Tag Archives: sepsis

Dead Space

dead

1 – having lost life, no longer alive

2 – having the physical appearance of death; a dead pallor

3 – not circulating or running; stagnant: dead water; dead air

 

space

1 – the infinite extension of the three-dimensional region in which all matter exists

2 – an empty area which is available to be used

dead space – a calculated expression of the anatomical dead space plus whatever degree of overventilation or underperfusion is present; it is alleged to reflect the relationship of ventilation to pulmonary capillary perfusion

Walking back into the ED room to get a signature from the nurse I’m momentarily surprised at the level of commotion surrounding the man that was my patient just a few minutes ago. I look up to the overhead monitor that displays his vitals and see the obvious cause for excitement – asystole, the most stable heart rhythm in the world, is marching across the screen and slowly erasing the beautiful complexes of normal heart beats as it fills the screen with the flat line of death. The Paramedic Intern pulls a short step stool out from the corner just as the attending MD makes the call for him to begin CPR. Well, I guess my differential diagnosis was correct, small comfort considering he’s dead now.

There’s a question in paramedicine that is useful to the Paramedic in deciding a course of action on any given call – is this person big sick or little sick? The speed at which we can determine the acuity level of any given patient helps us in determining how fast we move through the call. On occasion the first look at a patient can tell you everything you need to know in terms of acuity. As I walked into the bedroom I could see that this is one of those times. My new patient looked up at me from the bed and it’s obvious that this is big sick and I’ll be moving fast today.

The firefighters arrived just a few seconds before us so they’re still attaching the monitor  leads and trying to get a blood pressure. I know what they’ll find based on the patient’s skin signs alone. The term – pale/cool/diaphoretic – gets overused in our business but it still surprises me when I see these skin signs manifest on a patient. A man of his ethnic background would be hard pressed to look pale so the fact that he looks ashen tells me all I need to know. My first thoughts on a call like this are about extrication. I want to get this guy out of here, into my ambulance, and start driving. Everything else can be figured out on the way to the hospital but the main priority is getting him from the bedroom to the ambulance. The problem is that he’s over two hundred pounds and there are three flights of stairs between me and my ambulance.

I send my partner back to the rig for a stair chair as I start to take in the vital signs and patient history to see if I can paint a picture of the last few hours that led to this big sick presentation. It seems that he and his wife were out running some errands and he started feeling sick about an hour ago. He vomited once and now he’s presenting with an altered mental status, very low blood pressure (72/48), fast heart rate (118 bpm), clear lung sounds, and skin signs that are screaming “heart attack” at me. Of course that was until I ran the 12-lead for the second and third time. The results keep showing nothing even remotely concerning in the cardiac department. In his altered state the only intelligible uttering I can make out from him is, “I…can’t…breathe…”

I put a non-rebreather oxygen mask on him and start the trek of three flights of stairs to the ground floor and the relative comfort of my ambulance where I can start to figure this thing out. The new stair chairs with the revolving treads make quick work of the stairs while preserving our backs in the process. It seems we’re on the ground floor in just a minute or two and headed towards the ambulance.

Finally inside the ambulance, I have decent light and all of my tools at hand so I can try to analyze his condition while driving to the closest hospital. I’ve already ruled out the possibility of a STEMI (S-T elevation myocardial infarction – a.k.a. heart attack), which would require a cath-lab, so I am free to head to the nearest hospital. As I check his 12-lead a fourth time – on the right side this time, still looking for the elusive STEMI – the firefighters decide it’s a good opportunity to leave. Figures. Looks like I’m on my own on this one.

With lights flashing and the siren singing a duet with the air horn I bounce down the road while starting two IVs in my quickly fading patient. Once that’s done I set up two bags of warm saline flowing wide open to drop as much fluid on him as possible and try to keep that blood pressure out of the double digits.

I slip the non-rebreather off of his face and put on a nasal cannula that has a receptacle for reading the exhaled breath and measuring the end tidal carbon dioxide (EtCO2). I actually do a double take as the reading comes back as 8 when the normal reading should be between 35 and 45. Hell, I’ve stopped CPR and pronounced people dead with higher EtCO2 readings!

A number this low just doesn’t make sense. I listen to lung sounds again and they are still coming up clear. I check his blood sugar to rule out a DKA (diabetic ketoacidosis)  presentation and it comes up perfect. Sepsis could possibly take the reading this low and explain the presentation but not with an onset of just one hour. There’s only one other differential diagnosis that is making sense to me right now and when that flashes into my head I’m more relieved than I can admit to see the bright lights of the ED out of the back window as my partner backs us into a spot by the double doors and I prepare to give my findings to  the doctors on the other side.

In these days when science is clearly in the saddle and when our knowledge of disease is advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers. 

Dr. Harvey Cushing

 

Ghost Rider

ghost

1 : any faint shadowy semblance; an unsubstantial image; a phantom; a glimmering; as, not a ghost of a chance; the ghost of an idea

2 : the disembodied soul; the soul or spirit of a deceased person; a spirit appearing after death; an apparition; a specter

3 : to die; to expire

rid·er

1 : someone who rides on an animal such as a horse, or on a vehicle such as a bicycle or motorcycle

2 : a supplementary clause or amendment added to a legislative bill, insurance policy, or legal document

As a rule, the more bizarre a thing is the less mysterious it proves to be. It is your commonplace, featureless crimes which are really puzzling, just as a commonplace face is the most difficult to identify.

Sir Arthur Conan Doyle – Sherlock Holmes – “The Red Headed League”

I walk into the small eight-by-eight foot room with a single empty desk pushed up against the wall. Two men with guns strapped to their waists follow me in and sit down in the Spartan chairs to either side of the desk. Obviously the chair left for me is the “hot seat.” I don’t see a spotlight shining on the chair but there’s no mistaking the fact that this is an interrogation room and the men with the guns and badges have some questions for me today.

“Let the record show that Detective Jones and Detective Brown are present with Paramedic KC. Today is one, one, eleven at 1500. Paramedic KC, do you recognize this man?” He slides a picture across the table to me – actually it’s a mug shot with lines showing height behind a perturbed looking man facing the camera.

“Yes sir. He was my patient three weeks ago.” I’m starting to wonder if this is the time when I should ask for a lawyer. At least they didn’t read me my Mirada rights. I wonder if that’s a good thing or a bad thing. Either way it’s obvious that the conversation is being recorded by the way that they are verbally describing the occupants of this very uncomfortable room.

“Can you sign here please? This acknowledges that you recognize the person in the photograph and that he was your patient on the date written below.” OH CRAP! This is starting to sound serious…

“So, the man in that picture passed away three days ago and we’re looking into the cause as a possible homicide. Can you describe the circumstances in which you met this man and what transpired during the time you were with him?”

— 

Medic-40, copy Code-3 for the man who fell of his bicycle three days ago.” The radio crackles to life interrupting the enjoyment of my afternoon quad-espresso over ice.

“Medic-40 copy, we’re en-route.” Kevin flicks the lights on and chirps the siren to enter traffic headed in the direction of the call. Seriously? Code-3 for a three day old bike accident?

As we pull up to the Church’s Chicken I see a man sitting on a bench by the door with three firefighters standing around him. The guy has to be 450 pounds and from the rig I can see that he’s interacting so he’s probably okay. “Let’s leave the gurney in the rig and see if this guy can walk.”

“Exactly what I was just thinking.” Kevin and I are on the same page. Lifting a man that size on a gurney is a group effort and anything to avoid injuring ourselves is a good thing. Classic, a fat man sitting in front of Church’s, who would have thought…?

As I’m getting out of the rig the man stands up with the firefighters and starts to lumber towards us. Awesome, he walks!

Once he’s situated on the gurney, in the back of the rig with me, I start asking questions as Kevin starts entering information into the computer. It’s not exactly a stat call so we have time to sit here and do an assessment prior to rolling to the ED.

“Okay, so I understand you fell off of your bicycle three days ago. Why are you calling us today?” I’m taking a blood pressure and getting him hooked up to the monitor while I ask questions.

“Cuz it just kep gettin’ worser so I has to get checked out.” He’s pleasant enough and almost seems apologetic for having to call us. It’s a normal occurrence for us; people with no insurance put off going to the clinic as long as they can and then call 911 to get treated in the Emergency Department.

“What got worse?”

“All this swelling in my face. This ain’t normal for me.” I wiggle past him to the foot of the gurney so I can see his face straight on. Sure enough – now that I look at him straight on I see that his face isn’t symmetrical – his jaw and cheek are swollen on the right side.

“Yep, that’s swollen all right. So this all happened in the last three days?” He nods his head and it looks like it hurts him just to do that. “Okay, let me feel your jaw.” I put my hands on either side of his mandible and he opens and closes his mouth, wincing in pain as he does it. No clicking that I can feel and the jaw seems solid – probably not broken – but it’s hard to say with all the fat and swelling deforming the normal jaw lines. I pull out my flashlight and look inside his mouth and I’m met with a putrid smell and green/yellow puss on the right side. Yikes!

“Looks like you got a pretty bad infection in there.” The infected teeth and the vitals that I got are starting to add up to a pretty sick guy, quite possibly a lot worse than he looks.

“I got bad teeth, you know, don’t go to the dentist all that much. I think when I got hit they got knocked loose a little. Then I start spitting that yellow stuff today so I called you.” Fair enough, but hold up…

“You got hit? I thought you fell off of your bicycle.” I’m having a very hard time picturing this man on a bicycle. I’ve gone to calls for a lot of bicycle accidents and I can’t remember anyone being over 200 pounds, much less 450.

“Yeah, you know, when I hit the ground.” Okay have it your way. I check out the side of his face with my flashlight and don’t see any road rash or bruising – just inflamed swelling and a bit of redness.

Either way, the damage is done, and all I can do is treat what’s in front of me so I start transporting him to the ED while I look over his fat skin in hopes of finding a vein for an IV. His heart rate is in the 130s and respirations of 32 with an end tidal carbon dioxide of 23. The temporal thermometer comes back with a fever of 101.7. Everything is adding up to sepsis but it’s still a little early so he’s not going into shock yet. At the ED they’ll drop a few liters of fluid on him and start some IV antibiotics. They’ll take x-rays of the jaw to see if the infection has progressed to the bone – if so he’s in for some pretty painful surgery. I can get the process started now and see about taking the edge off of the pain.

I crack open an ice pack and have him hold it to his jaw as I thread a 22 gauge catheter into the only vein I can find – in his knuckle. It’s too small to get very much fluid on board during my short trip to the ED but I leave it wide open just to start the process as I break open the morphine vial.

He’s a big guy so I’m sure he can take as much morphine as I’d be allowed to give him so I’m surprised as we’re pulling up to the ED he tells me that his 10/10 jaw pain is now a 0/10. Awesome! At least I did something for him.

As we push him into the ED a triage nurse that I don’t recognize is taking my report. “Fell off his bike three days ago? You can take him to the lobby.” There’s a nursing strike right now and this woman has a thick southern accent – she probably just flew in to help staff the hospital and isn’t too familiar with how we do things in this county.

“Yeah, can’t do it. I started an IV and gave him fifteen of morphine. If he’s not septic yet he will be in a few hours.” Sorry if I’m inconveniencing you by actually treating patients…

“You did what? Oh fine! Give him Hall-6.”

My last memory of him is sitting in the corner of the ED as he thanked me and waved goodbye.

“So you never saw a bicycle at the Church’s Chicken?” Detective Brown has been taking notes while Detective Jones asks some follow-up questions.

“No, didn’t see any bicycle. He said it happened three days ago so it didn’t surprise me not to see one. I still can’t picture a man his size on a bicycle but that’s what he said.”

“Anyone standing around him when you arrived?”

“Just the firefighters.”

“Okay, KC, I think that’s about all the questions we have for you. We appreciate you coming in.” What, that’s it?

“Can I ask what happened? I mean, why a homicide investigation?”

“Well, we’re still trying to figure out what exactly happened. I can tell you that he was treated at the ED and ultimately transferred to University Hospital for surgery to clean up an infected jaw. He eventually died at that facility from the injury. There were no medical malpractice issues but the cause of the injury is suspect so we’re looking into it.”


Paralanguage 1/3

para·lan·guage

1 : nonverbal means of communication, such as tone of voice, laughter, and, sometimes, gestures and facial expressions, that accompany speech and convey further meaning

2 : vocal features that accompany speech and contribute to communication but are not generally considered to be part of the language system, as vocal quality, loudness, and tempo: sometimes also including facial expressions and gestures

3 : communication other than verbal

We’re responding to a home in the suburban sprawl area of my mostly urban county for “the unknown.” I used to get upset or nervous when the call wasn’t spelled out for me before I got there but now I’ve learned to embrace the unknown. At a time when the world economy is so uncertain, and the local government is cutting services, I’ve come to see the unknown as job security.

Walking into the bed room I see a man in his sixties laying on the bed with only his boxer shorts on. The fire lieutenant (LT) is using a bag to squeeze air into the mans mouth while the fire medic is checking a blood sugar. He looks up at me with just a touch of sweat on his brow. “Hey guys. So, per family, this guy is just sitting on the bed and his eyes roll back in head head and he goes unresponsive. Currently he’s: GCS-3 (completely unresponsive), irregular heart rate in the 150s, agonal respirations, oxygen saturation in the 70s, lungs sound like junk. He’s got a history of hypertension, diabetes, renal failure, pneumonia, seizures, he’s been sick for three days, and missed dialysis yesterday.” He looks down at the glucometer then back up at me. “And his blood sugar is 382.” FUCK ME!?! This guy is the quintessential train wreck!

There’s half a dozen things wrong with this guy that could cause this current state and lead to death very soon. At times like this paramedics fall back on ABCs – airway, breathing, circulation. Not having a patent airway and not breathing will kill someone faster than anything else so it’s our first priority. LT is managing the airway by holding my new patients head at a good angle and he’s breathing for him by squeezing the bag. I pull my stethoscope and listen to lung sounds; rhonchi, crackles, rice crispies, pop rocks, and an angry donkey – junk. The unknown sucks!

LT looks up at me. “We could C-PAP him.” It stands for continuos positive airway pressure. Basically a very tightly fitting mask with very high flow oxygen that helps to keep the lungs inflated and push out fluid. It’s usually used with congestive heart failure patients with fluid in the lungs.

“I can’t C-PAP an unconscious patient.” The LT is medically trained to the level of EMT-B so he may not be fully versed the the paramedic advanced life support protocols. C-PAP is contra-indicated for the unconscious patient.

“Yeah, but it might help.” He’s persistent.

“It might but I still can’t do it.” I turn to Scottie. “Can you grab the tarp from the rig? I just want to get moving with this guy.” It takes the five of us to carry him out on a big tarp with handles on the edges. We get him loaded into the ambulance and the fire medic jumps in with me as Scottie starts the drive to the ED with our strobes on and siren blaring.

My patients mentation has been improving a little over the last few minutes of getting high flow oxygen. The fire medic is starting an IV while I’m pushing a tube down the nostril so as to have a more patent airway. Suddenly big, round, and frightened eyes stair up at me and he starts ripping off electrodes and struggling with us. Guttural animalistic noises are coming out of him and it’s all we can do to save the IV. He’s combative and altered yet, strangely, I’m okay with that.

Paramedics have a saying that pertains to working with babies – a crying baby is a good baby. If a baby is crying you know he has a good airway and he’s definitely breathing. Well, the same is true for this guy. I’d rather have him agitated and altered than unresponsive; so this is actually an improvement. Looking out the back windows I see that we’re pulling into the ED parking lot.

I made sure that we transported to an ED that specializes in strokes and heart attacks so I know that anything that I was not able to check will be dealt with at the appropriate level. Sometimes in EMS there is nothing we can fix in the field; it’s just better to drive and get the patient to the ED so they can sort out what is going on.

I’m standing at the back of the rig as Scottie is cleaning up my mess. “Can you believe the LT actually wanted to put him on C-PAP?” An arm reaches past me to the box on the door that we keep full for the fire department restock. The LT pulls out a non-rebreather mask. Scottie has the “dear in the headlights look” as I turn to face to LT. “Hey, I really appreciated your help on this one, thanks fore letting me borrow your medic for a ride to the ED.” It’s my lame attempt to cover the fact that I just made an unflattering remark about the man while he was standing right behind me.

“Yeah, no problem.” And he walks off. CRAP!

Ultimately the patient had pneumonia which led to sepsis. Checking on him four days later I come to find out he’s still in ICU. He was already in an advanced stage of MODS (multiple organ dysfunction syndrome) and at the time his prognosis was not favorable for recovery.

I go out of my way to ensure I have good relationships with the Fire Department crews that I respond with. Yet this was a comment I made in the heat of the, post adrenaline, moment that was inappropriate. In EMS your partner is your sounding board and I sounded off in an unsecured place; with the doors open while parked at the ED. I should have shown better discretion and I wish it didn’t happen. But all I can do is move on to the next call.

Peaceful Warrior 3/3

Walking into the small bedroom with the fire medic we can actually feel the heat radiating off of the little old man laying on the bed. He’s frail and skinny, dressed in traditional Punjab garb and a matching turban on his head with a long white beard. Sitting on a side table by the bed I see the Kirpan. It’s a curved knife, one of the five external articles of faith, that symbolizes the safety of all and the carrier’s personal duty and responsibility as a Sikh to protect the innocent in the message of peace.

The family called us because he’s “not acting right.” It’s a common call in this mostly urban county and pretty much just means I have to rule out everything with a full work up. My new patient tracks me with his eyes as I kneel beside the bed to put my hand on his chest; attempting to get a quick read of core body temperature. Even through his light clothing he’s really hot and I notice he’s not sweating – bad sign.

“Does he speak English?” I’m addressing the grandson who followed us into the bedroom. In families that are recent immigrants I find that the children make the best translators as they learn English through the schools.

“I speak little English,” replies the boy in a thick accent and not directly addressing my question. I don’t think I’m going to get much translation on this call.

I try going back a forth a few times to get an assessment of my patient’s mentation, his normal baseline, medical history, allergies, medications etc. I’m batting about 50% on getting straight answers and quickly decide to stop waisting time and get moving to the hospital.

I take the time to explain to the family that I’m going to have to remove my patient’s turban. He’s burning up and I need to start the cooling process. They’re not happy about taking off his turban but eventually we have an understanding that it’s the best thing for him. As I’m taking off the turban and shirt I notice he’s wearing adult diapers and there’s a plastic sheet on the bed. Checking his pulse I see that he’s in the 130s. It’s pretty obvious where this is going.

As I slip the turban from his head I notice the long, uncut hair neatly wound around the top of his head and secured with the Kanga, a wooden comb. The uncut hair and comb are two more of the five external articles of faith which symbolize cleanliness and tidiness. Sikhs believe that the hair, like everything else, is a gift from god and therefore remains uncut.

He’s light enough that I can just cradle him and move him to the gurney myself. While carrying him to the gurney his arm dangles in front of me with the Kara – iron bracelet – resting against his outstretched hand. Heading towards the ambulance I have a working differential diagnosis and I’m mentally running through treatment options.

The elderly who wear diapers and have incontinence issues often get urinary tract infections. This often leads to fever and sepsis if it’s not treated quickly. Laying on the plastic sheet with all of his clothes on he was radiating heat and increasing the fever. Eventually he stops sweating as he gets dehydrated. The elevated heart rate is the body’s compensation mode – attempting to circulate an ever-decreasing fluid level and fight off the infection.

I tell Scottie we can start transporting right away. I’m on the fence about lighting up the rig and driving fast but decide against it as I can’t confirm his level of consciousness because of the language barrier. If anything changes I’ll light it up but for now we’re driving Code-2. I check his vitals, run a 12-lead, and use the temporal thermometer. Wow!

I poke my head through the pass through to give Scottie the ring down information. “78 year old male, possible ALOC (altered level of consciousness), language barrier, fever by two days, temp of 106.2, sinus tach at 138. Go ahead and call it a sepsis alert also. Code-2 for now.”

Our county recently initiated the use of sepsis alerts. Sepsis has finally blipped on the collective radar of the hospitals in the county and they’re asking us to give them an early heads up when it’s a strong possibility. Basically people were sitting in the waiting room or stuck in triage and were getting overlooked in the critical first stages of sepsis where aggressive treatment of fluids and antibiotics can reverse the downhill spiral of MODS (multiple organ dysfunction syndrome).

I start a very large IV and turn the fluid on letting it go wide open. With this size needle I should be able to get a liter on board during the ten minute drive to the ED. I break out some ice packs and place them on his neck, in the armpits, and tuck them into his diapers at the femoral artery. Reaching over to the control panel I flick the air conditioning on high. The best thing I can do for my patient is an aggressive fluid challenge and try to get the fever down.

As I’m pulling the gurney out at the hospital I look up to make eye contact with a patient I can’t communicate with other than giving him a reassuring look. He has a peaceful look on his face as he looks down at the IV in his arm. His gaze continues down his arm to the iron bracelet and he seems just a little more relaxed for the reminder of his faith. I envy him.

After running a lot of calls in a part of the county that has a high Sikh population I became curious about their culture. I started reading and researching to learn more about them. I feel it’s important for a Paramedic to understand the people who live in the community so as to better serve their needs. It was fascinating to learn of their rich history and devout faith with a focus on: honesty, equality, fidelity, militarism, meditating on God, and never bowing to tyranny. I find them honorable, caring, hard working people. But most of all I see that they are just like everyone else – they have the same illnesses, the same vices, and the same ideals; they are human just like everyone else.