Case: Tourist drops in the Port Authority

[Asysin2leads]

As the old song says, it is indeed Christmas time in the city. Right now in my area people from all over the country are wandering around in a semi daze looking at lights and getting drunk. Needless to say, lately, I have been very busy. Upon finishing a transport of a guy who needed 5 mgs of a kick in the ass to the ER, we are dispatched for cardiac arrest in Port Authority Bus station, confirmed by responding Port Authority Police Officers (Port Authority of NY/NJ, Nicholas Cage in that film about 9/11, in case you're wondering). My partner does a great job of installing the fear of God into the motorists between us and the Port Authority, and arrive to find a 68 year old male pale, pulseless, apneic, pupils fixed and dialated, having CPR performed assisted by BVM by responding officers. Officers state man collapsed after getting off bus with wife, AED was applied, delivered shock once, no ROSC. I thought to myself that usually Christmas is depressing, but this is going to take the cake. However, at least we'll get to try out the new CPR guidelines and our new cardiac arrest protocols.

I had my partner take over compressions while the officer continued to ventilate with BVM. Applied EKG pads, and briefly interrupted compressions to evaluate the rhythm, and found it to be a very fine ventricular fibrillation. My partner resumed compressions as the monitor charged, and I defibrillated at 360 joules, which patient converted into and idioventricular rhythm, and my partner immediately resumed compressions. I prepared the IV and asked the wife about his medical history which was quite extensive, including coronary artery surgery and an episode of cardiac arrest in the hospital about 3 years prior. BLS back up arrives, they take over compressions as my partner goes to intubate and I obtain IV access. As my partner attempts intubation, patient gags on the blade. I now have visions of vegetative family members on respirators during Christmas dancing through my head. Again, we briefly stop compressions to evaluate rhythm, and it appears to be a ventricular tachycardia, however, strong radial pulses are felt and patient is noted to be breathing spontaeneously. I have one of the EMTs take a blood pressure taken which holy Jesus, Mary, and Joseph is 120/P. I administer a bolus of Amiodarone 300mg in 20 cc D5W, and the patient converts to sinus rhythm with severe ST elevations and wide QRS complexes. Respriatory is rate 28, adequate, lungs clear bilaterally, saturation 92% and climbing. Instructed BLS to prep to transport, contacted telemetry, recieved orders for 1 amp sodium bicarbonate followed by one amp D50, followed by an additional ampule sodium bicarbonate en route. On way out of Port Authority, patient responds to verbal stimuli. Upon arrival at hospital, patient is able to weakly give first name. Patient is then started on amiodarone drip and nitroglycerin drip, found to be having a massive MI (well, duh), and transferred to MICU prior to going to cath lab.

Took a field trip to the MICU today, visited with the patient, who was awake, alert, with no major tubes sticking out of him resting comfortably in the ICU and his only major complaint was the quality of the food at the hospital. He is scheduled for for the cath lab on Monday. In other words, he's fine. I shook his hand and told him that given the odds of just happening to go into cardiac arrest after being on a long bus ride through the middle of no where in a facility with EMT trained police officers and an ALS ambulance less than 1 minute away, he should consider playing the lottery. I many times cynically differentiate between the terms "dead" and "in cardiac arrest". This guy, initially, I really would have categorized as "dead". I guess the AHA might actually know something.

[Dustdevil]

Dude... the only times I have ever cried in my EMS career have been those occasions just as you described. When you enter a room and see what was a dead body now sitting up in bed, watching TV, eating solid food, and cracking wise as if nothing ever happened, there is no more emotionally elating feeling in the world.

Congrats to him and to you!

[strippel]

I love it when a plan comes together.

Maybe you gave the family the best Christmas present ever.

[Andrewtx]

Great post. Thanks asys.

[BushyFromOz]

I cant help but wonder if those who advocate the abolishion of ALS on the premise that BLS intervention is the only proven method of treating cardiac arrest victims would try and argue the same point here?

What a great story Asys

[akroeze]

I cant help but wonder if those who advocate the abolishion of ALS on the premise that BLS intervention is the only proven method of treating cardiac arrest victims would try and argue the same point here?

What a great story Asys

I'll play devil's advocate here.

From what he posted, BLS IS what saved this guy's life. The early CPR and early defib. After defib at 360 x 1 he got an idioventricular rhythm. Before ANY ALS interventions could be performed the patient had ROSC. So how did ALS help in bringing him back?

[Dustdevil]

So how did ALS help in bringing him back?

Manual defibrillation, and the rhythm interpretation which proceeds it, is still ALS where I come from.

And, of course, this is only my speculation, but I bet that V-tach wasn't planning on sticking around very long on its own.

Your mileage may vary.

[BushyFromOz]

BLS and ROSC does not equate to a save IMHO. If you cant keep an output, all the BLS in the world is not going to help.

You can only cook that potato so many times before its totally baked

[akroeze]

Manual defibrillation, and the rhythm interpretation which proceeds it, is still ALS where I come from.

And, of course, this is only my speculation, but I bet that V-tach wasn't planning on sticking around very long on its own.

Your mileage may vary.

Counter arguement would be that an SAED/AED would have likely shocked him as well. If not, then a few minutes of CPR may have made it coarse enough to shock, which if I am to understand correctly (could be wrong) has a higher chance of success anyway.

I totally agree that post resuscitation VTach needs ALS. The statement was something to the effect that ALS is needed to get ROSC. I was taking the contrary to that. Most studies only speak of getting ROSC from ALS maneuvers. I'm not talking about post-ROSC.

BLS and ROSC does not equate to a save IMHO. If you cant keep an output, all the BLS in the world is not going to help.

You can only cook that potato so many times before its totally baked

My arguement would be, prove that he wasn't going to keep his output on his own without the drugs.

There was a BLS save when I was in school with defib alone. When the guy was being wheeled into the ER he was CAOx3. No ALS, so that proves that it is possible.

Don't get me wrong, I'm not saying I agree or disagree with ALS helping in arrest. I just feel rather contrary today

[BushyFromOz]

LMAO - dude...you play devils advocate well

Strong work man! 8)