Oops, I Fixed You!

Author Frank Herbert wrote, "The most consistent principles of the universe... are accident and error." He was right.

It's happened to all of us. You get on scene, the patient is genuinely sick for once, and despite your best efforts, they get better. I don't mind that they get better, of course, but if I'm going to look smart in front of the ER staff, I'd really prefer to do it because I actually AM smart.

Occasionally, that does happen. I was once dispatched for chest pain. Routine call type, right? First responders get on scene and triage the patient "Red". That may or may not indicate a Type Red patient, of course. Our first responding agencies tend to overtriage patients, which is the way to do it. I would much rather go in expecting a Red and find a Green than the other way round. Ruins your whole day. This night, the patient was as red as red gets. OK, OK, he was really grey, rapidly turning blue. And sweaty. And short of breath. And clutching his chest. Which makes sense, considering he was having a BIG anteroseptal MI. (For those not fluent in Paramedic, he was having a heart attack localized by the EKG to the front portion of his heart, as well as the septum that divides the ventricles. It's commonly referred to as "The Widowmaker". This particular type of heart attack can easily spread to take out the heart's built in pacemaker nodes, leading to a lethal arrythmia. If a paramedic is ever going to get nervous about a patient, this is the one. These folks die with depressing regularity.) The good news is that we can actually do something about that. So, I did the normal stuff. He chewed four baby aspirin (Which judging by his expression was far more unpleasant than the chest pain. Again for those unfamiliar with the treatment, aspirin is administered for a couple reasons. First, it acts as an anticoagulant, which can prevent the clot that may be blocking an artery and causing the heart attack from getting worse. Secondly, as an anti-inflammatory, it can help minimize the damage done by the lack of blood flow to the heart. So everyone should have aspirin around the house all the time. It saves lives.), we started an IV, and hit him with nitro. The nitro dilates the coronary arteries, increasing blood flow to the heart. If an artery isn't completely blocked, this can often relieve the chest pain by restoring blood flow to areas that need it. It will also cause one hell of a headache if you don't need it, which is why the inmates that claim chest pain in an effort to get out of jail rarely do so more than once. I gave morphine, and we rolled for the hospital. Our closest cath lab was about 20 minutes down the road. During transport, I continued with the nitro and morphine, and by the time we got to the hospital, the patient was pain free. And had a normal looking EKG. And normal cardiac markers. Yep. Stopped it dead in it's tracks. I had transmitted the EKG, so the cath lab folks were waiting for me. When they saw the patient, they asked if there was another ambulance coming. Nope. This is your guy. I fixed him for you. They cathed him anyway, and found that the LAD, the main artery to the front of the heart was 98% blocked. He was, as we phrase it in the field, circling the drain. Everything fell into place somehow, and we managed to get him in and out of the hospital in a couple days. The cardiologist told both the patient and me that I had definitely saved his life. All in a day's work.

The second one was somewhat less of an ego boost. Similar start, dispatched to a chest pain. The patient is on the third floor of an apartment building with no interior hallways, just catwalks and exposed stairwells, and it's COLD out. Figures. We begin our assessment, and find that the patient is in SVT, with a heart rate of 180. OK, uncomfortable, but an otherwise healthy person can sustain it for a while. It's easily fixed with a dose of adenosine, one of the more dramatic drugs we carry on the ambulance. Think of adenosine as a kind of chemical circuit breaker. When it's given, it travels to the heart and stops it briefly, giving the electrical system a chance to reset itself. After that, in an ideal world, the heart then restarts itself in a normal rhythm. Once that happens, the paramedic's heart then restarts, because it stopped as you see that period of flatline on the monitor. The longest I've seen was six VERY long seconds. Most of the time, it's less than a second, followed by a big burst of electrical activity accompanied by a patient yelling "Oh, shit!", or some variant thereof. (The whole stopped and restarted heart thing is kinda painful.) All of that keys on gaining IV access, which we didn't do. Three of us tried for almost 15 minutes, and we got nothing. This poor lady had nothing for veins. Finally we decided to implement Paramedic Emergency Procedure #1: If all else fails, put the patient in the back of the ambulance and take them to the hospital. Vagal maneuvers (Bearing down like you're trying to overcome the worst constipation you've ever had.) hadn't worked, maybe cold air would. Both of those stimulate the vagus nerve, which can slow heart rate. Sometimes that can put you back into a normal rhythm, other times it just makes you pass out and causes your panicky family to call 911 so we can tell you to eat more fiber. It can also kill you if you have a really iffy heart, so don't go overboard, OK? And eat more fiber. Or, there's always option "D", which is it doesn't do anything. That's what our patient picked. So we carried her down three flights of stairs in the stair chair, got her to the cot, and made our way to the ambulance. The OSHA approved way to do that was probably to walk down the sidewalk to the handicap parking space, and use the ramp there. The Fire/EMS way is to take the most direct route, regardless of obstacles, in this case a four inch curb. I lifted the foot end over the curb, but apparently "Hey, watch out for the curb!" doesn't translate into Firefighter. So the head wheels dropped four inches, jolting the patient, who promptly exclaimed, "Hey! I feel better. Do I have to go to the hospital?" A quick look at the monitor, and sure enough, she's in a normal sinus rhythm. Not one to look a gift horse in the mouth, I told her her heart was beating normally again, but she still should go and get it checked out. She agreed, and that was us on the way to the ER. They always love it when we deliver a patient with no complaint, no symptoms, and normal vital signs. Here you go. Fixed her. Whoops.

Never argue with results, I guess.