Still alive!

Hello all!
Sorry for the absence. Life has been pretty crazy lately. Much has changed since August! I'll be writing soon to fill in the blanks there.

The purpose of this post is to announce with pride that my Paramedic Cherry finally got popped.
I've had a fair amount of run-of-the-mill calls since i got my card in mid-August. Quite a few BLS runs, and quite a few simple ALS runs. You know what I mean; O2, IV (usually a saline lock), ECG, check blood sugar, keep em comfortable, and have a nice cruise to the hospital. I've had a few that induced a mild pucker factor, but nothing that seriously puckered me up or tested my knowledge retention.

Well, that changed the other day. I've been running a pretty stupid schedule for the last month or so... 0000-0800 at dispatch, 0900-1800 or 2000 at QVA, and just praying for peaceful days so i can sleep before I have to go back to dispatch. I've had a few days that were busy and I got diddly for sleep, but for the most part it's been ok.

Anyway, I got home from work on Monday morning, slept for a few hours. A while after I got up, I had to go into town for something. On my way back, I was coming around the corner about a block up for the fire station when I heard "QVA, EMS".
"Well, this is convenient, I'm right here already."
---QVA, Medical Emergency, 12345 Back Rd., 70 y/o male, Possible Cardiac---
*Yawn* "Yep. ECG, IV, O2, check blood sugar, maybe some Nitro and Aspirin, transport, etc etc..."

The other 2 members of my crew answered up. One of whom is one of the best Ambulance Drivers you'll ever see (Before you all gasp and start calling me names, he is actually strictly an ambulance driver. Was an EMT once upon a time, but now just drives. And boy, can he drive. It's a lot more comforting when you hear Mike answer up, especially when the weather is bad. The guy gives one heluva smooth ride and he can also whip the ponies very effectively and safely when he needs to). The other crew member was an EMT who has a history of issues. Some of these issues include agitating fragile situations, not following directions, etc. Nice woman, but has a history, ya know? So right there, a small part of me groaned and hoped for a BS call. We all got to the station and went on our merry way, over the river and through the woods, to cardiac's house we go...

On arrival, we backed into a nice snowblown driveway (we picked up some accumulation the other day... this locale had 10-12 inches.) I assigned the crew to get the Monitor, Airway bag, and stretcher while I went in and got the scoop.
I knocked on the door, heard "Come in", and went in. To my left sat an elderly gent, a little on the heavyset side, sitting on a recliner with his hands on the arms in a tripod position of sorts. He was obviously short of breath and a bit on the pale side.

This is the conversation and sequence of events that followed:
Me: "Hi, I'm Adam, I'm a Paramedic with the ambulance, what's going on today?"
Him: "Well, I'm having a hard time catching my breath, my chest feels funny, and my blood pressure is acting weird."
Me: "Define 'weird'."
Him: "Well, this was my last one, I took it with my machine here," pointing at the bottom set of numbers on a legal pad.
Me: *Looks down at legal pad and sees 72/52, eyebrows promptly raise, I reach for his wrist for a radial pulse... nada. Reposition... Nada. Hmmmm... Put on my ears and listen to his chest... clear lung sounds in all fields, heart sounds are kinda quiet and kinda fast. Couldn't tell how fast, but it sounded a little Tachy.*
Him: "Then I took it just before you walked in and my machine said 'ERROR'"
Me: "Hmm."

At this point, my crew walked in. I promptly reached for a BP cuff and directed the EMT to get the monitor set up for me. Inflate cuff to 160... 150, 140, 130, 120, 110, 100, 90... Nothin. Eyebrows start to crunch as I drop past 80, 70, 60, still nothin. I hit 50 and suddenly I heard a sound that instigated one intense pucker factor; "beepbeepbeepbeepbeepbeepbeepbeepbeep." "Please let that be a pager ," was the first thought to cross my mind. Alas, it was not to be. I looked at the cardiac monitor to my right and saw a bright green "200" over a picture perfect narrow complex tachycardia.

"Feces," I thought. "Thiiiiisss is gonna be fun."

Driver has been around long enough to know good from bad on ECGs and I see his eyebrows raised also. "You did bring your lead foot with you today, right?" I quietly ask, to which he smiles and nods. Sweet.

"Sir, which hospital would you like to go to?" *Please say RMH, please say RMH, please say RMH* (I'm not too fond of RMH, but it is the closest facility at a distance of 20 miles and pretty much a straight shot from QV to there.)
"RMH," states the patient.
"Good choice," I said to Pt. To EMT, I said, "Mike and I will load him up and get him outside, I need you to go set me up an IV start kit, a line, and get the Adenosine out." Off she went after she finished putting him on 02, Mike and I got him loaded up and carried the stretcher down the porch stairs, then wheeled him to the rig.
The EMT was still spiking the bag for me. I rechecked his radials, very weak and very fast. At least I can feel them now, I thought.

I reached across to the opposite bench, grabbed an 18 ga, a tournequet, gauze, alcohol prep, and the venigaurd (the clear sticky piece of plastic we use to secure IV sites.) On goes the tournequet and after a few seconds I started looking for an AC. (Antecubital vein. It runs under the surface in the crook of your elbow, its a good size vein.) I could just barely feel it there. I prepped the site, took a deep breath, crossed my fingers, inserted the needle... Flash! Shweeet!
This was the perfect night for a successful first stick. Got it hooked up and it flowed beautifully. I know sometimes AC's can be positional but this baby was flowin no matter how the arm moved.

Once the IV was in, I again asked for the Adenosine and was promptly handed a small brown glass vial. Phenergan. WTF. Tell me we're not setting the tone here...
"Nononono. Adenosine. White boxes, one with a red end, 2 with yellow ends."
Next I'm handed a box of Lidocaine. I start to get up to get it myself when they finally found it. They also set me up some 10 cc flushes. Come to find out, the drug shuffle was the only issue of the whole call. We really did have a good flow going among the crew and the EMT was actually keeping her head on straight today. Sweet.

I told Mike that we were good to go so he hopped up front and took off. I got the first Adenosine dose (6mg) set up and told the EMT to squeeze the IV bag hard when I told her to.
I gave the guy the Adenosine prep speech (you might feel funny, you might get dizzy, your chest might hurt for a minute, but this should make you feel better), hit 'Record', kinked off the line, slammed in the first 6mg of Adenosine, slammed in the flush, and told EMT to squeeze. Looked at the monitor.... Holding steady at 196. "Ok, not uncommon for the first 6 to be ineffective, lets go for 12." Got the next dose of 12 mg ready, record, kink, slam, slam, squeeze... Nada. Didn't even skip a beat. WTF. All of a sudden, pt says he feels a little better. BP is 118/72 with a pulse rate of 190. Nice. He also had about 400cc's of saline in by then.

Ok, 3rd dose.. Set up for the final 12 mg, record, kink, slam, slam, squeeze... Whats this? Brakes! Rate slows down to 133, plateaus, then climbes back up to 188. Dangit.
Then just to confirm what I was thinking, I pulled out my protocol book...
"For Narrow Complex Tachycardias >150 bpm, Immediate Syncronized Cardioversion is indicated. You may attempt a brief medication trial. For NCT's <150, cardioversion is usually not indicated."

Dammit, I do NOT want to have to zap this guy without Valium or Versed, but he is still haulin
ass, completely refractory to the Adenosine... Hmmmm. HEY! We just got Cardizem! And everything about this guy is stable except for his rate...

So I called Resource and asked for RMH. Once I had RMH on the phone, I gave them the scoop, told them his current vitals, told them that he was refractory to the whole series of Adenoside, that cardioversion was the next thing on the protocols but this guy was pretty stable, and I mentioned that we now have Cardizem. I was told to stand by.
A minute later, they asked if I had Amiodarone.
"Yes, I have Amiodarone..." *Why the hell do they wanna know if i have Amio?*
"Oh wait, QVA, Standby again."
"Ok."
"QVA, is it wide complex or narrow complex?"
"Narrow complex! *I already told you SVT-narrow complex, knucklehead*
"OK, Stand by again..... QVA, do you have Cardizem?"
"Why, Yes I do!"
"Ok, standby again...... QVA, per Dr Soandso, Give the pt 20 mg of Cardizem IV over 2 minutes."
"Copy RMH, Per Dr Soandso, 20 mg Cardizem IV over 2 minutes, we're see you in 5-7 mins."
"That's affirmative QVA, transport and advise, we'll see you when you get here."

So out comes the Cardizem. Mixed it up, shook it up, looked it over, plugged it into the line, and slowly started pushing the plunger, keeping an ear on the monitor. About 10 mg into the dose, I heard the monitor slowing down. I looked over and saw that we were at 165 and dropping. Sweet! It progressively made its way down to 100 then started bouncing between 130 and 90. Once the whole dose was in, the rate danced around for a minute and then settled down at 96 and regular. I looked at our pt and his eyes were kinda wide as he took a deep breath.
"I bet you feel better." I said.
"Wow, Do I ever! Can I go home now?" he asked with a laugh.

By this point, we were almost at the hospital and we took another set of vitals: 124/62, 96, 18. B-E-A-U-tiful! I like this Cardizem stuff! We took the guy into a room, transfered him over to their bed, gave report, then started writing, had the Doc who gave me the order for the Cardizem sign my PCR, talked to him for a few minutes, finished up, and off we went. Of course, I forgot to turn in the hospital copies of my PCR's so we had to turn around about 10 minutes away from the hospital on the way home to drop of the paperwork. I was happy thought. If forgetting to turn in my paperwork was the worst thing that happened out of that whole call, it was a damn good night. And my EMT was great for the whole call. Every time she checked his vitals she checked his lung sounds. Fantastic.

So that was my first real pucker-factor call with me in the role of lead. And I didn't even screw anything major up. I was a little nervous about my first big call, but all turned out well and I remembered just about everything I needed to, so hopefully I can continue to do alright.
No codes or other major shit calls yet *knocking hard on the desk* So far so good!
Well, I will sit down sometime in here and fill y'all in on current events soon.
Take care!