Posted by: medicblog999 | October 27, 2009

Whats your worst fear?

asthma1

There are many things in this job that can cause the heart rate to rise and the adrenaline to start flowing, but two scenarios continue to worry me, but have fortunately not presented themselves to me yet.

The first one is the patient who is choking, and I mean really choking, not just got a little something stuck and is struggling to get it out. What I am talking about is the patient that has become unconscious, is turning blue/purple and nothing that you can do is going to help them. We do not have needle cricothyroidotomy in the NEAS as it is one of those skills that is deemed to risky to do due to the lack of practice that we would have to actually perform it, and the rarity that we would actually use it. Imagine the scenario with a child and it becomes even more un-thinkable.

The second one is that patient with life threatening asthma, who no matter what you do, continues to deteriorate and eventually goes into respiratory arrest. If this happens, you will not be able to ventilate the patient and continued ‘bagging’ will likely only hyper inflate their chests and cause a pneumothorax or even tension pneumonthorax. Yes, we have drugs that can work before the patient gets to this stage, but the feeling of helplessness would be truly horrific to have to actually watch someone die through suffocation, and not be able to intervene.

I thought I was going to have to deal with the second one just the other day!

Called to a 42 yr old female, known asthmatic, who was having breathing difficulties. The address was less than 10 minutes away so Tom, my partner for the night, and I make a quick drive through the early morning traffic and arrive at her house.

As I walk round the house to the back door, I see that the door is open and the patient, Julia, is tripoding in the door way. Tripoding is a term that we use to describe the position that asthmatics tend to assume when they are really struggling to shift air. They basically lean forward from the waist, either sitting or standing, with both arms outstretched and holding onto something (shaped like a tripod). This is to maximise the movement f their chests and try to get as much air in and out of their lungs as possible.

As I approach Julia, I get a quick ‘Hiya’ and a smile. She doesn’t actually sound too bad just as I was making my rapid initial assessment. She was able to complete a short sentence, looked a good colour, was obviously having some difficulty, but there wasn’t too much of a wheeze to hear. I get out my stethoscope and have a quick listen in to her chest, where I hear widespread ‘quiet’ wheezes, across both of her lungs. This starts to get me worried, as the only thing worse than a wheezing asthmatic that you can hear as you walk in the door, is a ‘quiet chest’. The wheezing becomes difficult to hear, as the airways have constricted to such a degree that the amount of air moving in and out has decreased to the point where it can be hard to hear through a stethoscope.

Her oxygen sats were surprisingly good at 89% and she was a little tachycardic at 112 beats per minute.

She gave me the history of getting up from bed at 8am and feeling tight chested. She used her own inhaler a number of times but it didn’t seem to be working. Her chest became tighter still, so she decided to call 999. She has had previous admissions to hospital with her asthma, but no intensive care visits and has never had to be ventilated to help her breathe.

Even so, I don’t like how this appears. I start her on a salbutamol and atrovent nebuliser and give the all knowing look to my partner that without any words says ‘Time to get a move on mate! she’s not well’

Tom quickly returns with the carry chair and we move Julia onto it to push her out of the house, thereby minimising any effort that she has to do. What happened next was expected…

As we placed her in the chair, she was asked to sit back so that we can put a belt around her chest to stop her falling out of the chair. The chair then has to be reclined onto its back wheels to push it along the path. However, the LAST thing anyone wants to do who feels as though they are struggling for breath is to be restrained in any which shape or form. As soon as we tried to sit her back, the panic kicked in, and she became really distressed.

Now comes the difficult bit, I have someone who has the potential to very quickly develop from severe asthma to life threatening asthma (an important distinction to make). All I want is her on the back of the ambulance and moving to hospital, but if I try and hurry her too much, it is just going to progress things faster, as she will panic and breath faster. So I giver her a couple of minutes outside in the fresh air, I hold her hand and try and calm her down then we make the decision to let her keep pitched forward and only loosely place the strap around her chest. Tom then proceeded with the difficult task of pushing her to the vehicle whilst Julia was sitting forward on the edge of the chair. Not normal protocol, but you do what you have to in the best interests of the patient.

By the time she is on the tail lift of the ambulance, she starts to become combative and gasping for air. Really not a good sign, and I start to wonder if this is going to be the one who I can do nothing to help with.

Time for gently gently has now past. We get her neck to the stretcher and lift her onto it. I decide the best option is to let her sit with her legs either side of the stretcher and the lap belt around her waist. She should be restrained with the 5 point harness, but she would never tolerate it, so I do what’s best for her.

As I cannulate, Tom gets an I.M injection of adrenaline ready.

Cannula in……500mcg Adrenaline 1:1000 in………Cannula flushed……..200mg Hydrocortisone I.V in..

(On a side note, which scientist developed hydrocortisone to give the side effect of an extremely itchy anus???)

Her O2 sats remain in the high 80`s, but she looks like she is starting to get tired now.

We head off to the A&E department with lights and sirens. The Pre-alert goes in.

Half way up to the hospital (about 7 minutes after she got her adrenaline and hydrocortisone), Julia looks over and tells me that her

“breathing………feels a little………better”

Thank God for that!!

As we continue to the hospital, I can see her starting to relax. She is by no means out of the woods for this episode of her asthma yet, but it looks like she is going the right way. By the time we get her to A&E, she is back to the way she was when I arrived at the house. I hand over to the nurses and doctors and finish my patient report form. As I am about to leave, Julia calls over to me. As I stand by her side, she grabs my hand and kisses the back of it…

“Thank you so much!, I thought that was it tonight…..Thank You”

In my head I say ‘I thought so too!

M999: “No problem Julia, It’s great to see you looking a bit better. Take Care”

I honestly feel that she had a lucky escape that night. If we had been further away, if she had left it a few more minutes to call 999, it may have been a very different ending for her.

But we weren’t, and she didn’t, and she is going to be okay (for now anyway)

Phew!!!

So, what’s your worst fear?

Advertisements

Responses

  1. First of all…I'm new to this blog (found you through this network of other EMS blogs), but I am a big fan already. I like the way you describe things, so it feels like I'm running the call too. Nice work.Accolades aside…and moving onto my fear. I think the one you described would be right up there with the best of 'em. My fire dept is mostly BLS and we don't transport. There are a few of us who are EMT – Intermediates, which gives us a little more ability with drugs etc, but at some point a patient needs a medic who can give them more advanced drugs and maybe even a needle in the neck. I think having your patient above and knowing that we sometimes have a 10 -15 minute response time for an ALS ambulance and another 25 – 30 minutes to get to the hospital on a good day would make my anus itch a bit too. Especially since the best I can do for her is an albuterol nebulizer, mixed with a little ipratropium. I could get an IV going so I can give her some 1:10,000 epinephrine, but only the medics are allowed to give the steroids & mag sulphate. That'll be the day I am hoping that the ALS ambulance headed our way is driven by “The Stig” from Top Gear.

  2. First of all…I'm new to this blog (found you through this network of other EMS blogs), but I am a big fan already. I like the way you describe things, so it feels like I'm running the call too. Nice work.Accolades aside…and moving onto my fear. I think the one you described would be right up there with the best of 'em. My fire dept is mostly BLS and we don't transport. There are a few of us who are EMT – Intermediates, which gives us a little more ability with drugs etc, but at some point a patient needs a medic who can give them more advanced drugs and maybe even a needle in the neck. I think having your patient above and knowing that we sometimes have a 10 -15 minute response time for an ALS ambulance and another 25 – 30 minutes to get to the hospital on a good day would make my anus itch a bit too. Especially since the best I can do for her is an albuterol nebulizer, mixed with a little ipratropium. I could get an IV going so I can give her some 1:10,000 epinephrine, but only the medics are allowed to give the steroids & mag sulphate. That'll be the day I am hoping that the ALS ambulance headed our way is driven by “The Stig” from Top Gear.

  3. Worst fear? Airway issues you can do nothing about, such as severe asthma. Once you've lost the airway, you've lost everything.

  4. Worst fear? Airway issues you can do nothing about, such as severe asthma. Once you've lost the airway, you've lost everything.

  5. its amazing that if this was ten years ago the outcome could have been alot worse, as we couldnt even give salbutamol, our treatment has progressed so much in the last decade

  6. Hi, new here, as I have only recently found your blog.Worst fear, two actually, airway, as you said, because as BLS there is so very little one can do if someone is really starting to loose their airway and the medic unit has not arrived yet, and kids, because in my district we so very rarely run them that I still feel very new when running them.

  7. Hi, new here, as I have only recently found your blog.Worst fear, two actually, airway, as you said, because as BLS there is so very little one can do if someone is really starting to loose their airway and the medic unit has not arrived yet, and kids, because in my district we so very rarely run them that I still feel very new when running them.

  8. Thanks for the kind word Limey!Hey, what a great blog you could write after being part of both sides of the Atlantic!P.s, ahhh, but who actually is the stig?

  9. And where will we be in 10 years to come. Thats the question. EMS 3.0 maybe??

  10. Thanks for the kind word Limey!Hey, what a great blog you could write after being part of both sides of the Atlantic!P.s, ahhh, but who actually is the stig?

  11. And where will we be in 10 years to come. Thats the question. EMS 3.0 maybe??

  12. Thank you from a ill person for all the work and care that E.M.S. teams provide across the world here in U.K we take things for granted and never say thanks To all emergency care workers keep up the good work and it is nice to be able to use the internet to see how it is done in other countries God bless you all and take care because i care from kevin Omagh North Ireland

  13. Thank you from a ill person for all the work and care that E.M.S. teams provide across the world here in U.K we take things for granted and never say thanks To all emergency care workers keep up the good work and it is nice to be able to use the internet to see how it is done in other countries God bless you all and take care because i care from kevin Omagh North Ireland

  14. Thank you from a ill person for all the work and care that E.M.S. teams provide across the world here in U.K we take things for granted and never say thanks To all emergency care workers keep up the good work and it is nice to be able to use the internet to see how it is done in other countries God bless you all and take care because i care from kevin Omagh North Ireland


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Categories

%d bloggers like this: