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Patient Care

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The Attack One crew arrives for their shift in the early hours and are waiting for the overnight crew to return from their last call. It’s been a busy night for that group; it’s clear they’ve only been back to the station for a few minutes since midnight. As they pull into the station, the tones drop for another response, a report of a “man ill.” The crews rapidly exchange personal gear and reassign the computer, and the exhausted crew stumbles into the dayroom.

“The Attack One equipment needs to be restocked. We’ve used everything in the past few hours and haven’t been able to get a minute to repackage and resupply,” the outgoing paramedic reports.

The fresh day crew, along with a paramedic student assigned to them, leaves in Attack One for the medical response. Additional information indicates the patient is a man who is unable to urinate. The wife greets the Attack One crew at the door and reports that her husband is in an upstairs bathroom and has not been able to urinate for the entire night. This has occurred in the past, and he has a history of prostate problems. He is in so much discomfort now that his wife cannot transport him in their car.

The crew moves through the large home and finds the man standing at the bathroom sink, running his hand under some cold water, noticeably uncomfortable. The crew members and student interview him; he says all his discomfort is in his lower abdomen and penis, he passed some blood in his urine the day before, and he’s had no fever, vomiting or problems with his bowels. His vital signs are stable. He asks if he can make one more attempt to urinate before they leave the house.

The paramedic holds the man as he stands over the toilet but notes he is now getting a little sweaty. The man bears down to try to urinate, then mumbles, “I feel weak and want to sit—”

Then he goes limp. The paramedic catches him and lowers him first onto the toilet seat and then to the floor. He reaches to find a pulse, expecting to find a slow rate, but cannot find any pulse at all. He tries in multiple spots, and none is present. He notes the man has stopped breathing.

“Go get our defibrillator-monitor and airway bag,” he instructs one of the EMTs. “You start chest compressions,” he tells the paramedic student. “Rate of 110 beats a minute until we get our defibrillator.”

The crew begins their work. The bathroom is large enough to accommodate the resuscitation, and the wife is present and holding her husband’s hand.

The EMT returns with pieces of equipment he has assembled in a bedsheet. He quietly notifies the paramedic that the Attack One equipment was in disarray, as the last two calls on the night shift must have needed all their gear. “Everything was opened up, and none of our bags were intact,” he reports in a soft voice. “I just grabbed everything I thought we would need.”

“No problem, we will get our job done. Thank you!” the paramedic replies.

They quickly apply the monitor and find the patient in ventricular fibrillation. The paramedic student and wife both remove their hands from the patient as the first shock is administered. The monitor shows a return to sinus rhythm, and the patient has a slow pulse.

“He has a pulse,” the paramedic tells the wife, “so ma’am, we are OK with you staying here and holding his hand if you will let us work around you efficiently as we prepare him for the ambulance.”

The wife is grateful. “You guys work, and I’ll just talk quietly to him. He’s had heart problems before, but never anything like this, and he had a stress test a month ago they told us showed no problems. Did this happen because of his prostate?”

“Can’t tell, ma’am, but we will prioritize the care of his heart right now,” the paramedic responds.

The paramedic is now digging through the supplies. There are no masks in the bag, so oxygen is provided by a high-flow cannula. The monitor leads are applied, and the patient is in a sinus bradycardia. The IV bag is seriously depleted, but the paramedic uses the student’s hands as a tourniquet, places an 18-gauge catheter and puts a saline lock on the catheter and tapes it down.

The patient’s rhythm suddenly changes to v-fib again. “Everyone clear!” says the paramedic, and a second shock converts the patient again to a sinus rhythm.

“Ma’am, your husband’s heart rhythm is unstable, so we may have to provide shocks at any time. We are going to work quickly now to stabilize him, and we’ll start him on some medicine to try to stabilize the rhythm, and then we’ll transport him to a hospital capable of caring for his heart.”

After a few exchanges, the wife and paramedic agree on a hospital that has heart capability and has done the man’s prior heart testing. The EMTs are preparing the patient to be lifted onto the stretcher. The wife has left to gather some belongings and contact relatives by phone.

Ongoing shortage issues have made it challenging to find medicines in the drug box on a good day, and today the box is also depleted by earlier calls. The paramedic finds the lidocaine, administers a bolus and starts a drip at about 2 mg a minute.

As they prepare to move the stretcher through the house, the patient develops ventricular fibrillation again. This time it takes two shocks to return the rhythm to normal. The patient is not breathing, so the paramedic decides he will intubate before they try to move him out of the well-lit bathroom.

“The last thing we want to do is have this man vomit and aspirate as we try to move him,” the paramedic tells the student. “The airway needs to be under good control as we get him down the steps.”

The airway kit has also been disrupted. The paramedic finds an 8.0 endotracheal tube, a straight blade and a handle with a dead battery. With no delay, he finds the pediatric handle, switches the batteries and intubates the patient on the first pass. Oxygen saturation remains at 98% throughout.

“Let’s move!”

The student interrupts: “The patient is now in asystole.” The monitor shows a flat line, although all leads and wires are in place. The student prepares to compress the chest, but the paramedic asks if the patient has a pulse.

“He’s in flat line,” the student replies.

“Always check for a pulse,” the paramedic reminds him. The student does so and reports he can feel a carotid pulse. “I am starting compressions, though, because the monitor says he’s flat line!”

The paramedic stops him and begins to troubleshoot the monitor, wires and leads.

The patient’s wife has returned, seen the monitor is flat and heard the student find the patient dead. “No,” the paramedic reassures her, “I have my hand on his pulse right here, and his pulse is very regular and strong, so he is doing OK. Our monitor must be malfunctioning. But my hand is just fine as a monitor, so that is how we will make sure he is doing well as we move him to the ambulance.” The wife is asked to go ahead and clear the stairs and level below so they can move the stretcher.

As they try one more time to move, the pulse disappears. The paramedic finds none, so they deliver another shock, and again the pulse is restored. The shock also has one more effect: The patient’s bladder starts to empty.

“His bladder is way full; we can’t let him empty it onto himself and the stretcher,” the paramedic notes. “Give me the trash can.”

The crew creates a little plastic channel from the patient’s penis to the trash can, and the paramedic massages the patient’s bladder until they have emptied everything they can. There is a lot of urine, a little blood obvious in it. While the paramedic performs the bladder work, he has the student hold his fingers on the patient’s radial pulse and report every little bit that it’s still present and regular. He keeps looking at the monitor screen showing the flat line.

The paramedic asks, “Will you describe the heart rhythm for me? Would you call it ‘pulseful asystole’?”

Now the student is really perplexed. “But it’s flat, with all the leads on,” he replies. “Don’t we treat that?”

“No, we don’t, we treat the patient!”

The paramedic tries to put the pieces together. “Our monitor is obviously malfunctioning and won’t give us a cardiac rhythm or pulse oximeter reading. But we still have the best monitor, and that is our fingers. We have a stand-alone pulse oximeter in the ambulance and will use that until we get a replacement monitor that I requested from the EMS supervisor. Until she gets here, you are our monitor and are doing a darn good job! Let us know if the pulse changes again. And there is no such thing as ‘pulseful asystole’!”

Finally it appears they can move to the ambulance, with the student fingering a pulse, the patient’s bladder empty and the stretcher dry, the endotracheal tube in place, and the patient starting to breathe on his own. As they get to the vehicle, the supervisor arrives with a working monitor, and it gets attached to the patient. He is in a sinus rhythm.

“C’mon, sir!” the crew urges the patient as they load him. His rhythm stays stable en route to the hospital, and a cardiac alert is given.

Hospital Course

The emergency department is prepared, and the EMTs take the patient into the resuscitation area. The emergency physician and cardiologist do a quick assessment and order a quick chest x-ray, and the patient moves on to the cardiac intervention lab.

The Attack One crew retreats to the EMS room in the ED, and the crew leader announces they’ll be out of service until they have completely restocked and checked their vehicle and have all their equipment prepared.

The patient is found to have some coronary artery disease but no permanent damage. The cardiologist thinks the stress of the overnight urinary obstruction was enough to cause the patient’s coronary disease to trigger a dysrhythmia. The patient recovers well, and his prostate problem is also addressed while he’s in the hospital.

Case Discussion

The crew here was faced with an incident where a patient had an unexpected cardiac arrest, then a stuttering resuscitation from recurrent ventricular fibrillation. The rescuers provided immediate chest compressions and rapid and sequential defibrillation. Then equipment and supply problems began to challenge them.

Equipment safety is incredibly important in emergency patient care. Equipment used in EMS can be dangerous to both patients and providers, so training must be focused on safe use across a broad range of environments. It is necessary for all personnel to understand the most important tools used in emergency care. They can be described as “platforms.”

• Platforms for patient movement—These begin with boards, chairs and straps on which a person can be laid or sat and carried. The next tools are based on wheels or tracks and are human-powered to date. These are designed for longer-distance patient movement. These have become larger, with mattresses and features built for safety and comfort and cleanability. With increased size and weight, the safety of the patient is improved but the risk to EMTs is increased, whether a patient is on the stretcher or not.

• Platforms for patient monitoring—Patient monitoring always begins with the EMT’s fingers and eyes. Monitoring platforms now include devices that monitor cardiac rhythm, pulse oximetry, carbon monoxide, carbon dioxide, blood pressure and more. Additional devices use a very small amount of blood to give important patient information, like blood sugar. Some monitors are configured to deliver interventions, like defibrillation, either automatically based on built-in algorithms or based on human commands.

• Platforms for patient treatment—These include supplies necessary for delivering oxygen, intravenous fluids, medications, airways, body part immobilization and special treatments. These are often built in modules based on patient type or problem (e.g., delivering a baby, providing care to a child or treating a fracture).

• Platforms to manage multiple patients—These are modules of equipment for portable use in multiple-casualty incidents and military applications. Multi-outlet oxygen, triage and treatment packages, and documentation elements are parts of these platforms. There are also vehicles built for multiple-patient management, which include wireless patient monitors, stretchers and treatment equipment.

• Platforms for special-event EMS—These include modules for upright or reclining cots, water sprayers (or heaters), water and food, and communications. These can also be configured for public health, with provisions for inoculations, respiratory protection and public education.

• Platforms for moving very large individuals, in both emergency and in nonemergency circumstances—These include larger cloth devices with multiple handles, oversize stretchers, large patient-compartment elements, and a winch to improve loading.

EMS agencies utilize their equipment through individual pieces or in platforms based on their routine patient needs and the capabilities of their EMTs. Packages of equipment make it easier to move in and out of vehicles and through outside weather. They require continuous monitoring to make sure they are adequately stocked and their components not expired.

Every EMT must also remember that for every piece of equipment, there needs to be a backup. As in this case, each element of care may need to go back to its most basic form to be effective for the patient.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.

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