems like an interesting protocol nonetheless. I do understand that you are the new person and perhaps not in the best position to start rocking the boat.

Take care,

chbare.

Link to comment
Share on other sites

No worries, seems like an interesting protocol nonetheless. I do understand that you are the new person and perhaps not in the best position to start rocking the boat.

Take care,

chbare.

Exactly!! However If I get into trouble providing pt care and correctly. I will have fun making things right with me and the company. I can not see a single atty not siding with me over providing proper pt care. I DARE them to fire me! :devilish:

Link to comment
Share on other sites

×
×
  • Create New...