A Shot Across The Bow

Friday, June 10 2005

Our call was in the wee hours to a retirement community for a “difficulty breathing”. This is Bad Juju – ya gotta breathe – so we went loud, fast and flashy. Our closest medic was on another call, so I noted that the next available medic coming in was from two dues over.

Arrive on scene, whip out the cot, toss a Lifepak, airway and aid bags onto it and begin rolling inside. The security guy let us in and told us the floor. No sign of the medic yet, so let the elevator doors slide closed and get there.

Navigating a maze of silent corridors, second-guessing ourselves at each intersection. We finally run into someone who led us the rest of the way to the room.

A nurse stood between our patient’s bed and an oxygen concentrator – a machine that drags O2 out of room air and concentrates it into a mask or nasal cannula.

Our patient was very elderly but looked surprisingly well. The patient’s skin was pink and dry – good circulation and oxygenation may be implied there. The patient was laying flat in bed – not sitting up gasping for breath, nor propped up with pillows. I greeted the patient and she replied in full sentences, no wheezing, and her replies were oriented and proper. Eyes PERL, smile and grips equal bilaterally, good distal PMS. Hmm.

Despite the presence of the concentrator (which was turned off) the patient had no mask or cannula on. Oxygen saturation levels confirmed the patient’s apparent O2 levels – 95+%. Lung sounds clear all fields, good tidal volumes, patient is calm and seems fine.

The patient did not want to go with us to the hospital because she had all kinds of things planned for the day. Thinking of giving the medic a break, DTs raises his radio and cancels the medic, then begins talking the patient into getting checked out. The medic, we hear over the radio, acknowledges and tells the dispatcher that they’re out of service for a while, restocking or some such. (Old hands can see exactly what’s coming.)

Finally, the patient agrees to come with us to the hospital for a checkout. DTs asks the nurse, “Say, by the way, who called 911? Was it you or the patient?” “Oh, I did,” says the nurse, “When I found her slumped on the toilet.”

“The you what okay start over” stutters DTs.

“I was making rounds, and the patient was slumped on the toilet. Her pulse ox was 64%. I put her on oxygen and got her to bed.”

“Well well.” says DTs. “And you took the patient off the oxygen…?”

“Just a second before you came through the door.”

Okay, well, that explains the lovely high O2 sat we got, and the patient’s color. Straining on the toilet is a classic path to heart attack (“grunting” activates the vagal nerve, which slows the heart rate.) And when your heart stops, well, you might just stop breathing too.

Oh shit oh dear. And Yankees in the cellar.

The patient is on our cot, we’re ready to go. Patient still looks and sounds great, strong regular pulses, good sats, clear lung fields… DTs is torn. We can be at the ER by the time any medic can get to us, so that decides the path.

We’ll go ahead and take her, but damn! I wish I could start a line, and put her on the cardiac monitor. I want that O2 sat level up to 100%, so I bump the liters per minute twice en route. Hold hands the whole way – DTs has a less scientific but equally accurate pulse monitor built into his fingertips. Strong and regular. Keep the chitchat flowing – note to field providers, hearing about your patient’s grandchildren is a cheap and easy airway monitor.

Transport was uneventful (thankfully) and the ER cardiologist found no problems. Still, scary stuff.

Lessons learned: 1) Never send the medic home unless you are one; 2) Never assume anything re the patient, disposition, etc. 3) Patients who might require CPR are far scarier than patients on whom one is performing CPR already.

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