21 Chapman St — unknown

Location: SEMS HQ

Time: 7:18 Thursday

Conditions: Warm and foggy

Equipmentfully stocked

 

Dispatch

You punched in expecting the usual foggy, yawny Thursday morning, and managed to get most of the way through checking out the truck, but as you rattle around in the base fetching cannulas and gauze, the tones keep dropping and crews keep going out. By the time you’ve sorted everything out and dropped your butt onto the couch, you’re the only unit remaining at the base, and you share a wary look with Steve.

It’s only a few seconds after that the tones blare again, and you rub your temples, remarking “I think we have too much experience” as the speakers crackle…

[Ambulance 61, 6-1, 21 Chapman Street; 2-1 Chapman St… unknown complaint. EMDing now. Engine 1’s responding. 61?]

Click to expand

 

Response

As you grab the base radio, you frown. Chapman… Chapman…

“61, we have 21 Chapman. Can we get a cross-street?”

“61… cross is Pleasant. Chapman crosses Pleasant as Monadnock. On the lakefront, between Mass Ave and the highway.”

Steve is already halfway out the door, calling back, “I know where it is.”

“Rogah,” you tell the radio, and follow him out.

Engine 1 must’ve been drinking decaf this morning, and you beat them out the doors. Steve pulls onto Pleasant and starts humming along. The city is just starting to wake up and there’s traffic on the streets.

As you stare at the mapbook, you remark, “There was a time when rush hour didn’t start until 8. All these people need better jobs.”

He lets that go. “Addison, Hopkins, Peabody…” he reads from street signs.

“Two more. Lakeview, Spring Valley, then Chapman on the left.”

21 Chapman turns out to be one of the smaller duplexes on the waterfront. Most of this area is low-income residential, and you’ve done your share of overdoses and shootings here, but it’s predominantly decent families just trying to get by. Still, you’re glad to see an SPD cruiser parked at the curb as you pull up. The officer’s just getting out.

As you arrive, the radio tells you, “61, per the calltaker… there’s a language barrier, unable to get any more information. Update if you need additional resources.”

“61 copies. Show us on scene,” Steve replies as you hop out.

There are stairs galore, so he grabs the stairchair as you fetch the first-in and airway bags. Engine 1 pulls up, and you give them a wave. After a moment’s reflection, you grab the AED as well, and start tromping up the stairs with the SPD officer behind you.

The doorway marked 21 reveals more narrow stairs inside, and you climb, hearing as you do an agitated chatter of voices from above. You turn the corner and follow the sounds into a bedroom.

 

Scene

It’s a well-kept master bedroom, and an older woman is standing inside yammering at a younger man in what sounds like Korean. She’s obviously distressed, clutching at her face and weeping. Wife and son, you figure.

On the large bed, you see an elderly man beneath the sheets. He appears to be generally well and nicely-groomed, but somewhat pale, lying supine with his head on the pillow, eyes closed. Entering the room, you drop your bags and say, “Hi everyone. What’s going on?”

Predictably, you only get some rapid-fire Korean in response, with the older woman pointing urgently at the man in bed. You nod in all-knowing comprehension and move that way as Steve enters behind you.

 

Initial Assessment

Approaching the man, you bend down and gently shake his shoulder. “Hey there,” you call. He doesn’t stir.

You flip your hand and give him a firm, grinding pinch on the trapezius for several seconds. “Hey!” He makes no response, and seems generally flaccid. Through the pajama top, he feels somewhat cool.

You pull down the covers, exposing his arms and torso. With one hand you take his wrist, feeling for a radial pulse; with the other you palpate at his neck for a carotid. While your fingers do the walking, you gaze at his chest and abdomen for respirations.

Several seconds pass in silence. Steve drops the stairchair and pushes aside a few things to reach the other side of the bed. The firefighters pile in from the stairs and start filling the room.

You reposition your hands once, twice, staring at nothing as you try to summon up a pulse somewhere. But you’re having no luck, even when you stop bothering with the radial and make an earnest attempt to locate a carotid. You see no movement of the chest or abdomen either. He feels distinctly cool, although not cold.

 

 

 


 

 

After six or seven seconds, the prickly feeling at the back of your neck forces you to look up at Steve and say, “No pulse, no breathing. Let’s get him on the ground.”

He grunts and pulls off the blankets to expose the man fully. One of the firefighters asks, “What are we doing, CPR?”

“Yes sir.”

“Cool.” He shoves at the bed, pushing the tail into the wall to clear some space on the ground. Steve grabs the man’s legs, you take him under the arms, and together you lift him onto the floor. He’s light, and easily mobile with no apparent rigor.

Immediately, you kneel down, place your hands over the sternum between the nipples, lock your arms and begin chest compressions — hard, rhythmic, oscillating thrusts twice every second. The wife starts to wail, and the son pulls her out of the room.

“Got the AED?” you ask Steve, who kneels down on the other side, knees crunching. He flips off the lid from the AED and turns it on: Stay calm, it advises reassuringly.

Meanwhile, you switch to one-handed compressions — ensuring you’re still hitting a good depth and rate, which isn’t too difficult with the small patient — and use your other hand to key your shoulder mic. “Operations, Ambulance 61,” you hail steadily.

“61.”

“Cardiac arrest, start ALS.”

“… 61, you have a cardiac arrest. ALS will be from the west end. Break — P2?”

You switch back to two hands. Steve is working around you to grab the pajama top, and with a couple hard yanks, he pops off the buttons. As your hands rise between compressions, he tugs the fabric clear, exposing the chest.

He tears open the pre-connected pads, peels off the backs and slaps them onto the right pec and left ribs, positioning them around your hands as you continue pushing. Looking up, you ask the firefighters — “Can someone hop in here and start dealing with the airway? Throw an OPA in there, set up a BVM.”

One of the younger guys moves toward the head. Looking around, you realize that you’re missing what you’re usually missing. “And can someone else run down and grab our suction, a backboard, and the C-spine bag? Um… and maybe a spare oxygen tank if you could.”

“We brought our O2 up,” the lieutenant tells you.

“Oh, okay. Can someone look for some meds? Maybe see if you can get any info from the family?”

The firefighter has inserted an OPA, plugged a BVM into the oxygen and is perched over the head. “You gonna stop for a second?” he asks you.

You’re probably on your hundredth compression, but, well, no. “No, give it a second, let’s get a shock onboard if we can.”

The AED has been telling you to call for help, start compressions, and so forth, but finally the computerized voice tells everyone to Stand clear — analyzing.

You lift off your hands, hovering over the chest but obviously not touching. “Everyone clear?” Steve and the firefighter scoot their knees away a couple inches.

A few agonizing seconds pass, then you hear: No shock advised. Resume CPR.

 

 

 


 

 

 

Well, okay. You start pushing again. “Thirty more and we’ll bag,” you tell the firefighter.

The other guy clatters back into the room, leaning the backboard outside. “Just bring that suction in here,” you call.

As you pass twenty compressions, you gradually start counting aloud. “Twenty five, twenty six, twenty seven…” When you hit 30, you catch the firefighter’s eye and nod. He squeezes in one breath, another, and you immediately start compressing again after a pause of only a couple seconds.

“Let’s rotate after this one,” you announce. “Steve, you wanna do compressions, I’ll grab the head?”

“Sure.” He positions himself on the other side of the chest, ready to jump in.

“I got some meds here,” a firefighter announces as he appears in the bathroom doorway. “Ah… let’s see, lisinopril, metoprolol, simvastatin… combivent… doxycycline… allopurinol… iron… oh, and the name on the bottles is Kim Gyong-Si, DOB 7/10/43. So… about seventy years old. Can’t find a DNR on the fridge or anywhere.”

“Great, thank you. Twenty six, twenty seven, twenty eight, twenty nine, thirty.” You pull away from the chest, and as the firefighter squeezes the bag, Steve replaces your hands with his. While he starts pumping, you take the BVM and scoot over to the head.

“P5 is on scene,” you hear your radio crackle. “A61, what’s your status?”

You key back, “61, we’re working him upstairs. Bring your monitor and meds, we’ve got the rest.”

Steve makes it through a round of compressions, and you squeeze in two quick breaths before he resumes pushing. Suddenly, like magic, two figures darken the doorway carrying a giant monitor and a huge box of drugs. Ah, the cavalry.

“Hey hey hey,” one of them greets you.

It’s Liz Sola, a recently-minted medic after a bunch of years working in Scenarioville as BLS. Last you heard, she’s still feeling out her oats as a showrunner, but she’s competent with the nuts and bolts. Behind her comes the silent Ben Doherty, who you haven’t seen in ages — he’s been a medic here for over fifteen years, but nowadays just part-time, since he’s a full-time MICU RN at St. Vincent’s. Ben’s been around the block a few times, but he’s also getting a little older and seems to be talking less and less and fishing more and more.

You give a little wave with the BVM. “Hi guys. Seventy-ish years, found in bed, no pulse or breathing when we got here. No further info, unless you guys speak Korean; he was just laying there. I’m figuring a ‘woke up dead’ scenario. No problems BLSing the airway so far, we’ve analyzed once with the AED, no shock advised. Found some meds, the usual cardiac, including a beta blocker I think, combivent, an antibiotic…”

Liz slides down and starts unpacking the monitor. Steve is starting to look a little winded, so you gesture to one of the firefighters to take over the BVM and switch out at the next pause. Meanwhile, Ben places the med box on a wooden bureau and unlocks it, pulling out bits and pieces.

“Nothing on downtime?” Liz asks.

“Nope. He was cool but not cold, no rigor or anything. From what I can tell there is not one word of English spoken here.” You catch the eye of the fire lieutenant, who was trying to converse with the family earlier. He shakes his head.

Liz has her electrodes out. “Let’s get these pads off,” she says, reaching for them.

“Hang on, hang on,” you say as you pump. “I think we’re about to analyze again, let’s give it a chance.”

Sure enough, the robot voice tells you to stop CPR and stand clear. You pull off and Liz grudgingly holds back.

Shock advised, the box announces victoriously. Charging.

“Here we go,” you grunt. You wish you could be compressing, but your AEDs get angry if you compress while charging. Instead you just nod at Steve, who put his finger over the button and nods back. You’ve done this a few times before.

“Everyone clear?” They are.

Push flashing button to —

Steve thumbs the button, and it interrupts to: Shock delivered. Continue CPR.

As soon as you hear it talking, you’re back on the chest pushing. “Okay,” sighs Liz, “I’m pulling these off.”

“Go for it.” She peels away the AED pads and replaces them with the combo pads for their monitor, then sticks on the ECG electrodes.

“Okay, stop for a sec?” she asks.

You give her a beady eye like she just asked you to turn your head and cough. “You want me to stop compressions so you can see the rhythm?”

“Yes.”

There’s a long pause while you push, push, push. Finally, you reply, “Okay, I’ll give you two seconds, you better print a strip.”

She looks like she wants to deliver a shock upside your head, but instead just presses a button and starts recording. Once the paper strip is humming out, you lift your hands clear — “All clear” — for a couple moments, then immediately resume compressions. She stops printing and lifts the strip to inspect it.

Wordlessly and invisibly, Ben has sliced one of the patient’s pant legs up to the groin, and you look over just in time to see him zap an IO into the left tibia. The dude does not mess around. He flushes it and starts drawing up epinephrine.

“V-fib,” Liz declares. “Coarse V-fib. Let’s shock again.” She dials up the amps.

“Give it a minute,” Ben says quietly. He’s squeezing in a bolus of epi.

After a couple more cycles of CPR, he nods at her. “All right, let’s go ahead and shock. Charge now, when you’re ready we’ll pause for a second, confirm the rhythm and shock.”

“I can stay on here while you defib,” you offer.

“No, you can’t,” he tells you bluntly. Oh well. There was actually a memo a few months ago from Dr. Pers and the clinical staff declaring that hands-on defibrillation was “not approved” for use by SEMS, so if the whole gang isn’t on board you’d better skip it.

“Fair enough,” you reply. “Okay, let’s get ready then — everyone stay clear — on my count, I’m going to clear on three. One, two, three.

You pull off your hands, and Liz hesitates with a finger over a button while she stares intently at the lines dancing across the screen. “V-fib again, shocking –” she presses the button. “Delivered.” You immediately resume compressions.

 

 


 

 

Liz leans back onto her heels. “I’ll take a look at that airway.”

“Epi’s in,” Ben notes. “Next round is prepped.”

Liz nudges aside Steve and peers into the patient’s mouth for a few moments, then turns and unfolds her intubation roll. Snapping a Mac blade onto the handle, she tilts back the head in earnest and searches for cords. Satisfied, she takes the ET tube that Ben hands her and starts poking it in.

You watch her fish aimlessly for a few seconds while you push on the chest. Finally, she looks up at you, frustrated.

“Almost. It’s moving around too much. Stop just a minute?”

“I don’t think so.” You say it with a half-joking chirp, but you’re quite serious.

Glaring, she makes another attempt, but is becoming visibly more annoyed.

Ben taps on her shoulder. He’s holding a bougie out. “Try that?”

She just pulls out the blade and swears. “I got nothing. I’m going to use a King.”

Ben just nods. “Let me take a shot?” he offers gently.

He slides in, holding the bougie and laryngoscope.

You’re getting taxed from the continuous compressions, so you nod at the firefighter to jump in. “Get right in here, put your hands next to mine — I’m just going to pull off and you get right back on. Exactly like I’m doing, deep, twice a second, just boom boom boom. Don’t miss a beat. Okay, one, two, three –” you pull off and he takes your place.

“Beautiful. Little bit slower and deeper, really aim for the floor. And all the way up at the top. Big, long strokes like you’re working a floor pump. There you go.” You lean back, wiping off sweat.

Ben is staring intently into the airway, bobbing his head slightly in time with the compressions. “Give me just a little pressure on that trachea?” he asks Liz. “Toward me and to the right.”

She manipulates the larynx. “Ah… no…” He releases the bougie, reaches over, and gently maneuvers it. “Just right there. Hold it exactly like that.”

While she maintains the pressure, he takes the bougie again and eases it forward. “Okay, I’m in.” He slips the tube over the bougie and inflates the cuff.

Liz hands him the end-tidal capnography attachment, which he secures to the tube, followed by the BVM. He squeezes as she auscultates over the abdomen and then the lung fields.

“Nothing on the belly… good sounds on the chest.”

Ben is staring at the monitor, which is tracing the capnography waveform. There are a series of visible bumps corresponding with the chest compressions, but after each squeeze of the bag, a much larger hill appears.

“Nice waveform… cap about 18. Looks good.” He screws a tube holder into place, firmly securing the endotracheal tube.

“Let’s do a rhythm check,” Liz announces.

“Okay, same drill,” you say, indicating the firefighter. “Count of three, you come off, she’s going to print a quick rhythm strip, then right back on, okay? No more than a couple seconds.”

He nods tightly. They pull it off with only a brief interruption in flow.

Scooting over, you take the bag from Ben. “I gotcha.” He moves back toward the feet.

“V-fib again,” Liz says.

“Go ahead and shock,” replies Ben.

“Okay, one more time then, on three? Everyone get clear on two, when I say three I’m pushing this button.”

You approve. Liz seems to be embracing your “on three” drill.

“One, two” — everyone pulls away from the chest, lifting up their hands to emphasize the distance — “three, delivered.” The firefighter hops back on the chest and you resume gently squeezing the bag every eight seconds.

There’s a chatter of Korean from the kitchen, sounding like a new voice. The lieutenant pokes his head in. “Hey, the son just showed up, he speaks English if you want to talk.”

 

 

 


 

 

 

“Hang on,” Ben says as he gets ready to push some more epi into the IO. Liz is peering at an arm, looking for IV access.

You nod at Steve and hand him the bag. “I got it.”

Walking into the kitchen, you find the family with a new addition, a man appearing in his early 20s, wearing a suit and appearing flustered. “Hi there,” you say. “You speak English?”

“Yes, I’m Kwang-Ho Kim, that is my father.”

You extend a hand and shake. “I’m Sam, from the ambulance service. We’re trying to get a little more information; would you mind translating?”

“Yes, of course. My mother does not speak any English, or my brother.”

“That’s fine. Can you ask what happened this morning?”

He says a few words, and gets a patter of Korean back. Translating, he tells you, “She says… she woke up at about 7:00… he woke up too… but he said he was feeling bad… so she got up to make him some tea… and when she came back he was asleep and would not wake up.”

“How long was she out of the room? How long between when she saw him awake,” you make a gesture to emphasize the interval, “and when she found him not moving?”

“She says… perhaps ten or fifteen minutes only.”

“Okay. When he said he was feeling bad, what does that mean? Bad how?”

“He was feeling… just bad… ill, rubbing his chest… he sometimes has indigestion.”

“How has he been recently? Yesterday for instance? Any problems or illness?”

“She says no.”

“All right. What sort of medical problems does he have?”

“Ah… his blood pressure is high… and his cholesterol, quite high… he has some breathing trouble, he smoked for many years. He takes a…” he acts out sucking down an inhaler, “a medicine for that. His joints also give him pain sometimes. But he is pretty healthy. He walks every day.”

“Has he ever had a heart attack?”

There’s some back-and-forth. “She is not sure. I think… I think perhaps yes. He was in University Hospital for almost a week last year.”

“Does he have any allergies? To any medicines or anything else?”

They chatter for a while, and eventually the wife leaves the room and returns with a scrap of paper, which the son inspects. “Yes, he is allergic to… here…” he shows you the paper, pointing. Someone has written in pencil: “ALLERGIC TO DIGOXIN AND MORPHINE”

“Okay. So does he usually visit University Hospital?”

“Yes, usually. I think he has been to Memorial Hospital several times also.”

“Great, thank you.” You clasp your hands and slow down a little. “I want to let you both know what’s going on right now. Right now, her husband is very sick. When we found him, he was not breathing, and his heart wasn’t beating. We’re doing everything we can to try and revive him. It sounds like she called us quickly, and we got here quickly, so that’s all a good thing, but you need to understand that it’s possible he will not survive.”

Kwang-Ho hesitates, and then carefully translates to his mother. She stiffens, but seems to be calming down and takes it well. “She says… she says okay.” He takes a deep breath. “Thank you. Will you take him to the hospital?”

“Yes, we probably will, but right now his best chance is if we do everything we can here. If we get his heart beating again, we’ll bring him to the hospital. Either way we’ll let you know what’s going to happen as soon as we can.”

“Thank you.” He guides his mother to the kitchen table and sits with her.

You turn and reenter the bedroom. You’re surprised to see another face in the party — Captain Miller, the C13, one of the younger officers and a pretty good medic. Ex-military. There are quite a few chefs in the kitchen already, so he’s just standing with his arms crossed, doing the big-picture thing and giving the whole scene a hairy eyeball.

“Hey Captain. Glad you could make it.”

He nods at you. “Sam. Good show.”

Addressing the room, you say, “Okay folks, here’s the story per the wife. They both woke up about 7:00, he was conscious but complaining of some general malaise, maybe nausea and chest discomfort, she left the room to make some tea, returned around 10-15 minutes later, he was unresponsive and she called right away. So downtime is somewhere between zero and 15 minutes, plus our response, so maybe a max of 19, 20 minutes. No recent complaints, history of hypertension, high cholesterol, seems to be gout and mild COPD, possibly a heart attack last year. Followed at Jefferson. Allergic to dig and morphine.”

“Got a med list?” Miller asks you.

“Yeah, uh…” you look around and find the lieutenant. He hands you his paper with the meds and demographics. “Yeah, right here. How are we doing?”

“More epi, shocked again, still V-fib,” Liz answers. “Just gave some amio.”

You see that someone’s managed to get a couple bilateral IVs as well. “What’s the end-tidal?”

Ben looks up from squeezing the bag. “19.”

“So…” you shrug. “So-so. And it sounds like probably an underlying MI?”

“We’ll grab a 12-lead if we get a pulse,” says Capt. Miller. “Otherwise let’s keep working it. If nothing breaks after a few more cycles, we’ll transport.”

Nods all around. “Any other ideas?” Miller adds.

“Narcan?” Steve grunts.

“Seems like a real stretch if there’s no narcs in the house. Especially if he’s allergic to morphine. Maybe give it a shot later.”

“About time for a rhythm check?” Liz asks. Ben nods.

“I’m guessing V-fib again, so let’s just pause, I’ll confirm and shock right away if so. Okay, one, two, three” — everyone stops, she glances at the screen, and then thumbs the button. “Delivered, go ahead. V-fib.”

Ben goes back to squeezing the bag. With nothing else to do, you pull out your phone, meaning to turn on your audible metronome app to help pace compressions; one of the firefighters is on the chest now and seems to be a little erratic with the beat.

“Hey, hey, hey, look at that,” you hear Liz exclaim.

She’s staring at the monitor. The ETCO2 tracing shows a massive spike.

“30, 40, 50 — shit, I think we’ve got pulses, people.” She’s grinning.

On the display, you watch the ETCO2 reading cap at 55, then start trickling back down.

“Okay, keep it together,” Miller reminds everyone. “Let’s give it a minute to settle out and then do a pulse check.”

The CO2 stabilizes around 43 and stays there. After another thirty or forty compressions, Miller says, “All right… let’s stop compressions and bagging for a second. Ben, you have a carotid there?”

Ben feels at the neck. There’s silence in the room.

“How about that,” he says gruffly, but with a smile. “That’s a nice, strong, regular carotid.”

 

 

 


 

 

 

There are happy faces all around. “Okay, before we start high-fiving, let’s make sure we keep it that way,” says Miller. “Let’s get a pressure and a sat.”

You kneel down and wrap the automated BP cuff around a forearm, then press the button to cycle it. Steve clips the pulse ox probe to a finger on the other hand. Liz is rubbing at the sternum with her knuckles, but there’s still no reaction.

“Sat’s 97%,” Ben reports. “Beautiful waveform. Rate is 69.”

“Do you have any spontaneous respirations there?”

Ben is holding up the BVM, staring down. After a moment, he reports, “No.”

“Okay, let’s keep bagging. What’s that pressure?”

The NIBP finishes just after he asks. “103/71,” you read off.

Miller jots it down on a strip of tape stuck to his leg. He seems to be scribing all the times, which is something only a captain would think to do.

“What was that sugar from before?” he asks Steve.

“99.”

“I’m going to hang some fluid,” Liz announces.

“Wait one second,” says Miller. “Let’s use the chilled saline.”

He turns to one of the firefighters. “Could you run down to my truck, please? Pop open the trunk, there’s a cooler on the ground. Just open it up and grab one of the cold bags of saline.” Miller hands him the keys, and he takes off.

“Let’s get a 12-lead,” Ben grunts. “While we still can.”

“Yep.” You help Liz stick some more electrodes to the chest, fitting them around the big defib pads.

She prints off the 12-lead. The firefighter comes running back in and hands Miller the saline, who spikes it and plugs it into the big IV in the patient’s right AC. He’s standing, so he just clips the bag to one of his epaulets using a hemostat from his pocket. He look very regal, like a human IV pole.

“Sinus… normal sinus, borderline brady,” reports Liz as she peers at the ECG. “PVCs. I have… three or four boxes of elevation in V2, V3, V4, a little bit in V5, about three boxes of depression in II, III, aVF. First degree block.”

“Sounds like a STEMI to me,” says Miller. “Let’s get packaged and shoot over to Jefferson. I’m going to give them a call and activate them now so there’s absolutely no excuse if they’re not ready.”

He plays with his radio and brings up the hailing channel for JUMC. When they come on the line, he rattles off in a clipped military tone: “JUMC, Scenarioville Paramedic 2 with a STEMI activation. We have a 70-year-old male found pulseless, 15 minute downtime, V-fib on arrival. Four shocks, epi and amio, converted to normal sinus. Pressure now 103/71, remains apneic and unresponsive, he’s intubated. There is clear ST elevation with reciprocal changes in anterior leads, with anginal complaints reported prior to arrest. Infusing chilled saline now. Activate the cath lab and stand by for your hypothermia protocol. ETA will be about 17 minutes. Any questions or concerns?”

“No, thank you, we have the post-arrest patient with STEMI activation, 17 minutes. Jefferson out.”

Meanwhile, you’ve grabbed the backboard and rolled the patient atop. A few straps hold him down. Miller hands Ben the saline and steps into the kitchen to let the family know what’s going on. You try to coordinate how you’re going to carry this guy out amongst the countless tubes and wires.

“Okay, this BP tube is all tangled, I’m just going to pull this off. Let’s have you at the head, with the saline, and Liz behind you with the monitor. I’ll get the feet. Is there room to bag on the stairs? Okay, Steve will be on the right side bagging and watching the tube. Can someone get behind and just spot me? And you guys have those bags? Perfect.”

As a messy but relatively contained unit, you lift the board and start moving toward the stairs. It’s gnarly, but you fit, and nobody dumps anything or anyone.

Outside, you realize that nobody thought to grab the stretcher. A couple of the firefighters quickly fetch it from the P2 and drop it down. You lower the board atop and secure some straps.

“Okay, monitor on the back, hang that saline.” You load them into the P2, Steve handing the BVM off to Liz as the stretcher rolls inside.

“All right, how are we doing, do we need a minute?”

“No,” says Liz, “I think we’re all set. Captain, can we get some more of that saline?”

“Yep, hang on.” He disappears and returns with a couple more liters of chilled NS.

“You all need me back here?” Miller asks.

“I think we’re okay.”

“All right, so then — Steve, you’re driving them? And Sam, you got the 61?”

Nods all around.

“I’m out of here then. Great work, everyone.” Miller waves, and he’s gone.

“Okay, let’s run. Jefferson, nice and easy, but get us there,” Ben says.

Steve nods and closes them in, then heads for the front. You walk over to the 61.

It’s not a long drive, although traffic has certainly picked up. You futz the rules a little and throw on your lights, following the P2 from a safe distance; you’d like to be there when they unload. Steve gets everyone there in under 5 minutes.

You park in the lot and walk over to the bay, meeting Steve in the back, where he throws open the doors. Everything looks much the same, although there are now ice packs wedged around the patient like he’s fresh fish.

“Still doing okay?” you ask.

“Yep,” Ben grunts. “Everything’s clear, go ahead.”

Steve pulls them out, and you take the BVM from Liz as the head clears.

You roll inside, and you’re immediately met in the hall by the attending — Dr. Smith or Smythe or something, you don’t know him well. He’s with another doc who you take to be the interventionalist.

“Hi. This is your code?”

“Yes sir.”

“Give me the quick story?”

Liz steps forward. “So, ah, it’s Mr. Kim, 70 years old. Awoke with his wife at 7:00 AM, complaining of some general chest discomfort and feeling poorly; she left him to make tea and returned about 15 minutes later to find him unresponsive. No bystander CPR instructions due to a language barrier, but response in under five minutes, so downtime is between 5 and 20. Pulseless and apneic on BLS arrival, immediate CPR, no shock advised initially, then one from the AED. ALS arrived, we had coarse V-fib on the monitor, shocked two more times with persistent VF. Three rounds of epi and one of amio. Intubated during compressions, end-tidal was persistently around 19. Finally shocked again and converted to normal sinus with” — she hands him the first 12-lead — “elevation in V2 through V5. We’ve given about half a liter of cold saline and ice packs on the groin, neck, and axillae. Pressure’s about 110/80 now, rate mid 70s, sat 98%. Still unresponsive, no spontaneous respirations, end-tidal around 40. Allergic to dig and morphine.”

He peers at the monitor, pokes the patient a couple times and listens briefly at the chest. In the background, someone from registration takes down the patient’s name and date of birth. Meanwhile examining the ECG, the interventionalist asks, “Access?”

“There’s a 16 in the left AC and a 16 in the right, plus an IO in the left tibia. All patent.”

“All right. Stay on the stretcher, the team is waiting for you. Jim will bring you to the cath lab.” He indicates one of the nurses. “I’ll meet you up there.”

“Are you set up for the hypothermia?” Ben asks.

“Ah… can you keep the cold saline running?”

“Yes, we’ve got a couple more liters.”

“Do that for now, we’ll bring up the Arctic Sun momentarily.”

Ben nods, and you head upstairs with a couple of their staff. Elevator, turn a couple corners, and you’re there.

Inside the suite, a handful of people are waiting in gowns. You bring the stretcher alongside the treatment table, and many hands help lift the patient over. Liz gives her report again while the RT sets up a vent.

“All right, thank you folks. Great work.” They politely but firmly push you outside, and set about doing their thing.

You’d like to stay and watch, but you know it might be a while, and there’s always follow-up on these cases anyway. So the four of you roll back downstairs and start tackling the huge mess you’ve made of your gear.

During a lull, you find yourself alone with Liz. “Hey,” you tell her. “Sorry for being a Nazi about the compressions.”

She scrubs the stretcher with some sanitizing wipes and offers a grudging half-smile. “You know what, thanks for doing it. I mean, you were right, and I know that. It’s just hard to focus on that stuff when you’ve got this checklist in your head of what needs to get done, you know?”

You nod. “Oh, trust me, I get it.”

“But you’re right. I appreciate you keeping me honest. That was a good code.” She doesn’t sound thrilled, but she sounds pleased.

Tucking your shirt in and wiping some sweat from your forehead, you smile.

“Yeah. It was.”

 

 

Discussion

Diagnosis: cardiac arrest secondary to 100% LAD occlusion

You hear back from the clinical services department, which automatically follows up on both cardiac arrest and STEMI patients. The case is also discussed at the monthly SEMS M&M rounds hosted by Dr. Pers.

The patient is catheterized by the interventional team, and found with a near-total thrombus occluding the proximal LAD. It is successfully reperfused by balloon angioplasty, and a stent is placed.

The patient is transferred to the cardiac ICU with ongoing hypothermia therapy (via external cooling blankets). He remains unresponsive for the first two days, but after being gradually rewarmed, begins to show signs of life. After six days, he is extubated. Although he contracts a mild pneumonia during his stay, he has an otherwise excellent course of care, requiring no pressors.

Once stable, he undergoes surgical implantation of an implantable cardioverter-defibrillator (ICD), and is discharged to rehab with mild residual neurological deficits. Two months later, he returns home.

Dr. Pers highlights the case as a textbook example of excellent resuscitative care surmounting initial challenges to survival. You couldn’t agree more, and the fuzzy feeling stays with you for weeks. Score one for the good guys.

Comments

  1. In families like this many times the youngsters know perfect english and it seems prudent to locate someone who can speak for the family. We don’t know if they called because he was fine 10 minutes ago or if he’s been in home waiting to die and family was there saying goodbye. I honestly don’t know the protocol for the life of me. Possible thoughts:
    If he just recently stopped breathing it’s probably a good time to call for ALS intercept to get the guy tubed and poked. CPR and a can do attitude. I think there’s a list of things that must be noticed like pooling of blood, rigor, etc before he can be called DOA. If his death was an expected thing it’s time to ask about a DNR or living will. Any advanced directives will play big.
    A bit of care and empathy will go a long way. If you start beating on grandpa’s lifeless corpse because they called you to take his body you might piss off the family. And if you delay treatment because you can’t get any answers you’re gonna hate yourself and have some explaining to do.
    I guess that leads me to trying to communicate right away. If you can’t breach the language barrier with an in house interpreter I know there are numbers you can call to get a translator on the line quickly.

    • All good thoughts. Most places have criteria for withholding resuscitation, usually signs of obvious death — around here things like transection of the torso, decapitation, whole-body burns, heart or brain removed, or more plausibly rigor and lividity. Or, of course, a valid DNR in hand, but when in doubt you have to start resuscitation until someone comes up with it. Ya err on the side of working ’em.

      I know our company ostensibly has access to an interpreter service through dispatch, but I don’t know anyone who’s ever used it…

  2. As always, amazing scenario! These are invaluable to BLS & ALS providers alike.

  3. Good Scenario but no meds until after the second shock for VF/VT and we don’t stop CPR to check a rhythm after the shock, The person is an EMT from the sounds of it but don’t be afraid to tell the paramedic the protocols. 2 minutes minimum in between shocks. You know the old joke (that I made up) How many paramedics does it take to screw in a light bulb? 4 and a basic to bring them the light bulb 😉

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