After two consecutive shifts without turning a wheel, we all had that feeling that something was coming. The night got started with pretty simple runs back to back- frankly “below our pay grade” kind of stuff. Returned to quarters after the second and I had the audacity to try to lay down… universe had other plans.
Some hours prior now, a 34/f called EMS from home, complaining of difficulty breathing. According to the EMS run sheet, she told the local squad that she semi-recently suffered a broken rib “that punctured my lung” and has been “putting off getting treatment for a lung infection”. The EMS report notes she is alert, oriented, notably dyspneic but oxygenating well. Also reports bilateral coarse breath sounds. EMS administered albuterol and transported to the local ED- a L3 Trauma, Cardiac Interventional and Primary Stroke Center.
The ED physician’s note reports that upon his initial examination of the patient, she was profoundly dyspneic (able to provide minimal hx), pale and diaphoretic. Also noted JVD, questionable rightward tracheal deviation and absent left breath sounds. POCUS found absent lung sliding on the left (present R). Needle decompression was performed which released a small amount of air and (after a period of time with suction) close to a liter of purulent drainage. At some point later, the catheter would be removed. Shortly after the patient was intubated. Chest X-ray showed complete white out of left hemithorax with mediastinal shift. Initially hypertensive on arrival, the patient became progressively more hypotensive. Levophed was initiated and a central line was placed. CBC was delayed in the lab for unknown reason, but other labs were now resulting. Lactate 6.6. Procal 2.75. Gap 20. 30mL/kg fluid bolus and empiric abx were administered. Throughout all of this, the patient had been very tachycardic. Prior to securing the airway and administering fluids/pressors, this was presumed to be compensatory, but at this time the EKG showed a regular narrow complex rhythm with a rate of 160- ED physician questioned SVT and attempted 6 and 12 of adenosine with no change. Subsequent EKG better illustrated p waves confirming this was sinus tachycardia.
This takes us to around the time I dared to try to take a nap- now we get involved. The patient has been accepted in transfer to our base hospital ICU. The admitting diagnoses are pleural empyema and septic shock. We’re directed to make our way to the outlying hospital. Which just so happens to be the most outlying hospital in our network. About an hour total response time.
We eventually arrive to the ED and learn some new developments occurred in that time. The CBC finally resulted- WBC 38k and Hgb 6. Type and screen had been completed and when we arrived, 2 units of PRBC were on the way from blood bank. We also found the Levophed drip was now maxed, with MAP sitting around 70 and HR still in the 150s. The patient was sedated with propofol (35mcg/kg/min) and fentanyl (25mg/hr). Cefepime had been administered with vancomycin pending.
We spent about an hour on scene, stabilizing and packaging for transport. In that time, we started the vanc and administered the first unit of blood. Second unit was also initiated. Given the maxed out Levophed and still somewhat shaky hemodynamics, we requested the ED physician send a bag of Neo with us, along with orders to initiate and titrate as needed during transport. In addition to Levo, we do carry epinephrine and dopamine, but given the existent tachycardia, opted to request something that would avoid any more beta action, if we needed to add a second pressor. We had to wait a few minutes for this to come from pharmacy. When everything was all set to go, we switched from bedside to portable monitor and vent and set out for what was likely to be a 45min-1hour transport. Suctioned the airway right before we left the trauma bay… learned quickly we won’t be doing that again. Almost immediately, O2 sat plummeted. With all that’s going on in that chest, there’s not a lot of air actually moving. We need some PEEP and we need to not suck away that PEEP.
The second unit of blood was completed shortly after we left the ED. Correcting the anemia made a notable positive change as the heart rate improved from 150 to 120 (sinus tach). That and EtCO2 were the only reliable vital signs we were ever able to measure on our monitor. Between cool extremities, likely significant peripheral vasoconstriction and the fact we all know about how awesome and reliable our NIBPs are, I’m not sure we ever measured a reliable SpO2 and saw a pressure I believed once, maybe twice. Found ourselves wishing we’d pushed to get an A-line started before we left. Too late now. HR is improving, we’ve got decent pulses. The real problem didn’t start until the vent starts alarming. Peak pressure high. Tidal volume low. Wasn’t going to try suctioning again. We can tolerate a bit higher pressure for the short term. Increase PIP limit from 40 to 45… High pressure alarm again. Limit up to 50.. hitting 50 and would keep going if we so allowed. Check the chest again- ok, we’re still moving at least as much air as we ever have been. EtCO2 is still reasonable. No sign that under-sedation is to blame. Let’s see if we can ride it out. HR is holding around 120… I take a peak outside to get an idea where we are/how much longer… look back to monitor. Oh shit
120….80…60…50…40. EtCO2 is all but gone. Check the carotid (still present) while my partner grabs atropine. Check the chest again. Vent is pushing as hard as it can and there is no air movement. A more diminished version of the coarse junk I’d heard before on the right. Nothing on the left. Repeat the needle decompression. Look back to the monitor- 20. I’m not waiting for what’s next, start CPR. Partner starts yelling to driver to figure out our location. Still 20+ minutes out from our original destination. Minimum 10 to any other network ED (a freestanding would have been our closest network facility). But we’re 2-3 minutes from a university hospital satellite facility (L3) off the next exit. “Get us there, fast!” Partner takes over compressions while I make the shortest notification call I’ve ever made. I toss him an epi as I switch him back out- only med we had time to give. First rhythm check was agonal. Epi went in not even a minute before we pull into ED. I saw an accelerated idioventricular on the monitor as we’re unloading, with a carotid pulse to match. Kept that pulse at least until we moved to this woman’s second trauma bay bed of the night. Brady down and lost it again.
Continued to work the code with the ED staff for in total almost another hour. With each round of epi, we’d get a pulse back. Over the following minutes, as the epi wears off, she’d brady down and go asystolic again. Was given atropine, calcium, bicarb and and an epi drip was started. By the time we left, the decision had been made to call it if and when asystole next occurred… that took a while, as this round there was several minutes of a sustained idioventricular rhythm. Got down as low as 12/min, still with a palpable pulse.
The two questions we had after the fact were 1. Why did the ED not place a chest tube and 2. Should we have paused and asked for an A line before we left? In the time we were at the sending ED, we were tracking reasonable cuff pressures on the bedside monitor. Wasn’t until switching to ours that we couldn’t get a reliable measurement (we had a similar issue on our previous run- we have pulled that monitor off the truck to have biomed confirm everything is functional and calibrated).
While we didn’t strictly suspect pneumo, I still opted for decompression when the patient became peri-arrest on the basis that there was tension physiology. Presumed hypotension, poor air movement, high pressure on the vent. When I got home, I decided to do some googling and called up the search term “tension empyema”. Somewhat to my surprise, that very thing has been (sparsely) documented in the literature. I found three case reports, each a relatively young person who developed respiratory distress, hemodynamic collapse/tension physiology and eventually cardiac arrest, without trauma. Imaging and/or clinical exam in each case led providers to perform thoracostomy, draining large volumes of purulent fluid. While not all patients ultimately survived, in each case, thoracostomy resulted in improved hemodynamics and ventilation.
https://www.ajol.info/index.php/aas/article/download/126354/115870 https://emj.bmj.com/content/emermed/22/12/919.full.pdf (pg 13)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9272902/ Edit I’ve seen a few comments wondering why this patient wasn’t flown. They very likely would have been, but weather was below minimums.
So this is an alternative account but I need to vent after a VSA I went to yesterday that's been bugging me due to the fact the ALS crew was... Unfair.
So I'm with a partner I've never worked before and we have done 4 calls prior to this VSA.
Tones drop at ~1600 for a 47M had a syncope and now unconscious. Enroute light and sirens. Get updated that PT is VSA.
Arrive on scene with fire and fire makes entry while my partner and I put on our full PPE. ALS unit arrives 10 seconds after we arrive. After donning out ppe partner and I take the stretcher out and went to the front entrance. I took the monitor and would assist fire in cpr or whatever needs to be done while my partner (attending) gather's info.
PT is located in the living and fire is doing cpr with defib cable hooked up. Fire states 1 analysis no shocks given. Put my monitor on PTs left side while I go on opposite with the attunement cable because of more room and to transfer the cable from fires defib to out monitor. Tell fire to stop CPR while I analyze. PT had an idioventricular rhythm. I checked for a pulse. Pulse was present. Assessed my ABCs. PT had agonal respirations and fire was BVMing. Compliance was good but because of the respirations I and the fact PT was incontinent and possible seizure I told fire to put an OPA in and gave directions to do BVM. I get to the PTs right side since I know ALS is about to walk in and I'm about to start vitals with BP, SPO2, and temp. ALS walks in as I hit the BP button on out monitor. ALS guy asks why I haven't done a sugar or 12 lead yet. Told him I was about too but he arrived so I waited to see what he wanted first since I don't know his action plan and never worked with him before. Tells me to do sugars and 12 lead and to put in a BP cuff. Okay cool I checked the BP cuff I had on already and monitor came back as "too weak to read" and did a call out to him about it a d was about to do a 12 lead when he told me he wanted ETC O2 on then sugars and 12 lead. Cool I'll do it. Meanwhile him and his partner are trying to get an IV established. My partner was priming a bag for them. I got the ETCO2 nasal prongs on and was about to start the 12 lead. ALS guy then tells me to draw up atropine for him. I'm thinking okay cool but why can't you do that since you're partner is already trying to start an IV and you're on the PTs right side with more room beside your cardiac meds. Go to his side to draw up atropine for him. Give it too him and go back to my side to start the 12 lead. ALS guy then asks why I haven't start the 12 lead. Literally do the 12 lead. At this point the PTs HR was between 20 and 30 with barely a noticable pulse. I did the 12 lead for him and my partner was at this point setting up the glucometer for sugars. I check everything and the leads are at the designated spots not disconnected. At this point fire brought in a scoop and I help set it up trying to avoid the mess or wires and IV lines. Scoop connected and I start disconnecting ALS tells me V5 and V6 are disconnected and looks at me like I'm retarded just after is disconnected the leads. Okay I'll reconnect everything and print out another 12 lead and the monitor says STEMI but you can barely see any action potential on the the limb and precordial leads. Partner got a sugar and came back normal ALS guy wanted tape for the IV for his IV lock. Give him tape. At this point PT is packaged and ready to go.
Get PT on the stretcher. I go ahead of the group to open the doors and set up suction in the truck. ALS guy comes in and I ask what else he needs and told me the PT. Okay PT is loaded. Probably one minute after getting in the truck PT goes vsa. Start CPR. Anyways long story short PT had unknown outcome and even when given bicarb, calcium gluconate, and x4 epi the PT was still asystole.
We do a debrief after the call and I'm told/ babies it seemed as to why we should do a 12 lead and a sugar. ALS partner explains to me like I'm a new student why we must check a sugar. Thanks didn't fucking know why we should always check sugars /s. I explained myself to ALS guy and partner that I just did a BP and wanted to do 12 lead but no idea his action plan since I've had similar rosc in the past and other ALS personnel would say no and that we would do it in the truck or they have a different approach to things so since I didn't know what his thought process was I asked what he wanted when I done the stuff he wanted. In the debrief it seemed they just pinned it on me being dumb and not knowing what to do. ALS guy told me why the hell was everything tangled during packaging and to me if that was a concern why didn't your partner at the back of the truck not doing CPR start untangling shit than just do nothing while a firefighter was doing CPR and I'm getting you cardiac meds ready. ALS guy also questioned the positioning of my monitor since at one point fire kicked it by accident and somehow traveled around a couch. ALS guy made told me it was a bad spot to place it. No shit sherlock I didn't put it there fire accidentally kicked it there and I fixed the problem again.
Okay end rant.
We were called to a local Nursing Home for Respiratory Distress last day and arrive with a 7 man crew after reading the report on our tough book that it was a 94 y/o unconscious person who was still breathing. We get to the room and there is our patient with nursing staff on BIPAP. They stated that the pt was found unconscious and breaths were 6/m with a O2 sat of 68%. They used a BVM and got it up to 72%. On BIPAP the pt was at 86%. While most of my team was setting to work, unpacking the IV equipment, O2 bottles, CPAP, preparing to maybe intubate, I asked for all the paperwork on this pt and saw a DNRCC directive. This pt was clearly on the way out peacefully and there we all are sticking the patient with needles, hooking up this cumbersome face harness that FORCES air into the lungs and strapping it to the pts head, jostling this fragile older person about to prepare to rush them away to the nearest ER where the pt will die. I said "Stop." My team stopped. The nursing staff continued. "You have to get [this patient] to the hospital! What are you doing??" Me: "DNRCC". "That means nothing invasive, no ACLS!". I checked the pulse. "The pulse is faint and thready, bradycardic." I hooked up the monitor, allowing the CPAP to function to continue to function. O2 sat at 86%. Idioventricular rhythm with a pulse. "You are asking us to take this pt out of here so [the patient] doesn't die here right?". I got the signatures and we whisked the patient to our medic and drove lights and freaking sirens to the hospital. I gave report to the hospital as soon as we left and reported that this was a DNRCC patient. Upon arrival I produced the document and handed it to the attending who was in the room. He said "Okay lets keep the IV fluids. Keep CPAP going while I contact family." Family discontinued care. Doc returned while I was getting the RNs signature and stated "Discontinue and let me know when [the patient] starts agonal breathing."
He pulled me aside on my next run in to the same hospital (it's in our district) and told me that the doc there ordered that the pt be transported because there was still a possibility of resuscitation. When the ER attending confronted the doc that no, there was not. not from an o2 sat of 68% and the patient being that way for more than 4 hours, the doc stated "It's our protocol. Patients who are found down and still show signs of life don't die here."
COME ON PEOPLE. COME ON. 94. COULD HAVE DIED PEACEFULLY. WHAT DOES COMFORT CARE MEAN TO YOU?
TLDR: Nursing home orders 94 y/o DNRCC pt to have advanced resuscitative measures taken when the pt is basically braindead to keep the mortality rates down, and as a medic I can't refuse unless it's a DNR, not a DNRCC. Mad.