monday, Monday, MONDAY!!!

In my last entry, I wrote a list of "coming soon!" items. Doc Shazam commented on them as such:

"Just some guesses:
#2 - Normal saline?

#3 - DOA?

#5 - Hyperkalemia?

#6 - Did they survive???"

Well, Doc, and the rest of you reading, here you go:

"#2: Dehydrated Patient Miraculously Restored With a Miracle Drug!"

The call was dispatched as "sick person." This kind of call induces a lot of eye rolling at Lucky McGee's station as it usually means some indigent person who doesn't feel well and doesn't have cab fare.

We arrive at a single family home to find a woman in a postal carrier uniform sitting on the couch. She's drowsy and obviously uncomfortable. She said she's been having diarrhea all day. "It's like I'm peeing out of the wrong hole." Add a little vomiting and she's rather volume depleted. I check her skin turgor and am surprised to find it actually works like in the books.

Pinch a bit of your skin on your elbow, knee or other bony part. Generally, if you're not dehydrated it plops back into the shape it was before you pinched it. This is called your skin turgor. Patients who are dehydrated have poor skin turgor, that is their skin stays a bit in the shape it was pinched. It makes a little "tent." Sure enough, this woman had a little tent on her elbow after I pinched it.

We load her onto the cot and then into the ambulance. She's fading in and out of consciousness. She's so dehydrated that I can't get a line. her veins just fall flat when I try to start an IV. Lucky comes over at my request and starts a good one in the arm. Once the IV is started we hang a bag of fluid. Some jurisdictions use Normal Saline which is just water with the same salinity as blood (0.9%) but in this place they use what's called Lactated Ringers solution. It's got a bunch of stuff in it but is basically the same. Most importantly, It's got water!

By the time we arrive at the hospital, I have squeezed about 400 ml of fluid into my patient. She's woken up fully, is feeling much better and looking about 10 years younger.

Water, the miracle drug!

"3. How a nursing home killed my patient and I get the 'blame.'"

We get a call for "trouble breathing" at a nursing home.

As it usually goes in this particular city, the Fire department arrives before us and are already preparing the patient to be transported. I walk in and see an elderly man with a gastric tube (a tube going directly into the stomach through the abdominal wall) hunched over to his left side. He's pale, sweaty and trying desperately to breathe. The nursing home has him on 2 liters per minute (lpm) of oxygen by a nasal cannula. The first thing I do is haul out a non-rebreather mask and hand it to a firefighter.

"Hook him up to about 12lpm, willya?" I ask and it's done. I listen to the patient's lungs. He sounds really "gunky." This means I hear coarse crunchy noises in his lungs when he breathes. It's a sign that he's got some fluid or something in there. He's also using his accessory muscles to breathe and this is causing a lot of retractions. This means that his diaphragm and muscles in his ribs aren't enough and he's using his shoulders, neck muscles and more to try and open his lungs up. Right away, I see this guy is in trouble and we need to PUHA.

Pick Up, Haul Ass.

A nurse or attendant hands Lucky a sheaf of papers that contains the patient's conditions, medications list and some doctors orders. After delivering her payload, she promptly disappears.

*sigh!*

In the ambulance, Lucky and I get a line started and begin to debate whether or not we are allowed to intubate. The patient has what's known as a "Do Not Resuscitate - Arrest" or DNR-A. This means if he goes into cardiac arrest, we're not allowed to re-start his heart. It's not clear if we can intubate or take heroic measures before he goes into arrest. Either way, his oxygen saturation levels climb from 77% in the nursing home to 95% in the ambulance. I've accomplished this by sitting him up higher and straighter and increasing the flow of oxygen.

The ride to the hospital is very short and we deliver the patient to the emergency room and a waiting team. I read the patient's paperwork and find that he's on a gastric tube because he has no gag reflex and there is an order not to lower him any more that 30 degrees from. Dammit! When we had arrived at the nursing home, he was completely slumped over on his left side.

When we returned to the hospital later, the doctor who treated him came over to talk to me. He said that the resuscitation team did intubate him and suctioned about 500 ml of the "food" that's pumped into his stomach from his left lung. It appears that while he had been slumped on his side, the pudding-like nutrient stuff flowed up his esophagus and into his lungs. The patient did not recover from the insult to his system and later died. If someone would have checked on him and then simply sat him up, it might not have happened.

All day long, Lucky tells everyone how great I am, "He's already killed one today!"

*sigh!*

"5. Missed dialysis becomes nausea and vomiting becomes abdominal pain becomes premature ventricular contractions."

The call went out as stomach pains. In the nursing home we find the patient in a daybed clutching his stomach and in a lot of pain. He's sweaty and warm too. It's a riot in there. There are 2 nurses, a cop and about 3 other residents of the nursing home. Each one hollers a different fact at me.

Okeydoke. Load 'im up! He's got a shunt in his arm where he hooks up his dialysis machine. It appears he missed his last dialysis session and has been suffering diarrhea, vomiting and stomach cramps all day.

Neither Lucky or I can get an IV on this guy. His veins, what are left, are horribly scarred. Between the dialysis and history of IV drug use, he's a mess. Oxygen and monitor. The 3 lead shows some S-T elevation but it looks old. I set up for a 12-lead and get a good analysis when we stop at the hospital.

In the ER, I hand the 12-lead to the nurse. Peaked T-waves and PVCs popping out all over the place.

"Missed dialysis?" She asks me.

"Yep!" says I.

Your kidneys are responsible for regulating the amount of potassium in your blood. If you need dialysis, it's because your kidneys aren't doing a very good job at all. Miss a dialysis session and the potassium levels in your blood get too high. This messes with the operation of your heart's ability to work right.

Good call, Doc Shazam!

"6. Pulmonary Embolism (blood clot in the lungs) + thrombolytics + stopped heart = the ENTIRE ER staff is exhausted!"

While Lucky McGee and I were dropping off another patient in the ER, our driver came over to me.

"Hey, man go to the resuscitation room, you'll find that interesting."

Ok! I like interesting things. In the resuscitation there's a doctor doing chest compressions while a nurse ventilates an elderly woman. The woman has a cast on her right leg. Everyone else is kind of standing around watching.

In a "code" situation, everyone is usually doing something. It looks like chaos but often is very orderly. in this case I'm puzzled that nobody's doing anything. After a minute or two, a nurse relieves the doctor doing chest compressions. I'm watching the heart monitor while compressions are being done and there's a good, regular waveform. Nice job!

"What's going on?" I ask another doctor standing next to me.

Turns out this woman was riding in a car with her son driving. He was driving her from New England to Florida. She couldn't drive because she had broken her leg a week or so before. Half way to Florida, she just slumped over and stopped breathing. The son drove directly to the emergency room of this hospital.

The doctor thinks it was a pulmonary embolism. Her heart was in asystole (flatline) so they decided to try to break up the clot. They pumped her full of Alteplase, a clot-busting drug, and were moving it around her bloodstream (and her lungs) by doing CPR.

"The problem is," says the doctor to me, "Alteplase takes anywhere from 10 to 30 minutes to take effect. We've committed ourselves to this course of action for now."

I see other ER staff lining up to take their turn doing chest compressions. They start to eye me and my student badge. Uh Oh! I'm outta there! I've done enough CPR to last me a while.

We left before I heard the ultimate outcome of the patient but it wasn't looking good. She had apparently been "down" (not breathing) for a good 5-10 minutes before the son even got to the hospital.

DANG! That's a long post! Thanks to Doc Shazam for the comment and feedback. I'm riding with Lucky McGee again tomorrow. My certification tests and finals are coming up in the next 3 weeks. I'll try to post as much as I can.

--maddog